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Based on interviews and document review, it was determined the facility staff failed to ensure the care plan was updated to address restraint use for 1 of 6 sampled patients that had restraints used while a patient at the facility (Patient #4).

The findings included:

Patient #4's care plan failed to address the use of restraints.

Review of Patient #4's clinical record revealed the following restraint order dated 11/1/15 at 5:37PM and renewed on 11/2/15 at 10:29 PM: "Restraint type: Soft Limb restraint ... Restraint reason: Interference with medical treatment". The aforementioned restraint order did not specify how many or which limbs were to be restrained.

During an interview with Employee #32 (a registered nurse) on 2/4/16 at 11:30 AM, Employee #32 confirmed the first documentation of Patient #4 having restraints in use was on 11/2/15 at 8:30 PM. This first documentation indicated the restraints were 'continued'. No documentation was found to indicate when the restraints were first applied; and no documentation was found of Patient #4's actions that resulted in the restraint order.

Employee #32, during an interview on 2/4/15 at 11:55 AM, reported that the documentation on 11/2/15 at 8:30 PM of the restraints being 'continued' does not detail if the restraints were started at that time or had been started earlier. No documentation of restraint monitoring could be found between the time of the initial physician order on 11/1/15 at 5:37 PM and the 11/2/15 at 8:30 PM restraint documentation that indicated the restraints were 'continued'.

On 2/4/16 at 12:01 PM, Employee #32 was asked for Patient #4's restraint care plan. Employee #32 stated there is a care plan that addresses patient safety but not a care plan that specifically includes the use of restraints.

Based on interviews and document review, it was determined the facility staff failed to ensure restraints were implemented in a safe manner for 1 of 6 sampled patients that had restraints used while a patient at the facility (Patient #5).

The findings include:

Patient #5's restraint monitoring documentation sheet contained information that indicated restraint types other than those ordered by the physician were an option to use for the patient.

Review of Patient #5's clinical record revealed physician orders for restraints for violent or self-destructive behavior beginning on 1/19/15 for 'mittens' due to 'danger to self'. Patient #5 had a current order for 'mittens' at the time of the surveyor review on 2/4/15. Clinical documentation indicated the only restraints applied for Patient #5 were 'mittens'.

The facility's policy and procedure entitled, Restraints and Restraint Alternatives, included the following information: "Assessment / Monitoring / Observation for Violent and/or Self-Destructive Behavior ... Patient observations and interventions are documented by the RN every 15 minutes, or sooner according to the patient's need ..."

Patient #5's clinical documentation included a 'RESTRAINT MONITORING' form which allowed for documentation every 15 minutes while restraints were in use. A section, of this form, entitled 'TYPE OF DEVICES:' was divided into four areas: least, more, increasingly, and most. Review of Patient #5's 'RESTRAINT MONITORING' forms revealed the following:
- On 1/30/16, the form included 'mittens' under the 'more' area of the 'TYPE OF DEVICES' section but also included limb restraints for left wrist, right wrist, left ankle, and right ankle under the 'most' area of the 'TYPE OF DEVICES' section. No orders for left wrist restraints, right wrist restraints, left ankle restraints, and right ankle restraints were found in the patient's clinical record.
- On 1/31/16, the form included 'mittens' under the 'more' area of the 'TYPE OF DEVICES' section but also included limb restraints for left wrist, right wrist, left ankle, and right ankle under the 'most' area of the 'TYPE OF DEVICES' section. No orders for left wrist restraints, right wrist restraints, left ankle restraints, and right ankle restraints were found in the patient's clinical record.
- On 2/3/16, the form included 'mittens' under the 'more' area of the 'TYPE OF DEVICES' section but also included limb restraints for left wrist and right wrist under the 'most' area of the 'TYPE OF DEVICES' section. No orders for left wrist restraints and right wrist restraints were found in the patient's clinical record.
- On 2/4/16, the form included 'mittens' under the 'more' area of the 'TYPE OF DEVICES' section but also included limb restraints for left wrist and right wrist under the 'most' area of the 'TYPE OF DEVICES' section. No orders for left wrist restraints and right wrist restraints were found in the patient's clinical record.

Based on staff interviews, electronic clinic record reviews and facility document review, it was determined the facility staff failed to ensure restraint orders were specific and/or obtained in a timely manner for five (5) of six (6) patients with restraint orders. (Patient #1, 4, 6, 7, and 9).

The findings were:

1. Patient #1's clinical record was reviewed by one surveyor with multiple facility-provided navigators throughout both 2/03/16 and 2/04/16. The record contained two orders for restraints, the first order was for 11/04/15 and the second order was for 11/08/15.

The 11/04/15 order read, "Restraint type: Soft Limb restraint" and "Restraint reason: Interference with medical treatment." No specific order for how many limbs to be restrained or which limbs to be restrained were found. A registered nurse's (RN) documented on 11/04/15 at 6:52 PM read in part, "Upper extremity restraints applied bilat [sic] to prevent pulling at NG [nasogastric] tube."

The 11/08/15 order read, "Restraint type: Siderail x [times] 4, Mitt (comment on location), Soft Limb restraint" and "Restraint reason: Removing Life sustaining equipment, Interference with medical treatment." There was no evidence the order addressed location or quantity for mitts or soft limb restraints. Nursing documentation noted left and right wrist restraints were applied. No documentation for siderail x 4 or mitts was found.

On 2/04/16 the facility provided different electronic clinical record navigators in addition to the navigators provided at the start of the complaint survey. One of the new navigators was a hospitalist/informatic physician (Employee #39). This physician assisted in looking for clarifying information related to Patient #1's aforementioned restraint orders. He/She acknowledged the clinical record did not contain more specific information as to exactly what each restraint order intended for the bedside staff to implement. The order from 11/04/15, "soft limb restraints" did not indicate which limbs or how many limbs to restrain. The order from 11/08/15 listed three (3) different forms of restraints - siderail x 4, mitts, and soft limb restraints. The physician acknowledged it was not clear whether the ordering physician was ordering all three forms of restraints or intended for the bedside nurse to have options as to which restraint to use. He/she acknowledged the electronic medical record did not provide evidence of any other restraint used other than two (2) wrist restraints. The physician stated that in his/her experience, restraint orders were used as infrequently as possible and the order usually followed a conversation between the bedside nurse and the responsible physician that included exactly what was necessary and the least restrictive. The physician acknowledged that since the restraint orders were not specific to which limbs or how many limbs, this required the bedside nurse to determine which restraints to use. The physician said that for as long as he/she had practiced at this facility, it was well known that restraints were never to be applied to all four limbs.

The facility's policy titled, "Restraints and Restraint Alternatives" was reviewed on 2/03/16 and 2/04/16. No definition of "soft limb restraints" was found. On 2/04/16, the facility's Chief Nursing Information Officer (Employee #38) acknowledged the policy did not define soft limb restraints or indicate that four (4) limb restraints were never to be applied.


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2. Observations of care and a review of the clinical record of Patient #6 took place in the early afternoon hours of 02/03/16. Patient #6 was observed to be ventilator dependant and to have soft wrist restraints in use to both the left and right wrists.

Patient #6's clinical record included documentation that he/she was admitted to the unit on 02/01/16 at 9:22 PM. The "Restraint Flow Sheet" contained documentation that the restraints were first applied at 10:00 PM on 02/01/16, and remained in use continuously from that point to the time of the observations on 02/03/16. The physician's order for the aforementioned restraints was documented as a verbal order obtained by the RN (Registered Nurse) on 02/01/16 at 11:44 PM which was 1 hour and 44 minutes after the restraints were documented as applied and in use. The physician order contained the following documentation:
"Order Date/Time" was listed as "02/01/16 11:44 PM"
"Release Date/Time" was listed as "None"
"Start Date/Time" was listed as "02/01/16 11:43 PM"
"End Date/Time" was listed as "02/02/16 11:42 PM"
"Restraint type" was listed as "Soft Limb restraint"
"Restraint reason" was listed as "Interference with medical treatment" and "Removing Life sustaining equipment."
The clinical record review failed to provide evidence the RN obtained the verbal order for the restraints applied to Patient #6 immediately (within a few minutes) after the restraint was applied. The physician's order for "Soft Limb restraint" failed to specify if the restraints were to be applied for one, two, three, or all four limbs (extremities).

During the review of Patient #6's clinical record, a discussion took place with Employee #34, the RN/Clinical Director of the unit. He/she stated that when a situation occurs where restraints are needed quickly for the safety of a patient and the physician is not present to provide an order, the RN may implement restraint use, and a verbal order is usually obtained immediately from the physician. The Clinical Manager stated he/she was "not sure" why the aforementioned order was delayed in being obtained for Patient #6.

See also #3 below, for findings related to a review of the facility's policy regarding restraints.

3. A review of the clinical record of Patient #9 took place in the early afternoon hours of 02/03/16. Patient #9 was observed to be ventilator dependant and to have soft wrist restraints in use to both the left and right wrists.

Patient #9's clinical record included documentation that he/she was admitted to the unit on 01/27/16. The "Restraint Flow Sheet" contained documentation that the restraints were first applied at 8:00 PM on 01/28/16, and remained in use continuously from that point to the time of the observations on 02/03/16. The physician's order for the aforementioned restraints was documented as a verbal order obtained by the RN (Registered Nurse) on 01/29/16 at 8:04 AM which was 12 hours and 4 minutes after the restraints were documented as applied and in use. The aforementioned order contained the following documentation:
"Order Date/Time" was listed as "01/29/16 08:04 AM"
"Release Date/Time" was listed as "01/29/16 08:04 AM"
"Start Date/Time" was listed as "01/28/16 08:00 PM"
"End Date/Time" was listed as "01/29/16 07:59 PM"
"Restraint type" was listed as "Soft Limb restraint"
"Restraint reason" was listed as "Interference with medical treatment" and "Removing Life sustaining equipment."
The clinical record review failed to provide evidence the RN obtained the verbal order for the restraints applied to Patient #9 immediately (within a few minutes) after the restraint was applied. The physician's order for "Soft Limb restraint" failed to specify if the restraints were to be applied for one, two, three, or all four limbs (extremities).

During the review of Patient #9's clinical record, a discussion took place with Employee #36, the RN/Clinical Director of the unit and Employee #37, a staff RN who was regularly assigned to the unit. Both the Clinical Director and the staff RN assisted the surveyor in the navigation of the electronic clinical record of Patient #9, in order to complete the record review. The Clinical Director stated the section of the orders labeled "Order Date/Time" would be the space documenting the time the order was either entered by the physician, or received by the nurse as a verbal order. The Clinical Director acknowledged the verbal order for restraints dated 01/29/16 and timed at 08:04 AM for Patient #9, documents a delay in obtaining that order of 12 hours and 4 minutes from the time the restraints were first applied. The Clinical Director stated he/she thinks there may be an issue with how the electronic order entry process occurs, resulting in a failure to clearly identify the actual dates and times which verbal orders were obtained. The Clinical Director acknowledged the restraint orders for "Soft Limb restraint" for Patient #9, failed to provide orders specific to which limbs (one, two, three, or all four) would be restrained.

The facility's policy titled "Restraints and Restraint Alternatives" was reviewed. The policy read (in part) on page 3 of 13 as follows:
"B. Orders for Non-Violent and/or Non-Self Destructive Behavior
1. The use of restraints must be ordered by a Licensed Independent Practitioner (LIP), unless the patient's RN determines that the need to restrain the patient is clinically justified and an LIP is not immediately available, in which case restraint procedures may be initiated.
NOTE: In this instance, the LIP must be notified and a telephone or written order must be obtained as soon as possible."
The aforementioned policy did not address how a clinician should implement an order for "Soft Limb restraint" and did not provide guidance or direction regarding which limbs/extremities (one, two, three, or all four) would be restrained when the order reads "Soft Limb restraint."


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4. Surveyor review of the clinical record for Patient #7 was completed on 2/4/16 with the assistance of a record navigator provided by the facility (Employee #10). Review of the clinical record revealed the following:

Patient #7 was admitted to the facility on 1/15/16, review of the clinical record revealed restraints were ordered daily from 1/15/16 through 1/19/16 and from 1/23/16 through 2/3/16. Restraint type was documented as "soft limb restraint" on each of the orders. No direction was found on the orders as to how many limbs were to be restrained. Review of the documentation related to restraints revealed soft restraints documented as being implemented on the left and right wrists.

Review of facility policy entitled "Restraints and Restraint Alternatives" failed to reveal a definition of "soft limb restraints" or guidance as to the number of limbs which would be restrained when receiving an order for "soft limb restraints".


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5. Patient #4's physician order for restraints failed to identify the specific number of limbs to be restrained; and Patient #4's restraint documentation, including restraint monitoring documentation, failed to match the time frames of when the restraint orders were given.

Review of Patient #4's clinical record revealed the following restraint order dated 11/1/15 at 5:37 PM and renewed on 11/2/15 at 10:29 PM: "Restraint type: Soft Limb restraint ... Restraint reason: Interference with medical treatment". The aforementioned restraint order did not specify how many or which limbs were to be restrained.

During an interview with Employee #32 (a registered nurse) on 2/4/16 at 11:30 AM, Employee #32 confirmed the first documentation of Patient #4 having restraints in use was on 11/2/15 at 8:30 PM. This documentation indicated that soft limb restraints were applied to both upper extremities. Employee #32 reviewed the order entry process with the surveyor; it was noted that the individual giving the order could enter comments in the order detailing which limb or limbs were to be restrained. On 2/4/16 at 12:08 PM, Employee #32 acknowledged the individual entering the restraint order did not provide details, in the order, as to which limb or limbs were to be restrained.

The facility's policy and procedure entitled, Restraints and Restraint Alternatives, included the following information: "Assessment / Monitoring for Non-Violent and/or Non-Self Destructive Behavior ... Patients restrained for medical/surgical reasons are assessed and monitored by the RN, at a minimum, every 2 hours, or more frequently based on clinical judgement, and according to the patient's need. The assessment is initiated at the onset of restraint use and documented in the EMR (electronic medical record)."

The first documentation that Patient #4 had restraints in use was dated 11/2/15 at 8:30 PM; this documentation indicated the restraints were 'continued'. No documentation was found to indicate when the restraints were first applied; and no documentation was found detailing Patient #4's actions that resulted in the aforementioned physician restraint order.

Employee #32, during an interview on 2/4/15 at 11:55 AM, reported that the documentation on 11/2/15 at 8:30 PM of the restraints being 'continued' does not detail if the restraints were started at that time or had been started earlier. No documentation of restraint monitoring could be found between the time of the initial physician order on 11/1/15 at 5:37 PM and the 11/2/15 at 8:30 PM restraint documentation that indicated the restraints were 'continued'. No documentation was provided to the surveyor to address the gap in time from when the physician first gave the restraint order on 11/1/15 at 5:37 PM to when the first documentation indicating Patient #4 had restraints were in use and 'continued' on 11/2/15 at 8:30 PM.

Based on staff interview, review of clinical records and facility documents, it was determined the physician failed to be in compliance with the facility's policy requirements for renewal orders for restraints for Patient #6, one (1) of five (5) patients sampled requiring renewal orders for restraints.

The findings were:

The survey sample included a review of six (6) patients for whom restraints were applied during their admission as an inpatient to the facility. Of those six (6) patients, one (1) patient's restraints were discontinued prior to requiring a renewal of the physician's order. The sample included five (5) patients with restraints in use for a length of time which would require renewal of the restraint order.

Observations of care and a review of the clinical record of Patient #6 took place in the early afternoon hours of 02/03/16. Patient #6 was observed by the Medical Facilities Inspector (MFI) to be ventilator dependant and to have soft wrist restraints in use to both the left and right wrists.

A review of Patient #6's clinical record revealed documentation that he/she was admitted to the unit on 02/01/16 at 9:22 PM. The "Restraint Flow Sheet" contained documentation that the restraints had been applied at 10:00 PM on 02/01/16, and had remained in use continuously from that point to the time of the MFI's observations on 02/03/16. The physician's order for the aforementioned restraints was documented as a verbal order having been obtained by the RN (Registered Nurse) on 02/01/16 at 11:44 PM. The order contained documentation that the order ended/expired on 02/02/16 11:42 PM. The clinical record review failed to provide evidence another order for the renewal of restraints until 02/03/16 at 5:47 AM. The record failed to contain evidence that orders for restraints were obtained for the calendar date of 02/02/16.

During the review of Patient #6's clinical record, a discussion took place with Employee #34, the RN/Clinical Director of the unit. He/she stated being unable to find evidence of an order for renewal of the restraints for 02/02/16.

The facility's policy titled "Restraints and Restraint Alternatives" was reviewed. The policy read, in part, on page 3 of 13 as follows:
"B. Orders for Non-Violent and/or Non-Self Destructive Behavior
4. A new order must be written by the LIP [Licensed Independent Practitioner] every calendar day after completing an in-person evaluation of the patient."

In an end of day discussion on 02/03/16, the facility's management team were made aware that a review of the clinical record failed to provide evidence of a renewal order for restraints for one patient. The CMO (Chief Medical Officer) stated the management team had arranged for some additional personnel to be onsite on 02/04/16, and stated those personnel to be individuals with expertise in navigating the EHR/Electronic Health Record.

On the afternoon of 02/04/16, the Manager of Informatics (Employee #35) was informed the record review of Patient #6, failed to provide evidence of a renewal order for restraints for the calendar day of 02/02/16. The Manager of Informatics searched the clinical record of Patient #6, and stated he/she was unable to find an order for renewal of restraints for 02/02/16 as well.

Based on a review of clinical records, facility documents, staff interviews and in the course of complaint investigation, it was determined the nursing staff failed to administer drugs and biologicals per physician's orders for Patient #8 and Patient #3, two (2) of ten (10) patients sampled.

The findings were:

1. A review of the clinical record of Patient #8 took place in the early afternoon hours of 02/03/16. The clinical record contained documentation that Patient #8 was admitted to the unit on 01/24/16 and remained a current in-patient on 02/03/16. The record contained documentation the patient had a stage 3 pressure ulcer, present upon admission to the facility. The record contained an order dated 01/24/16, for a "Consult to Wound Ostomy Continence Nurse." The record contained the wound nurse's consultation dated 01/25/16, and it included the findings of a "Stage 3 pressure ulcer to Left ischial skin; Clean wound bed. Approximately 5cmx3cmx1cm." The consult contained the wound nurse's "Plan" which included "Will begin silver alginate packing under foam dressing to L [left] ischial ulcer." [Note: Silver Alginate is a wound care product which has an antimicrobial effect, is highly absorbent, and is often used to treat wounds with infection and excessive drainage.]

The record included a physician's order, documented as a verbal order taken by the wound nurse (RN) on 01/25/15 at 9:46 AM. That verbal order documented the following physician's orders for wound care: "Cleanse L [left] ischial pressure ulcer with wound cleanser; Cover with silver alginate then foam dressing" and orders the frequency as "daily." The review of the clinical record of Patient #8 failed to provide evidence the silver alginate had ever been used by the nursing staff while performing the wound care for the left ischial pressure ulcer. The nurses' documentation of wound care did not document that silver alginate was ever applied or used from the time it was ordered on 01/25/16 to the time of the record review on 02/03/16. The review of the record provided no evidence the order for the silver alginate was ever discontinued by the physician or changed to a different product.

During the review of Patient #8's clinical record, a discussion took place with Employee #36, the RN/Clinical Director of the unit as he/she assisted the surveyor in navigating the electronic clinical record. The Clinical Director acknowledged the documentation within the clinical record failed to provide evidence the silver alginate had been applied/used during the wound care of the left ischial pressure ulcer. The Clinical Director acknowledged the record failed to provide evidence the physician had discontinued the orders for the silver alginate or changed it to a different product.

In an end of day discussion on 02/03/16, the facility's management team were made aware of the concern that clinical documentation did not provide evidence of wound care provided per the physician's orders. The CMO (Chief Medical Officer) stated the management team had arranged for some additional personnel to be onsite on 02/04/16, and stated those personnel to be individuals with expertise in navigating the EHR/Electronic Health Record.

On the afternoon of 02/04/16 at 1:30 PM, Employee #10 (an RN and senior member of the facility's management team) was present in the conference room and assisting with navigating the electronic clinical records. Employee #10 was informed the record review of Patient #8, failed to provide evidence the silver alginate had been applied/used daily during wound care of the left ischial pressure ulcer, as ordered by the physician. Employee #10 searched the clinical record of Patient #8, and stated he/she was also unable to find documentation the silver alginate was ever used for the wound care of the left ischial pressure.


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2a. The facility staff failed to ensure Patient #3 had physician orders to guide the treatment of unstageable decubitus ulcers and the facility staff failed to ensure complete wound assessments of Patient #3's unstageable decubitus ulcers.

The following information was found documented by a registered nurse (RN) on 11/21/15 at 7:46 AM: "... bath done at midnight, patient able to sleep after, mepilex to sacral area intact endorsed as having sacral sore ..."

The following information was found documented by a RN on 11/22/15 at 3:02 AM: "... Patient has stage II decubitus ulcer at BL (bilateral) Buttocks [sic] with excoriations at sacral area. Wound care Nurse [sic] consult has been requested."

A wound care consult was found documented for Patient #3 on 11/22/15; the reason for the wound care consult was documented as "Stage II Bilateral Bottuck [sic] wound". A 'Wound Ostomy Continence Consultation' was documented on 11/24/15 at 7:54 AM; the following information was documented as part of this consultation: "Assessment ... Exam today: Bilateral buttocks with un-stagable ressure [sic] ulcers that represent full thickness tissue breakdown. Call CV PA to notify that wounds present and are evolving ... Plan ... Begin on Venelex to provide vasodilation and act as a barrier. Will follow. Will need specialty bed at Acute Rehab." No order was found for the planned Venelex. No documentation of the patient receiving the Venelex prior to discharge was found. Patient #3 was transferred from the hospital identified in this complaint on the evening of 11/25/12; the 'Final Assessment Time' of the bilateral buttock wounds was documented as 11/25/15 at 10:16 PM.

During an interview on 2/3/16 at 10:55 AM, Employee #15 (a registered nurse) acknowledged Patient #3 had no wound care orders placed on 11/22/15.

The facility staff provided the survey team with a policy and procedure entitled, Wound Care; this policy and procedure referenced the "Lippincott Procedure Manual" under the procedure section. The facility staff provided the surveyor with a copy of a document entitled, "Wound assessment" from the 'Lippincott Procedures' resource. The following information was found in the documented entitled, "Wound assessment": "A thorough wound assessment should consist of objective criteria and measurements that should promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. You should complete a comprehensive wound assessment during every dressing change, and compare the results to previous assessments so that you can monitor, communicate, treat, and document wound healing progression or complications ... Measuring the wound ... Measure the wound size with a disposable wound-measuring device (such as a a [sic] paper ruler or square, transparent card with concentric circles arranged in bull's-eye fashion and bordered with a straight-edge ruler). Use a uniform, consistent method for measuring the wound to facilitate meaningful comparisons for evaluating wound healing."

No documentation was found to indicate Patient #3's wound assessments included measurements of the wounds. The following wound information was found in a document entitled 'Default Flowsheet Data':
- "[REMOVED] Pressure Ulcer 11/24/15 Buttocks Left Unstagable[sic] ... Pressure Ulcer ... Date First Assessed: 11/24/15 Time First Assessed: 0807 Location: Buttocks ... Properties ... Orientation: Left Staging: Unstagable [sic] Present on Admission: No Final Assessment Date: 11/25/15 at 2216".
- "[REMOVED] Pressure Ulcer 11/24/15 Buttocks Right Unstagable [sic] ... Pressure Ulcer ... Date First Assessed: 11/24/15 Time First Assessed: 0808 Location: Buttocks ... Properties ... Orientation: Right Staging: Unstagable [sic] Present on Admission: No Final Assessment Date: 11/25/15 at 2216".
- "[REMOVED] Wound (Miscellaneous) 11/22/15 Coccyx Mid [sic] ... Wound Properties ... Date First Assessed: 11/22/15 Location: Coccyx Wound Location Orientation: Mid [sic] Final Assessment Date: 11/25/15 Final Assessment Time: 2216".

This is a complaint deficiency.

2b. The facility staff failed to ensure Patient #3's mediation orders were completely written to provide the necessary information for nursing staff to administer the medication.

The following medication order was found in Patient #3's clinical documentation:
hydralazine (APRESOLINE) injection 10 mg
Ordering Provider: (name omitted)
Ordered On: 11/01/15 2247
Dose (Remaining/Total): 10mg (-/-)
Route: Intravenous
Admin Instructions: (nothing documented for this section)
Starts/Ends: 11/01/15 2244 - 11/06/15 1048
Frequency: Every 4 hours PRN
Rate/Duration: -/-
Comments: (nothing documented for this section)

The order did not provide a reason for the medication. It was ordered PRN. (PRN is a medical abbreviation meaning 'as needed' or 'when necessary'.) The medication was used to treat an elevated blood pressure but no parameters were provided to indicate when (i.e., at what elevated blood pressure result) the ordering physician wanted the medication to be administered. Documentation indicated Patient #3 was provided this medication 13 times between 11/1/15 and 11/6/15.

During an interview with Employee#15 (a registered nurse) on 2/3/16 at 11:15 AM, Employee #15 acknowledged the hydralazine order did not include parameters to guide administration of the medication.