HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 clinical records (Pt. #1) reviewed, the Hospital failed to ensure an investigation was conducted to determine the reason a Patient received bruises and scratches.

Finding include:

1. On 7/11/17 at 12:00 PM, Hospital policy #: (RG) RSK.568, titled, "Critical Incident Review Process", effective 12/23/14, was reviewed. The policy included, "II. Definitions: 1. Patient Safety Incident: An undesirable or unanticipated negative event, or an event having [a] potentially harmful impact. Occurrence are evaluated through an individual case review..."

2. Pt. #1's clinical record was reviewed on 7/6/17. Pt. #1 was a 66 year old male, seen in the Emergency Department (ED) on 6/8/17, for a psychiatric screening and an unsteady gait. Pt #1's social work notes dated 6/9/17 at 12:47 PM, included Pt. #1 was treated for a brain injury in an Out of State Transferring Hospital for "a long hospitalization, coma, and brain surgery".

3. Pt. #1's flow sheets, dated 6/10/17 at 12:00 PM, included, "Patient verbally aggressive towards staff, refusing to get into bed, screaming that he was to leave at 12:00 PM regardless of discharge orders... Code BRT [Behavioral Response Team] called. Unable to medicate patient after trying to hold patient down with security ..." There was no documentation of injury to Pt. #1.

4. A physician order, dated 6/10/17 at 3:22 PM, included an enclosed bed with restraint monitoring every 2 hours. Pt. #1's flow sheets, dated 6/10/17 at 4:00 PM, included, "Patient aggressive toward staff, refusing to get into bed, order for enclosed bed received. Code BRT called for assistance getting Patient into bed..." There was no documentation of injury to Pt. #1.

5. Pt. #1's flow sheet dated 6/11/17 at 8:00 AM and on 6/12/17 at 8:00 AM, included, "Bilateral bruising observed to upper extremities. Mild scratch marks noted to right upper extremity". There was no prior documentation and there was no documentation that a doctor was informed or that an incident report was made.

6. On 7/6/17 at 3:00 PM, the 2017 incident report log was reviewed. There were 3 incidents related to Pt. #1's BRTs. The 3 incident reports were reviewed and there was no documentation of injury. There were no incident reports related to Pt. #1's bruises and scratches.

7. On 7/6/17 at approximately 11:00 AM, an interview was conducted with the Medcial Surgical Cardiac Unit Nurse Manager (E #7). E #7 stated that Pt #1 had an enclosure bed in place for safety. E #7 stated that the scratches and bruises on Pt #1 were from throwing himself around in the enclosure bed and throwing the call light around inside the bed. E #7 stated the call light was removed from the enclosure bed to prevent injury to Pt #1.

Based on document review and interview, it was determined for 4 of 4 clinical records (Pts. #1, 8, 9, & 10) reviewed for patients in non violent restraints, the Hospital failed to ensure the restraint order included the behavior of the patient that required restraints, as required by Hospital policy.

Finding include:

1. On 7/11/17 at 1:00 PM, Hospital policy #: (RG) PCT.672, titled, "Restraint Management", reviewed 6/15/15, was reviewed. The policy required, "Non-violent, Non-self-destructive... 4. The patient's behavior, indicating the reason for restraint... shall be documented in the order."

2. Pt. #1's clinical record was reviewed on 7/6/17 at 11:00 AM. Pt. #1 was a 66 year old male, seen in the Emergency Department (ED) on 6/8/17, for a psychiatric screening and an unsteady gait. A physician's order, dated 6/10/17 at 3:22 PM, included an enclosed bed non violent restraint. The order lacked the behavior of the patient that required the restraint.

3. Pt. #8's clinical record was reviewed on 7/10/17 at 10:00 AM. Pt. #8 was a 53 year old male, admitted on 5/23/17, with a diagnosis of acute seizures. A physician's order, dated 5/28/17 at 2:01 AM, included non violent soft 2 limb restraints. The order lacked the behavior of the patient that required the restraint.

4. Pt. #9's clinical record was reviewed on 7/10/17 at 12:50 PM. Pt. #9 was a 79 year old female, admitted on 6/3/17, with diagnoses of hip fracture and renal failure. A physician's order, dated 6/4/17 at 3:18 AM, included non violent soft 2 limb restraints. The order lacked the behavior of the patient that required the restraint.

5. Pt. #10's clinical record was reviewed on 7/10/17 at 1:25 PM. Pt. #10 was an 87 year old male, admitted on 6/23/17, with a diagnosis of acute respiratory failure. A physician's order, dated 6/23/17 at 9:34 PM, included non violent soft 2 limb restraints. The order lacked the behavior of the patient that required the restraint.

6. On 7/10/17 at 1:00 PM, an interview was conducted with the Director of Accreditation and Licensure (E #4). E #4 stated the behavior/reason for non violent restraints are included in the nursing notes.

Based on document review and interview, it was determined for 2 of 4 clinical records (Pts. #1 & 10) reviewed for patients in non violent restraints, the Hospital failed to ensure restraint monitoring was performed as ordered.

Finding include:

1. On 7/11/17 at 1:00 PM, Hospital policy #: (RG) PCT.672, titled, "Restraint Management", reviewed 6/15/15, was reviewed. The policy required, "Non-violent, Non-self-destructive... 1. The patient shall be monitored at regular intervals to be determined consistent with physician orders..."

2. Pt. #1's clinical record was reviewed on 7/6/17 at 11:00 AM. Pt. #1 was a 66 year old male, seen in the Emergency Department (ED) on 6/8/17, for a psychiatric screening and an unsteady gait. A physician's order, dated 6/10/17 at 3:22 PM, included an enclosed bed non violent restraint. A physician's order, dated 6/11/17 at 11:03 AM, included restraint monitoring every 2 hours. Restraint monitoring was missing on 6/11/17 between 4:00 PM to 8:00 PM, for 4 hours.

3. Pt. #10's clinical record was reviewed on 7/10/17 at 1:25 PM. Pt. #10 was an 87 year old male, admitted on 6/23/17, with a diagnosis of acute respiratory failure. A physician's order, dated 6/23/17 at 9:34 PM, included non violent soft 2 limb restraints. A physician's order, dated on 6/23/17 at 9:34 PM, included restraint monitoring every 2 hours. Restraint monitoring was missing on 6/24/17 from 8:00 AM until 6/25/17 at 2:30 PM, for 7.5 hours and on 6/25/17 from 2:30 AM until 6:30 AM, for 4 hours.

6. On 7/10/17 at 4:20 PM, an interview was conducted with the Director of Accreditation and Licensure (E #4). E #4 stated that the nurses probably did the assessments but missed charting the restraint monitoring on the 2 records.