HospitalInspections.org

Based on staff interviews and clinical record reviews, it was determined nursing staff violated professional standard of practice by failing to promptly notify the physician of a change in condition for 1 of 12 sampled patients (Patient #2).

The findings include:

Clinical record review revealed Patient #2 was transferred to the Intensive Care Unit for close observation at 1500 hours on 2/7/14. Review of the physician progress notes reveals the patient had episodes of agitation following an Upper Endoscopy .

On 2/7/14 at 9:20 PM the physician ordered bilateral soft wrist restraints (Medically necessary Restraints) due to the patient's attempts to remove medical device, and medically unsafe attempts at mobility.

Review of the Patient Care Notes on 2/7/14 at 9:50 PM reveals patient #2 was observed by the nurse pushing his left arm under the side-rail. The nurse documented, he assisted the patient in removing the arm The nurse wrote, he explained to the patient he could cause himself injury. The patient stated: he didn't care; that his left arm is broken, and accused the nurse of breaking his arm.

Per the 02/07/14 nurse's note in the clinical record, the nurse assessed the patient's left arm as follows: no swelling, no bruising at the site. The patient has full range of motion. The nurse wrote, it is of some concern at this time, that the patient seems to be trying to cause self-injury.

At 3:00 AM the nurse document, the patient is trying to get out of the bed, and is instructed about safety and call bell use. The patient still complains of pain and swelling to his left arm. The patient was assessed by a second RN who explained to the patient, his arm is not swollen, and also instructed the patient again on safety and call bell use. The RN the explained the patient 's condition to the Charge Nurse.

Review of the nurse's notes at 3:10 AM on 02/08/14 reveals the patient is still complaining of pain in the left arm. The RN documents there is some bruising at the site; the bruising appears to be old; There is no edema noted; The nurse took a photograph of the patient's left wrist at this time.
The nurse placed a call to the physician at 4:18 AM on 02/08/14. The physician ordered a portable x-ray of the left wrist. Further review of the medical record revealed a second request for a x-ray was made on 02/08/14 at 10:37 AM.

A request for Orthopedic consult was made 02/08/14 at 10:58 AM. The reason for the consult: Left wrist fracture.

The facility policy and procedures titled Restraint Monitoring specifies, monitoring of the restrained patient is to be documented every 20 minutes as per policy and procedure. The assessment includes signs of injury associated with restraint. Any change in physical or psychological response will be reported to the RN. The RN will determine if medical intervention is required. There is no supportive evidence found, or provided, in the medical record indicating monitoring of patient #2's wrist restraints every 20 minutes per policy.

The nurse failed to promptly notify the physician of a significant change in patient #2's condition. The patient began to complain of pain in the left arm, as of 9:00 PM on 02/07/14, the physician was not notified until 4:18 AM on 02/08/14. Furthermore nursing staff failed to substantiate / document evidence of monitoring the restrained patient as per policy.