HospitalInspections.org

Based on record review, interview, and policy review, the facility failed to implement a care plan related to restraint use for two of four sampled patients (#8 and #2).

Findings:

1. Observation on 03/07/11 at 10:40 AM showed patient #8 in bed at rest, with bilateral soft wrist restraints, a vest restraint, and four side rails in the raised position.

Medical record review for current patient #8, age 58, admitted on 02/17/11 with a diagnosis of near drowning, showed intermittent use of restraints from 02/17/2011 to the time of survey on 03/07/11.

During the medical record review, Registered Charge Nurse, Staff C, confirmed there was no care plan related to restraint use for patient #8.

2. Review of the discharged patient #2, age 82, admitted on 04/08/10 and discharged on 04/28/10 showed the use of restraints from 04/12/10 to 04/27/10. Closed medical record review for patient #2 showed there was no care plan related to the use of restraints.

3. Review of the facility policy titled "Restraints", dated as revised 12/10, showed there was not a policy instructing staff to care plan for restraint use.

Based on record review, interview, and policy review, the facility failed to obtain a written physician's order for four of four sampled patients with restraints. (#6, #8 & #5 and, #2)

Findings:

1. During an observation on 03/07/11 at 10:35 AM Patient #6 was observed in bed at rest, with head of the bed elevated, with one soft wrist restraint to the left wrist.
Medical record review for current patient #6, age 59, admitted on 3/4/11 with a diagnosis Weakness, confusion, and lung cancer showed intermittent use of restraints on 03/05/11.
Review of the physician's order dated 03/05/11 at 11:23 PM did not include a type of restraint to be used on the patient. There was no order from the physician instructing staff what type of restraint to use on the patient.

During the medical record review, Registered Charge Nurse, Staff C, confirmed there was no type of restraint ordered.

2. Observation on 03/07/11 at 10:40 AM showed patient #8 in bed at rest, with bilateral soft wrist restraints, a vest restraint, and four side rails in the raised position.

Medical record review for current patient #8, age 58, admitted on 02/17/11 with a diagnosis of near drowning showed intermittent use of restraints from 02/17/2011 to the time of survey on 03/07/11.

The physician's order dated 02/20/11 at 5:00 PM (good for 72 hours by facility policy) instructs the staff to use bilateral soft wrist restraints. The nursing narrative dated 02/22/11 at 5:30 PM documents the use of four side rails in the raised position in addition to the wrist restraints. There was no signed physician's orders for the use of side rails.

The physician's order dated 02/23/11 at 5:00 PM instructs the staff to use bilateral soft wrist restraints. The nursing narrative dated 02/25/11 at 5:37 PM documents the use of four side rails in the raised position in addition to the wrist restraints. There was no signed physician's orders for the use of side rails.

The physician's order dated 02/27/11 at 5:00 PM instructs the staff to use bilateral soft wrist restraints and a vest restraint. The nursing narrative dated 02/28/11 at 08:00 AM documents the use of four side rails in the raised position in addition to the wrist restraints. There was no signed physician's orders for the use of side rails.

The physician's order dated 03/02/11 at 5:00 PM instructs the staff to use bilateral soft wrist restraints. The nursing narrative dated 03/03/11 at 08:0 AM documents the use of four side rails in the raised position in addition to the wrist restraints. There was no signed physician's orders for the use of side rails.
During the medical record review, Registered Charge Nurse, Staff C, confirmed there was no order for the side rail use in the raised position.

3. Medical record review for current patient #5 showed a physician order for side rails and bilateral soft wrist restraints written on 03/06/11 at 03:30 AM. On 03/07/11 at 11:30 AM the physician's order was found unsigned.

During the medical record review on 03/07/11 at 12:30 PM, the Clinical Manager and the Risk Manager both confirmed the physician's orders were not signed within the twenty-four hour required time frame.

4. Review of the discharged patient #2, age 82, admitted on 04/08/10 and discharged on 04/28/10 showed the use of restraints from 04/12/10 to 04/27/10.

Review of the restraint orders showed the following:

Closed medical record review for patient #5, age 82, admitted 04/08/10 and discharged 04/28/10 with a diagnosis of dysphasia showed care planning related to fall, however, there was no care plan related to the use of restraints.

Physician's orders for restraints were found for the following days:

04/12/10 03:00 AM-for Vest restraint and side rails-not signed by the physician.

04/14/10 03:00 AM-for Vest restraint and bilateral wrist restraints-not signed by the physician.

On 04/15/10 at 7:48 PM the nursing narrative documents the use of restraints including vest restraint and bilateral wrist restraints. There was no signed physician's orders for the use of these restraints.

On 04/16/10 at 05:31 AM the nursing narrative documents the use of restraints including side rails x four, vest restraint and bilateral wrist restraints. There was no signed physician's orders for the use of side rails.

On 04/17/10 at 09:58 AM to 3:01 PM the nursing narrative documents the use of restraints including side rails x four, vest restraint and bilateral wrist and ankle restraints. There was no signed physician's orders for the use of side rails or the ankle restraints.

On 04/22/10 at 08:00 AM the nursing narrative documents the use of restraints including side rails x four, vest restraint and bilateral wrist. There was no signed physician's orders for the use of side rails.

On 04/23/10 at 04:00 AM the nursing narrative documents the use of restraints including side rails x four, vest restraint and bilateral wrist. There was no signed physician's orders for the use of side rails.

On 04/24/10 at midnight to 04:00 AM the nursing narrative documents the use of restraints including side rails x four, vest restraint and bilateral wrist. There was no signed physician's orders for the use of side rails.

On 04/25, 04/26, & 04/27/10 the nursing narrative documents the use of restraints including vest restraint, bilateral wrist restraints and four side rails in the raised position. There was no signed physician's orders for the use of these restraints. Review of the nursing narrative documents the use of restraints including side rails x four, vest restraint and bilateral wrist during the three days.

During the medical record review on 03/07/11 at 2:30 PM, the Risk Manager both confirmed the physician's orders were not signed within the twenty-four hour required time frame.

5. Review of the facility policy titled "Restraints", dated as revised 12/10, states, in part, the following:

Policy, in part, states:
- Protective Devices/Mechanisms include, but are not limited to: Side rails (No more than 3 of 4).
-Notifies the physician to validate the order for restraints by clinical protocol. The order must be obtained within 12 hours of restraint initiation and the physician must evaluate the patient and sign the order within 24 hours.
-Orders for clinical restraint protocol are limited to 72 hours from the time of the order placement.

Based on record review and interview, the facility failed to insure the medical staff enforced the rules and regulations of the facility for two (2) of nine (9) sampled records. (# 1 and 5)

Findings:

Review of record for patient #1 failed to provide evidence of a discharge summary.
Review of record for patient #5 failed to reflect the "time" on physicians' orders written on 03/03/11, 03/05/11, and 03/06/11.
Review of the Facility Medical Staff Rules and Regulations and Facility Policy on "requirements of a medical record" reflected a requirement that the physician complete a discharge summary within 30 days of discharge; and the facility medical record policy "requirements of a medical record" required that all orders must be timed.
Interview with Risk Manager and the Clinical Supervisors of Telemetry, PCU, and ICU on 03/07/11 at 11:15a.m., 12:30 p.m., and 3:15 p.m. confirmed the records were complete at time of review and did not include the required information.

Based on record review and interview, the facility failed to ensure one of two patients with Foley catheters received documented care. (#8)

Findings:

Medical record review for current patient #8, age 58, admitted on 02/17/11 with a diagnosis of near drowning showed the presence of a Foley catheter (tube to drain urine from the bladder into a collection bag) from 02/17/11 to 02/28/11. There was no documentation of any cleaning or care of the catheter from 02/17/11 to 02/28/11.

Review of the facility policy titled "Foley Catheter Protocol" dated as revised 12/10, states in part, Perform and document catheter care at least once a shift; more often if there is soiling with drainage, blood, or feces.

During the medical record review, Registered Charge Nurse, Staff C, confirmed there was no documentation of care of the Foley for patient #8.