HospitalInspections.org

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Based on document review and interview, in 1 of 7 medical records, the facility did not ensure orders for non-violent two point restraints were renewed timely.

This failure places all patients at risk for being in restraints without a physician's order.

Findings:

Review of medical record (MR) for Patient #4 revealed the nurse documented on the patients flowsheet bilateral wrist restraints at 3:00 PM on 4/21/18. The physician's renewal order was not written until 5:00 PM, 2 hours later.

On 4/22/18 the previous restraint order expired at 7:26 PM. The nurse documented on the patients flowsheet bilateral wrist restraints at 8:00 PM on 4/22/18. The physicians order was not renewed until 9:41 PM, 1 hour and 41 minutes later.

Per interview with Staff C, Administrator, two-point not violent restraints automatically default to a 24-hour expiration and 24-hours is the time allowed for any non-violent restraint.

The facility Policy and Procedure, titled "Use of Restraints for Non-Behavioral Health", last revised 1/2014, lacks instructions for nursing staff to obtain renewal orders when patients need to remain in restraints after 24 hours.
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Based on record review, document review, and interview, in 3 of 7 medical records (MR) reviewed, the facility did not ensure nursing staff documented two-point non-violent restraint monitoring every 2 hours or the removal of the restraints.

This failure places all patients at risk for remaining in restraints.

Findings:

Review of Patient #5's MR identified that on 5/8/18 at 1:44 PM the patient was documented as having non-violent bilateral wrist restraints.

The order for the wrist restraints was written on 5/7/18 at 1:43 PM and expired on 5/8/18 at 1:43 PM. There was no documented evidence that the patient was removed from restraints at that time.

The next order for the wrist restraints was not obtained until 6:02 PM on 5/8/18.

There was no documented evidence the patient remained in or was removed from the restraints between 1:43 PM and 6:02 PM on 5/8/18.

Per interview with Staff L, Registered Nurse, at 11:30 AM on 5/8/18, the nurse stated the patient went to dialysis during that time. However, review of the patient's dialysis documentation also revealed a lack of documentation for restraints during dialysis.

Per Staff L, staff are taught to document by exception, and do not document when a patient comes out of restraints, but only document when a patient is in restraints.

Per interview with Staff C, Administrator, at 11:35 AM on 5/11/18 she stated that when the physicians restraint order is placed, the computer system automatically prompts the nurses on their "work task list" to document a restraint assessment. When the order expires, the prompt to document restraints ends.

Staff C also stated "Unless [the nurse] documented "criteria met" then restraints should be in place and monitoring documented every 2 hours.`

The facility policy and procedure titled "Use of Restraints for Non-Behavioral Health", last revised 1/2014, instructs "the staff nurse will document...every 2-hour monitoring...[and]...discontinuation of restraint..."

The same lack of documentation regarding restraints was noted in the medical record of patients #9 & #10.
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Based on Medical Record (MR) review, document review and interview, in 1 of 6 medical records, the nursing staff did not document the daily shift assessments on a Behavioral Health patient (Patient #1).
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This inconsistent documentation may affect other providers' ability to monitor the patients' condition and provide appropriate care.
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Findings include:
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Patient # 1 MR identified that the patient presented to the psychiatric emergency department by ambulance on 4/14/18. The patient had a past medical history of schizophrenia and was admitted to the in-patient psychiatric unit on 4/15/18. The nursing staff documented an admitting assessment of the patient at 10:06 PM. The admission assessment documents the patient was alert, oriented, respiratory WDL (within defined limits), lungs clear, breath sound clear, cardiac WDL, peripheral vascular WDL ...(and) vital signs obtained upon arrival to unit."
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However, there was no daily shift assessments containing a "Brief Physical Assessment" documented by the nursing staff on 4/16/18 or 4/17/18, making it difficult to determine if there was changes in the patient's condition. This was confirmed during the afternoon of 5/9/18,
with Staff A (Nursing Trainer) and B (Nursing Instructor) at the time of the medical record review.

During an interview of Staff C (Administrator) on 5/10/18 at 10:30 AM, she stated "There is no policy for the nurses to document a daily assessment on Behavioral Health patients."
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The facility's "Nurse - Epic Care Inpatient Quick Start Guide" dated 2014, contains the following statements " ...Document an assessment: In Doc flowsheets, select Assessment tab to complete an ...assessment. Add a column for the time when you perform the assessment and document your findings ...".
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During an interview of Staff A at 11:30 AM on 5/12/18, she stated "at the end of the [EPIC] class each individual gets a (personal) log-in that gives them (access to) a specific navigator depending on their area of service. Psych [nurses] get educated on the Behavioral Health Navigator, which includes the Daily Shift Assessment flowsheets."
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