HospitalInspections.org

Based on medical record review and document review, restraints were not implemented in accordance with hospital policy in the Emergency Department (ED) as evidenced by failure to assess, evaluate and document restraint use for 2 of 4 patients (Patient # 10 and 16).

Findings Include:

Review of policy "Restraints- Acute Medical Surgical" last revised 10/10 revealed orders for the use of restraints shall be dated and timed; include a specific reason for the restraint, the type of restraint and a specific limited period of time for use. Patients will be monitored minimally every 30 minutes. A registered nurse must assess the patient immediately after restraint application and then every two hours. Documentation shall include: orders, alternatives to restraints, type of restraint, plan of care, patient/family education, results of patient monitoring/assessments and significant changes in the patient's condition. Discontinuation of restraints and the patient's behavior reflecting improvement supporting discontinuation shall be documented and the plan of care revised accordingly.

Review on 2/8/12 of the ED initial assessment nursing note dated 1/22/12 at 2226 for Patient #10 revealed the patient was agitated and restrained for safety due not following commands and thrashing in bed. Haldol was given with minimal effect. No evidence of a physician order, nursing restraint record or nursing assessments for restraints was found in the ED record.

Review on 2/8/12 of the ED medical record for Patient # 16 revealed the following:
- An order for 4 point restraints was written on 1/23/12 at 1952.
- The nursing restraint record which lists physician orders, attempted alternatives, behavior requiring restraints, type of restraint and health teaching is blank.
- Review of the nursing assessment for restraints dated 1/23/12 at 1845 indicates restraints were applied correctly and circulation/comfort was checked off. Patient #16's behavior is listed as "yelling" and response is "tolerating." No evidence of additional nursing documentation related to continued use and/or release of restraints and nursing assessments/ safety checks were found in the medical record while the patient was housed in the ED.

Based on medical record review and documentation review, the QAPI program did not ensure ongoing and continual assessment of the medical care provided by emergency services as evident by failure to implement corrective actions for identified issues with radiology services.

Findings Include:

Review of the M&M summary/QI report dated 11/23/11 revealed the following "Patient #1 was diagnosed with clavicle and humerus fractures and discharged home. He returned with shortness of breath and chest pain 2 days later and was diagnosed with multiple rib fractures and a hemothorax. Patient #1 was admitted to trauma. No poor outcome but the care could be improved by documenting study reads on the chart and in PACS. The ED reads of the studies were not documented on the chart or in PACS. Additionally, there was no evidence of a radiology read on the chest x-ray obtained on 10/14/11 until 10/17/11."

The facility determined there was not a poor outcome, however, the patient returned to the ED on 10/16/11 and was diagnosed with rib fractures and hemothorax status post fall. The patient was admitted to the intensive care unit and required intubation and chest tube insertion. There is no evidence to indicate the facility addressed the identified issues related to the delay in radiology interpretation of the films obtained on 10/14/11.

Based on medical record review and documentation review, the facility did not ensure the integration of emergency services with radiology services as evident by the delay in the interpretation of radiological films for Patient #1. This delay resulted in a failure to meet the standard of care.

Findings Include:

Review of the Emergency Department (ED) physician face sheet pages 1 & 2 revealed Patient #1 arrived on 10/14/11 at 2027 and was triaged at 2032 after falling down 3 steps at home at 1830 and landing on his back. An orthopedic consult and x-rays of the chest, left clavicle, left humerus and left shoulder were ordered. He was diagnosed with a left clavicle/humerus fracture. The patient was discharged and instructed to follow up with the physician within 7-10 days.

Review of the physician order sheet for Patient #1 dated 10/14/11 revealed at 21:59 x-rays of the left clavicle, humerus and shoulder were ordered. At 23:12 a portable chest x-ray was ordered.

Review of the ED physician face sheet dated 10/16/11 revealed Patient #1 returned to the ED on 10/16/11 with increased shortness of breath. Following an evaluation the patient was diagnosed with rib fractures and hemothorax status post fall and admitted to the intensive care unit.

Review of the portable chest x-ray for Patient #1 obtained on 10/14/11 at 2312 revealed the films were not interpreted until 10/17/11 at 0816. The interpretation revealed a left sided pleural based density. In light of the history of trauma may represent loculated hemorrhage within the pleural cavity. Pulmonary congestion noted. Follow-up x-ray of the chest is suggested until resolution of pleural based density.

The case was reviewed by an independent physician reviewer. This review concluded that the standard of care for Patient #1's 10/14/11 ED visit was not met due to the failure to address the abnormal chest x-ray, which in an elderly patient status post fall suspected of a loculated hemorrhage in the pleural cavity could have led to further observation or additional imaging studies prior to discharge

There was no evidence to indicate the chest x-ray obtained on 10/14/11 was reviewed by the ED physician prior to the patient's discharge on 10/15/11. In addition, there was a delay in radiology review of the the films, which if read could have led to further observation or additional imaging studies prior to discharge.