HospitalInspections.org

Based on record review and interview, the facility failed to ensure procedures in their medical staff bylaws were followed by a physician, as evidenced by lack of authentication, date, and timing of restraint/seclusion/emergency behavioral medication orders for 1 of 1 patients, within 96 hours (Patient #2).

Findings included:

Review of facility's Medical Staff Bylaws, Rules and Regulations, last approved for 2023 showed that all orders, if dictated over the phone, shall be signed, dated, and timed by the attending physician within 96 hours.

Record review on 3/7/23 of Patient #2's medical records showed the following:

On 2/13/23, 2/20/23, and 2/21/23, the patient had behavioral emergencies. All three times, Patient #2 was restrained, given the emergency medications Haldol 10 mg IM (intramuscularly), Ativan 2 mg IM, and Benadryl 50 mg IM, and was also secluded.

The orders were given via telephone by Staff #E (patient's physician). At the time of survey review on 3/7/23, the orders were not signed, timed, or dated for all three incidents.

In an interview on 3/7/23 at 1:30 pm, Staff #B acknowledged the lack of authentication by the ordering physician and stated that all the restraint orders should have been signed, dated and timed.