HospitalInspections.org

Based on document review, staff interviews, and video footage, the Hospital's administrative staff and the director of the nursing service failed to ensure that non-employee nursing care staff personnel was adequately supervised, as well as, following the policies and procedures of the hospital during care for 1 of 11 reviewed patient records, (Patient #1). Failure to provide adequate nursing supervision of non-employee nursing staff follow the policies and procedures of the hospital during the care of patient(s) resulted in the nursing staff failing to provide adequate patient care, which could result in unidentified new or existing health care conditions that could lead to prolonged illness or death for the patient. The Hospital's administrative staff identified an average daily census of 130 inpatients from July 2021 to June 2022.

Findings include:

1. Review of the policy for "Charge Role Responsibilities (Nursing)", effective 2/15/2022 revealed in part, "Monitoring of staff performance and intervening as indicated.

1. Evaluates staff performance during assigned shift and makes changes in
assignments as indicated.
2. Assures staff within their orientation period have appropriate supervision
based on progress in orientation.
3. Gives immediate feedback to staff on a shift-to-shift basis regarding
clinical and patient safety needs.
4. Monitors the orientation of staff who have temporary assignments to the
nursing department, following up at least once during the shift for support
and evaluation."

2. Review of job description for "Staff Nurse (RN)", effective 5/29/2020 revealed in part, " ... independently follow Mercy's standards along with policies and procedures while caring for patients... Follows Mercy's safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries."

3. During review of Patient #1's medical record, on 11/13/2022 RN A was floated to the MICU, during which RN A was caring for Patient #1 who was diagnosed with congestive heart failure, chronic kidney disease and progressive pneumonia, in which the patient was placed on 12-15 liters of oxygen. Patient #1 significant condition caused the patient to become restless and confused, requiring the patient to be placed in restraints.

4. Review of video surveillance from Patient #1's room on 11/13/22, from approximately 17:54:20 to 18:12:53, showed RN A and Sitter B present in Patient #1's MICU room #2115. The video surveillance showed RN A and Sitter B worked together to place a rolled-up sheet across Patient #1's knees and RN A secured the sheet to the bed on both sides to prevent the patient from lifting her legs off the bed. Patient #1's legs appeared to be restrained by the sheet for approximately 17 minutes.

5. Review of video surveillance from Patient #1's room on 11/13/22, from approximately 19:17:20 to approximately 19:39:47, showed Sitter B and Sitter C present in Patient #1's room. The video surveillance showed Sitter B and Sitter C worked together to place Patient #1's legs back under the sheet, previously secured to the lower left side of the bed, and Sitter B secured the right side of the sheet to the right side of the bed. Sitter C took another sheet, wrapped it around Patient #1's legs, wrapped it around the first sheet and wrapped it back around Patient #1's legs, to prevent Patient #1 from lifting her legs off the bed. Patient #1's legs were restrained by the sheets for approximately 8 minutes.

6. During a review of RN A's personnel and training record RN A was hired on 8/17/2022. RN A's Restraint and Seclusion training was completed on 8/12/2022 within the online training program Relias provided by the hospital.

7. During an interview on 12/13/2022, at 2:15 PM, RN D reported Charge Nurse E came to Patient #1's room to assist her with repositioning the patient and when they pulled the top sheet down, they noticed a sheet tied to the lower right bed rail and tied to the left D ring (a ring used to attach restraints or the corner of a bottom sheeted that is not a fitted sheet), which had been across the patient's legs. RN D confirmed this would be considered an inappropriate restraint and reported she entered a Midas report about the event.

8. During an interview on 12/13/22, at 3:00 PM, Charge Nurse E reported RN D asked her to come and help reposition Patient #1 and when they pulled the covers back, RN D found one end of a sheet tied to the bed. Charge Nurse E reported she then saw the end of the sheet on her side had also been tied to the bed and untied it. Charge Nurse E reported it looked like the sheet had been rolled up and placed across Patient #1's legs and tied to the bed. Charge Nurse E confirmed this would be considered an inappropriate restraint, confirmed with RN D who would enter the Midas report and confirmed she placed a note on the shift report to alert the MICU Nurse Manager to the incident.

9. During an interview on 12/15/22, beginning at 1:30 PM, with the MICU Nurse Manager, Patient Safety Officer, Risk Manager, Director of Quality, Patient Safety and Risk and the Director of Security and Behavioral Health, the group reviewed video evidence for the incidents with Patient #1, involving RN A with Sitter B, and Sitter B with Sitter C. The MICU Nurse Manager acknowledged when she became aware of the incident on the morning of 11/14/22, she did not identify the incident as potential dependent adult abuse, but viewed it as an inappropriate practice, related to restraints. The MICU Nurse Manager, while viewing the video evidence, confirmed RN A and Sitter B appeared in the first incident of restraint with a sheet and Sitter B and Sitter C appeared in the second incident. The Administrative Staff present at the interview, confirmed the sheets used to restrain Patient #1 appeared firmly tied to the bed, and a sheet would not be appropriate to restrain a patient and would be against hospital policy.