HospitalInspections.org

Based on review of facility policy, medical record review, observations, and interviews, the facility failed to obtain a physician's order for the use of physical restraints for two patients (#1 and #19) of 6 patients reviewed for restraints of 30 patients surveyed.

The findings included:

Review of facility policy titled "Restraint/Protective Devices" dated 6/2019, revealed "...The use of physical restraints requires written authorization of the physician/provider or his or her licensed independent designee who has conducted a face to face physical assessment of the patient prior to writing the order...The order duration may not exceed one (1) calendar day..."

Medical record review revealed Patient #1 was admitted to the Emergency Department (ED) on 6/2/19 at 5:35 AM for complaint of low blood sugar and unresponsiveness. Continued review revealed the patient had history of a stroke with right sided weakness. Further review revealed on 6/2/19 at 8:25 AM the patient was admitted to the facility as an inpatient. Continued review revealed the patient was assessed on 6/2/19 at 10:23 AM as "...awake, alert, and oriented to date place and person...Fall Risk Total: 15 [indicates a high risk for falls]..." Continued review revealed on 6/2/19 at 5:19 PM Patient #1 was moved to Medical Admission Unit (MAU) (a unit within the ED for patients waiting on an inpatient bed). Further review revealed no documentation of a physician's order for the use of restraints and no documentation a self-releasing abdominal belt or any other type of physical restraint was applied to Patient #1.

Telephone interview with Patient #1's wife on 6/20/19 at 8:30 AM revealed the morning of 6/3/19 and she found the patient restrained with a strap across him waist and chest. Continued interview revealed "....he was on his back with this jacket on him that was tied at all 4 corners...he could not release it by himself...his good arm [left arm] [the patient had right arm weakness related to history of a stroke] was inside the strap and he could not use it to get free from the restraint...he was not even able to scratch his nose if it itched..." Continued interview revealed a nurse removed the restraint when she insisted she remove it. Further interview revealed Patient #1 was unable to release the restraints because of the patient was unable to use his right arm and his left arm was inside the restraint.

Interview with Registered Nurse (RN) #1 on 6/19/19 at 7:25 AM, in the ED training room, revealed RN #1 remembered caring for Patient #1 in the Medical Admissions Unit (MAU) on 6/2/19. Continued interview revealed Patient #1's bed alarm was going off frequently and RN #1 applied a self-releasing abdominal belt to Patient #1 on 6/2/19 to prevent the patient from falling out of bed. Further interview revealed the nurse did not document the use of the belt or the patient's behaviors, conditions, or symptoms that required the use of the belt. Continued interview revealed a physician's order was not obtained because the abdominal belt had Velcro on the front, which the patient could release himself and was not considered a restraint.

Interview with RN #2 on 6/19/19 at 7:45 AM, in the ED training room, revealed RN #2 assisted RN #1 with the application of the self-releasing abdominal belt on Patient #1 during the night shift on 6/2/19. Further interview revealed the abdominal belt was applied to prevent the patient from falling out of his bed. Continued interview revealed there was no physician's order required for the use of the self-releasing belt, because the belt was not a restraint since the patient could release it himself.

Interview with the ED Director on 6/19/19 at 4:00 PM, in the ED Director's office, confirmed there was no physician's order for the abdominal belt for Patient #1. Continued interview confirmed an order was not needed for a self-releasing abdominal belt if the patient was able to remove it himself.

Medical record review revealed Patient #19 was admitted to the Intensive Care Unit (ICU) on 5/26/19 with diagnoses of Biliary Pancreatitis, Cholelithiasis, Left Lower Lobe Pneumonia, Urinary Tract Infection, Atrial Fibrillation, and First Degree Heart Block. Continued medical review revealed the patient was in soft wrist restraints daily from 5/26/19 until 6/19/19. Further review revealed there was no physician's order for the soft wrist restraints on 6/5/19, 6/6/19, 6/7/19, 6/8/19, 6/9/19, and 6/10/19, 6/17/9, 6/18/19, and 6/19/19 (9 days).

Observation of Patient #19 on 6/19/19 at 4:45 PM, in the patient's room, revealed the patient had mittens of both hands and soft wrist restraints on both wrists.

Interview with the Risk Manager on 6/19/19 at 4:45 PM, in the patient's room, confirmed Patient #19 was restrained with mittens on both hands and soft wrist restraints on both wrists.

Interview with the Risk Manager on 6/19/19 at 5:00 PM, in the Administration Conference Room, confirmed all restraints must be reordered by a physician daily. Continued interview revealed there was no physician's order for Patient #19's restraints on 6/5/19, 6/6/19, 6/7/19, 6/8/19, 6/9/19, and 6/10/19, 6/17/9, 6/18/19, and 6/19/19 and all restraints must be ordered by a licensed provider prior to being applied and restraint orders.

Based on review of facility policy, medical record review, observations, and interviews, the facility failed to document the condition or symptoms for use of a physical restraint for 1 patient (#1) of 6 patients reviewed for restraints of 30 patients surveyed.

The findings included:

Review of facility policy titled "Restraint/Protective Devices" dated 6/2019, revealed "...The use of physical restraints requires written authorization of the physician/provider or his or her licensed independent designee who has conducted a face to face physical assessment of the patient prior to writing the order...The order duration may not exceed one (1) calendar day..."

Medical record review revealed Patient #1 was admitted to the Emergency Department (ED) on 6/2/19 at 5:35 AM for complaint of low blood sugar and unresponsiveness. Continued review revealed the patient had history of a stroke with right sided weakness. Further review revealed on 6/2/19 at 8:25 AM the patient was admitted to the facility as an inpatient. Continued review revealed the patient was assessed on 6/2/19 at 10:23 AM as "...awake, alert, and oriented to date place and person...Fall Risk Total: 15 [indicates a high risk for falls]..." Continued review revealed on 6/2/19 at 5:19 PM Patient #1 was moved to Medical Admission Unit (MAU) (a unit within the ED for patients waiting on an inpatient bed). Further review revealed no documentation the patient had exhibited any behaviors of conditions that required the use of a restraint and no documentation a self-releasing abdominal belt or any other type of restraint was applied to Patient #1.

Telephone interview with Patient #1's wife on 6/20/19 at 8:30 AM revealed the morning of 6/3/19 and she found the patient restrained with a strap across him waist and chest. Continued interview revealed "....he was on his back with this jacket on him that was tied at all 4 corners...he could not release it by himself...his good arm [left arm] [the patient had right arm weakness related to history of a stroke] was inside the strap and he could not use it to get free from the restraint...he was not even able to scratch his nose if it itched..." Continued interview revealed a nurse removed the restraint when she insisted she remove it. Further interview revealed Patient #1 was unable to release the restraints because of the patient was unable to use his right arm and his left arm was inside the restraint.

Interview with Registered Nurse (RN) #1 on 6/19/19 at 7:25 AM, in the ED training room, revealed RN #1 remembered caring for Patient #1 in the Medical Admissions Unit (MAU) on 6/2/19. Continued interview revealed Patient #1's bed alarm was going off frequently and RN #1 applied a self-releasing abdominal belt to Patient #1 on 6/2/19 to prevent the patient from falling out of bed. Further interview confirmed the nurse did not document the use of the belt or the patient's behaviors, conditions, or symptoms that required the use of the belt.

Refer to A-0168.

Based on policy review, staffing schedule review, and interviews, the facility failed to ensure adequate numbers of licensed nurses staff the Emergency Department (ED) on 1 day (6/2/19) of 20 days reviewed during the period of 6/1/19 - 6/20/19.

The findings included:

Review of the facility's policy titled "Baroness Hospital Emergency Department Scope of Services" revised on 10/2018, revealed "...A nurse to patient ratio goal of 4 [patients] to 1 [nurse], based on patient acuity, is the staffing goal for patients being treated in the emergency department..."

Review of the ED Staff Assignment sheet dated 6/2/19 revealed the Medical Admissions Unit (MAU) (unit within the ED for admitted patients waiting on an inpatient bed and staffed by ED personnel). Further review revealed the MAU had 17 patients and was staffed by 2 Registered Nurses (RN) (8.5 patients per nurse) during the 7:00 PM to 7:00 AM shift. Continued review revealed no documentation any additional staff was assigned to the MAU.

Interview with RN #1 on 6/19/19 at 7:25 AM, in the ED training room, revealed RN #1 worked in the MAU on 6/2/19, remembered the MAU had 17 patients, and RN #1 and RN #2 were the only staff assigned to the MAU during the 7:00 AM to 7:00 PM shift. Further interview revealed the main ED was extremely busy that night and RN #1 had to leave the MAU multiple times to assist in the main ED with the treatment of critical patients; leaving RN #2 alone in the MAU with 17 patients. Continued interview revealed "...we were overcrowded...extremely busy...I had to help with a code [resuscitation of a patient] over in the ED...there were just two nurses in the MAU for 17 patients...we were short of staff [that night]...we are short of staff often..." Further interview revealed the RN was unable to document in patients' medical records because "...I was too busy to document..."

Interview with RN #2 on 6/19/19 at 7:45 AM, in the ED training room, revealed RN #2 worked in the MAU on 6/2/19. Continued interview revealed on 6/2/19 the MAU had 17 patients with RN #1 and RN #2 the only staff assigned to the MAU during the 7:00 AM to 7:00 PM shift. Further interview revealed "...it was just the two [RN #1 and RN #2] of us...we were short of staff...we needed 3 people in the MAU..."

Interview with the ED Director on 6/19/19 at 4:00 PM, in the ED Director's office, confirmed on 6/2/19 there were only 2 nurses assigned to the MAU during the 7:00 AM to 7:00 PM shift. Continued interview revealed the staffing goal for the MAU was for 6 patients to 1 nurse and when the MAU was full (17 patients) 3 licensed staff was needed to be adequately staffed. Further interview confirmed the MAU was not adequately staffed on 6/2/19 with 2 licensed staff and 17 patients.

Refer to A-0168.