HospitalInspections.org

Based on policy and procedure review, open and closed medical record reviews, and staff interviews, hospital staff failed to obtain a daily physician order for non-violent restraints per policy for 2 of 2 restrained ventilator patients reviewed. (Pts # 6 & 12 ).

The findings include:

Review of hospital policy "Safety - Restraint", date approved May, 2015, revealed "...RESTRAINT for NON-VIOLENT/ NON-SELF-DESTRUCTIVE BEHAVIOR (Previously Acute Medical-Surgical Restraint) ...2) the following are required when a restraint intervention for non-violent/non-self-destructive behavior to prevent interference with medical/therapeutic treatment: ....c) Order renewed by physician/PA [Physician Assistant]/ nurse practitioner daily, based on assessed need to continue use of restraint (no standing order or PRN orders), with face to face assessment within 24 hours. ..."

1. Open medical record review, on 09/30/2016, revealed Pt # 12 was admitted on 09/24/2016, with diagnoses of sepsis (life-threatening infection) and pneumonia (lung infection) and was on a ventilator. Review revealed restraints were initiated on 09/25/2016 at 0000, the left wrist restraint discontinued on 09/27/2016 at 1659, and the right wrist restraint was removed 09/29/2016 at 1530. An initial order for a restraint for non-violent or non-self destructive behavior, review revealed, was done 09/24/2016 at 2203, with a stated duration of 2 days, and a Restraint Monitoring order was also placed. Review revealed a non-violent restraint order on 09/26/2016 at 2203 (48 hours later). Another renewal order was placed 09/27/2016 at 1659. Record review did not reveal a restraint order for 09/28/2016 or 09/29/2016 prior to discontinuation (over 46 hours after the last restraint order).

Interview with RN # 1, on 09/30/2016 around 1215 revealed the restraint monitoring order is what generates the restraint to appear on the flowsheet for documentation of restraint monitoring, it is not the same as the restraint order. Interview revealed there were some missing daily restraint orders on the Pt # 12's record.

Interview with Administrative Staff (AS) # 1, on 09/29/2016 at 1310, revealed there was a change since the new computer system. Interview revealed the new system showed a 2 day order, but the current policy requires a daily order. Follow-up interview on 09/30/2016 at 1250 revealed "I understand it now" in relation to the restraint monitoring order versus the actual restraint order and that providers were placing "the incorrect order". Interview revealed they have a learning opportunity.

2. Closed medical record review, on 09/28/2016, revealed Pt #6 was admitted 07/17/2016 with diagnoses including, among others, pneumonia, hypoxemia (low oxygen in the blood), and respiratory failure and was subsequently placed on a ventilator. Review revealed soft wrist restraints were applied on 07/19/2016 at 0900 and discontinued on 07/21/2016 at 1130, reapplied on 07/22/2016 at 0800 and discontinued on 07/24/2016 at 0800. Review of restraint orders revealed an initial order on 07/19/2016 at 1135 for "Restraints non-violent or non-self destructive....Frequency: Continuous....2 Days....Restraint reason: Pt. attempt to remove med [medical] dev [device]....Restraint type: 2 Point-Wrist Soft. ..." Non-Violent Restraint Monitoring orders were also placed on 07/19/2016 at 1135 to "Follow Restraint Management Policy". Review did not reveal a restraint order on 07/20/2016. Further review revealed two (2) Non-Violent Restraint Monitoring orders on 07/22/2016 at 1536 to "Follow Restraint Management Policy" and two (2) Non-Violent Restraint Monitoring orders on 07/23/2016 at 1628, also to "Follow Restraint Management Policy". Review did not reveal any orders after 07/19/2016 that defined the time limits, the reason, or the type of restraint. Review did not reveal daily restraint orders as defined in policy.

Interview with Administrative Staff (AS) # 1, on 09/29/2016 at 1310, revealed there was a change since the new computer system. Interview revealed the new system showed a 2 day order, but the current policy requires a daily order. Follow-up interview on 09/30/2016 at 1250 revealed "I understand it now" in relation to the restraint monitoring order versus the actual restraint order and that providers were placing "the incorrect order". Interview revealed they have a learning opportunity.

Based on policy and procedure review, medical record review, hospital document review and staff interview, hospital staff failed to place the name of a patient who expired within 24 hours of soft wrist restraints on the internal death log and failed to make an entry into the medical record within 7 days of the date and time the death was recorded on the log for 1 of 1 deaths reviewed that occurred within 24 hours of restraint. (Pt #6)

The findings include:

Review of hospital policy "Safety - Restraint", date approved May, 2015, revealed "...When no seclusion has been used and when the only restraints used on the patient are wrist restraints composed solely of soft, non-ridgid (sic) cloth-like material, the hospital does the following:....ii) Records in a log any death that occurs within 24 hours after a patient has been removed from such restraints. The information is recorded within seven days of the date of death of the patient. iii) Documents in the patient record the date and time that the death was recorded in the log. iv) Documents in the log the patient's name, date of birth, date of death, name of attending physician or other LIP (licensed independent practitioner) responsible for the care of the patient, medical record number and primary diagnosis(es). ..."

Closed medical record review, on 09/28/2016, revealed Pt #6 was admitted 07/17/2016 with diagnoses including, among others, pneumonia (lung infection), hypoxemia (low oxygen in the blood), and respiratory failure and was subsequently placed on a ventilator. Review revealed soft wrist restraints were applied on 07/19/2016 at 0900 and released 07/21/2016 at 1130. Review revealed the soft wrist restraints were reapplied 07/22/2016 at 0800 and remained until removed on 07/24/2016 at 0800. Pt # 6 expired on 07/24/2016 at 1625 (8 hours, 25 minutes after the restraints were removed). Record review on 09/28/2016 (66 days after Pt #6's death) did not reveal documentation of the date and time the death was recorded on the internal log.

Review of the Internal Log revealed two names on the log, but did not reveal the name of Pt #6.

Staff interview, on 09/28/2016 at 1700, with Administrative Staff (AS) # 2 revealed there is an internal log kept for recording deaths when a patient is in restraints or within 24 hours of restraints. Interview revealed Pt # 6 expired within 24 hours of being in a restraint and that information for Pt #6 was not recorded in the log or in the patient's medical record. Interview revealed hospital policy was not followed. Interview revealed "We know we have opportunities related to restraint documentation."

Based on policy and procedure review, closed medical record review, and staff interview the hospital failed to have a complete and accurate medical record by failing to document vital signs, reassessments, and a patient's response to interventions in 1 of 10 records reviewed. (Pt # 6)
Review of Policy "Assessment-Patient Assessment/Reassessment by Nursing Staff", dated 08/2015, revealed "...PURPOSE: To obtain accurate and pertinent data essential to identify patient needs for nursing care and to implement the nursing process. POLICY: 1) The assessment and reassessment of the patient's needs for nursing care is performed by the Registered Nurse within the specified time frames or as indicated by patient acuity....4) ....The RN is responsible for reviewing and assessing data collected/documented by the nursing assistant.... 6) The following definitions are used to describe type of assessment.... b) System specific reassessment: Assessment of patient condition focused on one (or more) systems....7) Documentation of assessment is performed in the electronic charting system.... 12) Reassessment of patients are performed by the assigned Licensed Nurse to determine the patient's response to care/treatments at the defined time frames or when the patient's condition/diagnosis changes....b) Medical Surgical: systems-specific reassessment every four hours. Policy review did not reveal notation of expected vital sign frequency.
Closed medical record review revealed Pt # 6 was admitted 07/17/2016 with diagnoses that included, among others, pneumonia (lung infection), hypoxemia (low oxygen in blood), and respiratory failure. Record review revealed vital signs (VS) on 07/18/2016 at 0554 were Temperature (T) 98.9, Pulse (P) 102, Respirations (R) 21, Blood Pressure (BP) 122/73 and Pulse Oximetry (Ox) 93%. At 1020, while moving from the bed to chair, the Pulse Ox was 80% (normal range greater than 90%) and at 1030 it was 86%. Another Pulse Ox was not documented until 1416 (3 hours, 46 minutes), which was 92%. Record review also did not reveal reassessment of VS until 1416 (8 hours, 38 minutes after the 0554 VS) with results T 98.3, P 107, R 22, BP 115/65. At 2136, record review revealed T 97.7, P 58, R 18, BP 138/82 and Pulse Ox 99%. On 07/19/2016 at 0100, review revealed a Respiratory Therapist (RT) note showing P 112 and R 38, with a Pulse Ox of 90%. Record review did not reveal evidence of other VS taken at that time, and did not reveal another respiratory rate check until 0430 (3 1/2 hours after R of 38 recorded) and did not reveal notation of a physician being notified of the 38 respiratory rate. At 0430 (7 hours after the last full VS check), review revealed VS were T 98.1, P 122, R 24, BP 142/80, and Pulse Ox 85%. Review revealed a note beside the Pulse Ox reading "reported to nurse". Record review did not reveal reassessment of pulse ox documented. Review revealed blood gases were collected at 0642 with an arterial pO2 of 50 (reference range 75-100) and revealed the patient was intubated and placed on a ventilator at 0826. Medical record review did not reveal documentation of a rapid response notification or arrival (a team who provides advanced clinical assessment skills when a patient's condition is getting worse).
Staff interview, on 09/29/2016 at 1035, with RN #2 revealed this RN recalled Pt # 6. RN #2 stated Pt #6 was restless and kept pulling the BiPAP off which caused his sats to drop down into the 80's. Interview revealed the RN was in and out of the room all night and called respiratory therapy several times. RN #2 stated respirations were reassessed after the elevated result and improved. Further, RN # 2 said, when notified about the pulse ox, RT was called and worked with the patient. Interview revealed the physician was called, and ordered a blood gas. Rapid response was also called, RN #2 stated. Interview revealed it was a busy night, all the focus was on the patient, and RN #2 did not get to the computer to document it all.
Staff interview, on 09/29/2016 at 1310, with Administrative Staff #1, revealed there was a new computer system in place and there were some issues. Interview revealed they did not find notation of the rapid response in the medical record and could see other issues, including VS documentation, as well. AS #1 stated they saw it as a documentation concern.
NC00119775