HospitalInspections.org

Based on medical record review there is no evidence Patient #1's representative was provided the right to make informed decisions regarding care in a timely manner.

Findings Include:

Review of the surgical consent form dated 5/9/11 revealed the patient's mother gave verbal consent for drainage of pseudocyst X2, cholecystectomy and feeding tube.

Review of the General Surgery Physician Assistant note dated 5/17/11 revealed the patient's mother was informed regarding the patient's hands.

There is no evidence the patient's mother was informed of the intent to apply fiberglass casts to Patient #1's hands as a means of restraint prior to the application or that she was immediately notified once the problem with the patient's hands as a result of the restraints was identified on 5/13/11.

Based on interview and medical record review restraints were not ordered or implemented appropriately and safely in accordance with hospital policy for Patient #1.

Findings Include:

Review of the facility's restraint policy, entitled "Restrictive Interventions for Medical Necessity (Enclosure bed/ Geri chair/ Limb/ Vest Restraint", last revised 6/10, revealed restraints are defined as any physical or mechanical device, attached to or adjacent to the patient's body, that the patient cannot easily remove, which restricts freedom of movement or normal access to one's body. All orders for restraints are to be signed, dated, timed and include a time specific period for which restraint is applied, not to exceed 24 hours and includes the type of restraint to be used and the specific medical indication for the restraint.

Review of the facility's restraint protocol, entitled "Restraint Protocol: Enclosure bed/ Geri chair/ Limb/ Vest Restraint for Medical Indications", last reviewed/revised 10/10, revealed restraint types include enclosure bed, geri chair with locked table in place with the intent of preventing ambulation, wrist/ankle, vest, full side rails when a patient is able to move. Four and five point restraints are utilized for behavioral management with a separate protocol in place. Safety and ongoing assessment include observation of the patient every 30 minutes and release of all restraints every two hours with an assessment of skin integrity and performance of range of motion.

Review of physician postoperative orders dated 5/9/11 revealed an order for restraints, although the specific type of restraint was not identified. There were no further orders for restraints until 5/12/11.

Review of perioperative record nurses' notes dated 5/9/11 at 4:00pm revealed a fiberglass splint wrapped with ace bandages was placed on both hands by the surgeon as a restraint.

Interview with Staff # 3 on 1/24/11 revealed a decision was made to apply the fiberglass casts to the patient's hands due to the patient's continual disruption of medical devices preoperatively despite mitts, wrist restraints and 1:1 sitters. The casts were removed and replaced with kerlix type wraps two days later, once the patient was not in as much danger if he pulled his tubes out.

Review of nursing restraint progress notes revealed documentation of the use of wrist restraints on 5/10/11 from 6:00pm to 6:00am and on 5/11/11 from 6:00pm to 6:00am despite the lack of a specific order.

Review of nursing progress noted dated 5/13/11 at 2:30pm revealed the following documentation: "Ace wraps to both hands removed to assess skin on hands and fingers. Finger under ace wraps tightly wrapped with tape. Tape gently removed. Hands whitish from decreased circulation. Tip of right middle finger black in color. Tip of left thumb blackened in color. Blisters began to form on both little fingers as circulation returned. Various red areas on both hands."

There is no evidence restraints were ordered in accordance with the facility's policy or that the hand wraps that were placed following removal of the casts were released and the patient's hands assessed until 5/13/11 when the wraps were removed.

Based on interview and medical record review, the medical staff was not accountable for the quality of the medical care provided to Patient #1 relative to the application of fiberglass casts to both hands, and once removed, the application of wraps to both hands as a means of restraint.

Findings Include:

Review of the facility's restraint policy, entitled "Restrictive Interventions for Medical Necessity (Enclosure bed/ Geri chair/ Limb/ Vest Restraint)", last revised 6/10, revealed restraints are defined as any physical or mechanical device, attached to or adjacent to the patient's body, that the patient cannot easily remove, which restricts freedom of movement or normal access to one's body.

Review of the facility's restraint protocol, entitled "Restraint Protocol: Enclosure bed/ Geri chair/ Limb/ Vest Restraint for Medical Indications", last reviewed/revised 10/10, revealed restraint types include enclosure bed, geri chair with locked table in place with the intent to prevent ambulation, wrist/ankle, vest, full side rails when a patient is able to move. Four and five point restraints are utilized for behavioral management with a separate protocol in place.

Review of perioperative nurses' notes dated 5/9/11 at 4:00pm revealed a fiberglass splint wrapped with ace bandages was placed on both hands by the surgeon as a restraint.

Review of the operative report dated 5/9/11 revealed the following documentation: "Prior to awakening, a portion of fiberglass casting (lightly) was placed around both hands to hopefully control the patient from pulling out tubes despite wearing mittens throughout the time and despite the nurse assuring me he has been restrained 100% of the time."

Interview with Staff #3 on 1/24/11 revealed a decision was made to apply the fiberglass casts to the patient's hands due to the patient's continual disruption of medical devices preoperatively despite mitts, wrist restraints and 1:1 sitters. The casts were removed and replaced with kerlix type wraps two days later, once the patient was not in as much danger if he pulled his tubes out.

Interview with Staff #8 on 1/23/11 revealed after the surgeon removed the fiberglass casts, the patient was able to move his fingers with no evidence of bruising, swelling or blistering. After the casts were removed, the surgeon placed wraps on the patient's hands. Staff #8 did not observe the application of the wraps, but did note that after the wraps were in place, the tips of a few fingers were visible.

Review of surgical progress note dated 5/12/11 revealed the following documentation: "Very agitated last evening. Ativan increased. Patient pulled out JVAC despite 24/7 observation and restraints and hands tied up in ace/tape."

Review of nursing progress noted dated 5/13/11 at 2:30pm revealed the following documentation: "Ace wraps to both hands removed to assess skin on hands and fingers. Finger under ace wraps tightly wrapped with tape. Tape gently removed. Hands whitish from decreased circulation. Tip of right middle finger black in color. Tip of left thumb blackened in color. Blisters began to form on both little fingers as circulation returned. Various red areas on both hands."

A means of restraint (fiberglass casting and hand wrapping), not consistent with hospital policy was utilized for this patient. In addition, there is no evidence to indicate that following the removal of the fiberglass casts, that the restraint that was applied in its place, was removed and the patient's hands assessed until 5/13/11 when the wraps were removed.