HospitalInspections.org

Based on restraint policy review, medical record review, observation and staff interview the nursing staff failed to obtain a physician's order for the use of restraints for 2 of 3 non-violent/non-self-destructive behavior patients reviewed (#7, #3).

The findings include:

Review of current hospital policy titled, "Safety: Restraint" revealed "A physician will order the use of restraint or seclusion or delegate the writing of restraint or seclusion orders to physician assistants and nurse practitioners."

1. Open medical record review of patient #7 revealed an 85 year old patient admitted on 09/12/2010 with a diagnosis of altered mental status and stroke. Record review revealed no documentation of a physician's order for the application/usage of restraints on 9/21/10 from 1015-1600 (approximately 6 hours). Medical record review revealed documentation that the patient was continually restrained from 1015-1600.

Observation on 09/22/2010 at 1000 of patient #7 revealed the patient was restrained bilaterally with mitten restraints.

Interview with the Director of Patient Safety on 09/23/2010 at 1100 revealed there was no documentation of a physician's order for patient #7 to be restrained on 09/21/2010 from 1015-1600. The interview revealed a verbal order for the restraints had been given to the nurse on 09/20/2010 at 1015. The interview revealed the verbal order expired on 09/21/2010 at 1015. The interview revealed a physician's order was not obtained until 1600 on 09/21/2010. The interview confirmed the patient was restrained without a physician's order. The interview revealed the hospital policy for restraint usage for non-violent /non-self-destructive behavior patients is to be renewed every 24 hours. Interview revealed the Director of Patient Safety thought the requirement for renewal every 24 hours for non-violent/non-self-destructive behavior patient was written in the restraint policy. Interview revealed the hospital standard of practice is to have a physician's orders renewed every 24 hours for the usage of restraints on non-violent/non-self-destructive behavior patients.

2. Closed medical record review of patient #3 revealed a 75 year old admitted on 07/14/2010 for a laparoscopic cholecystectomy. Medical record review revealed the patient was restrained with bilateral wrist restraints on 7/31/2010 for 24 hours and on 8/2/2010 for 24 hours. Record review revealed no documentation of a physician's order for restraints on 07/31/2010 and 08/02/2010. Record review revealed documentation by the nursing staff at 08/05/2010 at 0332 "applied mittens to right hand." Record review revealed no documentation of a physician order for the restraint on 08/05/2010.

Interview with the Director of Patient Safety on 09/23/2010 at 1100 revealed there was no documentation of a physician's order for patient #3 to be restrained on 07/31/2010 and 08/02/2010. The interview confirmed the patient was restrained without a physician's order. The interview revealed the hospital policy for restraint usage for non-violent /non-self-destructive behavior patients is to be renewed every 24 hours. Interview revealed the Director of Patient Safety thought the requirement for renewal every 24 hours for non-violent/non-self-destructive behavior patient was written in the restraint policy. Interview revealed the hospital standard of practice is to have a physician's orders renewed every 24 hours for the usage of restraints on non-violent/non-self-destructive behavior patients. The interview revealed the nursing staff should have obtained a physicians order for the use of restraint. The interview revealed the staff was "not aware until last week during a CMS (Centers for Medicare & Medicaid Services) workshop mittens are considered a restraint." The interview revealed there was no documentation of a physician's order for restraint on 08/05/2010.

Based on administrative management staff and physician interviews the hospital failed to ensure a qualified physician served as the director of respiratory care services on a full-time or part-time basis in order to supervise and administer the service properly.

The findings included:

Interview on 09/23/2010 at 0930 with the hospital's Director of respiratory care services revealed "We do not have a Medical Director." Further interview revealed "We have not had one in a number of years." Interview revealed the hospital's contract with the former respiratory care services medical director expired "years ago" and the decision was made not to renew the contract. Interview revealed if physician supervision and guidance is needed the respiratory care department staff consults Physician A, the Intensive Care Unit (ICU) medical director. Further interview revealed respiratory care services are provided to all nursing units of the hospital, not just the ICU. Interview revealed "I am aware of the requirement, it was discussed with my Vice-President and it has not been addressed at this point." Further, interview revealed the Director's Vice-President is no longer an employee of the hospital. Interview confirmed the hospital's respiratory care services did not have a full-time or part-time physician Medical Director.

Interview on 09/23/2010 at 1035 with Physician A revealed "I am the Medical Director for the ICU, NOT respiratory care services." Interview revealed as the Medical Director of the ICU he does provide supervision and guidance for the respiratory care services provided within the ICU (i.e. ventilator protocols, bronchodilator use), however, he does not "sign off" on other respiratory care services provided throughout the hospital. Interview confirmed the hospital's respiratory care services did not have a full-time or part-time physician Medical Director.

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