HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patients reviewed for restarints usage, the Hospital failed to ensure a physician's order was obtained for restraints.

Findings include:

1. The Hospital's policy titled, "Use of Restraints (2/27/2020)" was reviewed on 1/5/2020 and included, "Restraint is the direct application of physical force to a patient ... to restrict his or her freedom of movement ... that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. ... Determination if a device is a restraint: Not considered - Any device that can be easily removed intentionally by the patient in the same manner as it was applied by staff ... A licensed practitioner must provide an order [for restraint usage]."

2. The clinical record of Pt. #1 was reviewed on 1/4/2021. Pt. #1 was admitted 11/6/2020 with the diagnosis of Intracranial Hemorrhage (brain bleed).

-The History and Physical, dated 11/7/2020 at 1:12 PM, included that Pt. #1 had severe left sided paresis (weakness) and right sided neglect, requiring comprehensive rehabilitation.

- The Physical Therapy assessment, dated 11/7/2020, included that Pt. #1 was a maximum assist of 1-2 staff for all activities of daily living (bathing, eating, dressing, transferring). Pt. #1 was unable to ambulate and required the use of a wheelchair for all out of bed activities.

-The nursing (E#1) assessment of Pt. #1 on 12/5/2020 at 5:07 PM included, "Fall risk - Mental status impaired - forgets limitations."

- Pt #1's clinical record lacked a physician's order for a seatbelt alarm as a restraint.

-The nurse's notes, dated 12/5/2020, did not have any restraint usage documented.


3. The Registered Nurse (E#1), who cared for Pt. #1 on 12/5/2020, was interviewed on 1/5/2020 at 1:00 PM. E#1 stated that Pt. #1 had a seat belt alarm on and it was not intended as a restraint. However, E#1 was not sure if Pt. #1 could easily remove it on his own.

4. The Chief Nursing Officer (E#4) was interviewed on 1/5/2020 at 10:40 AM. E#4 stated, "The seat belts are self-releasing, so are not considered a restraint. Unless, the patient is not able to physically release or is not cognizant enough to release the belt, then it is considered a restraint and an order should be obtained."

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) patients with a Hand Off Transfer/Therapy order, the Hospital failed to ensure that nursing staff followed a physicians order.

Findings include:

1. The Job Description for Registered Nurses was reviewed on 1/5/2021 and included, "Implements physician orders".

2. The "Culture of Safety" staff education slides included, "Fall Bundles for high risk patients ... should consider HOT (Hand - off Therapy)."

3. The clinical record of Pt. #1 was reviewed on 1/4/2021. Pt. #1 was admitted 11/6/2020 with the diagnosis of Intracranial Hemorrhage (brain bleed). A physician's order, dated 11/30/2020 at 1:55 PM, included, "Hand off between staff only."

-A nurse's note (E#1), dated 12/5/2020 at 6:27 PM, included, "Patient [Pt. #1] fell at approximately 5:00 PM. Patient had previously been exhibiting confusion and upset, continuously attempting to get out of bed. Patient was yelling and very adamant upon returning to room after being placed in a wheelchair and hallway with staff for safety reasons."

-The post fall assessment, dated 12/5/2020 at 5:35 PM, included, "Fall witness: Unwitnessed fall."

4..The Registered Nurse (E#1), who cared for Pt. #1 on 12/5/2020, was interviewed on 1/5/2020 at 1:00 PM. E#1 stated, "I knew [Pt. #1] had a hand off order [not to leave alone when in the chair], but it couldn't have been more that 45 seconds as I walked towards the nurses' station. I truly don't know how [Pt. #1] got into the room that fast."

5. The Chief Nursing Officer (E#4) was interviewed on 1/5/2020 at 10:40 AM. E#4 stated that a patient will have a Hand Off Therapy (HOT) order when they are a higher risk for a fall. E#4 stated, "Usually the patient is impulsive or lacks judgement. Then the HOT is ordered, and the patient must remain in line of sight, with increased supervision. Patients should not be left alone when out of bed if a HOT has been ordered." E#4 stated that there is no policy specific to HOT orders, it is only referenced in other policies.