HospitalInspections.org

Based on a review of facility policy, patient records, facility documentation, facility video, and staff interviews, the governing body failed to assume full responsibility for implementing, enforcing, and monitoring facility policies and procedures in the area of ensuring patient rights, nursing care, treatment planning, patient restraint, and medical records.

Findings were:

Review of facility policies and patient records revealed the facility failed to ensure that informed consent was obtained correctly; failed to ensure patients received care in a safe setting; failed to ensure when restraint was used it was the least restrictive intervention; failed to modify treatment plans after restraint; failed to ensure that the use of restraint was implemented by staff in accordance with safe and appropriate techniques; failed to ensure that the use of restraint was in accordance with an order by a physician; and failed to ensure a patient ' s right to privacy as a patient was unnecessarily carried down a unit hallway in a personal restraint.
Cross refer A 0115

Review of patient records, facility policies, facility video, facility documentation and staff interviews revealed the facility failed to ensure that a registered nurse supervised and evaluated nursing care for each patient, failed to ensure that nursing services were monitored and evaluated, and failed to ensure that nursing patient care and monitoring was documented.
Cross refer A 0385

Review of medical records and facility policies revealed the facility failed to ensure that all patient medical record entries were legible, complete, and properly dated, timed, and authenticated.
Cross refer A 0450

Review of facility policies, staff interviews, and patient records revealed the facility failed to ensure that each patient had a completed, comprehensive treatment plan.
Cross refer B 0118

Review of facility documentation, facility video, policies and procedures, staff interview, and patient record revealed the facility did not ensure that nursing progress notes were completed for care of patients.
Cross refer B 0127

Review of facility documentation, patient records, staff interviews, facility video, and facility policies and procedures revealed the facility failed to ensure that the nursing director monitored and evaluated the nursing care furnished in the facility.
Cross refer B 0148

Based on a review of facility policies and patient records, the facility failed to ensure that informed consent was obtained correctly; failed to ensure patients received care in a safe setting; failed to ensure when restraint was used it was the least restrictive intervention; failed to modify treatment plans after restraint; failed to ensure that the use of restraint was implemented by staff in accordance with safe and appropriate techniques; failed to ensure that the use of restraint was in accordance with an order by a physician; and failed to ensure a patient ' s right to privacy as a patient was unnecessarily carried down a unit hallway in a personal restraint.

Findings were:

During a review of facility policies and patient records, the facility failed to ensure that informed consent was obtained, informed consent forms were completed per facility policy, and failed to obtain a completed consent form for each individual psychoactive medication.
Cross refer A 0131

Review of facility documentation, facility video, policies and procedures, staff interview, and patient record revealed the facility did not ensure a patient ' s right to privacy as a patient was unnecessarily carried down a unit hallway in a personal restraint.
Cross refer A 0143

Review of facility documentation, facility video, policies and procedures, staff interview, and patient record revealed the facility did not ensure a patient ' s right to care in a safe setting as the patient sustained an injury and was restrained incorrectly.
Cross refer A 0144

Review of facility video, staff interview, medical records, and facility policy revealed the facility failed to ensure that least restrictive interventions were used in a restraint and rationale documented.
Cross refer A 0165

Review of facility video, staff interview, medical records, and facility policy revealed the facility failed to ensure that a written modification was made to a patient ' s treatment plan after restraint.
Cross refer A 0166

Review of facility policies, facility video, staff interviews, and medical record revealed the facility failed to ensure that the use of restraint was implemented by staff in accordance with safe and appropriate techniques.
Cross refer A 0167

Review of patient record, facility policy, facility documents, and staff interview revealed the facility failed to ensure that the use of restraint was in accordance with an order by a physician.
Cross refer A 0168

Based on a review of facility policies and patient records, the facility failed to ensure that informed consent was obtained, informed consent forms were completed per facility policy, and failed to obtain a completed consent form for each individual psychoactive medication.

Findings were:

Review of the medical record for Patient #5 revealed a psychoactive medication consent form was filled out for Haldol, Cogentin, and Melatonin was signed by the physician, however there was no documented evidence that the patient or Legally Authorized Representative provided informed consent or signed the consent form and there was no documented evidence of a telephone consent. The physician did not date the consent form.

Review of the medical record for Patient #1 revealed The " Consent to Treatment with Psychoactive Medication " form had a list of 5 medications, including Ability (antipsychotic), Melatonin (sedative) Lamictal (mood stabilizer), Intuniv (miscellaneous), and Adderall (stimulant). There was only one consent form completed, which included all 5 medications on one form, so the facility failed to obtain a completed consent form for each individual psychoactive medication.

In addition to the record for Patient #1, review of the records for the following patients revealed that the facility failed to obtain a completed consent form for each individual psychoactive medication:
? Patient #3 Abilify, Melatonin, Topamax, Adderall, Sertraline, Hydroxyzine
? Patient #4 Trileptal, Straterra, Vistaril, Melatonin, Loratadine
? Patient #5 Seroquel, Depakote, Haldol, Melatonin
? Patient #6 Zoloft, Vistaril, Olanzapine, Thorazine, Benadryl, Seroquel
? Patient #7 Seroquel, Vistaril, Zoloft, Intuniv, Trileptal
? Patient #8 Concerta, Abilify, Intuniv, Vistaril
? Patient #9 Sertraline, Geodon, Trileptal, Intuniv, Thorazine, Benadryl
? Patient #10 Thrazine, Vistaril, Benadryl

Review of the record for the following 7 out of 10 patients revealed that the informed consent obtained from the Legally Authorized Representative (LAR) via telephone had only one signature of a staff witness for telephone consent. There was also no signature from the LAR for the following patients.
? Patient #1 on 10/2/12
? Patient #3 on 10/24/12
? Patient #5 on 9/17/12, 9/22/12
? Patient #6 on 10/22/12
? Patient #7 on 9/21/12
? Patient #9 on 9/3/12, 9/5/12, 9/13/12
? Patient #10 on 9/6/12, 9/7/12

Facility policy entitled, " Informed Consent for Treatment with Psychoactive Medication, Policy Number 1000.34 stated, in part, " 3. Informed consent to medication is required to be obtained by individual medication, and not by medication class ...
11. When parent(s) or LAR are not physically available, telephone consent will be obtained.
11.1 When telephone consent is obtained the following shall occur: ...
11.1.2 The nurse who supplied the information regarding prescribed medications will sign the statement.
11.1.3 A second staff member will witness the phone approval of the parent/LAR
11.1.4 The parent/LAR will countersign the document as soon as possible during his/her next visit.

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility documentation, facility video, policies and procedures, staff interview, and patient record, the facility did not ensure a patient ' s right to privacy as a patient was unnecessarily carried down a unit hallway in a personal restraint..

Findings were:


Review of a facility video recording revealed that Patient #1 was restrained by Staff #1, a Mental Health Technician, and unnecessarily carried by Staff #1 in an unsafe manner and not according to facility policy on 10/6/12 approximately 35 feet down the unit hallway for patient bedrooms. The patient did not appear to be acting in an aggressive manner while being carried down the hallway.

Review of the medical record for Patient #1 revealed no documented evidence of an order for the restraint which occurred around 0800 on 10/6/12.

Review at 1:50 pm on 11/13/12 of the facility video recording of the 10/6/12 incident with Staff #3 QM Director, revealed that one Mental Health Assistant (MHA) Staff #1 went into the room of Patient #1 and in less than a minute exited the room carrying Patient #1. Patient #1 was held with her back to the chest of Staff #1 and the arms of Staff #1 were around the front of the patient ' s torso holding the crossed arms of Patient #1 in a basket hold-like position. Staff #1 carried the patient in this position (with her feet approximately 1.5 feet above the ground) from the room of Patient #1 to the quiet room, approximately 35 feet down the unit hallway. There was no noticeable aggressive behavior by Patient #1 while she was being carried down the hallway.

In an interview with Staff #3, QM Director the afternoon of 10/6/12, after viewing the restraint hold and carrying of the patient on video, when asked, Staff #3 stated that that type of restraint is not supported by policy. She also stated that the patient should not have been carried down the hallway in that manner. Staff #3 stated that there was no restraint order, even though the patient was restrained. Staff #3 stated that there should have been a restraint order, but " we didn ' t do it. "

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
3. A physical restraint will be implemented by trained staff at the direction of the clinically competent Registered Nurse or in phone consultation with the physician.
3.7 Staff members must provide a [protected, private, and observable environment that safeguards the personal dignity and well-being of the individual being restrained when possible ...
4. No physical restraint shall be used:
4.2 For the purpose of convenience of staff members or other individuals ...

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility documentation, facility video, policies and procedures, staff interview, and patient record, the facility did not ensure a patient ' s right to care in a safe setting.

Findings were:

Review of the medical record for Patient #1 revealed that she incurred a " Friction injury to R mid back " while being pulled from under a desk by Staff #1 on 10/6/12. Review of the Daily Progress Note for Patient #1 signed but not timed by nurse practitioner on 10/16/12 stated, " She has a abrasion (sic) on her (R) side of her back. Appears to be a rug burn or scrape. RN says that pt became upset and was rolling around on the floor when she was restrained by MHA and taken to quiet room. "

Review of the facility video recording revealed that Patient #1 was restrained by Staff #1, a Mental Health Technician, and carried by Staff #1 in an unsafe manner and not according to facility policy on 10/6/12. The patient did not appear to be acting in an aggressive manner while being carried down the hallway.

Review of the medical record for Patient #1 revealed no documented evidence of an order for the restraint which occurred on 10/6/12. The patient was not assessed by an RN for the restraint and was not assessed by an RN until the mother reported it during visitation later in the day.

Review of facility Serious Incident Reports, incident date 10/6/12 involving Patient #1, revealed the incident occurred at 0800 and the mother brought the rugburn injury to the attention of the staff (the registered nurse) during visitation with the patient at approximately 1615 on 10/6/12.

Review of the Daily Nursing Assessment for 10/6/12 at 2100 for Patient #1 conducted at the beginning of the night shift did not include any documented evidence that the nurse assessed the patient ' s injury. There was no documented evidence of an assessment of the patient ' s injury/abrasion for the duration of her stay by nursing, medical staff, or therapy staff on 10/7/12, 10/8/12 and the discharge date 10/9/12.

Review of Master Treatment Plan for Patient #1 revealed no documentation of the patient restraint which occurred on 10/6/12, and no documentation of the rug burn injury which occurred on 10/6/12.

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
3. A physical restraint will be implemented by trained staff at the direction of the clinically competent Registered Nurse or in phone consultation with the physician.
3.1 Staff will call for assistance; there must be at least two staff involved, in the event physical restraint of the patient is necessary ...
3.5 Physical restraints should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician ' s order ...
3.7 Staff members must provide a [protected, private, and observable environment that safeguards the personal dignity and well-being of the individual being restrained when possible ...
4. No physical restraint shall be used:
4.2 For the purpose of convenience of staff members or other individuals ...
7.2 The RN must secure a Verbal or Telephone Order ...from the physician as soon as possible following a restraint incident.
7.3 The RN will sign, date, time and complete the Physician Orders for Physical Restraint-Acute Care

Facility Policy entitled, Reassessment of the Patient, Policy Number: 900.5 stated, in part, " 1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.
2. The Registered Nurse reassesses at a minimum in the following circumstances:
2.1 Change in patient condition,
2.2 Physical complaint,
2.3 Use of restraint/seclusion procedure ...
5. Findings from assessment activities will be documented in the progress notes. "

Review of facility policy entitled, " Scope of Assessment by Discipline " Policy Number 900.2.3 stated, in part, " VII. Continual Reassessment A. it is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient ' s condition, documented in the progress notes and the Master Treatment Plan. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility video, staff interview, medical records, and facility policy, the facility failed to ensure that least restrictive interventions were used in a restraint and rationale documented.

Findings were:

Review of the medical record for Patient #1 revealed that she incurred a " Friction injury to R mid back " while being pulled from under a desk by Staff #1 on 10/6/12.

Review at 1:50 pm on 11/13/12 of the facility video recording of the 10/6/12 incident revealed that Patient #1 was restrained by Staff #1, a Mental Health Technician, and carried by Staff #1 in an unsafe manner and not according to facility policy on 10/6/12. The patient did not appear to be acting in an aggressive manner while being carried down the hallway. Staff #1 went into the room of Patient #1 and in less than a minute exited the room carrying Patient #1, who was held with her back to the chest of Staff #1 and the arms of Staff #1 were around the torso of Patient #1held in a basket hold-like position by Staff #1. Staff #1 carried Patient #1 in this position (with the feet of Patient #1 approximately 1.5 feet above the ground) from the room of Patient #1 to the quiet room, approximately 35 feet down the hallway. There was no noticeable aggressive behavior by Patient #1 while she was being carried down the hallway. The quiet room and the end of the hallway could not been observed on the video due to the camera angle.

In an interview with Staff #3, QM Director the afternoon of 10/6/12, after viewing the restraint hold and carrying of the patient on video, when asked, Staff #3 stated that that type of restraint is not supported by policy. She also stated that the patient should not have been carried in that manner. Staff #3 stated that there was no restraint order, even though the patient was restrained. Staff #3 stated that there should have been a restraint order, but " we didn ' t do it. "

In an interview with Staff #1, Mental Health Assistant, when asked if she should have continued to restraint Patient #1 and carry her in a basket hold down the hallway, Staff #1 stated, " She wasn ' t squirming when I had her, it wasn ' t tight, I just picked her up. She was not wiggling when I carried her. "
Staff #1 confirmed that she had been trained that two people should be involved in this type of restraint.

In an interview with Staff #1 a Mental Health Technician on 11/13/12, she stated that she reported the injury and the restraint that occurred the morning of 10/6/12 to the RN.

Review of the medical record for Patient #1 revealed no documented evidence
describing the steps or interventions used prior to the use of the needed restraint or seclusion, and no documented evidence of any rationale for the use of restraint or seclusion, and no documented evidence that less restrictive measures were tried or considered.

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
3.1 Staff will call for assistance; there must be at least two staff involved, in the event physical restraint of the patient is necessary ...
3.5 Physical restraints should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician ' s order ...

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review medical records, and facility policy,and staff interview, the facility failed to ensure that a written modification was made to patient treatment plans after restraint.

Findings were:

Review of the medical record for the following 5 out of 10 patients that were restrained revealed no written modification to the treatment plan:
Patient #1 restrained on 10/6/12
Patient #4 restrained on 10/12/12
Patient #5 restrained on 10/1/12
Patient #6 restrained on 10/1/12
Patient #9 restrained on 9/10/12 and 9/21/12

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility policies, facility video, staff interviews, and medical record, the facility failed to ensure that the use of restraint was implemented by staff in accordance with safe and appropriate techniques.

Findings were:

Review of the medical record for Patient #1 revealed that she incurred a " Friction injury to R mid back " while being pulled from under a desk by Staff #1 on 10/6/12. Review of the Daily Progress Note for Patient #1 signed but not timed by nurse practitioner on 10/16/12 stated, " She has a abrasion (sic) on her (R) side of her back. Appears to be a rug burn or scrape. RN says that pt became upset and was rolling around on the floor when she was restrained by MHA and taken to quiet room. "

Review of the facility video recording revealed that Patient #1 was restrained by Staff #1, a Mental Health Technician, and carried by Staff #1 in an unsafe manner and not according to facility policy on 10/6/12. The patient did not appear to be acting in an aggressive manner while being carried down the hallway.

Review of the medical record for Patient #1 revealed no documented evidence of an order for the restraint which occurred around 0800 on 10/6/12. The patient was not assessed by an RN for the restraint and was not assessed by an RN until the mother reported it during visitation later in the day, approximately 1615 on 10/6/12.

Review at 1:50 pm on 11/13/12 of the facility video recording of the 10/6/12 incident with Staff #3 QM Director, revealed that one Mental Health Assistant (MHA) Staff #1 went into the room of Patient #1 and in less than a minute exited the room carrying Patient #1. Patient #1 was held with her back to the chest of Staff #1 and the arms of Staff #1 were around the front of the patient ' s torso holding the crossed arms of Patient #1 in a basket hold-like position. Staff #1 carried the patient alone in this position (with her feet approximately 1.5 feet above the ground) from the room of Patient #1 to the quiet room, approximately 35 feet down the hallway. There was no noticeable aggressive behavior by Patient #1 while she was being carried down the hallway. The quiet room and the end of the hallway could not been observed on the video due to the camera angle.

In an interview with Staff #3, QM Director the afternoon of 10/6/12, after viewing the restraint hold and carrying of the patient on video, when asked, Staff #3 stated that that type of restraint is not supported by policy. She also stated that the patient should not have been carried in that manner. Staff #3 stated that there was no restraint order, even though the patient was restrained. Staff #3 stated that there should have been a restraint order, but " we didn ' t do it. "

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
3. A physical restraint will be implemented by trained staff at the direction of the clinically competent Registered Nurse or in phone consultation with the physician.
3.1 Staff will call for assistance; there must be at least two staff involved, in the event physical restraint of the patient is necessary ...
3.5 Physical restraints should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician ' s order ...
3.7 Staff members must provide a [protected, private, and observable environment that safeguards the personal dignity and well-being of the individual being restrained when possible ...
4. No physical restraint shall be used:
4.2 For the purpose of convenience of staff members or other individuals ...
7.2 The RN must secure a Verbal or Telephone Order ...from the physician as soon as possible following a restraint incident.
7.3 The RN will sign, date, time and complete the Physician Orders for Physical Restraint-Acute Care

Facility Policy entitled, Reassessment of the Patient, Policy Number: 900.5 stated, in part, " 1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.
2. The Registered Nurse reassesses at a minimum in the following circumstances ...
2.3 Use of restraint/seclusion procedure ...
5. Findings from assessment activities will be documented in the progress notes. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of patient record, facility policy, facility documents, and staff interview, the facility failed to ensure that the use of restraint was in accordance with an order by a physician.

Findings were:

Review of the medical record for Patient #1 revealed she was restrained on 10/6/12. There was no documented evidence of a physician ' s order for restraint in the medical record.

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, " All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of patient records, facility policies, facility video, facility documentation and staff interviews, the facility failed to ensure that a registered nurse supervised and evaluated nursing care for each patient, failed to ensure that nursing services were monitored and evaluated, and failed to ensure that nursing patient care and monitoring was documented.

Findings were:

Review of patient records, facility policies, and staff interview revealed the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as a patient was not assessed by a nurse after an injury and after a restraint, and an order was not obtained for the restraint.
Cross refer A 0395

Based on a review of facility documentation, facility video, policies and procedures, staff interview, and patient record, the facility did not ensure that nursing progress notes were completed for care of patients.
Cross refer B0127

Based on a review of facility documentation, patient records, staff interviews, facility video, and facility policies and procedures the facility failed to ensure that the nursing director monitored and evaluated the nursing care furnished in the facility as patient restraint was not ordered and reflected in the facility restraint documentation.
Cross refer B0148

Based on a review of patient records, facility policies, and staff interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as a patient was not assessed after an injury and after a restraint, and an order was not obtained for the restraint.

Findings were:

Review of the medical record for Patient #1 revealed that she incurred a " Friction injury to R mid back " while being pulled from under a desk by Staff #1 on 10/6/12. Review of the Daily Progress Note for Patient #1 signed but not timed by nurse practitioner on 10/16/12 stated, " She has a abrasion (sic) on her (R) side of her back. Appears to be a rug burn or scrape. RN says that pt became upset and was rolling around on the floor when she was restrained by MHA and taken to quiet room. "

Review of the facility video recording revealed that Patient #1 was restrained by Staff #1, a Mental Health Technician, and carried by Staff #1 in an unsafe manner and not according to facility policy on 10/6/12. The patient did not appear to be acting in an aggressive manner while being carried down the hallway.

In an interview with Staff #1 a Mental Health Technician on 11/13/12, she stated that she reported the injury and the restraint that occurred the morning of 10/6/12 to the RN.

Review of the medical record for Patient #1 revealed documentation by Staff #1,the Mental Health Technician that she reported the restraint and the injury to the RN. The medical record revealed no documented evidence of an order for the restraint which occurred on 10/6/12. The patient was not assessed by an RN for the restraint and was not assessed by an RN until the mother reported it during visitation later in the day.

Review of facility Serious Incident Reports, incident date 10/6/12 involving Patient #1, revealed the incident occurred at 0800 and the mother brought the rugburn injury to the attention of the staff (the registered nurse) during visitation with the patient at approximately 1615 on 10/6/12.

Review of the Daily Nursing Assessment for 10/6/12 at 2100 for Patient #1 conducted at the beginning of the night shift did not include any documented evidence that the nurse assessed the patient ' s injury. There was no documented evidence of an assessment of the patient ' s injury/abrasion for the duration of her stay by nursing, medical staff, or therapy staff on 10/7/12, 10/8/12 and the discharge date 10/9/12.

Review of Master Treatment Plan for Patient #1 revealed no documentation of the patient restraint which occurred on 10/6/12, and no documentation of the rug burn injury which occurred on 10/6/12.

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
3. A physical restraint will be implemented by trained staff at the direction of the clinically competent Registered Nurse or in phone consultation with the physician.
3.1 Staff will call for assistance; there must be at least two staff involved, in the event physical restraint of the patient is necessary ...
3.5 Physical restraints should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician ' s order ...
3.7 Staff members must provide a [protected, private, and observable environment that safeguards the personal dignity and well-being of the individual being restrained when possible ...
4. No physical restraint shall be used:
4.2 For the purpose of convenience of staff members or other individuals ...
7.2 The RN must secure a Verbal or Telephone Order ...from the physician as soon as possible following a restraint incident.
7.3 The RN will sign, date, time and complete the Physician Orders for Physical Restraint-Acute Care

Facility Policy entitled, Reassessment of the Patient, Policy Number: 900.5 stated, in part, " 1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.
2. The Registered Nurse reassesses at a minimum in the following circumstances:
2.1 Change in patient condition,
2.2 Physical complaint,
2.3 Use of restraint/seclusion procedure ...
5. Findings from assessment activities will be documented in the progress notes. "

Review of facility policy entitled, " Triage System " Policy Number 900.21 stated, in part, " 3. The RN assesses the medical priority and acts accordingly:
3.2 Priority 2 - Required the notification of an on-site or on-call physician.
3.2.1 Examples of priority 2 situations include:
3.2.1.2 Wound or trauma requiring minor first aid or wound cleaning or dressing. "

Review of facility policy entitled, " First-aid Treatment " Policy Number 1000.8 stated, in part, " 1. RN/LVN evaluates the injury for the determination of the appropriate level of care. "

Review of the record for the following 7 out of 10 patients revealed that the informed consent obtained from the Legally Authorized Representative (LAR) via telephone had only one signature of a staff witness for telephone consent. There was also no signature from the LAR for the following patients.
? Patient #1 on 10/2/12
? Patient #3 on 10/24/12
? Patient #5 on 9/17/12, 9/22/12
? Patient #6 on 10/22/12
? Patient #7 on 9/21/12
? Patient #9 on 9/3/12, 9/5/12, 9/13/12
? Patient #10 on 9/6/12, 9/7/12

Facility policy entitled, " Informed Consent for Treatment with Psychoactive Medication, Policy Number 1000.34 stated, in part, " 3. Informed consent to medication is required to be obtained by individual medication, and not by medication class ...
11. When parent(s) or LAR are not physically available, telephone consent will be obtained.
11.1 When telephone consent is obtained the following shall occur: ...
11.1.2 The nurse who supplied the information regarding prescribed medications will sign the statement.
11.1.3 A second staff member will witness the phone approval of the parent/LAR
11.1.4 The parent/LAR will countersign the document as soon as possible during his/her next visit.

Review of the record for Patient #1 revealed a Daily Nursing Assessment dated 10/6/12, but the time was not legible. The time, as written, could be interpreted as 1000, 1200, or 1800. Timing of medical record entries establishes a time frame within which a patient care activity occurred. Timing of entries is necessary for patient safety by establishing a baseline for future actions, such as assessments, risk management, or quality activities. The illegible time was confirmed in interview with Staff #4 Director of Nursing the afternoon of 11/13/2012.

Review of the record for Patient #2 revealed the following incomplete nursing documentation:
? Nursing Treatment Plan not dated or timed
? Vital Signs record 15 of 15 vital sign entries were not initialed by nursing staff; the signature/initial key was left blank and was not completed by any of the staff.
? Restraint documentation form Date of Restraint left blank; time parent/guardian notified left blank.
? Restraint/Seclusion Documentation Form date left blank; RN Assessment for restraint left blank.
? Precaution/Observation Checklist level of monitoring boxes not checked/form incomplete

Review of the record for Patient #3 revealed the following incomplete nursing documentation:
? Restraint/Seclusion Documentation Form Date of Restraint left blank
? Post-Restraint/Seclusion Debriefing Note not signed by patient in space provided with no indication why the patient did not sign; not timed.
? Treatment Plan incomplete: chronic problems space provided left blank, 2 of 5 pages do not have patient identifying information on the page (name, MR number), signatures of the treatment team missing, including nursing; and physician did not sign/date/time the form in space provided.

Review of the medical record for Patient #6 revealed the following incomplete nursing documentation:
? Post-Restraint/Seclusion Debriefing Note was incomplete as it was not dated, timed, all items on the form were left blank, the staff did not sign, the patient did not sign in space provided with no indication why the patient did not sign or date the form in the space provided.
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.

Review of the medical record for Patient #7 revealed the following incomplete nursing documentation:
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.
? Post-Restraint/Seclusion Debriefing Note was incomplete as it was not timed, and the patient did not sign in space provided with no indication why the patient did not sign.

Review of the medical record for Patient #8 revealed the following incomplete nursing documentation:
? Master Treatment Plan: page 1 was incomplete as the patient ' s chronic or controlled problems was left blank; nursing did not sign the treatment team form, and the physician did not sign/date/time the form in space provided.

Review of the medical record for Patient #9 revealed the following incomplete nursing documentation:
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.
? Post-Restraint/Seclusion Debriefing Note was incomplete as 3 out of 4 sections of the form were left blank; the form was not signed by patient in space provided or reason why patient didn ' t sign; not timed; there was no staff signature and the form was not dated or timed in the space provided.

Review of the medical record for Patient #10 revealed the following incomplete nursing documentation:
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.
? Post-Restraint/Seclusion Debriefing Note was incomplete as the form was not signed by patient in space provided or reason why patient didn ' t sign

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of medical records and facility policies, the facility failed to ensure that all patient medical record entries were legible, complete, and properly dated, timed, and authenticated.

Findings were:

Review of the record for Patient #1 revealed a Daily Nursing Assessment dated 10/6/12, but the time is not legible. The time, as written, could be interpreted as 1000, 1200, or 1800. Timing of medical record entries establishes a time frame within which a patient care activity occurred. Timing of entries is necessary for patient safety by establishing a baseline for future actions, such as assessments, risk management, or quality activities. The illegible time was confirmed in interview with Staff #4 Director of Nursing the afternoon of 11/13/2012.

Further review of the record for Patient #1 revealed the following:
? Master Treatment Plan: page 1 was incomplete as chronic or controlled problems was left blank; the physician did not sign/date/time the form in space provided.
? Consultation note was not timed
? 20 out of 20 Group Documentation Forms were incomplete as the space was left blank for " How does the patient ' s behavior reflect progress toward his/her identified goals? "
? Multidisciplinary Progress Notes were not timed on the following dates: 10/2/12, 10/3/12,10/4/12, 10/6/12, 10/7/12, 10/8/12, 10/9/12.
? Therapy Documentation Notes were not timed on the following dates: 10/3/12, 10/4/12, 10/6/12 (x2 notes).

Review of the record for Patient #2 revealed the following:
? Nursing Treatment Plan not dated or timed
? Admitting orders not signed, dated or timed by the physician
? PRN/Medication Order Guideline/Protocol Sheet not signed, dated, or timed by the physician.
? Vital Signs record 15 of 15 vital sign entries were not initialed by staff; the signature/initial key was left blank and was not completed by any of the staff.
? Restraint documentation form Date of Restraint left blank; time parent/guardian notified left blank.
? Physician Orders for Restraint/Seclusion, physician signed and dated but left time blank/incomplete.
? Restraint/Seclusion Documentation Form date left blank; RN Assessment for restraint left blank.
? Precaution/Observation Checklist level of monitoring boxes not checked/form incomplete

Review of the record for Patient #3 revealed the following:
? Multidisciplinary Teaching record not timed
? Restraint/Seclusion Documentation Form Date of Restraint left blank
? Post-Restraint/Seclusion Debriefing Note not signed by patient in space provided with no indication why the patient did not sign; not timed.
? Treatment Plan incomplete: chronic problems space provided left blank, 2 of 5 pages do not have patient identifying information on the page (name, MR number), signatures of the treatment team missing; and physician did not sign/date/time the form in space provided.

Review of the medical record for Patient #4 revealed the following:
? Multidisciplinary Teaching Record was not timed, spaces were left blank on the form
? Master Treatment Plan was not signed by members of the treatment team; the physician did not sign/date/time the form in the space provided, and there were multiple blanks left incomplete.
? Restraint/Seclusion Documentation Form Date of Restraint left blank

Review of the medical record for Patient #5 revealed the following:
? Multidisciplinary Teaching Record was not timed,
? Master Treatment Plan had multiple blanks left incomplete, including Chronic or controlled problems and the physician did not sign/date/time the form in space provided
? Restraint/Seclusion Documentation Form Date of Restraint left blank

Review of the medical record for Patient #6 revealed the following:
? Multidisciplinary Teaching Record was not timed and spaces were left blank
? Master Treatment Plan had multiple blanks left incomplete, including chronic or controlled problems and the physician did not sign/date/time the form in space provided
? Post-Restraint/Seclusion Debriefing Note was incomplete as it was not dated, timed, all items on the form were left blank, the staff did not sign, the patient did not sign in space provided with no indication why the patient did not sign or date the form in the space provided.
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.

Review of the medical record for Patient #7 revealed the following:
? Multidisciplinary Teaching Record was not timed and spaces were left blank
? Master Treatment Plan: page 1 was incomplete as none of the page was completed, which included the patient ' s strengths, disabilities, long term goals, discharge plans, living arrangements, diagnoses, chronic or controlled problems; the physician did not sign/date/time the form in space provided.
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.
? Post-Restraint/Seclusion Debriefing Note was incomplete as it was not timed, and the patient did not sign in space provided with no indication why the patient did not sign.

Review of the medical record for Patient #8 revealed the following:
? Multidisciplinary Teaching Record was not timed and spaces were left blank
? Master Treatment Plan: page 1 was incomplete as the patient ' s chronic or controlled problems was left blank; nursing did not sign the treatment team form, and the physician did not sign/date/time the form in space provided.

Review of the medical record for Patient #9 revealed the following:
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.
? Multidisciplinary Teaching Record was not timed and spaces were left blank
? Master Treatment Plan: page 1 was incomplete as the patient ' s chronic or controlled problems was left blank; the physician did not sign/date/time the form in space provided.
? Post-Restraint/Seclusion Debriefing Note was incomplete as 3 out of 4 sections of the form were left blank; the form was not signed by patient in space provided or reason why patient didn ' t sign; not timed; there was no staff signature and the form was not dated or timed in the space provided.

Review of the medical record for Patient #10 revealed the following:
? Restraint/Seclusion Documentation Form Date of Restraint was left blank.
? Post-Restraint/Seclusion Debriefing Note was incomplete as the form was not signed by patient in space provided or reason why patient didn ' t sign

Review of facility policy entitled, " Scope of Assessment by Discipline " Policy Number 900.2.3 stated, in part, " VII. Continual Reassessment A. it is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient ' s condition, documented in the progress notes and the Master Treatment Plan. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility policies, staff interviews, and patient records, the facility failed to ensure that each patient had a completed, comprehensive treatment plan.

Findings were:

Review of Master Treatment Plan for Patient #1 revealed no documentation of an update for a restraint of Patient #1 which occurred on 10/6/12, and no documentation of a rug burn injury which occurred on 10/6/12. The treatment plan was not dated to show the initial date. The only signature on the form was in the " Physician Signature/Credentials " box on the form; the box for the initial date was left blank. The blank for " GAF " was left blank. There was no signature or documentation in the blanks for " Patient Signature, Parent Signature ... via phone, Therapist/Social Worker/case manager, or Nurse Signature/Credentials. " The Physician Signature/Credentials and the Date/Time boxes on the form were left blank. There were no documented signatures to indicate that the treatment team met regarding this patient. The members of the treatment team did not sign or date the Master Treatment Plan.

Review of the Master Treatment Plan for Patient #3 revealed an incomplete treatment plan as the chronic problems space provided was left blank, 2 of 5 pages did not have patient identifying information on the page (name, MR number), signatures of the treatment team missing; and physician did not sign/date/time the form in space provided.

Review of the Master Treatment Plan for Patient #4 revealed an incomplete plan as it was not signed by members of the treatment team; the physician did not sign/date/time the form in the space provided, and there were multiple blanks left incomplete.

Review of the Master Treatment Plan for Patient #5 revealed multiple blanks were left incomplete, including chronic or controlled problems and the physician did not sign/date/time the form in space provided.

Review of the Master Treatment Plan for Patient #6 revealed multiple blanks left incomplete, including chronic or controlled problems and the physician did not sign/date/time the form in space provided

Review of the Master Treatment Plan for Patient #7 revealed that page 1 was incomplete as none of the page was completed, which included the patient ' s strengths, disabilities, long term goals, discharge plans, living arrangements, diagnoses, chronic or controlled problems; the physician did not sign/date/time the form in space provided.

Review of the Master Treatment Plan for Patient #8 revealed that page 1 was incomplete as the patient ' s chronic or controlled problems was left blank; nursing did not sign the treatment team form, and the physician did not sign/date/time the form in space provided.

Review of the Master Treatment Plan for Patient #9 revealed that page 1 was incomplete as the patient ' s chronic or controlled problems was left blank; the physician did not sign/date/time the form in space provided.

Review of the medical record for the following 5 out of 10 patients that were restrained revealed no written modification to the treatment plan:
Patient #1 restrained on 10/6/12
Patient #4 restrained on 10/12/12
Patient #5 restrained on 10/1/12
Patient #6 restrained on 10/1/12
Patient #9 restrained on 9/10/12 and 9/21/12

Review of facility policy entitled, " Scope of Assessment by Discipline " Policy Number 900.2.3 stated, in part, " VII. Continual Reassessment A. it is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient ' s condition, documented in the progress notes and the Master Treatment Plan. "

Facility policy entitled, Medical Records Documentation Requirements, Policy Number 1400.4 stated, in part, " All members of the treatment team must sign and date the Master Treatment Plan. "

Review of facility policy entitled, " Updated Integrated Assessment " Policy Number 900.6 stated, in part, " An Integrated Assessment Update will be completed in order to maintain the patient ' s continuity of care and integrity of the medical record ...
3. The Treatment Team will use the updated information to develop the new Interdisciplinary Treatment Plan in order to meet the current patient-care needs and reflect current level of care. "

Review of facility policy entitled, " Scope of Assessment by Discipline " Policy Number 900.2.3 stated, in part, " VII. Continual Reassessment A. it is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient ' s condition, documented in the progress notes and the Master Treatment Plan. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility documentation, facility video, policies and procedures, staff interview, and patient record, the facility did not ensure that nursing progress notes were completed for care of patients.

Findings were:

Review of the medical record for Patient #1 revealed that she incurred a " Friction injury to R mid back " while being pulled from under a desk by Staff #1 on 10/6/12. Review of the Daily Progress Note for Patient #1 signed but not timed by nurse practitioner on 10/16/12 stated, " She has a abrasion (sic) on her (R) side of her back. Appears to be a rug burn or scrape. RN says that pt became upset and was rolling around on the floor when she was restrained by MHA and taken to quiet room. "

Review of the facility video recording revealed that Patient #1 was restrained by Staff #1, a Mental Health Technician, and carried by Staff #1 in an unsafe manner and not according to facility policy on 10/6/12. The patient did not appear to be acting in an aggressive manner while being carried down the hallway.

Review of the medical record for Patient #1 revealed no documented evidence to indicate the patient was assessed by an RN for the restraint. There was no documented evidence the patient was assessed by an RN until the mother reported it during visitation later in the day.

Review of facility Serious Incident Reports, incident date 10/6/12 involving Patient #1, revealed the incident occurred at 0800 and the mother brought the rugburn injury to the attention of the staff (the registered nurse) during visitation with the patient at approximately 1615 on 10/6/12.

Review of the Daily Nursing Assessment for 10/6/12 at 2100 for Patient #1 conducted at the beginning of the night shift did not include any documented evidence that the nurse assessed the patient ' s injury. There was no documented evidence of an assessment of the patient ' s injury/abrasion for Patient #1 the duration of her stay by nursing staff on 10/7/12, 10/8/12 and the discharge date 10/9/12.

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, " All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
3. A physical restraint will be implemented by trained staff at the direction of the clinically competent Registered Nurse or in phone consultation with the physician. "

Facility Policy entitled, Reassessment of the Patient, Policy Number: 900.5 stated, in part, " 1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.
2. The Registered Nurse reassesses at a minimum in the following circumstances:
2.1 Change in patient condition,
2.2 Physical complaint,
2.3 Use of restraint/seclusion procedure ...
5. Findings from assessment activities will be documented in the progress notes. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.

Based on a review of facility documentation, patient records, staff interviews, facility video, and facility policies and procedures the facility failed to ensure that the nursing director monitored and evaluated the nursing care furnished in the facility.

Findings were:

Review of the medical record for Patient #1 revealed that she was restrained on 10/6/12.

Review of facility report of Restraints and Seclusions for the month of October, 2012 revealed 14 restraints/seclusions, listed by date, chart #, patient name, gender, age and staff involved. There was no documented evidence in the report of the restraint of Patient #1 which occurred on 10/16/12 by Staff #1.

Facility policy entitled, Physical Restraint (Acute Care), Policy Number 1000.44 stated, in part, All physical restraints require a physician ' s order to be obtained by the clinically competent Registered Nurse (RN) as soon as possible following the initiation of a physical restraint...
8.2 The DNS [Director of Nursing Services] or designee will be responsible for tracking & trending all physical restraint episodes. "

The above findings were confirmed in an interview with the facility Administrator, Director of Nursing, and Director of QA/Risk Management the afternoon of 11/13/12 in the conference room.