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Based on record review and confirmed through staff interview the facility failed to assure the use of restraints was applied in accordance with their Policy and Procedure for 1 patient. (Patient #25). Findings include:

Per review the facility's policy, last revised in July 2013 and titled Restraints, stated that physical restraint "may only be used......: A. To treat a specific medical condition. B. To provide care and services necessary for the individual to achieve the highest practicable level of well being. C. To prevent self-injury or injury to others. D. When lesser restrictive measures have been ineffective." The policy also stated, "VI. Nursing Responsibilities:....ED...A. Assessment of specific problems, for which a restraint is considered will be made upon admission and whenever use of a restraint is initiated. Upon administration of use of a restraint the specific problem will be documented in the patient/resident record. The patient's plan of care must include......evidence that less restrictive means of restraint were attempted, but ineffective...B. A nurse may initiate use of a physical restraint....but must obtain a Physician Order within (1) hour. The order must include the type of restraint to be used, the reason for use, and time frame....D. A physician or other licensed independent practitioner, must see and evaluate the need for restraint within (1) hour after the initiation of this intervention."

Per record review Patient #25, who presented to the ED on 9/30/13 with suicidal ideation, agitation and alcohol intoxication, had soft wrist restraints applied without indication for use of the restraints, without a physician order and without evidence that less restrictive measures had been attempted and proven ineffective prior to initiation of the restrains. A nursing note, dated 9/30/13 at 11:00 PM, stated; "restraint check, pt able to move (his/her) hands...", indicating that restraints had been applied to each of the patient's hands at some point following arrival in the ED at 5:51 PM. Follow up nursing notes at 11:27 PM and 11:38 PM, respectively, stated; "Left dept. to CT scan.....soft restraints removed", and "returns from CT scan, Will keep soft restraints off as long as pt remains cooperative." A provider note, dated 10/1/13 at 12:40 AM - an hour and 40 minutes after the 11:00 PM nursing note, indicated a re-evaluation of the patient had been conducted and stated the patient had become aggressive, leaving [his/her] room....was escorted back to her room....continued to be aggressive verbally escalating.....attempted to exit [his/her] exam room again, and was held up by.......In [his/her] attempt to resist, it appears the patient may have slipped....struck [his/her] head on the base of the stretcher in the room and then the floor....was assisted back onto the cot, and restrained for [his/her] safety....." Although the record indicates there was one to one constant observation of the patient, and despite the physician note at 12:40 AM on 10/1/13, there was no indication of when or why restraint use was initiated, no evidence that less restrictive measures had been attempted and found to be ineffective prior to use of restraints and no physician order for the restraints.

ED nurse #1 confirmed, during interview at on 12/3/13, that there was no evidence of when or why the restraints had been initiated, no evidence that less restrictive measures had been attempted and proven to be ineffective prior to the restraint intervention and no physician orders for use of the restraints. This was also confirmed by the Director of Patient Care Services during interview on the afternoon of 12/4/13.

Based on observation and staff interview the facility failed to assure the safe and secure storage of all drugs in the ED (Emergency Department). Findings include:

Per observation, during tour of the ED, at 11:41 AM on 12/11/13, an unlocked Dental kit box, containing 30 vials of marcaine (a local anesthetic) 0.5% and benzogel, containing 20% benzocaine (pain reliever) was found stored in an unlocked cabinet in the trauma room.

During interview, at the time of the observation, RN#1 confirmed the drugs were stored in an unsecured manner and stated there was no process or policy to assure accountability of the drugs. The Director of Pharmacy stated, during interview at 10:00 AM on 12/12/13, that the drugs ' should be locked ' . S/he indicated that nursing was responsible for locking the box, and further stated that the drugs within the box were ' non formulary, non traditional meds."

Based on observation and staff interview the facility failed to assure an ongoing infection control process in the ED (Emergency Department) for cleaning and disinfection of commodes used by patients. Findings include:

Per observation, during tour of the ED at 11:41 AM on 12/11/13, one commode, used by patients, was stored in the dirty utility room and one was stored in one of two bathrooms utilized by patients. RN #1 stated, during interview at the time of tour, that, although the commodes looked clean, s/he was unsure if they had been cleaned or not as there was no process to confirm it. S/he stated the bathrooms, utilized by patients, are cleaned by housekeeping, and a piece of paper is placed across the seat to identify that cleaning has occurred. S/he further stated that commodes, which are brought to patients for use in their rooms, are cleaned by nursing staff after the patient is discharged and usually stored in each of the patient bathrooms for future use, however, there is no process for identifying whether or not the commodes have been cleaned.

Based on record review and confirmed through staff interview nursing failed to conduct ongoing assessments, in accordance with standards of nursing practice, of the needs of one patient for whom the initial assessment revealed elevated BP (blood pressure) and for whom a change in clinical condition had occurred. (Patient #25). Findings include:

Per record review Patient #25, who presented to the ED on 9/30/13 with suicidal ideation, agitation and alcohol intoxication, and whose BP (blood pressure) was elevated, at 176/98, at 6:04 PM, did not have a reassessment of the BP until more than 5 hours later at 11:21 PM. In addition, although a provider note indicated the patient sustained a head injury as the result of a fall in the ED at approximately 10:00 PM and suffered a subdural hematoma, and although the patient was not discharged until 9:01 AM on 10/1/13, there was no evidence that ongoing assessments of the patient's neurological status or VS occurred after 1:24 AM on 10/1/13.

The Director of Patient Care Services confirmed there was no evidence of ongoing reassessments of the patient's clinical status, during interview on the afternoon of 12/11/13. S/he further stated that the facility's policies and procedures did not address the frequency of reassessments and that nursing staff are expected to use the standards reflected in the Lippincott Manual of Nursing Practice.


Lippincott Manual of Nursing Practice

Based on record review and confirmed through staff interview the facility failed to assure that documentation was complete for 1 patient's record. (Patient #25). Findings include:

Per record review Patient #25, who presented to the ED on 9/30/13 with suicidal ideation, agitation and alcohol intoxication, lacked documentation to justify the use of soft wrist restraints. A nursing note, dated 9/30/13 at 11:00 PM, stated; "restraint check, pt able to move (his/her) hands...", indicating that restraints had been applied to each of the patient's hands at some point following arrival in the ED at 5:51 PM. Follow up nursing notes at 11:27 PM and 11:38 PM, respectively, stated; "Left dept. to CT scan.....soft restraints removed", and "returns from CT scan, Will keep soft restraints off as long as pt remains cooperative." Despite this information there was no documentation regarding; the time the restraints were applied, indication for the use of restraints, less restrictive measures employed and determined to be ineffective prior to initiation of the restraints and no physician order for the intervention. In addition, although the patient's BP was elevated, at 176/98, at 6:04 PM and although a provider note indicated the patient sustained a head injury as the result of a fall in the ED at approximately 10:00 PM and suffered a subdural hematoma, there was no documentation that a subsequent BP was checked until 12:29 AM on 10/1/13, and although the patient was not discharged until 9:01 AM on 10/1/13, there was no documentation of further VS or neurological assessments after 1:24 AM on 10/1/13.

The Director of Patient Care Services confirmed the lack of complete documentation in Patient #25's record, during interview on the afternoon of 12/11/13.