HospitalInspections.org

Based on a review of hospital documentation, employee files, policies, and interviews for 25 of 30 employee files reviewed, the hospital failed to ensure background checks were completed prior to employees having access to patients and patient information in accordance with hospital policy. The findings include:

On 5/3/23, thirty (30) employee files were reviewed with the Director of Human Resources and Human Resource Staff Member #1. It was determined that 25 newly hired employees did not have criminal background checks completed prior to working, and the employees had direct access to patients and/or patient information. The employees included 6 Medical Assistants (Employees #220, 221, 223, 224, 225), 2 Patient Observers (Employees #226, 227), 1 Respiratory Therapist (Employee #228), 1 Cardiac Nursing Clinician (Employee #229), 2 Security Guards (Employees #230, 231), 1 Accounts Payable (Employee #232), 1 Customer Service Agent (Employee #233), 1 Registration Specialist (Employee #234), 1 Ultrasonographer (Employee #235), and 8 Medical Receptionists (Employees #236, 237, 238, 239, 240, 241, 242, 243).

Interview with the Director of Human Resources and Human Resource Staff Member #1 on 5/3/23 at 9:15 AM identified that a new temporary worker submitted the background checks for the 25 employees but did not receive the results prior to the employees working, and should have.

Interview with the Director of Performance Improvement on 5/3/23 at approximately 8:45 AM identified that the background checks should have been completed prior to the employees starting work.

The hospital policy for Employment Procedure identified in part, that job offers were contingent upon successful completion of background checks.

Based on clinical record reviews, review of hospital policies, and interviews for four of five patients who were restrained (Patients #202, 203, 221 and 222), the hospital failed to ensure that specific patient behaviors were documented every 15-minutes to assess for restraint discontinuation at the earliest possible time. The findings include:


a. Patient #202 was admitted to the Emergency Department (ED) on 4/24/23 at 4:23 PM with a diagnosis of seizures. A physician's note dated 4/24/23 at 6:13 PM described the patient as being combative on 3 separate occasions. Physician orders dated 4/24/23 at 6:14 PM directed the patient to be placed in 4-point soft restraints for a danger to self and others as evidenced by biting, kicking, and punching. Patient #202 remained in restraints from 6:14 PM to 8:44 PM (2 hours and 30 minutes). Review of the clinical record with the Assistant Director of the ED on 5/1/23 at 9:30 AM noted that the electronic record lacked documentation of specific patient behaviors every 15-minutes that necessitated the ongoing need for restraints during the 2 hours and 30 minutes that the patient was restrained.

b. Patient #203 was admitted to the ED on 4/29/23 at 7:53 PM with a diagnosis including Suicidal Ideation. A Nurses note dated 4/29/23 at 7:59 PM identified the patient as combative, screaming, yelling, cursing, and making verbal threats, as well as attempting to assault hospital security staff. A physician's order dated 4/29/23 at 7:58 PM directed the patient to be placed in 4-point soft restraints. Patient #203 was in restraints from 7:58 PM through 9:43 PM (1 hour and 45 minutes). Review of the clinical record with the Assistant Director of the ED on 5/1/23 at 9:30 AM noted that the electronic record lacked documentation of specific patient behaviors every 15-minutes that necessitated the ongoing need for restraints during the 1 hour and 45 minutes that the patient was restrained.

c. Patient #221 was admitted to the hospital on 2/6/23 with a hypertensive emergency. The admission history and physical dated 2/7/23 identified Patient #221 spoke Creole and required an interpreter (daughter). Nursing documentation dated 2/9/23 at 1:58 AM indicated Patient #221 was assaultive, aggressive, hostile, pulling at lines and tubes, thrashing and was unable to follow instructions.

Review of the physician orders and Medication Administration Record (MAR) dated 2/9/23 noted Ativan 0.5 milligrams (mg) intravenously (IV) was administered as ordered at 1:53 AM. The physician order dated 2/9/23 at 1:58 AM directed 4-point soft locked restraints (bilateral wrists and ankles). The physician's order and MAR dated 5/9/23 identified Haldol 2mg IV was administered at 2:46 per the physician's order.

Nursing assessment treatment documentation dated 2/9/23 noted Patient #221 was thrashing, yelling, unable to follow safety instructions, and 4-point restraints were in place at 1:58 AM. The physician assessed Patient #221 at 1:59 AM and documented the patient continued to require violent restraints. Physician and nursing assessments dated 2/9/23 identified an interpreter was utilized at the beginning of the restraint application but was unsuccessful because the patient was disoriented.

Nursing assessment treatment records for restraints dated 2/9/23 by the RN or Patient Care Assistant (PCA) lacked monitoring or safety check documentation for 2:15 AM, 2:30 AM, 2:45 AM and 3:00 AM. Review of the every 15-minute nursing assessments dated 2/9/23 at 3:14 AM, 3:29 AM, 3:44 AM, 3:58 AM identified the patient with a thrashing behavior and urinary incontinence. Every 15-minute nursing assessment documentation dated 2/9/23 from 4:13 AM to 8:28 AM noted Patient #221 was constantly punching (even though the patient was in 4-point restraints) and a urinary catheter was in place. Restraints were discontinued at 8:43 AM on 2/9/23.

Review of the electronic documentation for restraints and interview with the Director of Performance Improvement on 5/3/23 at 10:15 AM noted nursing staff were documenting the behavior that required the restraint use and were not consistently documenting the "restraint behavior description" which was a "free text" area to document the current behavior exhibited by the patient. Nursing staff failed to accurately monitor/document the patient's exhibited behavior to ensure restraints were discontinued at the earliest possible time.

d. Patient #222 was brought to the ED on 4/5/23 at 5:22 PM in police custody and in handcuffs and was admitted with a diagnosis of intoxication. Nursing narratives dated 4/5/23 indicated Patient #222 was swinging at staff and police, threatening to hit staff and police, could not be verbally deescalated, and was placed in 4-point restraints with a sitter.

RN restraint documentation dated 4/5/23 at 5:31 PM noted 4-point soft locked restraints were initiated per the physician's order dated 4/5/23 at 5:32 PM. Although Patient #222 was monitored by the nurse at 5:46 PM, 6:01 PM, 6:16 PM, 6:31 PM and 6:46 PM, the patient's behavior that warranted the continued use of the restraint was not documented. Nursing documentation identified restraints were discontinued at 7:01 PM when the RN documented an assessment of the patient's behavior as no longer exhibiting physical abuse to others.

Safety checks performed by the Patient Care Associate every 15-minutes or sooner dated 4/5/23 from 5:32 PM to 7:02 PM lacked documentation of patient behaviors.

The clinical record lacked documentation that Patient #222's behaviors warranted the continued use of the restraints or whether the restraints could have been discontinued at an earlier time.

The hospital policy entitled Restraint and Seclusion revised 2/2023 identified that safety checks are completed every fifteen minutes while in restraints and should include the behaviors necessitating the continued use of the restraint. Restraint or seclusion must be discontinued at the earliest possible time. The policy further directed the nurse to monitor behaviors necessitating the continued use of restraints every two hours. However, the policy direction for every two-hour behavioral monitoring rather than more frequent behavioral monitoring would not ensure the patient was removed from restraints at the earliest possible time.


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