HospitalInspections.org

Based on observation and interview, the facility failed to provide personal privacy for 1 (P#8) of 10 (P#1-10) randomly selected patients. This failed practice did not allow the privacy for the patient.

The findings are:

A. On 10/29/19, at 11:15 am, it was observed P#8 was asleep on a hospital bed in the hallway in front of the ED doors. He woke up and asked 3 different nurses at 3 different times (approximately 5 minutes in between each request) to be taken to the restroom. A 4th staff member, a patient technician suggested she would provide a hand-held urinal and for the patient to urinate, using the urinal while in the hallway.

B. On 10/29/19, at 12:00 PM, during interview, S#1 CNO stated, "He [P#8] is in the hallway so he can sleep it [the intoxication] off." When asked if it was private to have him use the bathroom in the hallway with only a sheet to cover him, she further stated, "That's not private at all. That should not happen, that's not right."

C. On 12/18/19, at 1:30 PM, during interview, S#16 RN was asked if it is standard practice to have a patient urinate in a urinal in the hallway with only a sheet for privacy. She stated, "With a Hallway Patient? I would probably get him to the restroom. Yeah, I wouldn't leave him in the hallway to go [urinate]."

Based on record review and interview, the facility failed to have the physician sign the orders for restraints every four hours as required in 1 (P#4) of 10 patients (P#1-10). There was also no face-to-face assessment by the physician and with in 1 hour of placing patient in restraints. This failed practice could result in patients being left in restraints longer than necessary.

The findings are:

A. Review of P#4's medical record revealed, he was admitted for Suicidal Ideation and became combative with staff. He was then placed in restraints. The same order for restraints was repeatedly used:

1. Doctor's order written for "a continuous violent restraint on 06/22/19 at 1201 - 4 hours," the ordering doctor signed on 07/02/19 at 7:10 am by S#10 MD which was 10 days after the restraints were used on the patient.

2. Doctor's order written for "a continuous violent restraint on 06/22/19 at 1601 - 4 hours," the ordering doctor signed on 07/02/19 at 7:10 am by S#10 MD which was 10 days after the restraints were used on the patient.


B. Review of Restraint Order Use Justification dated 01/13/17 form number ORDS0247 indicates, "Violent Restraint - All patients must have a face-to-face evaluation by provider within 1 hour of restraint incitation and document in the medical record."


C. Review of Patient Care Restraint Policy Version 7 dated 05/08/18 indicates,

"8. Violent/Behavioral Restraints

B. When a patient's violent or self-destructive behavior presents an immediate or serious danger to the patient or others, immediate action is needed. The patient may be restrained.

C. An order for restraint must be written within minutes of applying the restraint. Within minutes is defined as no longer than 10 minutes.

D. The use of restraint must be in accordance with the order of a physician or designee who is responsible for the care of the patient

i. In an emergency situation, a RN may initiate the restraint as long as a physician is notified as soon as possible generally within 1 hour and a telephone or written order is obtained. (Exception: When the restraint is initiated based on a significant change in the patient's condition, the physician must be notified immediately.). Additional trained staff may assist the RN in the initiation of the restraints.

ii. A physician, physician assistant or QLP [Qualified Licensed Practitioner] who has been trained according to requirements must see the patient within one hour after initiation of the intervention to evaluate the patient's immediate situation, reaction to the intervention, medical condition, and the need to continue or terminate the restraint. The face to face evaluation is performed even if restraints were removed prior to the evaluation."


D. On 12/18/19, at 12:13 PM, during interview, S#10 MD, the ordering physician for P#4, stated he did not recall this patient or any care or orders for this patient. He could only confirm, "orders need to be signed within an hour after placement of restraints [both violent and non-violent]."

Based on record review and interview, the facility failed to provide and document a comprehensive assessment which would have determined the most appropriate intervention necessary to effectively manage a patient who was attempting to remove an oxygen mask and IV for 1 (P#2) of 10 patient (P#1-10) records reviewed. This failed practice may have contributed to further injury, additional complications, and death while a patient experiencing respiratory problems was restrained. The findings are:

A. Record review of "Medical History" dated 3/25/19 revealed, P#2 was a 30 year old female classified as morbidly obese (BMI-body mass index or measure of body fat 40.9) admitted with streptococcal sepsis (infection).

B. Record review of "Obesity and Respiratory Disease" journal article from Chronic Respiratory Disease dated 2008 revealed, "it has already been well established that obesity can lead to obstructive sleep apnea (OSA) and obesity-hyperventilation syndrome (OHS)" (sleep is interrupted and ventilation is inadequate for oxygenation).

C. Record review of P#2's laboratory results dated 03/27/19, at 4:01 am, revealed, Hemoglobin (the iron-containing oxygen-transport protein in red blood cells) 7.0 (normal 12-16 g/dl) and Hematocrit (ratio of the volume of red blood cells to the total volume of blood) 22.7 (normal 36-48 %).

D. Record review of P#2's "All Non-Resultable Orders - Transfusion Administration revealed a transfusion of red blood cells was ordered on 03/30/19. No documentation of transfusion of red blood cells to increase P#2's hemoglobin could be found until after P#2 suffered respiratory arrest and anoxic brain injury (no oxygen to the brain).

E. Record review of P#2's:

1. "Exam: CT (computerized tomography)" dated 03/25/19 revealed,"no lobar consolidation (fluid in lung), effusions (buildup of fluid between the layers of tissue that line the lungs), pneumothorax (collapsed lung that occurs when air enters the space around lungs)."

2. "Exam: XR (xray) chest one view" dated 03/25/19 revealed, "There are low lung volumes with bibasilar pulmonary opacities, right worse than left." (Basilar consolidation is a pathologic disease process that takes place with certain types of lung infections. Consolidation can block air flow through the lungs, causing shortness of breath and fatigue).

3. "Exam: XR chest one view" dated 03/29/19 revealed, "Dense consolidation identified throughout the left lung has worsened slightly from prior examination."


F. Record review of P#2's "Vitals I/O last 3 completed shifts" dated 03/29/19 at 0600 (6:00 am) revealed P#2 consumed 500 mL (unit of measure) of fluid by mouth, had 1449 mL IV (intravenous fluid) infused and had 125 mL of urine output (intake 1949 mL, output 125 significantly more fluid in than out). The same document revealed "decreased breath sounds".


G. Record review of P#2's "ABG (arterial blood gas) results" dated 03/29/19 at 3:33 am revealed:

1. pH (measure of acidity or alkalinity) 7.42 normal listed as 7.35-7.45

2. pO2 (level of oxygen) 52 "low" normal listed as 70-91

3. pCO2 (carbon dioxide level) 46 "high" normal listed as 32-48

4. Oxygen saturation 86% "low" no normal listed

5. HCO3 (bicarbonate level) 30 high normal listed as 18-23

ABG test was not repeated prior to the respiratory arrest (patient stopped breathing) at 5:37 pm.


H. Record review of "Nurse.org" article undated revealed, "According to the National Institute of Health, typical normal values are: pH: 7.35-7.45; Partial pressure of oxygen (PaO2): 75 to 100 mmHg; Partial pressure of carbon dioxide (PaCO2): 35-45 mmHg; Bicarbonate (HCO3): 22-26 mEq/L; Oxygen saturation (O2 Sat): 94-100%.


I. Record review of P#2's "Hospitalist Note" revealed that on 03/29/19 at 3:00 am, P#2 was reported to have an episode of "respiratory distress and agitation". P#2 was placed on BIPAP (machine that sends pressurized air through a tube into a mask that fits over the nose).


J. Record review of P#2's "Daily Progress Note" dated 03/29/19 at 7:38 am revealed, "Became more agitated and delirious overnight. Patient still confused receptively slightly better cognitively this morning."


K. Record review of "Orders" dated 03/29/19 at 6:46 am revealed P#2 was placed on wrist restraints due to "interfering with essential medical treatment; Continuous- until specified."


L. Record review of the facility's policy "PATIENT CARE- Restraint Policy" Section D, dated 05/08/2018 stated, "The use of restraints occurs after alternatives to such use have been considered and/or attempted as appropriate. Such alternatives may include but not necessarily limited to:

I. Re-orientation
II. De-escalation
III. Increased observation or monitoring
IV. Use of a sitter
V. Change in the patient's physical environment
VI. Review and modification of medication regimens"


M. Record review of P#2's clinical record (all 659 pages provided by the facility after being asked to provide the complete record) revealed no documentation of other alternatives (sitter or review and/or modification of medication regimen) used prior to applying restraints when P#2 was attempting to remove the BIPAP.

N. Record review of "Orders" dated 03/29/19 at 5:37 pm revealed orders for restraints continued until 5:37 pm when restraints were removed during code blue (a medical emergency that a patient experiences such as cardiac or respiratory arrest).


O. Record review of P#2's "Medication Administration Record" revealed that P#2 was medicated with Lorazepam prn (anxiety medication given as needed) on 03/29/19: 2 mg at 05:32 am and 1 mg at 09:59 am the same day at 12:07 pm, nurse documented that patient was sound asleep and did not give a dose of Lorazepam and she documented "did not want to further sedate the patient." S#12 (Registered Nurse) did not document a re-assessment for P#2's continued restraint needs.


P. Record review of P#2's "Medication Administration Record" revealed that on 03/29/19 at 2:56 pm, 2 hours and 23 minutes after nurse documented that P#2 was sound asleep, Haldol 2 mg (Haldol is a medication that may cause sedation and is used to treat psychosis) was administered but there was no documentation of re-assessment as to why Haldol was given.


Q. Record review of P#2's "Flowsheet" and the "Non-Violent Restraints" dated 03/29/19 revealed assessments that were conflicting and stated the following:

FLOWSHEET
Time Level of Consciousness / Orientation Level / Behaviors/Mood
08:00 am Drowsy; Easily Aroused / Oriented to person, situation, place/ Agitated; Labile; Restless
12:00 pm Drowsy; Easily Aroused / Oriented to person, situation, place /Agitated; Labile; Restless
04:00 pm Drowsy; Easily Aroused / Oriented to person, situation, place/Agitated; Labile; Restless

NON-VIOLENT RESTRAINTS
Time Clinical Justification / Mental Status and Cognitive Function
07:00 am Interfering with essential Lines, tubes and medical treatment /
Agitated; Confused; Disoriented

11:00 am Interfering with essential Lines, tubes and medical treatment /
Agitated; Confused; Disoriented

03:00 pm Interfering with essential Lines, tubes and medical treatment /
Agitated; Confused; Disoriented


R. Record review of an article titled "Respiratory Failure" from medlineplus.gov undated revealed "low oxygen level in the blood can cause shortness of breath and air hunger. A high carbon dioxide level can cause rapid breathing and confusion."


S. "Code Documentation" 3/29/19 at 7:43 pm "about 5:45 (pm) the nurse was called into the room "because pt (P#2) became bradycardic (heart rate below normal limits). She had pulled off her oxygen and monitors, cpr (cardiopulmonary resusitation) was begun immediately and bvm (bag, valve mask) ventilation was started."


T. Record review of "Daily Progress Note" dated 04/01/19 at 10:09 am "Poor prognosis. Critically ill due to cardiorespiratory arrest status post ROSC (resumption of sustained perfusing cardiac activity associated with significant respiratory effort after cardiac arrest with associated respiratory failure, acute kidney injury, encephalopathy - brain damage, probable anoxic brain injury - no oxygen to the brain). Family to decide if they want to proceed with terminal extubation (death after removing mechanical breathing machine)." And "Unresponsive without sedation for more than 72 hours."


U. On 10/30/19 at 3:00 pm, during interview, S# 2 Quality Director verified that per their restraint policy, orders for nonviolent restraints are only to be renewed every 72 hours but further confirmed that patients required frequent monitoring.


V. On 10/29/19 at 11:00 am, during interview, S#2 Director of Quality and Risk confirmed that in situations where patients are exhibiting high risk behaviors, the facility provides a 1:1 sitter for safety. He further stated that the facility has a pool of personnel that can work as sitters and this can be a nurse aide, a patient care technician or even a Registered Nurse if necessary.


W. On 10/31/19 at 01:00pm, during interview, S#2 confirmed that the quality department responsible for monitoring restraint cases failed to monitor and perform a "focus review" on P#2.


X. On 10/31/19 at 1:30 pm during interview, CNO (Chief Nursing Officer) confirmed that she was aware that the ICU staff needed additional education and training (including the use of restraints) and an educator had been hired and had been employed in the ICU (for about a week) to ensure the nurses provided care based on standards of practice guidelines. CNO also confirmed the RN assigned to care for P#2 on the day of the respiratory arrest was no longer employed by the facility.

















42511

Based on record review and interview, the facility failed to demonstrate that patients in restraints are efficiently and effectively assessed and monitored by ICU personnel who demonstrated knowledge of their well-being including but not limited to respiratory and circulatory status, vital signs or any special needs for 1 (P#2) of 10 (P#1-10) patient records reviewed. This failed practice has the potential to cause further harm or complications to patients and may affect all current and future patients of the facility.
The findings are:

A. Record review of P#2's "Hospitalist Note" revealed, on 03/29/19 at 3:00 am, "Called by nurse for pt (patient) had a change in status. Pt has respirations that are shallow and rapid. ABG was obtained. Pt. placed on BiPAP (sic) (machine that sends pressurized air through a tube into a mask that fits over the nose). Pt stating that she is getting tired and allowed Bipap to be initiated. I called [name of another physician] and notified him of pt's possible intubation (placement of a tube in the airway and machine delivered breathing) and he stated after ABGs read to him 'pt is breathing good so if patient's ph drops to below 7.3 then we can intubate'." Ph level at that time from ABG was 7.42. ABG test was not repeated throughout the day.

B. Record review of P#2 "Orders" dated 03/29/19 at 06:46 am revealed that P#2 was also placed on restraints through a verbal order, "Continuous until specified." No document of an assessment was found.

C. On 10/30/19 at 3:00 pm, during interview, S#2 (Quality Director) verified that per their restraint policy, orders for nonviolent restraints are only to be renewed every 72 hours but further confirmed that patients required frequent monitoring.

F. Record review of an article titled "Respiratory Failure" from medlineplus.gov undated revealed "low oxygen level in the blood can cause shortness of breath and air hunger. A high carbon dioxide level can cause rapid breathing and confusion".

G. Record review of P#2's clinical records on the "flowsheet record" section revealed abnormal vital sign levels but no documentation of care coordination with the doctor.
Time Pulse Respiration Blood Pressure (BP) Oxygen Saturation (SpO2)
07:05 am 140 48 93/56 83%
11:05 am 141 52 84/39 94%
11:15 am 135 49 98/40 94%
03:05 pm 128 52 91/48 92%

H. On 10/30/19 at 3:00 pm S#5 (Clinical Ops Analyst) confirmed that vital signs usually are taken automatically by machines in the ICU (Intensive Care Unit) but did not necessarily mean that the nurse was at bedside and reviewing vital signs each time the machine automatically takes the blood pressure, pulse, oxygen saturation and respiratory rate.

I. Record review of "Medline Plus Medical Encyclopedia" undated revealed, Normal vital sign ranges for the average healthy adult while resting are:
· Blood pressure: 90/60 mm Hg to 120/80 mm Hg
· Breathing: 12 to 18 breaths per minute
· Pulse: 60 to 100 beats per minute

J. On 12/18/19 at 12:15 pm CNO confirmed staff require competency training in restraint use.

Based on record review and interview, the facility failed to ensure that patients who received multiple medications that may have cumulative adverse effects are appropriately monitored and assessed according to acceptable standards of practice for 1 (P#2) of 10 (P#1-10) patient records reviewed. This failed practice may cause further harm or complications to patients which may include but are not limited to drowsiness or sedation, confusion, slurred speech, respiratory depression or even death and may affect all patients in the facility. The findings are:

A. Record review of P#2's "Medication Orders" dated 03/26/19 at 12:46 am revealed that P#2 was prescribed Librium four times daily for alcohol withdrawal.

B. Record review of P#2's "Physician Order" dated 03/27/19 at 06:03 am revealed that P#2 was started on CIWA (Clinical Institute Withdrawal Management - clinical assessments regarding alcohol withdrawal symptoms and management) protocol, The protocol requires Lorazepam (anxiety medication) be given as needed per CIWA. CIWA requires documentation of assessments and medication administration but in 2 instances, namely on 03/28/19 at 08:17 pm and on 3/29/19 at 09:59 am, Lorazepam was given but there was no documentation of P#2's sedation level or behavioral condition.

C. Record review of P#2's "Medication Administration Record" revealed that P#2 was medicated with Lorazepam prn (given as needed) on 03/29/19: 2 mg at 05:32 am and 1 mg at 09:59 am. Record review of the MAR also revealed, the same day at 12:07 pm, nurse documented that patient was sound asleep and did not give a dose of Lorazepam and she documented "did not want to further sedate the patient." No documentation of reassessment by the RN was found in the document.

D. Record review of P#2's "Medication Administration Record" revealed, that on 03/29/19 at 2:56 pm, 2 hours and 23 minutes after nurse documented that P#2 was sound asleep, Haldol (antipsychotic medication) 2 mg was administered.

E. Record review of Haloperidol Half-life After Chronic Dosing : Journal of Clinical Psyc ...
journals dated 2004 revealed, "In normal subjects after a single dose, haloperidol half-life has been reported to range 14.5-36.7 hours (or up to 1.5 days). After chronic administration, half-lives of up to 21 days have been reported."

E. Record review revealed no documentation of P#2's level of consciousness before Haldol was given at 2:56 pm.

F. An attempt was made to interview the nurse administering the medication, but the RN is no longer employed at the facility.

G. Record review of P#2's "Flowsheet" dated 03/29/2019 revealed multiple vital signs automatically taken on the patient at different times by the electronic blood pressure machine. Record review further revealed nurse assigned to care for P#2 manually timestamped and reviewed the flowsheet records only two times, at 02:09 pm and at 09:25 pm.

H. On 10/30/19 at 3:00 pm S#5 (Clinical Ops Analyst) confirmed that vital signs usually are taken automatically by machines in the ICU (Intensive Care Unit) but did not necessarily mean that the nurse was at bedside and the one who validated and reviewed the vital signs.

I. Record review of "Lippincott Manual of Nursing Practice 11th Edition" dated 2019 revealed, "If nonpharmacologic approaches have been applied consistently and have failed to adequately reduce the frequency and severity of behavioral symptoms that have the potential to cause harm to the patient or others, then the introduction of medications such as antipsychotics, benzodiazepines, anticonvulsants,antidepressants, and sedatives may be appropriate but will still need to be carefully and routinely monitored over time."