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Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to obtain a timely physician order for the use of restraints for two of two open restraint records reviewed (MR1 and MR2).

Findings include:

A review on September 14, 2011, of facility policy "Restraints Used to Manage Non-Violent, Non-Destructive Behavior," effective September 7, 2011, revealed, " ...Initiation of Intervention ... B. A licensed independent practitioner, house staff or other dependent auxiliary health care provider whose scope of privileges permit ordering restraints should order restraints prior to the application of restraint. ... In emergency application situations the order must be obtained either during the emergency application of restraints or immediately after the initiation of the restraint. ... "

A review on September 13, 2011, of nursing documentation contained in MR1 revealed that bilateral soft wrist restraints were initiated on September 13, 2011, at 12:00 midnight. The physician order was not obtained until September 13, 2011, at 02:00 AM.

A review on September 13, 2011, of nursing documentation contained in MR2 revealed the patient was placed in bilateral soft wrist restraints on September 7, 2011, at 08:00 AM and remained in restraint through September 13, 2011, at 02:00 AM. Further review of physician orders revealed there was no order for the use of restraints on September 9, 2011, from 01:00 AM to September 10, 2011, at 07:00 AM, September 11, 2011, at 07:00 AM to 11:00 AM and September 12, 2011, from 12 midnight to September 13, 2011, at 02:00 AM.

An interview conducted on September 13, 2001, with EMP2 confirmed that the physician orders for the use of restraints were not properly ordered/reordered.


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?482.13(g)(1)(ii) The hospital must report the following information to CMS: Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion.

This is not met as evidenced by:

Based on a review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to notify CMS by the next business day of the deaths of patients within 24 hours of restraint usage for nine of 10 restraint death medical records reviewed (MR56, MR57, MR58, MR59, MR61, MR62, MR63, MR64, and MR65)

Findings include:

A review on September 15, 2011, of facility policy "Restraints Used to Manage Non-Violent, Non-Destructive Behavior", effective September 7, 2011, revealed: " ... Reporting: Risk management shall report to CMS and the Department of Health Division of Acute and Ambulatory Care any death that occurs while a patient is restrained, within 24 hours after the patient has been removed from restraints ... " Further review of the policy failed to reveal the requirement that the reporting of these deaths be completed by the next business day.

A review on September 15, 2011, of MR56, MR57, MR58, MR59, MR61, MR62, MR63, MR64, and MR65 revealed that the patients met the criteria for death within 24 hours of restraint usage. Further review of the medical records revealed that CMS was not notified by the next business day.

An interview conducted on September 15, 2011, at 11:30 AM with EMP1 confirmed that MR56, MR57, MR58, MR59, MR61, MR62, MR63, MR64, and MR65 died within 24 hours of restraint usage and that the deaths had not been reported to CMS by the next business day.

Based on observation and interviews with staff (EMP), it was determined that the facility failed to ensure that medications located on the crash carts throughout the facility were secured.

Findings include:

A tour of the nursing units revealed that throughout the facility the medications required for use during a cardiac arrest were maintained in tackle boxes located on the top of the crash cart. Further observation revealed that these tackle boxes were not securely attached to the crash cart.

An interview conducted on September 14, 2011, with EMP5 confirmed that the medication boxes were not securely fashioned and could easily be removed by unauthorized personnel. Further interview with EMP5 revealed that the facility did not have a policy to address the securing of the medication boxes.

Based on a review of facility policy, observation, and interview with staff (EMP), it was determined that the facility failed to properly label irrigation solution placed in the warming cabinet.

Findings include:

A review on September 14, 2011, of facility policy: "Warming of Intravenous and Irrigation Fluids," last reviewed May 7, 2011, revealed: " ... When placing fluids in the warmer, label the solution container with new expiration date/time. New expiration date is 14 days from date/time placed in the warmer ... "

Observation on September 14, 2011, of the sub-sterile C-Section OR revealed a fluid warming cabinet that contained 17 bottles of 1000 cc normal saline and 14 bottles of 1000 cc 0.9% normal saline that were not labeled or dated with an expiration date.

An interview conducted on September 14, 2011, at 2:00 PM with EMP6 confirmed that the 17 bottles of 1000 cc normal saline and 14 bottles of 1000 cc 0.9% normal saline were not labeled or dated with an expiration date.