HospitalInspections.org

Based on clinical record review, policy and procedure review, and interview, it was determined the facility failed to ensure a physician's order was obtained for restraints for two (#5 and #6) of five (#4-#8) patients in restraints and failed to ensure an order for restraints was obtained within one hour of implementation per the facility's established policy and procedure for two (#7 and #8) of five (#4-#8) patients in restraints. Failure to obtain a physician's orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints. The failed practice had the potential to affect any patient in restraints. Findings included:

A. Review of the facility's policy titled, "use of Emergency Safety Interventions/Restraints and Seclusion," with a revision date of June 2013 showed the Registered Nurse must have obtained a physician order prior to initiation of seclusion and a Registered Nurse may have initiated the use of a personal restraint before a physician's order was obtained, however, the order must be obtained within one hour of initiation of the procedure. The findings were confirmed in an interview with the Nursing Supervisor and the Corporate Compliance Specialist on 11/17/17 at 11:05 AM.
B. Review of Patient #4's clinical record on 11/17/17 showed the patient was placed in seclusion on 11/09/17 from 1:50 PM to 2:30 PM. There was no evidence of a physician's order for the seclusion. The findings were confirmed in an interview with the Nursing Supervisor on 11/17/17 at 11:05 AM.
C. Review of Patient #6's clinical record on 11/17/17 showed the patient was placed in a restraint on 11/11/17 from 3:40 PM to 3:41 PM. There was no evidence of a physician's order for the restraint. The findings were confirmed in an interview with the Corporate Compliance Specialist on 11/17/17 at 12:05 PM.
D. Review of Patient #7's clinical record on 11/17/17 showed the patient was in a restraint on 11/14/17 from 10:30 AM to 10:40 AM. The physician's order for the restraint was not obtained until 11/14/17 at 12:46 PM. The findings were confirmed in an interview with the Corporate Compliance Specialist on 11/17/17 at 11:20 AM.
E. Review of Patient #8's clinical record on 11/17/17 showed the patient was in a restraint on 11/14/17 from 11:30 AM to 11:45 AM. The physician's order for the restraint was not obtained until 11/14/17 at 1:05 PM. The findings were confirmed in an interview with the Corporate Compliance Specialist on 11/17/17 at 11:35 AM.

Based on staffing assignment reports review, policy and procedure review, and interview, it was determined the facility failed to ensure two (Unit One and Unit Two) of four (Unit One, Unit Two, Unit Three and Unit Four) patient care areas were staffed with licensed personnel (Registered Nurse and/or Licensed Practical Nurse) per the facility's established policy and procedure for 10 (from 11/03/17 to 11/13/17) of 38 (from 11/01/17 to 11/13/17) nursing shifts reviewed. Failure to staff per the facility's established policy and procedure placed the patients at risk of not receiving the care required based on the patient's needs. The failed practice had the potential to affect all patients receiving care on Unit One and Unit Two. Findings included:

A. Record review of the facility's policy titled, "Staffing Policy," with a revision date of April 2012 showed there was to be a ratio of at least one nurse (Registered Nurse or Licensed Practical Nurse) for every 12 patients during waking hours hospital-wide. The findings were confirmed in an interview with the Administrator on 11/15/17 at 2:30 PM.
B. In an interview with the Administrator on 11/15/17 at 1:40 PM, she stated there was a common nursing station for Unit One and Unit Two. She stated the nursing staff was shared for Unit One and Unit Two. She stated Unit One had a 16 bed capacity and Unit Two had a 20 bed capacity.
C. Review of the staffing assignment reports from 11/01/17 to 11/13/17 showed the following:
1) On 11/03/17 from 3 PM to 11 PM there were 14 patients on Unit One and 17 patients on Unit Two for a total of 31 patients. One Registered Nurse (RN) was listed to have worked on Unit One and one RN was listed to have worked on Unit Two.
2) On 11/04/17 from 7 AM to 7 PM there were 16 patients on Unit One and 20 patients on Unit Two for a total of 36 patients. One RN was listed to have worked on Unit One and one RN (along with the RN listed for Unit One) was listed to have worked on Unit Two.
3) On 11/04/17 from 7 PM to 7 AM there were 13 patients on Unit One and 20 patients on Unit Two for a total of 33 patients. Two RN's were listed to have worked on Unit Two and no RN's were listed to have worked on Unit One.
4) On 11/05/17 from 7 AM to 7 PM there were 15 patients on Unit One and 20 patients on Unit Two for a total of 35 patients. Two RN's were listed to have worked on Unit One and the same RN's were listed to have worked on Unit Two.
5) On 11/05/17 from 7 PM to 7 AM there were 15 patients on Unit One and 20 patients on Unit Two for a total of 35 patients. Two RN's were listed to have worked on Unit Two and no RN's were listed to have worked on Unit One.
6) On 11/06/17 from 3 PM to 11 PM there were 16 patients on Unit One and 20 patients on Unit Two for a total of 36 patients. Two RN's were listed to have worked on Unit One and no RN's were listed to have worked on Unit Two.
7) On 11/11/17 from 7 AM to 7 PM there were 16 patients on Unit One and 20 patients on Unit Two for a total of 36 patients. Two RN's were listed were listed to have worked on Unit One and the same RN's were listed to have worked Unit Two.
8) On 11/11/17 from 7 PM to 7 AM there were 14 patients on Unit One and 20 patients on Unit Two for a total of 34 patients. Two RN's were listed to have worked on Unit Two and no RN's were listed to have worked on Unit One.
9) On 11/12/17 from 7 AM to 7 PM there were 14 patients on Unit One and no number was listed for the number of patients on Unit Two. In an interview with the Administrator on 11/15/17 at 2:30 PM she confirmed there were 20 patients on Unit Two for a total of 34 patients. There was no evidence as to who worked on 11/12/17 from 7 PM to 7 AM.
10) On 11/13/17 from 3 PM to 11 PM there were 12 patients on Unit One and 17 patients on Unit Two for a total of 29 patients. One RN was listed to have worked on Unit One and one RN was listed to have worked on Unit Two.
D. The findings of C were confirmed in an interview with the Administrator on 11/15/17 at 2:30 PM. She confirmed the staffing ratio provided did not meet the requirement of the facility's established policy and procedure.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to ensure a Registered Nurse completed an initial admission assessment within four hours per the facility's established policy and procedure for two (#9 and #13) of seven (#9-#15) records reviewed for initial admission assessments. The failed practice did not allow for a baseline assessment of the patient's needs and had the potential to affect all patients admitted to the facility. Findings included:

A. Review of the facility's policy titled, "Assessment Procedures - Inpatient," with a revision date of March 2017 showed the nursing assessment was to be completed by a Registered Nurse within four hours of admission. The findings were confirmed in an interview with the Corporate Compliance Specialist on 11/16/17 at 3:35 PM.
B. Review of Patient #9's clinical record on 11/16/17 showed the patient was admitted to the facility on 11/11/17 at 6:19 PM. The MBH (Methodist Behavioral Hospital) Inpatient - Nursing Assessment was signed on 11/14/17 at 8:54 AM. In an interview with the Corporate Compliance Specialist, Nursing Supervisor and the Health Information Manager on 11/16/17 at 3:20 PM, they confirmed the initial Registered Nurse admission assessment had not been completed within four hours of the patient's admission.
C. Review of Patient #13's clinical record on 11/17/17 showed the patient was admitted to the facility on 11/11/17 at 1:31 PM. The Methodist Family Health - Nursing Assessment was signed on 11/14/17 at 8:51 AM. In an interview with the Corporate Compliance Specialist on 11/17/17 at 9:45 AM, he confirmed the initial Registered Nurse admission assessment had not been performed with four hours of the patient's admission.