HospitalInspections.org

Based on observation, the facility failed to provide patient care in a clean and safe setting.


Findings include:

During a tour of the Behavioral Health Unit on 9/20/16 approximately 10:45 AM, the tub room was observed to be dirty with rust stained floor, soiled curtain and dirt buildup on the floor.

This finding was brought to the attention of Staff A, Patient Care Director, who was present during the tour.

Based on medical record (MR) review and staff interview, in 1 (one) of 3 (three) medical records reviewed, the facility did not document the steps or interventions used prior to the use of restraint or seclusion. (Patient #3).

Findings include:

Review of the MR for Patient #3 identified: This 76 year old patient, with history of Parkinson and Dementia, was brought to the hospital by ambulance on 8/1/2016 13:40 (1:40 PM), with chief complaint of agitation. The patient was seen by the triage nurse at 13:45 (1:45 PM). The nurse noted that the patient was agitated, high risk for elopement and he was placed in 4 point restraint by EMS.
The patient Restraint Flowsheet dated 8/1/2016 13:00 (1:00 PM), documented the initiation of restraint, which was prior to the completion of the nursing assessment.
The nursing assessment did not document if the hospital applied restraint was appropriate for this patient, or the rationale for not using alternative interventions to restraints.

These findings were acknowledged by Staff C, Triage Nurse and Staff D, Nurse Manager, during interview on 9/23/2016 at 1:45 PM.

Based on medical record (MR) review, document review and interview, in 1 (one) of 3 (three) medical records reviewed, the facility did not ensure that the restraint plan of care and observation is based on an actual assessment and evaluation. (Patient #3).

Findings include:

The Security Department Incident Report Sheet, dated 8/1/16, was reviewed. The report stated that on 8/1/2016 at 1400 (2:00 PM), Patient # 3 was placed in 4 point restraint.

Review of the MR for Patient #3 identified: This 76 year old patient with history of GERD (Gastroesophageal Reflux Disease), Hypothyroid, Parkinson and Dementia, was brought to the ED by ambulance on 8/1/2016 at 13:40 (1:40 PM). The chief complaint was agitation. The triage nurse noted that the patient was seen on 08/01/16 13:45 (1:45 PM). The nurse also noted that the patient was placed in 4 point restraint by EMS.

The Restraints Flowsheet was dated 8/1/2016 13:00 (1:00 PM). This document indicated the restraint status and documented that the restraint protocol was initiated, which was prior to the triage nurse seeing the patient. There was no documentation that the restraint treatment plan was modified or the reason why this was not done after the patient was triaged.

This finding was acknowledged by Staff # C, Triage Nurse, during interview on 9/23/2016 at approximately 1:45 PM.

Based on medical record (MR) review, document review and interview, in 2 (two) of 3 (three) medical records reviewed, the facility did not ensure that the use of restraint is in accordance with the order of the physician or other licensed independent practitioner who is responsible for the patient. (Patient #2, #4)

Findings include:

1. Review of the Security Department Incident Report Sheet, dated 6/20/16: 11:35 AM thru 12:40 PM noted: Patient #2 was placed in 4 point restraint, as per MD, due to his aggressive demeanor. Staff A, Security Guard, wrote that on 6/20/16 at 11:35 AM, he and another security staff responded to a call for additional assistance to the crash room. On arrival, the medical staff was attempting to treat a patient who was being combative by kicking and swinging his arms. The MD wanted patient secured and 4 pointed. The security staff wrote that he and another security staff, along with medical staff restrained the patient.

Review of MR for Patient #2 noted: This 69 year old patient, with history of alcohol abuse, depression, was brought to the Emergency Department (ED) by ambulance on 6/20/2016 11:02 AM. The triage nurse noted that the patient was seen in the ED on 6/20/16 11:05 AM. The chief complaint was AMS (altered mental status).
The ED Nursing Assessment noted 6/20/2016 11:30 AM: patient agitated and violent with staff and that MD with security and other ED personnel were at the bedside.
At 1:29 PM, on 6/20/2016, the nurse noted patient is extremely agitated. MD aware. Security called and restraint applied.
Review of the restraint order noted that the physician order for 4 point restraint, was written on 6/20/2016 13:40 (1:40 PM).
It was noted that there was inconsistent documentation regarding the time of restraint application. The MD ordered 4 point restraint was written on 6/20/2016 13:40 (1:40 PM), and was not timely.


2. Review of the Security Department Incident Report, dated 9/13/16: 23:45 (11:45 PM) to 00:04 (04:00 AM) noted: The security staff responded to agitated patient call in ER, with sergeant and two other officers. Patient was refusing to change into hospital attire, became agitated and was restrained. Clothing changed by ER technician.

Review of MR for Patient #4 noted: This 75 year old male patient, a nursing home resident, with history of dementia, and hypertension, was brought to the ED by ambulance on 9/13/16 20:58 (8:58 PM) for an evaluation. The chief complaint was agitation, hitting the nursing home staff. The triage nurse noted that on arrival the patient was asleep, accusable, limited verbal response, answered to name. He as given Seroquel prior to arrival at the ED.
The physician noted that the patient was seen on 9/13/2016 21:14 (9 :14 PM): patient presents to ED for aggressive behavior at the nursing home per documentation from the nursing home, patient has been more aggressive and he was given Seroquel (antipsychotic medicine) and started on fluoxetine (antidepressant) medication. The physician noted patient is without complaint, calm and compliant.

The patient had a psychiatric consultation on 9/13/16 at 23: 30 11:30 PM and the psychiatrist noted "on exam, patient is uncooperative, pretends to sleep, refusing to answer any questions. As per security, patient resisting changing into patient gown and repeatedly asking what was going on and why he needed to change. He was not aggressive with security. Patient is completely calm now.

There was no documentation of a written order for the application of restraint. The clinical staff did not document the need or the behavior warranting the need for restraints or security watch.

The facility policy and procedure titled "Restraint-Application and Care of The Patient in Restrains Protocols," last revised 2/2016, described the following: A written order is required for each episode of physical hold. This policy was not implemented.

Staff # A and Staff B acknowledged these findings during interview on 9/23/2016 at approximately 1:00 PM.

Based on medical record review and interview, in 1 (one) of 3 (three) medical records (MR) reviewed, nursing staff did not ensure that the patient received care for pressure ulcers, as ordered by the physician. (Patient #1).

Finding include:

Review of MR for Patient #1, on 9/22/16 at approximately 12:40 PM, noted: the patient was admitted with Stage II and IV pressure ulcers on the right heel and sacrum, respectively. On 9/20/16 the physician ordered Normal Saline daily dressing to both pressure ulcers. It was noted that treatment was rendered on 9/20/16 and 9/22/16, but there was no nursing documentation to indicate why the treatment was not rendered on 9/21/20/16, as per physician's orders.

This was brought to the attention of Staff B, Patient Care Director on 9/22/16.