HospitalInspections.org

Based on document review, observation and interview the staff failed to complete 15 minutes checks on patients for 2 of 8 patients reviewed (patients 5 and 8).

Findings include:

1. Review of facility policy Seclusion & Restraint 140.02, last revised 12/2019, indicated the following. Appropriate assessment of a patient in restraints and seclusion shall be conducted every 15 minutes by trained competent staff/RN (Registered Nurse) and documented in the EMR (Electronic Medical Record). Assessment shall include but are not limited to: ...Circulation and range of motion in the extremities, skin integrity.

2. Review of patient 8's medical record (MR) indicated on 5/30/2020, at 21:00 patient put in restraint chair. Restraint ROM (range of motion) performed at 21:15. Discontinue episode at 21:30.

3. On 6/17/2020, at approximately 9:55 am review of video RR (Restraint Room) with N3 (Director of Nursing) and N4 (Clinical Director) of patient 8 from 5/30/2020. Video indicated patient in restraint chair for approximately 28 minutes and 41 seconds before N12 enters the room. Video indicated safety checks (range of motion) were not completed on all extremities before N12 enterers the room.

4. Review of N12 (Registered Nurse) personnel file indicated staff was counseled related to actions on 5/30/2020. Document stated, N12 failed to complete safety checks on a patient which was in restraints. The checks are to occur every 15 minutes. Additionally, N12 documented completion of checks when they were not done. Facility indicated this action are unacceptable.

5. On 6/16/2020, at 3:25 pm. interview with N3 (Director of Nursing) confirmed the following. On 5/30/2020, N12 documented in patient 8's MR safety checks that had not been performed.

6. Review of patient 5's (MR) indicated on 4/16/2020, an order was obtained and entered at 00:39 am, indicating the following. Patient on 15 minute checks for monitoring of left ear laceration, notify physician if bleeding occurs or worsening symptoms. Caregiver rounding documentation lacked rounding of patient 5 on 4/16/2020, from 00:25 am, through 01:29 am, (1 hour and 4 minutes). Patient rounded at 01:34 am, and not again until 2:29, am (55 minutes).

7. Interview with N2 (Quality Director) on 6/17/2020, at approximately 1:32 pm, confirmed patient 5's MR indicated the patient did not receive 15 minute checks as ordered.