HospitalInspections.org

Based on document review and interview, the facility failed to implement the restraint/seclusion policy related to the need for a restraint order to administer calming medications and related to documentation of the time of discontinue/release of a restraint/seclusion for 1 of 1 patient requiring restraint/seclusion, Patient #2.

Findings Include:
1. Review of the policy Seclusion and Restraint, policy/procedure number NR 605, last approved 2/19/16 indicated:
A. On page 7, under item h), it reads: "Discontinuation - The RN (registered nurse) or designee documents in progress notes: i) Time of discontinuation/release...".
B. On page 8, under "Physician Order": A physician order must include: "...i) Date and time of order. ii) Type of procedure...if restraint, type of restraint to be implemented. iii) Criteria/rationale for use. iv) Behavioral criteria for discontinuation. v) Time limit...".

2. Review of the medical record for patient #2 indicated:
A. On the "Seclusion Restraint RN 15 minute Assessment" form, nursing noted a "hold" at 0019 hours on 9/9/16, 0040 hours and 0205 hours.
B. On the Seclusion/Restraint 15 minute check form for MHTs (mental health techs), a "therapeutic hold" was documented at 0019 hours and 0205 hours.
C. Nursing progress notes on 9/9/16 indicated:
a. "0019: Pt stated he/she would not take a shot, so he/she had to be held for a few minutes to receive the injection...".
b. "0040 He/she was again held in a restraint until he/she calmed down and agreed to go to the QR (quiet room)".
c. "0205: the door was open, he/she needed to be held by staff while the bed was removed from the room...".
D. A physician order for restraint was written as a telephone order at 0050 hours on 9/9/16 for a 15 minute restraint.

3. At 10:25 AM on 10/20/16, interview with staff member #51, the director of nursing, confirmed that:
A. There should have been separate restraint orders for each episode of restraint documented for patient #2 on 9/9/16, not just the one 0050 hours order noted.
B. The progress notes by nursing do not indicate the time of release of restraint for the 0019 hours, 0040 hours and 0205 hours restraints for patient #2 on 9/9/16.

Based on document review and interview, the nursing executive failed to ensure the implementation of the fall precautions policy related to the lack of a post fall debriefing form completion for 5 of 5 patients who fell, Patients #1, #2, #3, #6 and #7.

Findings Include:
1. Review of the policy/procedure "Fall Precautions", policy number NR 601, last approved 5/9/14, indicated under "Procedures", on page 2: "...7) If a fall occurs, update or revise POC (plan of care) per treatment team recommendations. Complete Oaklawn Fall Debriefing form to provide data for supervisor investigation and prevention of further falls."

2. Review of patient medical records indicated:
A. Patient #1 had a fall documented on 9/16/16 at 0345 hours with no post fall debriefing document noted in the record.
B. Patient #2 had a fall documented on 9/8/16 at 1820 hours with no post fall debriefing document noted in the record.
C. Patient #3 had documentation of a fall on 7/3/16 at 2110 hours with no post fall debriefing document noted in the record.
D. Patient #6 had a fall noted on 9/11/16 at 7:25 AM with no post fall debriefing document found in the record.
E. Patient # 7 had two falls noted on 7/1/16 and had no post fall debriefing document found in the record.

3. At 10:10 AM on 10/20/16, interview with the director of nursing, staff member #51, confirmed that:
A. A post fall debriefing form was created and added to policy in 2014 by a previous director of nursing.
B. After a phone call with other staff members, it was determined that the form was never approved by the "forms" committee and thus not fully implemented, even though written in policy.
C. There was no fall debriefing, and no form completed, for any of the five patients who sustained a fall at the facility, as listed in 2. above.

Based on document review and interview, the nursing executive failed to ensure the implementation of the fall precautions policy related to adding fall precautions to the plan of care after a patient fall for 2 of 5 patients who fell, Patients #2 and #6.

Findings Include:
1. Review of the policy/procedure "Fall Precautions", policy number NR 601, last approved 5/9/14, indicated under "Procedures", on page 2: "...7) If a fall occurs, update or revise POC (plan of care) per treatment team recommendations. Complete Oaklawn Fall Debriefing form to provide data for supervisor investigation and prevention of further falls."

2. Review of patient medical records indicated:
A. Patient #2 had a fall documented on 9/8/16 at 1820 hours with no addition to the POC of fall precautions being implemented.
B. Patient #6 fell at 7:25 AM on 9/11/16 and lacked the addition to the POC of fall precautions being implemented.

3. At 10:10 AM on 10/20/16, interview with the director of nursing, staff member #51, confirmed that patients #2 and #6 lacked the addition of fall precautions to the POC, as required per policy, after their fall of 9/8/16.

Based on document review and interview the facility failed to ensure the implementation of its policy related to verbal and telephone order authentication for 1 of 1 patient with restraint/seclusion orders, Patient #2.

Findings Include:
1. Review of the policy Verbal/Telephone Orders, policy number NR 871, last approved 9/6/13, indicated under "Procedure", item 4): "The physician/advanced practice nurse must sign and date the T.O./V.O. (telephone order/verbal order): a) Within 48 hours for all orders except seclusion/restraint orders for residents in PRTF (psychiatric residential treatment facility) care...".

2. Review of the medical record for patient #2 indicated:
A. A telephone order was written by nursing at 0050 hours on 9/9/16 for "Seclusion for 4 hours" and "Restraint for 15 minutes" that was not yet authenticated by a practitioner.
B. A telephone order was written by nursing at 0445 hours on 9/9/16 to "Continue to seclude for 4 hours" that was not yet authenticated by a practitioner.

3. At 10:25 AM on 10/20/16, interview with staff member #51, the director of nursing, confirmed that the telephone orders for restraint and seclusion written on 9/9/16 should have been authenticated by the physician/advance practice nurse within 48 hours, as per facility policy, and were delinquent.