HospitalInspections.org

Based on document review and interview, the facility failed to review the Medical Staff Bylaws at least biennially. This deficient practice placed the facility at risk for unsafe medical staff practices.

A review of the hospital's Medical Staff Bylaws revealed the last date the Bylaws were approved was in 04/2020. Page 70 in the Medical Staff Bylaws documented, bylaws shall be reviewed at least biennially.

On 02/09/2024, the Director of Medical Staff Services confirmed the most recent date of adoption or approval of the hospital's Medical Staff Bylaws occurred during the month and year of 04/2020.

Based on record review, document review and interview, the facility failed to ensure when a restraint or seclusion was used to manage violent or self-destructive behavior, there must be documentation in the patient's record of a one hour face-to-face medical and behavioral evaluation.

A Nurse's Note dated 09/05/2023 at 4:51 AM, documented after two separate injections of Zyprexa 10 mg, the patient continued to be aggressive towards staff and during an intervention with hospital security. Patient 15 was placed in both upper and lower extremity restraints at 10:53 PM. A physician order was obtained via phone order at 11:11 PM on 09/04/2023.

Patient 15 remained in restraints for 4 hours, with evidence of 15 minute visual checks documented. Patient 15's clinical record lacked documented evidence a face-to-face evaluation had been conducted, assessing both the medical and behavioral condition of the patient by a qualified Registered Nurse or by a physician.

Documentation contained in a Nurse's Note dated 09/05/2023 at 4:51 AM, revealed the patient was again placed in restraints for aggression following the patient's release after the expiration of the first 4 hour order.

The hospital's policy entitled Restraints: Violent Behavior or Seclusion documented, a face-to-face evaluation is to be conducted no later than one (1) hour after the initiation of the intervention. This interview should be conducted by a physician, another licensed Independent Practitioner (LIP) or a trained Registered Nurse.

On 02/06/2024, the Performance Improvement Coordinator acknowledged a one (1) hour face-to-face evaluation should have been conducted following the restraint and seclusion of a violent patient which should assess four areas and would have included both the patient's behavior and medical conditions.