HospitalInspections.org

Based on clinical record review, policy review and staff interview, it was determined that for 1 of 1 (100%) restrained patients in the sample (Patient #3), a restraint was applied without a physician's order. Findings include:

A. Hospital policy titled "Restraint and Seclusion" stated, "...A physician's order is required when restraints/seclusion are used...An electronic/written or verbal order will be obtained prior to (or in an emergency immediately within 1 hour after) the application of restraints/seclusion...The physician's verbal order will be co-signed within 24 hours after the initial use of restraint/seclusion..."

Hospital policy titled "Standing Orders, Protocols, and Order Sets Approval and Governance Process" stated, "...Protocol orders are entered in the medical record by the licensed independent provider after a clinical assessment of the patient, prior to the initiation of the protocol..."

I. Review of Patient #3's medical record revealed:
- "Restraints non-violent or non-self destructive (Order 95478667) entered by Employee #16, ICU (Intensive Care Unit) RN (Registered Nurse), documents order mode as "...Per protocol: no cosign required..." created on 2/17/23 at 2:08 AM. No evidence that responsible physician cosigned the order.

II. In an interview with Employee #4, Manager of Clinical Nursing Informatics, on 2/24/23 at 12:46 PM, it was confirmed that the restraint order lacked a physician's signature, and was stated that Employee #16, ICU RN, should not have ordered restraints "per protocol" as the responsible physician would not be prompted to sign the order in the Electronic Medical Record (EMR).

Based on record review, policy and document review, and staff interview, it was determined that the hospital failed to follow Emergency Department (ED) guidelines and Hospital Rules for 1 of 4 ED patients (Patient #13) sampled. Findings include:

A. Hospital guidelines titled "5 Level Triage System" stated, "...Level II Presentation...Patients meeting level II criteria require immediate attention. They are to be placed in the treatment area...Level II patients will have ongoing reassessments, to include vital signs, a minimum of every...120 minutes, or more frequently..."

During an interview on 2/24/23 from 1:15 to 1:35 PM, Employee #5, Clinical Informatics Nurse, stated the documented acuity level of "emergent" for Patient #13 is the same as an acuity of "level II". During the interview, Employee #5 hovered the computer mouse over the documented "emergent" acuity level in Patient #13's electronic medical record which showed the note "Level 2"

I. Review of Patient #13's ED clinical record revealed:
- "Care Timeline" documents patient arrived at the ED on 10/15/(21) at 3:35 PM.
- Patient with complaint of fever and chills following colonoscopy earlier today (10/15/21).
- "ED Vitals" documents vital signs were completed at 10/15/21 at 3:40 PM with results of temperature 101.0 degrees F, pulse 120 beats per minute, respirations 20 breaths per minute, blood pressure 154/78, and SpO2 (O2 saturation) 95%.
- "Default Flowsheet Data" dated 10/15/21 documents patient was triaged at 3:42 PM and assigned an acuity level of II/Emergent.
- "Default Flowsheet Data" dated 10/15/21 documents patient was moved to ED waiting room after triage on 10/15/21 at 3:42 PM.

During an interview on 2/24/23 at 1:35 PM, Employee #5, Clinical Informatics Nurse, confirmed the finding that patient was not moved to an ED treatment room after triage.

II. Review of Patient #13's ED clinical record revealed:
- "Care Timeline" documents patient arrived at the ED on 10/15/(21) at 3:35 PM.
- Patient with complaint of fever and chills following colonoscopy earlier today (10/15/21).
- "ED Vitals" documents vital signs were completed at 10/15/21 at 3:40 PM with results of temperature 101.0 degrees F, pulse 120 beats per minute, respirations 20 breaths per minute, blood pressure 154/78, and SpO2 (O2 saturation) 95%.
- "Default Flowsheet Data" dated 10/15/21 documents patient was triaged at 3:42 PM and assigned an acuity level of II/Emergent.
- "Disposition" documents patient left ED without being seen (LWBS) on 10/15/21 8:18 PM
- No evidence patient was reassessed after being triaged at 3:42 PM (276 minutes).
- No evidence patient's vital signs were completed after 3:40 PM (278 minutes).

During an interview on 2/24/23 at 1:35 PM, Employee #5, Clinical Informatics Nurse, confirmed the finding of no evidence that Patient #13 was assessed, including vital signs, every 2 hours, while they were in the ED on 10/15/21 between 3:40 to 8:18 PM.

B. Hospital document titled "Bayhealth Medical Staff Rules and Regs" stated, "...all orders for treatments shall be in writing and signed by the Physician...verbal orders must be dictated by the physician...and signed by the physician...no...greater than 48 hours..."

During an interview on 2/24/23 from 1:45 to 2:00 PM, Employee #7, Senior Director Patient Care Services, stated the expectation is for standing orders to be signed by a physician in the same time frame as verbal orders.

I. Review of Patient #13's ED clinical record revealed:
- "CK W/Reflex (Order 75315343)" entered by Employee #15, ED RN (Registered Nurse), documents order mode as "...Standing; cosign required..." created on 10/15/21 at 3:43 PM and responsible physician signed order on 12/8/21 at 12:54 PM, 1,296 hours after order was entered.
- "Troponin I (Order 75315344)" entered by Employee #15, ED RN, documents order mode as "...Standing; cosign required..." created on 10/15/21 at 3:43 PM and responsible physician signed order on 12/8/21 at 12:54 PM, 1,296 hours after order was entered.
- "Phosphorus (Order 75315347)" entered by Employee #15, ED RN, documents order mode as "...Standing; cosign required..." created on 10/15/21 at 3:43 PM and responsible physician signed order on 12/8/21 at 12:54 PM, 1,296 hours after order was entered.

During an interview on 2/24/23 from 1:45 to 2:00 PM, Employee #7, Senior Director Patient Care Services, confirmed the finding that standing orders created on 10/15/21 at 3:43 PM were not signed by the physician within 48 hours.