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Based on staff interview, clinical record review, and facility policy and procedure review, the facility staff failed to ensure the protection of patients rights as evidenced by systematic failures regarding the implementation and documentation of the use of restraints.

Findings include:

During the survey conducted 10/2/17 through 10/5/17 the following standards were found to be out of compliance with regards to the use of seclusion and restraints:

482.13 (e)(2)
482.13 (e)(4)(ii)
482.13 (e)(9)
482.13 (e)(10)
482.13 (e)(16)(iii)
428.13(f)(2)

These standards address:
a. Use of least restrictive methods before initiation of physical restraints.
b. Physician orders for use of restraints including following orders.
c. Implementation of the facility policy and procedure regarding the use of restraints.
d. Discontinuation of the restraint at the earliest possible time regardless of the length of the order.
e. Monitoring of patients while in restraints.
f. Training of staff (providers).

A discussion was held with the facility administrative staff on 10/4/17 at 4:20 PM, regarding the issues identified with the implementation, training and documentation of the use of restraints.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure for one (1) of six (6) patient records reviewed for restraint use (Patient #11), there was indication of an assessment related to least restrictive methods prior to the initiation of a physical restraint.

The findings included:

1. Patient #11 was admitted 9/13/17 with diagnoses that included, in part, septic shock and diabetic ketoacidosis.

On 10/3/17 the surveyor reviewed the clinical record with Staff Member #8, (Registered Nurse, Clinical Risk). During the review of the records, the surveyor reviewed the application of "non-behavioral" restraint application for Patient #11. During the review, the surveyor asked Staff Member #8 to navigate through the clinical record in order to find documentation regarding the least restrictive alternative to restraint use that was attempted for the patient before the initiation of the use of restraints. An order dated 9/13/17 at approximately 1:55 p.m. documented the initial order for the use of wrist restraints to "prevent pulling tubes", however the clinical record did not contain documentation on the "restraint flowsheet" (area of the Electronic Medical Record- EMR) of any less restrictive alternatives or assessments related to least restrictive alternatives, prior to the application of the restraints. "Nurses Notes" were also reviewed and no documentation regarding the alternatives were found. Staff Member #8 stated, "This is where it should be documented, but I do not find any documentation for a less restrictive alternative."

Review of the facility policy and procedure "Restraints- Use of" documented, in part: "PURPOSE: Nursing is committed to prevent, reduce, and eliminate the use of restraints or seclusion whenever possible. This commitment is achieved through interventions that are directed at avoiding situations that have the potential to lead to the use of restraint or seclusion ...IV. PROCEDURE: ...2. Less restrictive mechanisms may include patient placement, diversion activities, positioning, change in medication regime, lighting, alarms, and family involvement in care. The least restrictive restraint device will be used based on the patient's assessment. 3. Documentation in the medical record must include behaviors (i.e. picking at tape, pulling at catheters, etc.) that interfere with medical care and that all other treatment options and alternatives have been attempted without success..."

On 10/4/17 at 4:20 p.m., the surveyor discussed the findings with Staff Members #1, 2, and 3.

Based on staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure the policy and procedure for the implementation and use of restraints was followed for five (5) of six (6)patients reviewed for restraint use, Patients #8, #9, #10, #11, and #12.

The findings included:

Review of the clinical records for Patients #8, #9, #10, #11, #12, and #18, revealed the facility did not follow the policy and procedure for the implementation and use of restraints in the following areas:

1. Use of least restrictive alternatives.
During the review of the records, the surveyor reviewed the application of "non-behavioral" restraint application for Patient #11. During the review, the surveyor asked Staff Member #8 to navigate through the clinical record in order to find documentation regarding the least restrictive alternative to restraint use that was attempted for the patient before the initiation of the use of restraints.

An order dated 9/13/17 at approximately 1:55 p.m. documented the initial order for the use of wrist restraints to "prevent pulling tubes", however the clinical record did not contain documentation on the "restraint flowsheet" (area of the Electronic Medical Record- EMR) of any less restrictive alternatives that were tried prior to the application of the restraints. "Nurses Notes" were also reviewed and no documentation regarding the alternatives were found.

Review of the facility policy and procedure "Restraints- Use of" documented, in part: "PURPOSE: Nursing is committed to prevent, reduce, and eliminate the use of restraints or seclusion whenever possible. This commitment is achieved through interventions that are directed at avoiding situations that have the potential to lead to the use of restraint or seclusion ...IV. PROCEDURE: ...2. Less restrictive mechanisms may include patient placement, diversion activities, positioning, change in medication regime, lighting, alarms, and family involvement in care. The least restrictive restraint device will be used based on the patient's assessment. 3. Documentation in the medical record must include behaviors (i.e. picking at tape, pulling at catheters, etc.) that interfere with medical care and that all other treatment options and alternatives have been attempted without success..."

2. Incomplete/no orders for the use of restraints.
For Patients #10, #9 and #12, the orders were incomplete. When entered in to the EMR (Electronic Medical Record) in the area for "restraint type" the orders documented only "wrist" or "ankle" or "mittens" and did not specify whether the restraint was ordered for one extremity, or bilateral extremities, and whether it was to be soft restraints or other.

The facility policy and procedure "Restraints, Use of" was reviewed and evidenced, in part: "...DOCUMENTATION: 2. Indicate the type of restraint device..."

Review of the clinical records for Patient # 10 revealed an order on 9/8/17 at 7:38 a.m. for "Behavioral" restraint- type "wrist". Review of the monitoring flow sheet revealed the patient was documented as having both wrist and ankle restraints applied as well as 4 (four) siderails. A "Progress Note" on 9/8/17 at 8:01 a.m. documented, "Wrist and ankle restraints applied to pt (patient)..." No order was found for the ankle restraints nor the siderails.

Patient # 9 on 9/22/17 at 11:34 a.m., had an order written for "Behavioral Restraint- wrist- ankle". Documented on the monitoring flow sheet beginning at 11:30 a.m., until 4:30 p.m. was "mitten unsecured R (right), Mitten unsecured L (left), and the soft restraints for the R (right) and L (left) wrists, and R and L ankles. No order was found at that time for the use of the mittens.

Patient #12 had an order on 9/11/17 at 5:10 p.m. for "Behavioral Restraint - wrist". According to documentation at 5:00 p.m. on 9/11/17, the patient had restraints applied to both wrists and both ankles. No order was found for the application of the ankle restraints.

On 10/4/17 at 10:30 a.m., Staff Member #8 assisted the surveyor to navigate the patient records. Staff Member #8 stated, in regards to the orders and documentation, "The orders are entered in the EMR and the staff documents based on the restraints that are applied...I can't speak to the difference in the order and the documentation..."

Review of the facility policy and procedure "Restraints- Use of" evidenced, in part : "...3. The initial order is entered into the electronic medical record (EMR)....each subsequent application of restraint or seclusion requires an order..."

3. Discontinuing restraints at the earliest possible time- regardless of the length of the order.
Review of the clinical record for Patient #9 revealed an order for the use of "Restraints Behavioral" on 9/22/17 at 1:44 a.m. . with "restraint type" "wrist and ankle" - "restraint 4 hours". There was also an order for the continued use of the restraints at 6:23 a.m. for "4 hours". Discontinuation criteria was documented as "No longer a danger to self. No longer a danger to others".

Review of the monitoring documentation for the restraint use for Patient #9 for the above orders revealed that on 9/22/17 from 12:15 a.m. through 5:15 a.m., for the 15 minute monitoring checks, the staff had documented at each entry "Patient Asleep". At 5:30 a.m., it was documented "confused", then from 6:00 a.m. through 6:45 a.m., the staff documented "patient asleep". The documentation also evidenced the patient remained with the restraints on both wrists and both ankles.

Review of the facility policy and procedure "Restraints, Use of" revealed, in part: "...Discontinuation of Restraints: Behavioral (Violent/Self Destructive) Discontinue when patient meets criteria..." There was no documentation in the "Progress Notes" or of an assessment describing behaviors which would warrant the continued use of restraints. The policy and procedure also documented that all patients"will have appropriate clinical justification for the use of restraints or seclusion; least restrictive device used..."

4. Monitoring per policy while in restraints.

A. Patient #8 was admitted on 8/21/17 with diagnoses which included, but were not limited to: Unresponsive, schizophrenia, change in mental status, and chronic oxygen dependency. On 8/26/17 at 8:15 a.m., an order was documented for "Restraints Non-behavioral, 24 hours, type- wrist" Further review of the required monitoring revealed an entry on 8/26/17 at 8:16 a.m. at the time of the initiation of the restraints. There was no further documentation of any monitoring of Patient #8 throughout the day. An entry in the "progress notes" on 8/26/17 at 6:00 p.m. evidenced, "Pt (Patient) DC (discharged) to (name of another facility) per (name) transport. Pt drowsy, confused, no respiratory distress...."

B. Patient # 10 was admitted on 9/7/17 with diagnoses that included, in part, schizophrenia. diabetes, cirrhosis, and chronic obstructive pulmonary disease (COPD). Review of the clinical record revealed an order for Behavioral - wrist" restraint "Order Date/Time: 9/8/17 07:38 AM - restraint 4 hr (hour)". Documentation in the clinical record revealed no 15 minute monitoring as per the policy. The documentation revealed monitoring occurred at 8:01 a.m., 9:34 a.m., 10:00 a.m., 10:15 a.m., 11:00 a.m., and 12:00 a.m., when it was documented the order was "continued" however the clinical record revealed a new order was not obtained until 9/8/17 at 1:41 p.m., which was more than two (2) hours from the required four (4) hour limit for the use of the restraint.

C. Patient #11 was admitted on 9/13/17 with diagnoses of septic shock, and diabetic ketoacidosis. On 9/13/17 at 4:57 p.m. an order was documented for "Non- behavioral Restraint- wrist" due to the patient "pulling at lines and tubes". Review of the monitoring for Patient #11 revealed no documentation of the required "every 2 hour" monitoring from 3:55 p.m. until 9:00 p.m.

D. Patient #12 was admitted on 9/4/17 with diagnoses which included non-traumatic rhabdomylosis. Review of the clinical record revealed an order was obtained on 9/11/17 at 5:10 p.m. for the application of "Behavioral Restraints". Further review of the required monitoring revealed Patient #12 was monitored at 5:00 p.m. when the restraints were applied, at 6:00 p.m. and 6:30 p.m. when it was documented the restraint was discontinued.

Review of the facility policy and procedure "Restraints, Use of" revealed the following, in part: "...E. Implementation of Restraints: MONITORING: Non-Behavioral (non-violent/non self destructive) - Every 2 (two) hours by trained and competent staff for signs of injury from the restraints, toileting, feeding, hydration, ROM (range of motion), circulation checks, etc. Behavioral (Violent/Self destructive)- The patient is assessed every 15 (fifteen) minutes for the following: vital signs (at a minimum respirations are assessed), hygiene and elimination, physical and psychological status and comfort...DOCUMENTATION: 4. Patient Observations/Interventions must be completed as indicated by type of restraint or need for seclusion...all items must be assessed..."

5. Training requirements for staff.

The facility staff failed to ensure seven (7) of nine (9) providers permitted to write orders for the use of restraints had received training in regards to the hospital policy for the use of restraints and seclusion, and failed to ensure that 2 providers had received a current update on the policy.

On 10/5/17 at approximately 8:40 a.m., the surveyor presented the facility with a list of providers who had ordered restraints for the six (6)patient records which were reviewed for restrain use.

At 10:30 a.m., on 10/5/17, Staff Member #43, (Manager of Education and Organizational Development) stated, "There are only two providers on this list that have had the training that we can find documented, and they are ED (emergency department) providers. One had the training in 2008, and the other is 2010. Part of the provider orientation (restraints) is that their preceptor is supposed to go over it with them. It is built in for the ED staff. We do not document any updates for physicians regarding reviews or revisions to the policy and procedure. I would assume they do that in their meetings but it is not tracked."

Review of the facility policy and procedure "Restraints- Use of" did not evidence specific inclusion regarding providers, however under "TRAINING" the following was documented, "Hospital trains staff on restraint or seclusion application at orientation, prior to application of restraints or seclusion annually.

On 10/4/17 at 4:20 p.m. and on 10/5/17 at 10:45 a.m., the surveyor discussed the concerns regarding the above with Staff Members #1, #2, #3, and #43. No further information was provided by the end of the survey.

Based on staff interview, clinical record review, and facility policy and procedure review, the facility staff failed to ensure restraints were implemented according to physician's orders, orders were complete, and that the appropriate restraint was used when needed for three (3) of six (6) restraint charts reviewed. Patients #9, #10, and #12.

The findings included:

1. Review of the clinical records for Patients #9, #10 , and #12, revealed with each order obtained or the use of restraints, the physician's order was not complete. The order was written in the electronic medical record (EMR) as "wrist" or ankle" There was no documentation on the order as to which wrist, or ankle, or if it were for bilateral extremities. On 10/4/17 at 10:00 a.m, the surveyor asked Staff Member #8 about the reason the orders were not specific. Staff Member #8 stated, "That's the choice they have in the EMR system. It doesn't let them choose bilateral, but that should be documented on the flowsheets..."

2. Review of the clinical records for Patient # 10 revealed an order on 9/8/17 at 7:38 a.m. for "Behavioral" restraint- type "wrist". Review of the monitoring flow sheet revealed the patient was documented as having both wrist and ankle restraints applied as well as four (4) siderails. A "Progress Note" on 9/8/17 at 8:01 a.m. documented, "Wrist and ankle restraints applied to pt (patient)..." No order was found for the ankle restraints nor the siderails.

3. Patient # 9 on 9/22/17 at 11:34 a.m., had an order written for "Behavioral Restraint- wrist- ankle". Documented on the monitoring flow sheet from 11:30 a.m. until 4:30 p.m. was "mitten unsecured R (right), Mitten unsecured L (left), and the soft restraints for the R and L wrists, and R and L ankles. No order for mittens was found, for this timeframe.

4. Patient #12 had an order on 9/11/17 at 5:10 p.m. for "Behavioral Restraint - wrist". According to documentation on 9/11/17 at 5:00 p.m., the patient had restraints applied to both wrists and both ankles. No order was found for the application of the ankle restraints.

On 10/4/17 at 10:30 a.m., Staff Member #8 assisted the surveyor to navigate the patient records. Staff Member #8 stated, in regards to the orders and documentation, "The orders are entered in the EMR and the staff documents based on the restraints that are applied...I can't speak to the difference in the order and the documentation..."

Review of the facility policy and procedure "Restraints- Use of" evidenced, in part : "...3. The initial order is entered into the electronic medical record (EMR)....each subsequent application of restraint or seclusion requires an order..."

On 10/4/17 at 4:20 p.m. the surveyor discussed the concerns with Staff Members #1, 2, and 3, in and end of day meeting. No further information was presented by the end of the survey.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that a restraint was discontinued at the earliest possible time for one (1) of six (6) records reviewed for restraint usage. Patient #9.

The findings included:

Patient #9 was admitted to the facility on 9/19/17 with a diagnosis that included, but was not limited to, seizures. Review of the clinical record for Patient #9 revealed an order for the use of "Restraints Behavioral" on 9/22/17 at 1:44 a.m. . with "restraint type" "wrist and ankle" - "restraint 4 hours". There was also an order for the continued use of the restraints at 6:23 a.m. for "4 hours". Discontinuation criteria was documented as "No longer a danger to self. No longer a danger to others".

Review of the monitoring documentation for the restraint use for Patient #9, for the above orders revealed that on 9/22/17 from 12:15 a.m. through 5:15 a.m., for the fifteen minute monitoring checks, the staff had documented at each entry "Patient Asleep". At 5:30 a.m., it was documented "confused", then from 6:00 a.m. through 6:45 a.m., the staff documented "patient asleep". The documentation also evidenced the patient remained with the restraints on both wrists and both ankles.

The surveyor asked Staff Member #8, at the time of the review 10/4/17 at 10:20 a.m., about the reason staff would leave the patient in behavioral restraints of all extremities (wrist and ankle) when the patient was documented as sleeping. Staff Member #8 stated, "I have no idea, but that is what they are documenting."

Review of the facility policy and procedure "Restraints, Use of" revealed, in part: "...Discontinuation of Restraints: Behavioral (Violent/Self Destructive) Discontinue when patient meets criteria..." There was no documentation in the "Progress Notes" or of an assessment describing behaviors which would warrant the continued use of restraints. The policy and procedure also documented that all patients"will have appropriate clinical justification for the use of restraints or seclusion; least restrictive device used..."

On 10/4/17 at 4:25 p.m., the surveyor discussed the concerns with Staff Members #1, 2, and 3 regarding a patient being left in four-point (all four extremities) restraints, when the documentation indicated the patient was asleep and was not posing a danger to him/herself or others. No further information was provided by the end of the survey.

Based on clinical record review, staff interview, and facility document review, the facility staff failed to ensure five (5) of six (6) patients who had orders for restraints, were monitored per facility policy to ensure continued safe and appropriate use of restraints. Patients #8, #10, #11,#12, and #18).

The findings included:

1. Patient # 8 was admitted on 8/21/17 with diagnoses which included, but were not limited to, schizophrenia, change in mental status, and chronic oxygen dependency. On 8/26/17 at 8:15 a.m., an order was documented for "Restraints Non-behavioral, 24 hours, type- wrist" There was no documentation which specified which wrist, or both wrists, or type of restraint to be used (soft or locked). Further review of the required monitoring revealed an entry on 8/26/17 at 8:16 a.m. at the time of the initiation of the restraints. There was no further documentation of any monitoring of Patient #8 throughout the day. An entry in the "progress notes" on 8/26/17 at 6:00 p.m. evidenced, "Pt (Patient) DC (discharged) to (name of another facility) per (name) transport. Pt drowsy, confused, no respiratory distress...."

2. Patient # 10 was admitted on 9/7/17 with diagnoses that included, in part, schizophrenia, diabetes, cirrhosis, and chronic obstructive pulmonary disease (COPD). Review of the clinical record revealed a 9/8/17 order for "Behavioral - wrist" restraint "Order Date/Time: 9/8/17 07:38 AM - restraint 4 hr. (hour)". Documentation in the clinical record revealed monitoring was not done every fifteen minutes, as per the facility policy. The documentation revealed monitoring occurred at 8:01 a.m., 9:34 a.m., 10:00 a.m., 10:15 a.m., 11:00 a.m., and 12:00 a.m., when it was documented the order was "continued" however a new order was not obtained until 9/8/17 at 1:41 p.m., which was more than two (2) hours beyond the required four (4) hour limit for the use of the restraints.

The order also documented the restraint being used was for "soft restraint R (right) wrist, soft restraint L (left) wrist, soft restraint R ankle, soft restraint L ankle and "4 siderails". The physicians order was only written for "wrist" and did not specify which wrist, or bilateral wrists, or the type of restraint (soft or locked). There was no order for the ankle restraint nor the four (4) siderails.

3. Patient #11 was admitted on 9/13/17 with diagnoses of septic shock, and diabetic ketoacidosis. On 9/13/17 at 4:57 p.m. an order was documented for "Non- behavioral Restraint- wrist" due to the patient "pulling at lines and tubes". The record lacked documentation of the patient being monitored every two (2) hours while in restraints, for the time period of 3:55 p.m. through 9:00 p.m.

4. Patient #12 was admitted on 9/4/17 with diagnoses that included, in part, non traumatic rhabdomylosis. Review of the clinical record revealed an order was obtained on 9/11/17 at 5:10 p.m. for the application of "Behavioral Restraints". According to documentation in the clinical record there was no clarification of what type of restraint (soft or locked) and to which wrist(s) the restraint was to be applied. Further review of required monitoring revealed Patient #12 was monitored at 5:00 p.m. when the restraints were applied, 6:00 p.m., and 6:30 p.m. (when the restraint was discontinued). This did not meet the policy requirement of monitoring every fifteen minutes behavioral restraints were used.

5. Patient #18 was admitted on 8/29/17 . A physicians order was written on 9/1/17 at 2:46 p.m. for "Non-behavioral restraints- wrist". There was no documentation found for monitoring from the time of the order until 8:00 p.m. On 9/19/17 at 8:24 p.m. Patient #18 had another order for "Non-behavioral restraint-wrist" and the order was renewed on 9/20/17 at 7:14 p.m. Review for the required two (2) hour monitoring revealed no documentation of monitoring from 2:00 p.m. on 9/20/17, until 12:28 a.m. on 9/21/17.

Review of the facility policy and procedure "Restraints, Use of" revealed the following, in part: "...E. Implementation of Restraints: MONITORING: Non-Behavioral (non-violent/non self destructive) - Every 2 hours by trained and competent staff for signs of injury from the restraints, toileting, feeding, hydration, ROM (range of motion), circulation checks, etc. Behavioral (Violent/Self destructive)- The patient is assessed every 15 for the following: vital signs (at a minimum respirations are assessed), hygiene and elimination, physical and psychological status and comfort...DOCUMENTATION: 4. Patient Observations/Interventions must be completed as indicated by type of restraint or need for seclusion...all items must be assessed..."

During the review of the clinical records on 10/4/17 at 9:10 a.m., the surveyor interviewed Staff Member # 8 regarding the documentation of the required monitoring for the patient charts reviewed. Staff Member #8 stated, "The documentation should be on the flow sheet. That is where they (staff) document the monitoring of the patient and that the checks were done."

On 10/4/17 at 4:20 p.m., the surveyor discussed the findings and concerns with Staff Members # 1, #2, and #3 regarding the use and monitoring of restraints.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure alternatives or other less restrictive intervention attempts were documented in the clinical record, for one (1) of six (6) records reviewed for the use of restraints, Patient #11.

The findings included:

Patient #11 was admitted 9/13/17 with diagnoses that included, in part, septic shock and diabetic ketoacidosis.

On 10/3/17 the surveyor reviewed the clinical record with Staff Member # 8, (Registered Nurse, Clinical Risk). The surveyor reviewed the application of "non-behavioral" restraint application for Patient #11. The surveyor asked Staff Member #8 to navigate through the clinical record in order to find documentation regarding the least restrictive alternative to restraint use that was attempted for the patient before the initiation of the use of restraints.

An order dated 9/13/17 at approximately 1:55 p.m. documented the initial order for the use of wrist restraints to "prevent pulling tubes", however the clinical record did not contain documentation on the "restraint flowsheet" (area of the Electronic Medical Record- EMR) of any less restrictive alternatives that were tried prior to the application of the restraints. "Nurses Notes" were also reviewed and no documentation regarding alternatives were found. Staff Member #8 stated, "This is where it should be documented, but I do not find any documentation for a less restrictive alternative."

Review of the facility policy and procedure "Restraints- Use of" documented, in part, "PURPOSE: Nursing is committed to prevent, reduce, and eliminate the use of restraints or seclusion whenever possible. This commitment is achieved through interventions that are directed at avoiding situations that have the potential to lead to the use of restraint or seclusion ...IV. PROCEDURE: ...2. Less restrictive mechanisms may include patient placement, diversion activities, positioning, change in medication regime, lighting, alarms, and family involvement in care. The least restrictive restraint device will be used based on the patient's assessment. 3. Documentation in the medical record must include behaviors (i.e. picking at tape, pulling at catheters, etc.) that interfere with medical care and that all other treatment options and alternatives have been attempted without success..."

On 10/4/17 at 4:20 p.m., the surveyor discussed the findings with Staff Members #1, #2, and #3.

Based on staff interview and review of facility documents, the facility staff failed to ensure seven (7) of nine (9) providers permitted to write orders for the use of restraints had received training in regards to the hospital policy for the use of restraints and seclusion, and failed to ensure that two (2) providers had received an update on the current facility policy.

The findings included:

Based on a review of six (6) patients for whom restraints had been ordered, the surveyor requested to review training records for the providers who had written the restraint orders.

On 10/5/17 at 10:30 a.m., Staff Member #43, (Manager of Education and Organizational Development) stated, "There are only two providers on this list that have had the training that we can find documented, and they are ED (emergency department) providers. One had the training in 2008, and the other is 2010. Part of the provider orientation (regarding restraints) is that their preceptor is supposed to go over it with them. It is built in for the ED staff. We do not document any updates for physicians regarding reviews or revisions to the policy and procedure. I would assume they do that in their meetings but it is not tracked."

Review of the facility policy and procedure "Restraints- Use of" did not evidence specific inclusion regarding providers, however under "TRAINING" the following was documented, "Hospital trains staff on restraint or seclusion application at orientation, prior to application of restraints or seclusion annually.

On 10/5/17 at approximately 10:45 a.m., during a meeting with Staff Members #1 and #43, the surveyor discussed the concerns regarding the training for providers regarding the facility policy and procedures for the use and ordering of restraints.

Based on staff interview and facility document review, for one (1) of one (1) patients (Patient #18) sampled for reconciliation of physician orders; the facility staff failed to resolve questions with the prescribing practitioner related to a medication which was administered to a patient without a corresponding order, that real or potential allergies or sensitivities were addressed prior to administration, and that the discussion and outcome were documented in the patient's medical record or a pharmacy copy of the prescriber's order.

Findings include:

A review of Patient #18's clinical record, noted six medications listed under "Allergies" on the admission history and physical (H&P) dated 8/29/17. One of the medications listed was Ativan, with the reaction documented as "twitching of arms, sweating, hives and anxiety".

The surveyor conducted an interview with Staff Member #41, an RN (registered nurse), on 10/5/17 at 11:00 AM. The surveyor asked Staff Member #41 about documentation that Ativan was administered to Patient #18 during a rapid response due to a seizure on 8/31/17 at 12:50 PM. Ativan was documented as an allergy in the medical record. The surveyor also discussed the Pyxis (medication dispensing system) override for the Ativan, and the lack of a corresponding order for Ativan in the medical record.

Staff Member #41 stated the following: "[physician] asked [patient] caregiver, who was present, what [patient's] reaction to Ativan was, and [caregiver] said it made [patient] hyper and anxious, [physician] was there and said to give 2 of IV Ativan, so [Staff Member #43], another RN pulled it from the Pyxis and gave it. A Versed/Fentanyl drip was started after that. There was so much going on with two rapid responses at the same time, I forgot to put in the order for the Ativan".

The record lacked documentation that the physician discussed Patient #18's listed allergy to Ativan with the caregiver prior to administration of the medication.

Staff Member #3, the chart navigator was interviewed on 10/3/17 at 3:15 PM when the surveyor noted that there was no physician order for Ativan which was documented as administered to Patient #18 on 8/31/17, during the seizure as described above, Staff Member #3 stated "I don't really see the true order for Ativan-during the code; a verbal order may be given, somebody would then have to go back and put the order in, I do not see the order for the Ativan".

On 10/4/17 the lack of an order for Ativan was further discussed with Staff Member #3, who stated "There is a list of meds used in emergencies that are over-ridable. If an over-ride is necessary, the nurse has to document the verbal order after the fact , then it links to the over-ride pull".

On 10/4/17 at approximately 11:30 AM, an interview was conducted with Staff Member #40, a pharmacist, who told the surveyor that administration of the Ativan, which was listed as a patient allergy would depend on if there was a discussion between the physician and family as to whether the benefits of giving the medication outweighed the risk". The pharmacist told the surveyor that there was an intervention documented related to the over-ride pull of the Ativan from the Pyxis, and presented the surveyor with an email dated 10/4/17 sent by Staff Member #44, the Clinical Pharmacy Manager, which stated "Lorazepam 2 mg/ml vial override pull occurred 8/31/17 at 1246 (12:46 PM) and was charted as given by RN at 1250 (12:50 PM). No medication order was entered or sent to the pharmacist verification queue for documentation of this order. Pharmacist intervention opened on 9/1/17 at 0902 (9:02 AM). The intervention type is "Code Blue Attendance". It is unclear what prompted this documentation to occur at this time (i.e. was this late documentation of an event that occurred the prior day?) I cannot tell if the code occurred on 8/31 or 9/1. The Code Narrator does not have documentation (that I can see).

The surveyor reviewed the Pharmacy intervention history, and noted that it was both opened and closed on 9/1/17 at 9:02 AM, and included the following information: documentation of a pharmacy intervention dated 9/1/17 at 9:02 AM which documented "Pt experienced status epilepticus w/ resp depression requiring RSI with etomidate/nmb. Lorazepam 2 mg iv (sic) given, etomidate/nmb. Pt placed on sedation with fent/versed".

No further follow-up documentation by the pharmacy staff related to the Ativan being administered without a physician order, or that Ativan was administered when it was documented as a medication allergy, was available for review.

During an interview with Staff Member (SM) #2, the Director of Quality and Patient Safety on 10/4/17 at 1:40 PM, SM #2 stated that he/she had talked with the nurse who cared for Patient #18 on 8/31/17, "There was another patient decompensating in the unit at the same time, and a rapid response was called, respiratory responded to the other patient. The nurse wasn't getting help, so the primary physician was called. The Ativan allergy was discussed with the doctor, and he/she decided it was worth administering Ativan. Staff Member #43 (another RN) pulled and gave the med to help. Pushing the code button doesn't necessarily cause the code to be called. Technically this would have been a rapid response but he/she needed help, there was miscommunication, so he/she pushed the code button. There would not have been a code note because it was a rapid response, not a code. We needed to have pharmacy talk with staff to get the Ativan order after that happened, when they realized no order had been obtained".

Findings were discussed with Staff Members #3, #40, and #41 as noted above, and on 10/5/17 at 3:00 PM administrative staff was made aware of the information as noted above.