HospitalInspections.org

Based on record review and interview, the hospital failed to ensure notice of patient rights for four (Pt's #1, #3, #4 and #5) of 19 patients.

This failed practice has the likelihood to impede patient knowledge of rights and thereby prevent patients the ability to fully exercise their rights.
(See Tag 0116)

Based on record review and interview, the hospital failed to ensure communication of patient admission to family member or POA for one (Patient #1) of 19 patients.

This failed practice has the likelihood to prevent the patient's family or representative from being included in the consent for treatment and the care planning process. (See Tag 0133)

Based on record review and interview, the hospital failed to ensure ongoing monitoring of behavior for one (Patient #10) of 19 patients

This failed practice has the likelihood to place all patients and staff at risk of emotional or physical harm due to poor supervision and assessment of needs and/or non verbal changes that could precede emotional or physical outbursts.
(See Tag 0144)

Based on record review and interview, the hospital failed to recognize restraint for one (Patient #2) of 19 patients.

This failed practice has the likelihood to place patients at risk of underassessment, no assessment, and failure to provide monitoring for the need and safety of restraint. (See Tag 0159)

Based on record review and interview, the hospital failed to ensure the least restrictive restraint interventions were ineffective for behavior management prior to the use of physical restraint for one (Patient #2) of two patients.

This failed practice has the potential to place patients at greater risk for the immediate use of unnecessary physical restraint usage for minor infractions or behavior changes that could be managed by less restrictive means. (See Tag 0164)

Based on record review and interview, the hospital failed to ensure the master treatment plan addressed use of restraint for one (Patient #2) of one patient.

This failed practice has the likelihood to place patients at risk of a delay in therapeutic intervention and unidentifed needs during discharge planning.
(See Tag 0166)

Based on record review and interview, the hospital failed to ensure restraint policy and procedure was followed for one (Patient #2) of two patients.

This failed practice has the likelihood to place patients and staff at risk of injury due to improper implementation, assessment, docmentation and review. (See Tag 0167)

Based on record review and interview, the hospital failed to ensure a restraint order was obtained for one (Patient #2) of one patients.

This failed practice has the likelihood to result in the unnecessary restraint of patients and missed opportunities for a less restrictive interventions. (See Tag 0168)

Based on record review and interview, the hospital failed to ensure physician notification of restraint for one (Patient #2) of one patients.

This failed practice has the likelihood to result in a miscommunication with primary practitioners, a delay in needed intervention, and an uncoordinated plan of care thereby impeding quality of care. (See Tag 0170)

Based on record review and interview, the hospital failed to ensure restraint assessment for one (Patient #2) of one patients.

This failed practice has the likelihood to place patients at risk of injury or death. (See Tag 0175)

Based on record review and interview, the hospital failed to ensure a face-to-face assessment following restraint termination for behaviors for one (Patient #2) of one patient.

This failed practice has the likelihood to place patients at risk of prolonged use of restraint and missed opportunity to address the cause of behaviors. (See Tag 0178)

Based on record review and interview, the hospital failed to ensure assessment of patient response following restraint termination for one (Patient #2) of one patient.

This failed practice has the likelihood to result in unnecessary patient restraint interventions and non therapeutic patient care. (See Tag 0188)

Based on record review and interview, the hospital failed to ensure notice of patient rights for four (Pt's #1, #3, #4 and #5) of 19 patients.

This failed practice has the likelihood to impede patient knowledge of rights and thereby prevent patients the ability to fully exercise their rights..

Findings:

A review of the clinical records for Patients #1, #3, #4 and #5 showed no signed notice of patient rights. Documentation showed no evidence the patients were informed of their patient rights upon admission to the facility.

On 07/01/20 at 2:15 PM, Staff O reviewed the clinical medical records for Patients #1, #3, #4 and #5 and stated there were no signed notices of patients rights and that every patient should have a signed acknowledgement of patient rights in their clinical medical record.

Based on record review and interview, the hospital failed to ensure communication of patient admission to family member or POA for one (Patient #1) of 19 patients.

This failed practice has the likelihood to prevent the patient's family or representative from being included in the consent for treatment and the care planning process.

Findings:

Patient #1
A review of the clinical record showed the patient was legally adjudicated and had a designated POA. Documentation showed no POA or family member notification of the patient's admission to the hospital.

On 07/01/20 at 2:15 PM, Staff O reviewed the clinical medical record and stated there was no documentation the patient's POA or family member had been contacted regarding the patient's admission to the hospital and that contact attempts should have occurred and been documented.

Based on record review and interview, the hospital failed to ensure ongoing monitoring of behavior for one (Patient #10) of 19 patients

This failed practice has the likelihood to place all patients and staff at risk of emotional or physical harm due to poor supervision and assessment of needs/and/or non verbal changes that could precede emotional or physical outburst.

Findings

Patient #10
A review of nursing notes, nursing shift assessments, orders and documents titled, "Patient 15 Minute Observation & Precautions" showed no documentation of a patient to patient altercation and showed no documentation of an increase in patient monitoring.

A review of a document titled "Quality Investigative Log" dated 06/26/20 at 10:34 AM showed Patient #10 repeatedly struck another patient on 06/25/20 at 8:04 PM.

A review of the "Patient 15 Minute Observation & Precautions" dated 06/24/20 included the 06/25/20 8:00 PM timeframe and did not show an observation level.

A review of the Patient "15 Minute Observation & Precautions" dated 06/25/20 showed an observation level of "Close Observation."

On 07/01/20 from 2:58 PM to 3:10 PM, Staff E reviewed the "Quality Investigative Log" and stated the following:
1. The levels of observation are every 15 minute monitoring, close observation where patient remains in line of sight, and 1:1 where patient is within an arm's length reach.
2. Staff should have called the doctor to obtain an order to increase the level of observation to close observation after the altercation and until the patient discharged.

On 07/02/20 at 3:35 PM, Staff V stated Close Observation was monitoring a patient every 15 minutes.

On 07/02/20 at 12:30 PM, Staff G stated there was no policy explaining the levels of observation or when or how to change the levels.

On 07/07/20 at 11:56 AM, Staff J stated:
1. If a patient became aggressive, he or she would likely increase the level of observation
2. Nurses could increase a patient's level of observation
3. He or she did not know if changing a level of observation required a doctor's order

Based on record review and interview, the hospital failed to recognize restraint for one (Patient #2) of 19 patients.

This failed practice has the likelihood to place patients at risk of underassessment, no assessment, and failure to provide monitoring for the need and safety of restraint.

Finding:

Patient #2
A review of a policy titled "Use of Restraints or Seclusion" read in part, "Physical restraint-any manual method, physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body."

A review of a PowerPoint document titled "Use of Restraints or Seclusion" read in part, "Definition of Restraint: Physical...Any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered restraint."

A review of a document titled "Quality Investigative Log" dated 01/28/20 showed the facility's Quality and Risk personnel reviewed video footage of four patient restraints occurring on 01/22/20. Documentation showed no restraint orders were obtained. Documentation showed the following:

1. Staff members held patient from 9:43 PM to 9:50 PM (seven minutes);
2. Staff members held patient from 9:53 PM to 9:58 PM (five minutes);
3. Patient was placed in a geri-chair with a tray that prevented the patient from moving about the unit from 10:00 PM to 10:18 PM (18 minutes);
4. Staff members held patient in a dayroom upright chair from 10:38 PM to 10:40 PM (two minutes);
5. Staff member stated, "didn't realize they had held [patient] for that long and agreed that [staff member] didn't do the documentation."

A review of a document titled "BH Note Addendum" dated 01/24/20 read in part, "Staff assisted to hold client until IM med given. Approximately 45sec's [sic]." Documentation showed no restraint order was obtained.

On 07/02/20 at 2:50 PM., Staff E stated:
1. Pt #2 was restrained by staff during an episode of behaviors;
2. there was no documentation of the 01/22/20 patient restraint incident;
3. there was no physician order for restraint use.

On 07/07/20 at 9:55 AM., Staff K stated the facility staff members did not follow facility policy and procedure related to the use of patient restraints and no physician order was obtained for use of patient restraint.

Based on record review and staff interview, the hospital failed to ensure the least restrictive restraint interventions were ineffective for behavior management prior to the use of physical restraint for one (Patient #2) of two patients.

This failed practice has the potential to place patients at greater risk for the immediate use of unnecessary physical restraint usage for minor infractions or behavior changes that could be managed by less restrictive means.

Findings:

Patient #2
A hospital policy titled, "Use of Restraints..." documented, "...if the restraint or seclusion is related to the clinical care of an individual...standards and this policy and procedure apply...a restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective...shall be used..."

A document dated 01/28/20, titled "Quality Investigative Log", documented the facility's "Quality and Risk" personnel reviewed video footage of an incident on 01/22/20 of patient restraint. The document stated, "Physical hold and geri-chair restraint without order." The documentation showed the patient was restrained by physical hold by staff members and with the use of a geri-chair from 9:43 p.m. through 10:40 p.m.

A review of the clinical record showed no documentation that least restrictive interventions were assessed as ineffective to manage the patient's behaviors prior to the use of physical restraint.

On 07/02/2020 at 3:16 p.m., Staff U stated:
1) if a patient showed an increase in behavior, the staff were to evaluate the reasons and attempt the use of least restrictive interventions and techniques.
2) the patient's behaviors, interventions used, and physician notification should have been documented on the "Patient 15 minute Observation and Precautions" flow sheet and in the nurse's notes, but there was no place to document behavioral interventions on the form.

Based on record review and interview, the hospital failed to ensure the master treatment plan addressed use of restraint for one (Patient #2) of one patient.

This failed practice has the likelihood to place patients at risk of a delay in therapeutic intervention and unidentified needs during discharge planning.

Findings:

Patient #2
A hospital policy titled, "Use of Restraints...", documented, "...if the restraint or seclusion is related to the clinical care of an individual...standards and this policy and procedure apply...a restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective...shall be used...document the reason for use of restraint...specify duration and frequency of administration...with an entered modification to the patient's plan of care..."

A document dated 01/28/20, titled "Quality Investigative Log", showed the facility's Quality and Risk personnel reviewed video footage of an incident on 01/22/20 of patient restraint. The document stated, "Physical hold and geri-chair restraint without order." The documentation showed the patient was restrained by physical hold by staff members and with the use of a geri-chair from 9:43 p.m. through 10:40 p.m.

A review of the clinical record showed no incident of the patient being restrained by staff members and showed no modification to the master treatment plan for the use of patient restraints.

On 07/02/20 at 2:50 p.m., Staff E stated:
1. Patient #2 was restrained by staff during an episode of behaviors.
2) there was no documentation of the 01/22/20 patient restraint incident and the master treatment plan was not updated to include the use of restraints.

On 07/07/20 at 9:55 a.m., Staff K stated staff members should have followed the hospital's policy and procedures related to the use of patient restraints.

Based on record review and interview, the hospital failed to ensure restraint policy and procedure was followed for one (Patient #2) of two patients.

This failed practice has the likelihood to place patients and staff at risk of injury due to improper implementation, assessment, docmentation and review.

Findings:

Patient #2
A hospital policy titled, "Use of Restraints...", documented, "...if the restraint or seclusion is related to the clinical care of an individual...standards and this policy and procedure apply...a restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective...each order for restraint...must sate maximum duration...documentation and the use of restraint or seclusion must be selected only when less restrictive measure have been found ineffective...the order must...specify approved facility methods...shall be used...document the reason for use of restraint...specify duration and frequency of administration...with an entered modification to the patient's plan of care...documentation of staff name, title...involved...completed...documented in the Restraint Log Book...documented in the...approved computerized quality reporting system...registered nurse...trained with specified requirements...must perform a face to face evaluation for...restraint use and document the need for restraint...within 1 [one] hour after the initiation of the intervention...after application of restraint, an immediate assessment is made by the RN [registered nurse]...with documentation verification in the patient's medical record...the condition of the restrained patient must be assessed, monitored, re-evaluated and documented...restraints will only be used with a physician/PA [physician assistant] order...the restraint flow sheet will be used for each occurrence of restraint..."

A hospital document titled, "Occurrence Management in the Strategic Quality Support System", documented, "The purpose of this occurrence management tool is to provide direction on managing an occurrence investigation and resolution...to...manage occurrences to prevent and reduce harm to patients...an occurrence...can be any happening which is not consistent with the routine operation of the facility or routine care of a patient...a hazardous condition...significantly increases the likelihood of a serious physical or psychological adverse patient outcome..."

A document dated 01/28/20, titled "Quality Investigative Log", documented the hospital's Quality and Risk personnel reviewed video footage of an incident on 01/22/20 of patient restraint. The document stated,"Physical hold and geri-chair restraint without order." The documentation showed the patient was restrained by physical hold by staff members and with the use of a geri-chair from 9:43 p.m. through 10:40 p.m.

A review of the hospital's grievance and incident report logs showed no documentation of a patient restraint incident on 01/22/20 and no attached patient restraint flow sheet.

A review of the clinical record showed no incident of the patient being restrained by staff members, no physician notification of restraint use by hold or geri-chair, no physician order for restraint use, no required RN Face to Face assessment, no modification to the master treatment plan, and no documented response to the use of patient restraint.

On 07/02/20 at 2:50 p.m., Staff E stated:
1. Patient #2 was restrained by staff during an episode of behaviors and
2. there was no documentation of the 01/22/20 patient restraint incident, no physician order for restraint use, and no required RN assessment.

On 07/07/20 at 9:55 a.m., Staff K stated staff members did not follow hospital policy and procedure related to the use of patient restraints.

Based on record review and interview, the hospital failed to ensure a restraint order was obtained for one (Patient #2) of one patients.

This failed practice has the likelihood to result in unnecessary restraint of patients and missed opportunity for a less restrictive intervention.

Findings

Patient #2
A review of policy titled "Use of Restraints or Seclusion" read in part, "use of a restraint or seclusion must be...in accordance with the order of a physician or a physician assistant."

A review of a document titled "Quality Investigative Log" dated 01/28/20 showed the hospital's Quality and Risk personnel reviewed video footage of an incident on 01/22/20 of four patient restraints. Documentation showed no restraint orders obtained Documentation showed the following:

1. Staff members held patient from 9:43 PM to 9:50 PM (seven minutes)
2. Staff members held patient from 9:53 PM to 9:58 PM (five minutes)
3. Patient was placed in a geri-chair with a tray that prevented the patient from moving about the unit from 10:00 PM to 10:18 PM (18 minutes)
4. Staff members held patient in a dayroom upright chair from 10:38 PM to 10:40 PM (two minutes)

A review of a document titled "BH Note Addendum" dated 01/24/20 read in part, "Staff assisted to hold client until IM med given. Approximately 45 seconds." Documentation showed no restraint orders were obtained.

On 07/02/20 at 2:50 p.m., Staff E stated:
1. Patient #2 was restrained by staff during an episode of behaviors and
2. there was no documentation of the 01/22/20 patient restraint incident and no physician order for restraint use.

On 07/07/20 at 9:55 a.m., Staff K stated the staff members did not follow hospital policy and procedure related to the use of patient restraints and no physician order was obtained for use of patient restraint interventions.

Based on record review and interviews, the hospital failed to ensure physician notification of restraint for one (Patient #2) of one patients.

This failed practice has the likelihood to result in a patient's physician being unaware of a need for intervention, thereby impeding quality of care.

Findings:

Patient #2
A hospital policy titled, "Use of Restraints...", documented, "...if the restraint or seclusion is related to the clinical care of an individual...standards and this policy and procedure apply...a restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective...each order for restraint...must sate maximum duration...documentation and the use of restraint or seclusion must be selected only when less restrictive measure have been found ineffective...be followed by consultation with the patient's treating/primary physician...with documentation verification in the patient's medical record...restraints will only be used with a physician/PA [physician assistant] order..."

A document dated 01/28/20, titled "Quality Investigative Log", documented the hospital's "Quality and Risk" personnel reviewed video footage of an incident on 01/22/20 of patient restraint. The document stated, "Physical hold and geri-chair restraint without order." The documentation showed the patient was physically restrained by staff members, and with the use of a geri-chair from 9:43 p.m. through 10:40 p.m.

A review of the clinical record showed no incident of the patient being restrained by staff members, no physician notification of restraint use by hold or geri-chair.

On 07/02/20 at 2:50 p.m., Staff E stated:
1) Patient #2 was restrained by staff during an episode of behaviors and
2) there was no documentation of the 01/22/20 patient restraint incident and no physician notification of restraint use.

On 07/07/20 at 9:55 a.m., Staff K stated staff members did not follow hospital policy and procedure related to the use of patient restraints. Staff K further stated the physician was not informed the patient had been restrained.

Based on record review and interview, the hospital failed to ensure restraint assessment for one (Patient #2) of one patients.

This failed practice has the likelihood to place patients at risk of injury or death due to no or partial supervision of patient physical condition.

Finding

Patient #2
A review of a policy titled "Use of Restraints or Seclusion" read in part as follows:
1. "Monitoring and assessment frequencies for violent restraint use will occur every 15 minutes. The condition of the restrained patient must be assessed, monitored, re-evaluated and documented. Parameters of the assessment are to include...respiratory and circulatory status, skin integrity, vital signs."
2. "Physical restraint-any manual method, physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body."

A review of a document titled "Quality Investigative Log" dated 01/28/20 showed the facility's Quality and Risk personnel reviewed video footage of four patient restraints occurring on 01/22/20 and documented the following:

1. Staff members held patient from 9:43 PM to 9:50 PM (seven minutes)
2. Staff members held patient from 9:53 PM to 9:58 PM (five minutes)
3. Patient was placed in a geri-chair with a tray that prevented the patient from moving about the unit from 10:00 PM to 10:18 PM (18 minutes)
4. Staff members held patient in a dayroom upright chair from 10:38 PM to 10:40 PM (two minutes)
5. Patient had been kicking, punching and spitting at staff.
6. Staff member stated, "didn't realize they had held [patient] for that long and agreed that [staff member] didn't do the documentation."

A review of a document titled "BH Note Addendum" dated 01/24/20 read in part, "Staff assisted to hold client until IM med given. Approximately 45sec's [sic]." Review of the medication administration record showed the only order for IM medication was administered on 01/22/20 at 11:20 PM.

A review of the clinical medical record showed the following:

No documentation of vital signs from 01/22/20 9:43 PM to 01/22/20 11:20 PM (6 missed assessments)
No documentation of circulatory status from 01/22/20 9:43 PM to 01/22/20 11:20 PM (6 missed assessments)
No documentation of respiratory status from 01/22/20 9:43 PM to 01/22/20 11:20 PM (6 missed assessments)
No documentation of skin integrity from 01/22/10 9:43 PM to 01/22/20 11:20 PM (6 missed assessments)

On 07/02/20 at 2:50 p.m., Staff E stated Pt #2 was restrained by staff during an episode of behaviors and there was no documentation of the 01/22/20 patient restraint incident.

On 07/07/20 at 9:55 a.m., Staff K stated the facility staff members did not follow facility policy and procedure related to the use of patient restraints.

Based on record review and interview, the hospital failed to ensure a face-to-face assessment following restraint for behaviors for one (Patient #2) of one patient.

This failed practice has the likelihood to place patients at risk of prolonged use of restraint and missed opportunity to address the cause of behaviors.

Findings:

Patient #2
A hospital policy titled, "Use of Restraints...", documented, "...if the restraint or seclusion is related to the clinical care of an individual...standards and this policy and procedure apply...a restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective...documentation and the use of restraint or seclusion must be selected only when less restrictive measure have been found ineffective...registered nurse...trained with specified requirements...must perform a face to face evaluation for...restraint use and document the need for restraint...within 1 [one] hour after the initiation of the intervention...after application of restraint, an immediate assessment is made by the RN [registered nurse]...with documentation verification in the patient's medical record...the condition of the restrained patient must be assessed, monitored, re-evaluated and documented..."

A document dated 01/28/20, titled "Quality Investigative Log", documented the facility's Quality and Risk personnel reviewed video footage of an incident on 01/22/20 of patient restraint. The document stated, "Physical hold and geri-chair restraint without order." Documentation showed the patient was restrained by physical hold by staff members and the use of a geri-chair from 9:43 p.m. through 10:40 p.m.

A review of the hospital's grievance and incident report logs showed no documentation of the patient restraint incident on 01/22/20 and showed no required patient restraint flow sheet attachment.

A review of the clinical record showed no incident of the patient being restrained by staff members, no Face to Face assessment, no description of behaviors, no documentation of restraint interventions employed, and no evaluation for appropriateness of the interventions that were used.

On 07/02/20 at 2:50 p.m., Staff E stated:
1. Patient #2 was restrained by staff during an episode of behaviors;
2. the patient was physically held by staff and was placed in a geri-chair with the tray in place;
3. there was no documentation of the 01/22/20 patient restraint incident or required Face to Face assessment by the RN.

On 07/07/20 at 9:55 a.m., Staff K stated:
1. the patient incident of restraint use was triggered from an employee injury report from 01/22/20;
2. there was no report of patient restraint incident on 01/22/20 entered into the SQSS reporting system;
3. staff members did not follow hospital policy and procedure related to the use of patient restraints.

Based on record review and interviews, the hospital failed to ensure assessment of patient response following restraint for one (Patient #2) of one patient.

This failed practice has the likelihood to result in unnecessary patient restraint interventions and non therapeutic patient care.

Findings:

A review of a hospital policy titled, "Use of Restraints..." showed requirements for:
1. restraint or seclusion related to the clinical care of an individual to be used only if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective;
2. the use of restraint or seclusion to be selected only when less restrictive measure have been found ineffective;
3. the registered nurse to perform evaluation for restraint use and document the need for restraint;
4. an immediate assessment by the RN after application of restraint to include patient response with documented verification in the patient's medical record and
5. the documented condition of the restrained patient including assessment, monitoring, and reevaluation.

Patient #2
A hospital review of video footage documented an incident on 01/22/20 involving a restrained patient. Documentation showed, "Physical hold and geri-chair restraint without order," and the patient was restrained by physical hold by staff members and with the use of a geri-chair from 9:43 p.m. through 10:40 p.m.

A review of the hospital's grievance and incident report logs showed no documentation of the incident of patient restraint on 01/22/20 and showed no required patient restraint flow sheet attachment or documented.

A review of the clinical record showed no incident of the use of patient restraint by hospital staff members, showed no documented assessment that described the patient's behaviors that would have resulted in the use of restraint, and no detailed assessment of the patient's response to the use of restraints.

On 07/02/20 at 2:50 p.m., Staff E stated:
1. Patient #2 was restrained by staff during an episode of behaviors;
2. the patient was physically held by staff and was seated in a geri-chair with the tray in place;
3. there was no documentation of the 01/22/20 patient restraint incident or descriptive identification of the patient's behaviors that would have required the use of restraints and
4. there was no detailed assessment of the patient's response after the use of restraint interventions.

On 07/07/20 at 9:55 a.m., Staff K stated:
1. the patient incident of restraint use was triggered from an employee injury report from 01/22/20;
2. there was no patient restraint incident from 01/22/20 entered into the SQSS reporting system;
3. the facility staff member did not follow facility policy and procedure related to the use of patient restraints.

Based on record review and interview, the hospital failed to ensure treatment plans addressed individualized patient needs for two (Patient #9 and Patient #10) of 19 patients.

This failed practice has the likelihood to result in delayed recognition and/or treatment of active problems that could influence patient recovery, functional status, and quality of life.

Patient #9
A review of documents titled "Master Treatment Plan" and "Plan of Care" showed no problem or goal addressing skin during the course of the hospital visit.

A review of documents titled "BH Nursing Note" read in part as follows:
06/26/20 at 6:05 AM - "He...had a small raised area under his lt (left) eye; upper cheek bone with 1/8 in. scratch to skin...cleaned scratched area with saline/gauze."
06/26/20 at 6:40 AM - "This am lt below the eye dk (dark) pinkish color with dk. pinkish to top of lt. lid."
06/26/20 at 4:38 PM - "patient...has a blackened left eye."

On 07/01/20 at 2:18 PM, Staff L reviewed the patient's medical record and stated wound care should have been included in the Master Treatment Plan so the wound could have been monitored for signs of infection.

Patient #10
A review of documents titled "Master Treatment Plan" and "Plan of Care" showed no intervention of increased level of observation following patient's assault of another patient.

A review of document titled "Quality Investigative Log" dated 06/26/20 at 10:34 AM showed Patient #10 repeatedly struck another patient.

On 07/01/20 at approximately 3:10 PM, Staff E reviewed the medical record and Quality Investigative Log and stated the Master Treatment Plan was not updated with an increased level of observation.

Based on record review and interview, the hospital failed to ensure grievance and restraint policies and procedures were followed for:
1. one (Patient #1) of five patients reviewed for compliance with facility grievance procedure after an allegation of patient bruising injuries and;
2. one (Patient #2) of two clinical records reviewed for compliance with facility policy and procedure related to use of patient restraints.

These failed practices have the potential for serious physical or psychological adverse patient outcomes for all patients subjected to actions that violate guidelines and hospital policy.

Findings:

A hospital document titled, "Occurrence Management in the Strategic Quality Support System (SQSS)", documented policy purpose and requirements as follows:
"The purpose of this occurrence management tool is to provide direction on managing an occurrence investigation and resolution...to...manage occurrences to prevent and reduce harm to patients...an occurrence...can be any happening which is not consistent with the routine operation of the facility or routine care of a patient...a hazardous condition...significantly increases the likelihood of a serious physical or psychological adverse patient outcome..."

A hospital policy titled, "Use of Restraints...", documented hospital restraint policy and requirements as follows:
"...if the restraint or seclusion is related to the clinical care of an individual...standards and this policy and procedure apply...a restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined and documented to be ineffective...each order for restraint...must sate maximum duration...documentation and the use of restraint or seclusion must be selected only when less restrictive measure have been found ineffective...the order must...specify approved facility methods...shall be used...document the reason for use of restraint...specify duration and frequency of administration...with an entered modification to the patient's plan of care...documentation of staff name, title...involved...completed...documented in the Restraint Log Book...documented in the...approved computerized quality reporting system...registered nurse...trained with specified requirements...must perform a face to face evaluation for...restraint use and document the need for restraint...within 1 [one] hour after the initiation of the intervention...after application of restraint, an immediate assessment is made by the RN [registered nurse]...with documentation verification in the patient's medical record...the condition of the restrained patient must be assessed, monitored, re-evaluated and documented...restraints will only be used with a physician/PA [physician assistant] order...the restraint flow sheet will be used for each occurrence of restraint..."

Patient #1
A review of the clinical record showed bruising at the time of admission and bruising which occurred during the hospital stay. The clinical record showed no documentation of incident reporting related to patient bruising.

A review of the hospital's grievance and incident log records show no documentation of a complaint called to the hospital on the day of the patient's discharge related to allegations of patient bruising.

On 07/01/20 at 3:35 p.m., Staff E stated:
1. she received a telephone call about bruising on the patient post-hospital discharge on 06/05/20;
2. the patient had bruising on admission to the hospital from a fall and experienced bruising from venipunctures for lab draws during the in-patient hospitalization;
3. the matter was resolved after the telephone call and was not entered into the SQSS reporting system and
4. the incident should have been entered into the SQSS reporting system because of the allegation of bruising to the patient.

On 07/07/20 at 10:03 a.m., Staff M stated:
1. all patient related incidents and reports related to patient care were entered into SQSS under quality of care for follow up and to track and trend complaints;
2. all staff were trained to report incidents and complaints and
3. there was no SQSS report of the 06/05/20 allegation of patient bruising.

Patient #2
A review of a "Quality Investigative Log" dated 01/28/20 documented hospital "Quality and Risk" personnel reviewed video footage of an incident on 01/22/20 which involved patient restraint. Documentation showed:
1 "Physical hold and geri-chair restraint without order;"
2. the patient was restrained by physical hold by staff members from 9:43 p.m. through 9:50 p.m. (seven minutes), 9:53 p.m. through 9:58 p.m. (five minutes), was then placed in a geri-chair at 10:00 p.m. through 10:18 p.m. (18 minutes), at 10:20 p.m. the patient was moved to the day room of the in-patient unit while in the geri-chair. At 10:38 p.m. the patient was held by four un-named staff members until 10:40 p.m. (two minutes).
3. The patient was then taken to their room.

Documentation of the event showed no physician order for the physical hold or for the use of the geri-chair during the incident.

A review of hospital Grievance and Incident report logs showed no documentation of the patient restraint incident on 01/22/20 and contained no patient restraint flow sheet attachment.

A review of the clinical record showed no incident of the patient being restrained by staff members, no physician notification of restraint use by hold or geri-chair, no physician order for restraint use, no required RN Face to Face assessment, no modification to the master treatment plan, and no documented response to the use of patient restraints.

On 07/02/20 at 2:50 p.m., Staff E stated:
1. Patient #2 was restrained by staff during an episode of behaviors.
2. the patient was physically held by staff and was seated in a geri-chair with the tray in place until the patient slid out of the chair onto the floor in an attempt to get out of it;
3. there was no documentation of the 01/22/20 patient restraint incident, physician order for restraint use, or required RN assessments.

On 07/07/20 at 9:55 a.m., Staff K stated:
1. the patient incident of restraint use was triggered from an employee injury report from 01/22/20;
2. There was no incident report entered into the SQSS reporting system;
3. the staff members did not follow hospital policy and procedure related to the use of patient restraints.