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Based on interview and record review, the hospital failed to obtain an order for the use of restraints (any manual method or device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) timely for one of three patients (Patient 13) when Patient 13 was placed in a restraint and an order was not obtained immediately. This failure had the potential to result in an inappropriate use of restraints.

Findings:

Review of Patient 13's medical record indicated she was admitted to the facility on 12/11/24 with fever (elevated body temperature) and lethargy (state of tiredness or drowsiness).

Review of Patient 13's Restraint Documentation indicated the application of restraints for Patient 13 started on 12/19/24 at 7:23 a.m. It indicted a soft restraint was placed on Patient 13's left upper extremity.

Review of Patient 13's Order Record, dated 12/19/24 indicated the patient had an initial order for restraints on 12/19/24 at 9:38 a.m.

During an interview and concurrent record review on 12/24/24 at 10:37 a.m. the Manager of Regulatory Compliance (MRC) stated it was okay for a nurse to place restraints on a patient prior to a physician order, but the nurse has to get an order as soon as possible. The MRC reviewed the hospital's restraint policy and confirmed Patient 13's restraint order should have been obtained within minutes after the restraint was initiated.

Review of the hospital's policy, "Patient Restraint/Seclusion," dated 7/1/2023 indicated, "When a physician or other licensed practitioner, authorized by State law to order restraints, is not available to issue a restraint or seclusion order, an RN with demonstatrated competence may initate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated."

Based on interview and record review, the hospital failed to follow the procedures of the hospital when:

1. Two of five patients (Patient 15 and 28) in the Emergency Department (ED) were not placed on a cardiac monitor timely.

2. There was no documentation indicating wound treatment was implemented as ordered for one of three patients (Patient 20).

These failures had the potential for patients' needs not being met and worsening health conditions.

Findings:

1a. Review of Patient 15's Emergency Provider Report, dated 12/16/24 indicated the patient, "was sent to the ED for a low-grade fever, irregular heart rate, and renal cell cancer." The report indicated he was seen by a provider on 12/16/24 at 7:10 p.m.

Review of Patient 15's ED orders, indicated he had an order for cardiac monitoring, dated 12/16/24 at 7:23 p.m.

Review of Patient 15's Emergency Patient Record indicated an electrocardiogram (EKG, a test that records the electrical activity of the heart) was done at 8:08 p.m.

Further review of Patient 15's Emergency Provider Report, dated 12/16/24 indicated EKG interpretation: time 8:08 p.m., heart rate 143 beats per minute, atrial fibrillation (AFib, a type of arrythmia or irregular heartbeat when the upper chambers of the heart [atria] beat to quickly), rapid ventricular response (RVR, when the contractions of the upper chambers of heart causes the lower chambers [ventricles] to beat too quickly).

Review of Patient 15's Emergency Notes, dated 12/16/24 at 8:44 p.m. indicated the patient's heart rate was elevated during vitals signs rounding. It indicated Patient 15 was in AFib RVR.

Review of Patient 15's Emergency Patient Record indicated the time the patient was placed on the cardiac monitor on 12/16/24 at 9:30 p.m.

During an interview and concurrent record review on 12/20/24 at 10:45 a.m., the Director of Emergency Services (DES) reviewed Patient 15's ED record and stated with the patient's EKG results AFib RVR, Patient 15 should be in a monitored bed.

During an interview and concurrent record review on 12/26/24 at 10:12 a.m., the Emergency Department Clinical Nurse Coordinator (EDCNC) stated patients presenting with cardiac concerns are placed on a cardiac monitor whenever they are put in a room. He stated ED staff try to get patients into a room as fast as they can. The EDCNC reviewed Patient 15's ED record and stated on 12/16/24, the day Patient 15 was in the ED, the department was very busy. He stated Patient 15 was placed in a recliner before he was moved into a room at 9:30 p.m.

1b. Review of Patient 28's Emergency Provider Report, dated 12/19/24 indicated the patient presented to the ED with persistent left-sided chest pain. The report indicated Patient 28 was seen by a provider on 9:43 a.m.

Review of Patient 28's ED orders, indicated he had an order for cardiac monitoring, dated 12/19/24 at 9:51 a.m.

Review of Patient 28's Emergency Patient Record indicated cardiac monitoring for Patient 28 occurred on 12/19/24 at 1:57 p.m.

During an interview and concurrent record review on 12/26/24 at 10:12 a.m., the EDCNC reviewed Patient 28's ED record and confirmed Patient 28 arrived in the ED on 12/19/24 at 9:41 a.m. and Patient 28 was placed on a cardiac monitor on 12/19/24 at 1:57 p.m. He stated that it seems like a long time.

During an interview on 12/26/24 at 11:16 a.m., the EDCNC confirmed Patient 28 first got in a room on 12/19/24 at 1:57 p.m. and that was the first time he was on continuous cardiac monitoring. He stated in an ideal situation, a patient with a cardiac-related issue will be placed in a room and on a cardiac monitor right after triage.

According to "Evidence-based Management of Atrial Fibrillation in the Emergency Department," dated 4/1/18, indicated the standard care for every patient with atrial fibrillation included, "all patients who are symptomatic, unstable, or have AF with RVR) require a cardiac monitor, oxygen if hypoxic [low levels of oxygen], appropriate IV [intravenous] access, frequent blood pressure monitoring, and application of defibrillation pads."

2. Review of Patient 20's History and Physical, dated 11/6/20 indicated the patient was admitted on 10/23/20 and the chief complaint was ventilator-dependent respiratory failure.

Review of Patient 20's Wound Care Note, dated 11/2/20 indicated the patient had a deep tissue pressure injury on the coccyx (bottom of the spine). The note indicated the Assessment/treatment plan was to cleanse with normal saline, apply, sensicare barrier, then cover with mepilex daily and as needed.

Patient 20's nursing documentation was reviewed. There was no documentation that indicated wound dressing changes were done on 11/5/20, 11/7/20, 11/8/20, and 11/9/20.

During an interview on 12/24/24 at 10:52 a.m., the wound nurse (WN) stated when the wound nurse sees a patient's wound, they make recommendations for the treatment plan. She stated if we put in a recommendation, it is expected that the bedside nurse does the daily treatment. The WN verified there was no documentation that indicated wound dressing changes were done on 11/5/20, 11/7/20, 11/8/20, and 11/9/20.

Review of the hospital's policy, Wound Assessment and Management: Vascular, Surgical, and Pressure, dated 6/18/2020 indicated, "Wounds will be assessed with every dressing change ... Every dressing change will include the following assessment: Location, Wound Bed Description."