HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to informing patients who receive outpatient treatment of their patient rights, providing care in a safe setting related to the protection of a patients physical safety related to patient monitoring, for 1 of 1 patients (Patient ID #1), and completion of a fall risk assessment for 4 of 7 patients in the Emergency Department (ED) (Patient ID #'s 1,3,4, and 5).

Findings are as follows:

1. The hospital failed to provide evidence that patients receiving treatment in outpatient services are being informed of their patient rights. Refer to A-117

2. The hospital failed to follow their own policy/guidelines for "patient rounding" for 1 of 7 patients in the Emergency Department (ED) resulting in poor quality of care. Refer to A-0144

3. The hospital failed to monitor a patient placed in a restraint device to ensure his/her physical and psychological needs were met. Refer to A-0144

4. The hospital failed to ensure that staff' understands the proper definition of a restraint resulting in a patient being placed in restraints without physicians' orders.

Based on policy review and staff interview, it has been determined that the hospital failed to establish and implement policies and procedures that effectively ensure that all patients and/or their representatives have the information necessary to exercise their rights for both inpatient and outpatient services.

Findings are as follows:

Surveyor review of the hospital's "Patients' Rights and Responsibilities Policy," which was approved on 3/12/2020, states, in part,

"Policy: Establish and recognize the rights and responsibilities of inpatients at [the hospital].
Inform patients of their rights and responsibilities as an inpatient at [the hospital] ..."

During an interview with the Systems Risk Management Director on 12/1/2021 at 10:46 AM, she acknowledged that the hospital policy lacked inclusion of the rights and responsibilities of the patient receiving outpatient services.

Based on medical record review and staff interview, it has been determined that the hospital failed to ensure that staff's knowledge of the definition of a restraint, and proper execution of the restraint procedure resulting in 1 of 2 patients, Patient ID #2, being placed in restraints without a physician's order, and failure to monitor Patient ID #2 according to policy, while in restraints.

A. The hospital's policy entitled "Non-Violent Restraints," last reviewed by the Restraint Policy Committee in 3/2020, states, in part:

" ...Definitions
A. Physical restraint is any method, or physical or mechanical device, material, or equipment that limits freedom of movement ...is attached to or adjacent to the patient's body that he or she cannot easily remove ...
b. Non-Violent/Non-self-destructive restraints are used to provide support to the medical and surgical needs of the patient.
General Principles applicable to Non-Violent Restraints: ...
2. Restraint order must:
a. Be in accordance with the order of the treating physician or designee ...
b. Must specify the reason for the restraint ...
d. In accordance with the patient's plan of care ...

Procedure ...
1. Indications for Non-violent Restraints:
a. The patient' is pulling at tubes, lines, or dressings
b. The patient is confused and interfering with the provision of care ...
d. The patient may unpredictably and suddenly awaken and harm himself/herself ...with a significant risk of self-extubation ....
e. The patient's treating physician ...documents an in-person assessment of the restrained patient at least once every 24 hours at which time restraint shall be either re-ordered or discontinued ...

3. Patient Monitoring and Documentation ...
e. Other monitoring activities as indicated by patient's presenting condition will be completed at least every two (2) hours or more frequently as indicated.
a. Monitoring activities include patient assessment for:
i. Signs of injury associated with the use of restraint
ii. Nutrition and hydration needs
iii. Circulation
iv. Range of motion
v. Hygiene and elimination
vi. Physical and psychological status and comfort
vii. Readiness for discontinuation or removal from restraint

4. Release and Reapplication ...
b. Reapplication of the restraint requires a new order unless the release of restraints occurred for the purpose of caring for a patient's needs ..."

Findings are as follows:

Review of Patient ID #2's medical record revealed s/he was admitted to the hospital in 11/2021 after experiencing a fall and syncope (dizziness). While inpatient, Patient ID #2 medically deteriorated. The patient was transferred to the hospital's Intensive Care Unit (ICU) on 11/28/2021, with respiratory failure requiring mechanical ventilation.

Further review of Patient ID #2's medical record revealed the patient was placed, by nursing, in soft wrist restraints from 11/28/2021 at 8:00 AM to 11/28/2021 at 10:00 PM, to prevent pulling on his/her ventilation tubing. Additionally, s/he was placed back in soft wrist restraints on 11/29/2021 at 11:00 AM and remained in restraints during surveyor observation on 12/1/2021 at 4:00 PM.

Surveyor review of the medical record for Patient ID #2 failed to reveal a physician's order for the use of restraints on 11/28/2021, 11/29/2021, and 11/30/2021. Additional review of the medical record for Patient ID #2 failed to provide evidence that nursing monitored the patient for signs of injury associated with the use of restraint, nutrition and hydration needs, circulation, range of motion, hygiene and elimination, physical and psychological status and comfort and readiness for restraint discontinuation or removal at least every two hours on 11/29/2021 from 11:00 AM (when they were reapplied) until 12/1/2021 at 8:00 AM, while the patient remained in restraints.

On 12/1/2021 at 3:53 PM, the surveyor interviewed Staff F, Registered Nurse caring for Patient ID #2 on 12/1/2021. When asked about the ICU's restraint practice, she stated, "We tie them down as soon as they are intubated."

During a surveyor interview with The ICU Nurse Director on 12/1/2021 at 9:50 AM, she acknowledged Patient ID #2 was placed in restraints without a physician's order. She further acknowledged, that after she interviewed Staff E, the Registered Nurse caring for Patient ID #2 on 11/30/2021 from 7:00 AM-7 PM, additional nursing education was necessary, as Staff E, along with other nursing staff, was identified as having a knowledge deficit relative to self extubation and the use of soft restraints.

During an interview with the Chief Nursing Officer on 12/2/2021 at 11:40 AM, she acknowledged that the hospital has an "opportunity for improvement relative to restraint use."

Based on record review and staff interview, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative providing nursing care in accordance with accepted standards of nursing practice.

1. The hospital utilized restraints without a physician's orders. Refer to A-0395

2. The hospital failed to monitor/document safety of the restrainted patient. Refer to A-0395

3. The hospital failed to follow their own policy/guidelines for "patient rounding" in the Emergency Department (ED). Refer to A-0395

4. The hosptial failed to perform the Memorial ED Fall Risk Assessment Tool (MEDFRAT) fall assessment within a timely manner for patients in the ED. Refer to A-0395

Based on medical record review, surveyor observation and staff interview, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice relative to the utilization of restraints without a physician's orders for 1 of 2 patients ID #2, Completion of nursing documentation for patient safety/monitoring while in restraints for 1 of 2 patients, ID #2.
Additionally, the hospital failed to follow their own policy/guidelines for "patient rounding"(monitoring) for 1 of 7 patients in the Emergency Department (ED), Patient ID # 1 and also failed to complete the Memorial ED Fall Risk Assessment Tool (MEDFRAT) within a timely manner for 4 of 7 patients, Patient ID #'s 1, 3, 4, and 5.

A. The hospital's policy entitled "Non-Violent Restraints," last reviewed by the Restraint Policy Committee in 3/2020, states, in part:

" ...Definitions
A. Physical restraint is any method, or physical or mechanical device, material, or equipment that limits freedom of movement ...is attached to or adjacent to the patient's body that he or she cannot easily remove ...

General Principles applicable to Non-Violent Restraints: ...
2. Restraint order must:
a. Be in accordance with the order of the treating physician or designee ...
b. Must specify the reason for the restraint ...
d. In accordance with the patient's plan of care ...

Procedure ...
2. Orders for Non-Violent Restraints

a. The patient's treating physician\designee orders the appropriate type of restraint prior to the application ...
d. The patient's treating physician or designee documents a face-to-face assessment of the patient within 24 hours of the initiation of the restraint, at which time, he or she shall either discontinue or write an order for the continuation of the restraint.
e. The patient's treating physician or designee documents an in-person assessment of the restrained patient at least once every 24 hours at which time restraint shall be either re-ordered or discontinued ...

3. Patient Monitoring and Documentation ...

e. Other monitoring activities as indicated by patient's presenting condition will be completed at least every two (2) hours or more frequently as indicated.
a. Monitoring activities include patient assessment for:
i. Signs of injury associated with the use of restraint
ii. Nutrition and hydration needs
iii. Circulation
iv. Range of motion
v. Hygiene and elimination
vi. Physical and psychological status and comfort
vii. Readiness for discontinuation or removal from restraint

4. Release and Reapplication ...

b. Reapplication of the restraint requires a new order unless the release of restraints occurred for the purpose of caring for a patient's needs ..."

Findings are as follows:

Review of Patient ID #2's medical record revealed s/he was admitted to the hospital in 11/2021 after experiencing a fall and syncope (dizziness). While inpatient, Patient ID #2 medically deteriorated and was transferred to the hospital's Intensive Care Unit (ICU) on 11/28/2021 with respiratory failure requiring mechanical ventilation.

Further review of Patient ID #2's medical record revealed the patient was placed, by nursing, in soft bilateral wrist restraints from 11/28/2021 at 8:00 AM to 11/28/2021 at 10:00 PM. Additionally, s/he was placed back in soft bilateral wrist restraints on 11/29/2021 at 11:00 AM and remained in restraints during surveyor observation on 12/1/2021 at 4:00 PM.

Surveyor review of the medical record for Patient ID #2 failed to reveal a physician's order for the use of restraints on 11/28/2021, 11/29/2021, and 11/30/2021.

Surveyor review of the medical record for Patient ID #2 failed to provide evidence that a face-to-face assessment was conducted by the treating physician within 24 hours of the initiation of the restraint to determine whether the restraint should be either continued or discontinued. Additionally, the medical record failed to provide evidence that the patient's treating physician documents an in-person assessment of the restrained patient at least once every 24 hours to determine whether the restraint shall be either re-ordered or discontinued.

Surveyor review of the medical record for Patient ID #2 failed to provide evidence that nursing monitored Patient ID #2 for signs of injury associated with the use of restraint, nutrition and hydration needs, circulation, range of motion, hygiene and elimination, physical and psychological status and comfort and readiness for restraint discontinuation or removal at least every two hours on 11/29/2021 from 11:00 AM (when the restraints were reapplied) until 12/1/2021 at 8:00 AM, while the patient remained in restraints.

On 12/2/2021 at 11:58 AM surveyor conducted an interview with the Resident caring for Patient ID #2, Staff A. Staff A acknowledged that he did not place orders for the restraints, he did not document the patient restraint use, and he did not perform a face-to-face assessment. regarding the patient's restraint use. He stated that this was an oversight on his part because "there was no prompt for documentation every 24 hours."

During an interview with the Attending responsible for the Resident on 12/2/2021 at 12:14 PM, he acknowledged that he did not review the orders or Resident's notes, as the plan was discussed during multidisciplinary rounds. He further stated that he does not co-sign the Resident Progress Notes as he writes his own Progress Note. The Attending acknowledged that he is ultimately responsible for the care provided by the Resident.

During an interview with the ICU Nurse Director on 12/2/2021 at 9:50 AM, she acknowledged that the medical record lacked evidence of every 2-hour nursing assessments being performed from 11/29/2021 at 11:00 AM (when the restraints were reapplied) to 12/1/2021 at 8:00 AM, while the patient remained in restraints. She further acknowledged that, when speaking with her staff, they have a knowledge deficit related to the use of soft restraints with intubated patients.

B. The hospitals policy entitled, "Patient Fall Prevention and Management," which was approved by the RW [Roger Williams Medical Center] Policy Committee on 3/20/2020, states, in part,

" ...C. Assessment and Intervention-Emergency Department Patients
1. Nurse completes the MEDFRAT [type of fall assessment that uses a scale rating] fall risk assessment for adult patients ...
a. Individualized interventions are put in place based on the fall risk assessment and may include, but are not limited to: ...
-hourly comfort rounds to address toileting, positioning, pain assessment ..."

1. Surveyor review of the medical record for Patient ID #1 revealed s/he was COVID positive and presented to the hospital's Emergency Department (ED) on 11/24/2021 at approximately 9:29 AM via ambulance with complaints of difficulty breathing. The physicians ED Visit Note from 9:41 AM states the patient's medical history was remarkable for multiple sclerosis, recently diagnosed Parkinson's disease, a lumbar compression fracture, hypertension, arthritis, and diabetes. The note further states that she has been bedridden for the past 2 years and describes the patient as weak.

Review of Patient ID #1's nursing documentation failed to reveal evidence of a MEDFRAT fall assessment being performed, as per policy. Further review of the medical record failed to reveal evidence of nursing performing hourly rounds to monitor the patient's wellbeing, or the patient being provided food or hydration by nursing from 10:48 AM until his/her discharge at approximately 5:59 PM.

During an interview with the ED Attending, Staff B, on 11/30/2021 at 1:20 PM, he stated that sometime during the afternoon of Patient ID #1's admission he observed the patient "on [his/her] right side, against the [stretcher] rail, with [his/her] arm located between the mattress and the rail." He further stated that he "let the siderail down" and moved the patient to the center of the bed. He acknowledged the patient asked him for a drink, which he provided to her.

On 12/1/2021 at 1:45 PM, surveyor interviewed Staff C, the Registered Nurse (RN) assigned to Patient ID #1 and two additional patients from approximately 9:20 AM until transfer of care at 3:18 PM. Staff C stated that approximately 15-20 minutes into her shift she responded to a Code Blue for another patient and was in the room with the other patient until her shift ended. She further stated that when from 9:20 AM until 3:18 PM, she looked through the glass to be sure the patient was "in the bed and not on the floor 1-2 times while walking to the Code Room for supplies, etc." but could not provide evidence of doing so. Additionally, Staff C acknowledged that she did not perform any assessments, provide food or hydration, or check vital signs for Patient ID #1 from 9:20 AM to 3:18 PM.

On 12/1/2021 at 8:51AM, surveyor interviewed Staff D, the RN assigned to Patient ID #1 from 3:18 PM until 5:59 PM, when the patient was discharged. Staff D stated that on 11/24/2021 she worked from 2:00 PM-9:00 PM, and that she was responsible for the charge nurse role and "a few other patients." Staff D stated that Patient ID #1 should have been monitored with hourly rounding and provided dinner; she further stated that it is her practice to document dinner, drinks, urine, stool, and comfort rounding.

During an interview with the Risk Management Coordinator on 12/1/2021 at 3:3 PM, she was unable to provide evidence of nursing documentation, including comfort rounding and providing food or nutrition for Patient ID #1 from 10:48 AM until 5:59 PM. Additionally, she was unable to provide evidence of the MEDFRAT fall risk assessment being performed for Patient ID #1.

2. Surveyor review of the medical record for Patient ID #3 revealed s/he presented to the hospitals ED on 11/24/2021 at 6:15 PM with complaints of a facial and dental injury after tripping and falling.

3. Surveyor review of the medical record for Patient ID #4 revealed s/he presented to the hospitals ED via rescue on 11/24/2021 at 10:58 AM from a nursing home with an ongoing urinary tract infection. A nurse's note from 11/24/2021 at 6:01 PM describes the patient as requesting to stand and use the commode. The note further states that the patient was "unable to stand" and "extremely rigid."

4. Surveyor review of the medical record for Patient ID #5 revealed s/he presented to the hospitals ED on 12/1/2021 at 5:57 AM from a nursing home for a psychiatric evaluation. The Triage Assessment from 12/1/2021 at 5:59 AM described Patient ID #5 as oriented to person only and s/he was assessed to have right sided weakness.

During an interview with the ED Nursing Director on 12/2/2021 at 12:45 PM, she stated that MEDFRAT fall risk assessments should be performed on all patients in the ED; however, she could not provide evidence of the MEDFRAT assessment was performed for Patient ID #'s 3 and 4. Additionally, she acknowledged that the MEDFRAT fall assessment was not performed in a timely manner for Patient ID #5, as it was performed approximately 22 hours after the patient's arrival.