HospitalInspections.org

Based on review of 8 personnel files it was determined that despite the hospital's policy and procedure requiring mandatory nursing in-service classes at specified intervals, the hospital failed to ensure that a certified Nursing Assistant hired as a Direct Care Aide (DCA) maintained current competencies in First Aid. Review of the personnel file indicates that at the time of the on-site investigation the last time the DCA had completed the competency was June 14, 2011and was due for the mandatory in-service in June 2013.

Review of medical records revealed failure of the hospital to modify the plan of care for patient's placed in seclusion or restraint. The hospital has been using a Level 3 form on which the treatment team documents their discussion of the episode with the patient but the plan of care is not up-dated regarding the use of restraint or seclusion.

Patient #1's behavior escalated to his attempting to throw a food crate at staff when he was unable to get extra food. The patient was prevented from throwing the crate by another patient. Patient #1 was not responsive to offer of quiet time, verbal re-direction and offer of medications. He attempted to fight the patient that prevented him from throwing the crate, the patient was placed in restraints at 7:50 PM on 7/18/13. The patient's care plan was not updated to include the use of restraint. In fact the patient's preference was seclusion but there was no documentation regarding why the patient was placed in restraint rather than his preference. This information could have been addressed during the care plan up-date. The use of the Level 3 form does not meet the requirement to update and the patient's plan of care .

Based on review of the hospital policy Seclusion/Restraint the hospital's policy failed to address the timely acquisition of the order for restraint or seclusion prior to its application or in emergency application situations.

The policy review revealed under III-E Initiation & Placement of Seclusion/Restraint requires a physician order. "If the physician is not available, and the situation warrants immediate seclusion/restraint, a registered nurse (RN) may authorize initiation of seclusion/restraints. The RN must notify and consult with a physician to obtain each order within 1 hour of the initiation of seclusion/restraint." The regulation requires that in emergency situations, the order must be obtained either during the emergency application of restraint or seclusion, immediately (within a few minutes) after the restraint or seclusion has been applied.

Based on review of the medical records it was determined that for a restraint episode for one patient reviewed the physician performed the required face to face evaluation but failed to document :
1.. The patient's reaction to the intervention;
2. The patient's medical and behavioral condition; and
3.. The need to continue or terminate the restraint or seclusion.

Patient #1 was admitted for court order evaluation on 7/17/13. As part of the admission assessment the patient identified that seclusion was his preferred intervention if he was angry and wanted to hurt himself or others. On 7/18/13 the patient's behavior escalated to his attempting to throw a food crate at staff when he was unable to get extra food. The patient was prevented from throwing the crate by another patient. Patient #1 was not responsive to the offer of quiet time, verbal re-direction and the offer of medications. He attempted to fight the patient that prevented him from throwing the crate, the patient was then placed in restraints at 7:50 PM. The patient was seen by the physician at 7:50 PM, under objective in the physician note was written " patient was observed face to face in no distress. This one-line statement does not document the required four elements of a face-to-face evaluation.

Based on review of 1 out of 11 open medical records, it was determined that the nurse failed to transcribe a medication per Federal and State laws and hospital policy.

Patient #3 was had medication orders written by the physician assistant on 7/22/13 at 3:20 PM and transcribed by the nurse at 6:00 PM. Review of the physician order sheet revealed that a new order for " MOM (Milk of Magnesia) 30 ml by mouth every bedtime as necessary if no bowel movement x 2 days " was written as a part of the orders. Review of the July 2013 (MAR) medication administration record revealed that the order for the MOM was not transcribed to the MAR sheet. The nurse failed to transcribe the order in accordance Federal and State laws and hospital policy and procedure.

On review of the Medication Administration Record (MAR)for Patient # 8 it was determined that nursing staff failed to consistently document the patient's heart rate prior to administering the medication Lisinopril; specifically on August 17 and 18. In addition, further review of the MAR indicates that on August 1st , and 2nd the nurse documented " REF " indicating refused, however it is unclear if the patient refused the Lisinopril on the 1st and 2nd of August or refused to have his blood pressure and heart rate taken. The only documentation under "Reason Medication Given /Not Given" on the MAR is for August 10th at which time the nurse documented that the patient refused medication.