HospitalInspections.org

Based on hospital policy review, open and closed restraint medical record reviews and staff interviews nursing staff failed to monitor a patient restrained per the hospital policy in 2 of 3 patients restrained (#1, #10).

The findings include:

Review of hospital policy "Restrictive Interventions" revised April 2015 revealed "...VII. INTERVENTION...E. Monitor patient response to the restraint; assist patients to meet the criteria for discontinuation of restraint. F. Assessment/monitoring/patient care: non-violent non-self destructive restraint utilization 1. Assess and document safety, circulatory status, affect/behavior, and correct device application at initiation. 2. Assess and document the following every 2 hours: a. Safety, circulatory status, affect, behavior and correct device application b. Strategies to reduce or remove restrictive intervention c. Whether less restrictive methods or alternative strategies are now possible d. Does patient continue to meet criteria for restraint use e. Skin care, range of motion, assistance with food, hydration and elimination. i. Remove restraint device every 2 hours to provide skin care and ROM (range of motion) as indicated. ii. Provide toileting, nutrition, hydration every 2 hours while awake as indicated. iii. Temporarily release or take restraints off to care for patient's needs such as feeding, toileting, ambulation, out of bed, interaction with staff, etc. 3. Record patient assessment, including response/behavior while in restrictive interventions as part of on-going monitoring of the patient...H. Assess patient and discontinue restraint at the earliest possible time regardless of the length of the order...VIII. DOCUMENTATION...B. Document assessments and interventions on Restraint Order Form/Restraint Documentation Form."

1. Open medical record review of Patient # 1 revealed a 50 year old patient admitted on 06/18/2016 with a diagnosis of trauma related to motor vehicle crash, facial fractures, rib fractures, spinal fractures and pneumomediastinum. Record review revealed the patient was ordered to be restrained with soft wrist restraints to the right and left wrists on 06/20/2016. Review of restraint documentation on 06/20/2016 revealed documentation of restraint monitoring at 1000, 1800 (8 hours since last monitored). Record review revealed the patient was ordered to be restrained with soft wrist restraints to the right and left wrists on 06/28/2016. Review of restraint documentation on 06/28/2016 revealed documentation of restraint monitoring at 1000, 1300 (3 hours since last monitored).

Interview with nurse management staff on 07/14/2016 at 1130 revealed there was no further documentation available of every two hour assessment and monitoring of the patient while restrained on 06/20/2016 from 1000-1800 and on 06/28/2016 from 1000-1300. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every two hours while in restraints.

2. Closed medical record review of Patient # 10 revealed a 42 year old patient admitted on 05/16/2016 with a diagnosis of right AKA (above knee amputation) necrotizing fasciitis and sepsis and was discharged on 07/13/2016. Record review revealed the patient was ordered to be restrained with soft wrist restraints to the right and left wrists on 05/22/2016 at 2253. Review of restraint documentation on 05/23/2016 revealed documentation of restraint monitoring at 0000, 0600 (6 hours since last monitored), 2100, 0100 on 05/24/2016 (4 hours since last monitored). Record review revealed the patient was ordered to be restrained with soft wrist restraints to the right and left wrists on 05/23/2016 at 2300. Review of restraint documentation on 05/24/2016 revealed documentation of restraint monitoring at 0100, 0500 (4 hours since last monitored).

Interview with nurse management staff on 07/14/2016 at 1130 revealed there was no further documentation available of every two hour assessment and monitoring of the patient while restrained on 05/23/2016 from 0000-0600, on 5/23/2016 from 2100-0100 on 05/24/2016 and on 05/24/2016 from 0100-0500. Interview confirmed nursing staff failed to follow hospital policy to assess and monitor patients every two hours while in restraints.

Based on hospital policy review, medical record review and staff interview, the hospital failed to ensure that a discharge planning evaluation for a dialysis patient requiring life-sustaining treatments were communicated in 1 of 3 sampled dialysis patient medical records (#3).

The findings include:

Review of hospital policy "Discharge Planning" (Reviewed/Revised: 02/02/2015 / 02/2015) revealed "II. Summary: To identify, coordinate and transition to the most appropiate level of care. To help identify patients that could potentially need discharge planning. VII. Documentation: A. During the evaluation the Clinical Care Coordinator (CCC) , Outcomes Manager (OM), Social Worker (MSW) and/or Discharge Planner (DP) will address and document findings related to support systems, cognitive abilities, and functional level prior to admission, previous use of community resources and anticipated needs at discharge. B. The CCC/OM/SW/DP finalizes the discharge plan, makes the appropriate arrangements for any post acute needs and document in appropriate software tool."

Closed medical record review for patient #3 revealed a 45 year-old female who was admitted to the hospital on 04/29/2016 through 05/11/2016 with documented diagnoses of "ESRD (End Stage Renal Disease), Medical Noncompliance, HTN (Hypertension), Anemia secondary to kidney disease and Bacterial Peritonitis." Review of the patient's record revealed the patient initially received hemodialysis through a left-groin internal jugular PermCath (central line) for life sustaining treatment with her last documented treatment at the hospital on 05/03/2016. The documentation revealed the patient began refusing hemodialysis according to the hospital's medical staff and nursing staff after 05/03/2016 which complicated her treatments for her anemia and infection. Further documentation from the medical staff in the patient's discharge summary revealed "ESRD, she was on Tuesday-Thursday-Saturday schedule. She (Patient #3) has been refusing hemodialysis, nephrology has been following. Initially she fired __(Name of Nephrology Medical Group) and now she is not stable for outpatient HD (Hemodialysis). Nephrology and myself (Physician #1) have been discussing the patient with complications of hyperkalemia including the risk of cardiac arrhythmia as fluid overload and death which can be prevented with hemodialysis but patient understands the risk, she was evaluated by neuropsych and she was competent to make decisions, and she continues to refuse hemodialysis. She did not allow psychiatry to evaluate her. As there is no active treatment ongoing while the patient is in the hospital, at this point, I do not see any benefit in keeping her inpatient status. The patient continued to ask me for a "plan" for which I recommended inpatient dialysis and she refused. Given the fact that outpatient dialysis clinic is not willing to accept her and the risks of hyperkalemia/arrhythmia'death were explained to her as she often refused dialysis here as well as blood transfusions, palliative care as well as nephrology have spoken to with the ED who is aware she will be arriving MWF (Monday-Wednesday-Friday) around lunchtime to be evaluated/dialyzed."

Review of the medical record revealed initial discharge planning was done completed on the day of admission 04/29/2016 by the discharge planning staff. Continued review revealed further documentation for discharge planning was conducted 05/02/2016, 05/04/2016, 05/06/2016, 05/07/2016 and 05/11/2016 (day of discharge). The review revealed the documentation failed to indicate any plan for the patient's life-sustaining post-hospital hemodialysis treatments as discussed in the physician's documentation or any results of the discharge planning evaluation discussed with the patient or the patient's representative.

Interview on 07/13/2016 at 1315 with the facility's Director of Clinical Care Management (Discharge Planning) revealed that patient #3's discharge planning from 04/29/2016 through her discharge on 05/11/2016 did not have any documentation within the "Discharge Planning / Intervention (Notes)" from any of the discharge planners regarding the patient's post hospital plan for continuing her hemodialysis. The interview confirmed that the discharge planning staff should have documented the patient's plan for her outpatient hemodialysis treatment with documentation in her medical record to show it was communicated with her. The interview confirmed the medical record finding.

NC00117271.