HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to immediately obtain an appropriate order for the use of a restraint or seclusion for the management of two (2) of three (3) violent or self-destructive patients reviewed.

The findings include:

On 12/12/23 at 10:12 am, the surveyor initiated the review of the restraint and seclusion documentation for Patient # (4-6) with the assistance of Staff Member #1.

Under the restraint flowsheet documentation of Patient #5, the surveyor observed that seclusion was initiated from 11/10/23 at 8:15 pm until 8:45 pm for the management of violent behavior.

The surveyor confirmed that the order for Patient #5's seclusion was not obtained until 11/10/23 at 8:45 pm following the discontinuation of the restrictive intervention.

Under the restraint flowsheet documentation of Patient #6, the surveyor observed that the patient was restrained in "Hard 4-Point" restraints on 10/30/23 at 9:30 pm until 10:45 pm for the management of violent behavior.
The surveyor confirmed that the order for Patient #6's violent behavioral restraints were not obtained until 10/30/23 at 9:59 pm.

At approximately 10:30 am on 12/12/23, the surveyor conducted interview with Staff Member #1. Following additional review of both Patient #5 and Patient #6's medical record, Staff Member #1 confirmed the surveyor findings were accurate. Staff Member #1 confirmed there were no other orders related to the restraint and seclusion interventions appropriate to the aforementioned timeframes.

In the afternoon of 12/12/23, the surveyor reviewed the facility policy titled, "Physical Restraint or Seclusion-Use of Restraints or Seclusion for Violent, Self-Destructive Patient Situations" (with last effective date of 07/27/23).

Under "Restraint or Seclusion Order (to manage violent or self-destructive behavior)" section of page two (2), the policy reads in part, "In the absence of an order, the RN may initiate use of restraints or seclusion in emergency situations. In emergency situations, the order must be obtained either during the emergency application of the restraint or initiations of seclusion or immediately (within a few minutes) after the restraint has been applied or seclusion has been initiated. Failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order".

On 12/13/23 at 4:15 pm, the surveyor met with Staff Member #2 and Staff Member #9 to disseminate the aforementioned findings regarding the use of restrictive interventions with opportunity for clarification and questions.

Based on interviews and document review, it was determined the facility staff failed to administer blood products in accordance with the ordered transfusion rate of 60 mL/hr for two (2) of three (3) patients reviewed with blood product transfusions.

The findings include:

On 12/11/23 at 12:36 pm, the surveyor initiated the review of patients who had received blood product transfusions with the assistance of Staff Member #1 and Staff Member #6.

The surveyor reviewed the order set information of Patient #2 and identified a provider order for the transfusion on 10/12/23, which stated, "Start infusion at 60 mL/hr x 15 minutes then increase rate to infuse entire unit within the specified transfusion duration above".

The blood product transfusion documentation for Patient #2 revealed that the transfusion was initiated on 10/12/23 at 8:41am with a rate of "75 mL/hr" (milliliter per hour). The same documentation revealed the rate remained unchanged throughout the remainder of the transfusion duration.

The surveyor reviewed the order set information of Patient #3 which revealed the provider had ordered the transfusion of Packed Red Blood Cells on both 10/13/23 at 1:44 pm.

The transfusion order had the same instructions regarding the initial transfusion rate-"Start infusion at 60 mL/hr x 15 minutes then increase rate to infuse entire unit within the specified transfusion duration above".

The surveyor observed that the first unit had been initiated on 10/13/23 at 5:18 pm with an initial rate of "75 mL/hr" for the first thirty-two (32) minutes of the transfusion.

In the afternoon of 12/11/23, the surveyor met with Staff Member #1 for interview. The surveyor informed the staff member of the discrepancies regarding the transfusion rate ordered by the provider and the rate administered. Staff Member #1 reviewed both blood product flowsheet documentation for both Patient #2 and Patient #3, and acknowledged the aforementioned variances.

In the evening of 12/11/23, the surveyor was provided the facility blood transfusion procedure titled, "Lippincott Procedure-Blood and blood product transfusion" (with last revision date of 08/21/23) by Staff Member #9.
Under page three (3), the document delineates the procedure for the administration of blood products, and state, "Start the blood transfusion at a slow rate as prescribed and increase the rate as prescribed if no signs of a reaction occur ..." [sic].

On 12/13/23 at 4:15 pm, the surveyor met with Staff Member #2 and Staff Member #9 to disseminate the aforementioned blood transfusion findings with opportunity for clarification and questions.

Based on interviews and document review, it was determined the facility staff failed to obtain an appropriate informed consent prior to the administration of blood products for one (1) of four (4) transfusions reviewed.

The findings include:

On 12/11/23 at 12:36 pm, the surveyor initiated the review of patients who had received blood product transfusions with the assistance of Staff Member #1 and Staff Member #6.

The blood transfusion flowsheet documentation revealed that Patient #1 had received a transfusion of red blood cells following a provider order on 10/15/23. Despite several efforts, the surveyor was unable to locate an informed consent associated with the blood products.

Under the Order Set information of Patient #1's medical record, the surveyor identified a nursing order ordered by the provider on 10/15/23 at 2:23 pm reading, "Verify hospital blood product consent form has been signed and witnessed".

At approximately 1:00 pm on 12/11/23, the surveyor voiced the concerns related to the lack of a blood product consent form for Patient #1 to Staff Member #1. Both Staff Member #1 and Staff Member #6 confirmed that no such consent was available within Patient #1's medical record related to the 10/15/23 hospitalization encounter.

In the evening of 12/11/23, the surveyor was provided the facility policy titled, "Transfusion of Blood Products" (with last effective date of 11/01/23) by Staff Member #6. Under "Procedure" section, the policy reads in part, "1. Obtain informed consent from the patient or legally responsible person ...b. Informed consent for blood product transfusion must be obtained once per hospital admission and documented via an electronic "Consent" Note Type signed by the initial ordering provider".

The same policy continued to read, "e. Nursing staff will obtain a signature from the patient or legally responsible person once per admission (or once every 90 days in ambulatory settings) using the BSMH Blood Product Transfusion Consent and Refusal Form and witness the form prior to initiating transfusion".

On 12/13/23 at 4:15 pm, the surveyor met with Staff Member #2 and Staff Member #9 to disseminate the missing informed consent for the blood transfusion with opportunity for clarification and questions.