HospitalInspections.org

A hospital must protect and promote each patient's rights.

This CONDITION is not met as evidenced based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to ensure a patient received oxygen by professional staff as ordered by a physician (Tag-0144) and failed to obtain a physician order for a physical hold restraint for 7 of 12 sampled patients with restraints reviewed (Tag-0168).


Cross Reference:
482.13(c)(2) Tag-0144: Patient Rights - Care in Safe Setting
482.13(e)(5) Tag-0168: Restraint Or Seclusion

Based on a review of facility documents, medical record (MR), and interviews with staff (EMP) it was determined the facility failed to provide care in a safe setting by ensuring a patient received oxygen by professional staff as ordered by a physician for one of 12 medical records reviewed (MR1).

Findings include:

Review of facility policy on May 16, 2023, titled "Oxygen Administration and Titration" last revised July 21, 2021, revealed "Policy Purpose: To safely and effectively titrate non-positive pressure oxygen for non-ventilated adult patients ... Roles/Responsibilities: All application and adjustments to oxygen are restricted to nurses, respiratory therapists, physical therapists (PT), and occupational therapists (OT). Patient Care Assistants (PtCAs) may NOT apply, titrate, or discontinue supplemental oxygen."

Review of MR1 on May 16, 2023, revealed a 67 year-old patient with history of Alzheimer's Dementia was sent to the Emergency Room. "Emergency Department ED Notes" on May 11, 2023, by EMP6, a facility PtCA, at 1:08 AM stated "Pt (patient) O2 (oxygen) dropped to 87% while sleeping. Pt placed on 2L (liters) nasal canula ..." Review of MR1 revealed no order for the oxygen.

During interview with EMP6 on May 16, 2023, at 12:06 PM EMP6 stated, she applied 2 liters of oxygen to MR1 when she saw patient's saturation drop below 90. EMP6 also stated "I'm not sure if the patient had an order for oxygen."

Interview with EMP1 and EMP2 on May 16, 2023, confirmed the findings noted above in facility policies and medical records.

Based on a review of facility documents, medical records (MR), and interviews with staff (EMP) it was determined that Lancaster General Hospital failed to protect patient's rights by failing to follow the established policy/procedure related to obtaining a physician order for restraint intervention on seven of 12 sampled patients with restraints reviewed (MR1, MR2, MR4, MR6, MR9, MR11 and MR12).

Findings include:

On May 16, 2023, review of facility policy "Restraint and Seclusion" effective date April 21, 2023, revealed "Policy Purpose: The purpose of this policy is to ensure patient safety and eliminate the inappropriate use of restraint and seclusion on all patients, regardless of the patient location within the hospital...Restraints: Mechanical Restraint: Any manual method, physical or mechanical device, material, or equipment that the patient cannot easily remove and which immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Examples may include but are not limited to: Physical holding in order to administer a medication against the patient's wishes ... Procedure: General Procedures for Any Restraint Use ... 4. The nurse who is overseeing the care of the patient can initiate the use of restraint after obtaining an order from the attending physician who is responsible for the care of the patient. 5. In an emergency situation, when the need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application, the order must be obtained from the LP either during the emergency application or immediately (within a few minutes) after the restraint has been applied."


Review of MR1 on May 16, 2023, revealed a 67-year-old patient with history of Alzheimer's Dementia was sent to the Emergency Room. "Emergency Department ED Notes" on May 11, 2023, by EMP5 at 12:12 AM stated "Security called to bedside for medication administration ... 12:15 am Security at bedside. Patient continues to scream profanities at staff. Patient then grabbed ED techs shirt and would not let go. Security assisted patient back into litter for this RN to administer Ativan." No physician order for the physical holding restraint was found in MR1.

Review of MR2 on May 16, 2023, revealed "Emergency Department ED Notes" on April 20, 2023, by EMP7 at 8:38 AM stated "Security arrived to assist writer ... Pt (patient) medicated per MAR (medication administration record) and moved ..." Further review of MR2 revealed in "Incident Report" entered by EMP8 on April 20, 2023, at 10:06 AM stated "Once the meds were ready, we once again attempted to deescalate patient and get patient to the bed without force, but we had to hold arms and assist patient to the bed. We kept patient restrained during the administering of the medication, which went without issue." No physician order for the physical holding restraint was found in MR2.

Review of MR4 on May 16, 2023, revealed "Emergency Department ED Notes" on April 16, 2023, by EMP9 at 11:35 PM stated "Security, two RNs, and BIT where unable to convince the patient to change. The patient was assisted by security and nursing to change, he remained resistant and attempting to kick, hit, and bite staff. To avoid injury to the patient and staff clothing had to be cut. Patient was placed in a yellow gown. Aggression continued, the provider was notified, and patient was given IM medications." Further review of MR4 on the Incident Report dated April 17, 2023, at 12:37 AM revealed "Once all additional officers arrived, we then gave the patient one last chance to change on their own and patient continued to refuse. At this time, we physically restrained the patient while [EMP9] cut their clothes off. Once the patient was changed [EMP9] then gave patient calming medications. Once the medications were given all officers released the patient and exited the room. No physician order for the physical holding restraint was found in MR4.

Review of MR6 on May 16, 2023, revealed in "Emergency Department ED Notes" on March 31, 2023, by EMP7 at 1:00 PM stated "Pt received IM Ativan and Haldol per order. Security at bedside to maintain patient and staff safety." No physician order for the physical holding restraint was found in MR6.

Review of MR9 on May 16, 2023, revealed in "Emergency Department ED Notes" on April 4, 2023, by EMP11 at 11:41 AM "Security at bedside for IM medication administration." No physician order for the physical holding restraint was found in MR9.

Review of MR11 on May 16, 2023, revealed in "Emergency Department ED Notes" on April 10, 2023, by EMP12 at 8:45 PM "Patient medicated per orders with security assistance." Further review of MR11 on April 11, 2023, at 12:24 AM revealed "Security called to assist and patient resisted during labs." No physician order for either physical holding restraint was found in MR11.

Review of MR12 on May 16, 2023, revealed in "Emergency Department ED Notes" on May 9, 2023, by EMP13 at 11:38 PM "Attempted to leave and had to be restrained by security. He did become violent and attempted to hit security. He was given chemical sedation." No physician order for the physical holding restraint was found in MR12.

During review of the twelve medical records of patients with restraints, MR1, MR2, MR4, MR6, MR9, MR11 and MR12 did not have a physician order for a patient restraint.

Interview with EMP1 on May 16, 2023, at approximately 3:00 PM confirmed the findings noted above in facility policies and medical records.

Interview with EMP2 on May 16, 2023, at approximately 3:05 PM confirmed the findings noted above in facility policies and medical records.

Interview with EMP5 on May 16, 2023, at 12:12 PM confirmed a restraint order was not obtained for MR1 being restrained by security to be administered medication.