HospitalInspections.org

Based on facility policy review, medical record review, and staff interview, the facility staff failed to order violent restraints in 4-hour time increments in 1 of 2 violent restraint patient records reviewed (Patient #5).

The findings included:

Review of facility policy, "(Named Health System) Restraint (Restraints) Policy" effective 09/22/2018, revealed, "...Violent restraint orders are: - Time limited: not to exceed; 4 hours for adults (18 years or older)..."

Closed medical record review of Patient #5 revealed a 39-year-old male admitted to the facility 03/30/2022 at 1706. Review of the Admission History & Physical dated 03/31/2022 at 0431 revealed, "Chief Complaint: 'I think I'm in alcohol withdrawal' History of Present Illness... PMH (previous medical history) alcohol use disorder, partial epilepsy (seizure disorder), ADHD (attention deficit hyper activity disorder), HTN (hypertension- high blood pressure), and anxiety who is admitted for management of severe EtOH (alcohol) withdrawal..." Review of a Nursing Progress Note dated 03/31/2022 at 1750 revealed, "Patient on medical hold and attempted to leave room... Security called. RRT (Rapid Response Team) called and OA (House Supervisor) notified. Four point restraints initiated. Primary team at bedside. Patient transported to ICU (Intensive Care Unit) by staff..." Review of Intensive Care Daily Progress Note dated 03/31/2022 at 2001 revealed, "...After arrival in our unit, he became increasingly combative and agitated, spitting on care workers and attempting to hit care workers. He was placed in four-point restraints requiring 4-5 people to hold him down. He had pulled out all of his IVs (intravenous lines). After discussion with pharmacy, he was given 2 mg (milligrams) of Ativan for acute agitation, and IM (injection) dose of phenobarbital was given. I was able to place an IV in his hand. Due to continued agitation, I gave him 52 mcg (micrograms) total of dexmedetomidine (sedating medication) over 3 doses. That did little to calm the patient. Security was called. Patient was given 40 mg IV ketamine (sedating medication), which sedated the patient sufficiently. We ensured his respiratory status was adequate. He was also started on a dexmedetomidine infusion... Physical Exam... Constitutional: ... Interventions: He is restrained..." Review of Physician Orders signed 04/01/2022 at 0133 revealed, "Restraints violent or self-destructive adult... Frequency: Continuous x (times) 4 hours for 1 day..." Medical Record review revealed violent restraints were initiated on 03/31/2022 at 1745 and monitored on a 15 minute basis until 04/01/2022 at 1532 (21 hours, 47 minutes). Record review failed to reveal a four hour time limit on an adult violent restraint order.

Interview on 04/07/2022 at 1500 with the CNS revealed the violent restraints were to be ordered in 4 hour increments. Interview revealed Patient #5's violent restraints were entered with a 24 hour duration. Interview revealed the electronic medical record was designed to stop physician order entries for longer than 4 hours, but this entry bypassed the safeguard.

Interview on 04/07/2022 at 1025 with Provider #4 revealed he initiated the violent restraints order signed 04/01/2022 at 0133. Interview revealed Patient #5 was aggressive towards staff and four point restraints were implemented to ensure patient and staff safety. Interview revealed Provider #4 recalled the violent restraint order and being readily available for monitoring the patient. Interview revealed that violent restraints had a 4 hour time limit, but could be renewed. Interview reveals Provider #4 did not recall releasing Patient #5 from the restraints despite his calmer demeanor.

Interview on 04/07/2022 at 1105 with RN #5 revealed she discontinued the violent restraints on Patient #5. Interview revealed Patient #5 was sleeping in 4 point restraints during shift change. Interview revealed RN #5 did not know how long violent restraint orders were good for. Interview revealed she discussed releasing Patient #5 from restraints with the medical team and they agreed.

Based on facility policy review, medical records review, and staff interview, the hospital's medical staff failed to perform medication reconciliation for 3 of 3 intensive care unit (ICU) patient records reviews (Patient #1, #2, and #3).

The findings included:

Review of facility policy, "[Named] Medication Reconciliation" effective 10/11/2021 revealed, "...4. The admitting provider reviews the home medication list and determines which medications shall be continued upon admission. Medications will be reviewed and reconciled by the health provider as soon as possible upon admission, but no later than 24 hours after admission."

1. Review of an open medical record revealed Patient #2 was a 62-year-old female admitted to the hospital's intensive care unit on 03/30/2022 with acute hypoxic hypercarbic respiratory insufficiency. The review revealed Patient #2 had a history of COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), DM2 (diabetes mellitus), morbid obesity, and low back pain. The review revealed the home medication was reconciled on 04/03/2022 (four days after admission) by a health provider. A review of the "History and Physical" dated 03/30/2022 at 1401 failed to reveal evidence the admitting provider reconciled Patient #2's home medication within 24 hours of admission to the hospital. The review revealed Patient #2 was discharged home on 04/05/2022.

Interview on 04/07/2022 at 1130 with the Clinical Team lead revealed the medication reconciliation should have been completed by the admitting provider within 24 hours of admission. The interview revealed the review of a patient's home medication was important to ensure that the patient's home medications were not contributing to the admitting diagnosis.

Interview on 04/07/2022 at 1400 with Provider #3 (the admitting provider) revealed that the ICU providers reviewed home medication to ensure that the patients' medications were not contributing to the patient's admitting diagnosis. The interview revealed that medication reconciliation was part of a complete assessment. The interview revealed Provider #3 admitted to not routinely reconciling patients' medication on admission.

2. Review of an open medical record revealed Patient #3 was a 59-year-old female admitted to the hospital's intensive care unit on 03/15/2022 with abdominal pain and hypotension. The review revealed Patient #3 had a history of ESRD (end-stage renal disease), DM2, GERD, severe PAD (peripheral vascular disease) s/p (status post) R BKA (right below the knee amputation), L AKA (left above the knee amputation), and with digit necrosis. The review revealed the home medication was reconciled on 03/20/2022 (five days after admission) by a health provider. A review of the "History and Physical" dated 03/15/2022 at 1557 failed to reveal evidence the admitting provider reconciled Patient #3's home medication within 24 hours of admission to the hospital. The review revealed Patient #3 was discharged home on 04/02/2022.

Interview on 04/07/2022 at 1130 with the Clinical Team lead revealed the medication reconciliation should have been completed by the admitting provider within 24 hours of admission. The interview revealed the review of a patient's home medication was important to ensure that the patient's home medications were not contributing to the admitting diagnosis.

Interview on 04/07/2022 at 1400 with Provider #3 (the admitting provider) revealed that the ICU providers reviewed home medication to ensure that the patients' medications were not contributing to the patient's admitting diagnosis. The interview revealed that medication reconciliation was part of a complete assessment. The interview revealed Provider #3 admitted to not routinely reconciling patients' medication on admission.



40677

3. Review of an open medical record revealed Patient #1 was a 33-year-old female admitted to the hospital's intensive care unit on 04/02/2022 with hyperkalemia. Medical record review revealed Patient #1 had a history of end stage renal disease. Review of the "History and Physical" dated 04/02/2022 at 1303 failed to reveal evidence the admitting provider reconciled Patient #1's home medications within 24 hours of admission to the hospital. Medical record review revealed Patient #1 discharged home 04/05/2022.

Interview on 04/07/2022 at 1130 with the Clinical Team lead revealed the medication reconciliation should have been completed by the admitting provider within 24 hours of admission. The interview revealed the review of a patient's home medication was important to ensure that the patient's home medications were not contributing to the admitting diagnosis.

Interview on 04/07/2022 at 1400 with Provider #3 revealed that the ICU providers reviewed home medication to ensure that the patients' medications were not contributing to the patient's admitting diagnosis. The interview revealed that medication reconciliation was part of a complete assessment. The interview revealed Provider #3 admitted to not routinely reconciling patients' medication on admission.


NC00187261