HospitalInspections.org

I. Based on document review and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure the hospital staff identified the use of restraints should not be considered a routine part of a falls prevention program. Please refer to A-0154.

2. Ensure the hospital's staff completed the 1-hour face-to-face medical and behavioral evaluation when the hospital staff used restraints or seclusion to manage violent or self-destructive behavior. Please refer to A-0184.

3. Ensure the hospital's staff documented in the patient medical record a detailed assessment of the patient's response to the intervention and a well-reasoned plan for the continued use of restraint or seclusion. Please refer to A-0188.

The cumulative effect of these systemic failures resulted in the hospital's inability to ensure staff utilized patient restraints appropriately.


II. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 10/10/19 at 2:00 PM. The hospital staff removed the immediacy on 10/11/19 at 1:15 PM, prior to the survey team exiting the complaint investigation, when the administrative staff took the following actions:

a. Under no circumstances will restraints be utilized as a fall prevention strategy. If restraint ordered or recommended, initiate escalation process.

b. Escalation process: If restraint ordered or recommended, RN (Registered Nurse) caring for patient will notify charge nurse to initiate escalation process. Charge RN will then notify the Unit Director, Administrative Director or CNO (Chief Nursing Officer) who will identify a PCT (Patient Care Tech), RN or nursing leader to report to the beside to provide 1:1 patient care.

c. For all patients assessed at high risk for a fall who have bed/chair alarm intervention in place, staff will perform hourly verification that alarm is active and document on check list.

d. Unit Nursing leadership will communicate in person or via telephone with every RN and PCT prior to next shift worked. The communication of this education is specified in the attached process change alert. Documentation will include date, time and mode of communication/education.

e. CMO (Chief Medical Officer) and/or hospital leadership will communicate in person or via telephone with each Hospitalist prior to next shift worked, of the process change alert.

f. Plan for monitoring: Unit leader and/or Charge RN will review all fall risks patients every 8 hours, utilizing the Cerner fall risk report, to validate that the appropriate fall prevention interventions are in place to include 1:1 sitter when appropriate, and to exclude use of restraints for fall prevention at all times.

g. Nursing leadership will perform daily review of all patients in restraints, utilizing Cerner restraint reports, to verify that no restraints are in use for fall prevention.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff did not use restraints instead of providing a nursing staff member to supervise the patients as a fall precaution for 2 of 65 patients (Patient #5 and Patient #9) reviewed. Failure to ensure nursing staff did not use restraints instead of providing a nursing staff member to supervise the patients as a fall precaution resulted in the nursing staff utilizing restraints to prevent patients from falling. The nursing staff's use of restraints for falls could potentially result in patients suffering greater injury trying to get out of the restraints, potentially even resulting in patients strangling themselves, instead of falling. The hospital's administrative staff identified 151 patients with medical restraints and 23 patients where the staff potentially used restraints to prevent patients from falling, during the prior 6 months.

Findings include:

1. Review of document "Corporate Policy Fall Prevention," effective 12/2018, revealed in part, "In addition to universal fall precautions, patients who score positive for injury on the ABC's (Age, Bones, Coagulation, a system used to determine which patients have a higher risk of injury from a fall) or who are at high risk for falls will have high risk fall prevention interventions in place. Mechanical restraints may increase injuries that occur with falls, and should be used with extreme caution with patients who are at high risk for falls and fall-related injuries...."

2. Review of the "Corporate Policy Patient Observers (Sitters) Policy," effective 12/2018, revealed in part, "This policy provides guidelines for the use of patient observers when patient condition warrants to prevent injury to the patient, minimize the use of restraints when other alternatives have been ineffective, and maintain cost-effective staffing to meet patients needs...."

3. Review of the document "Corporate Policy Restraint/Seclusion Management," effective 12/2018, revealed in part, "Alternatives to restraints will be used before the least restrictive method of restraint is utilized...."

4. Review of Patient #9's medical record revealed the nursing staff found Patient #9 on the floor of the hospital room, by their bed, at approximately 1:30 AM on 8/25/19. During the fall, Patient #9 suffered a cut above their right eyebrow.

On 8/26/19 at 12:30 AM, A Patient Care Technician (PCT) found Patient #9 on the floor of the hospital room. The nursing staff obtained an order for a chest/vest restraint (a type of vest resembling a vest, which allowed the staff to tie Patient #9 to the bed and prevent Patient #9 from leaving the bed) on 8/26/19 at 12:53 AM, because Patient #9 could not follow the nursing staff's direction for their medical care. The nursing documentation revealed that Patient #9 remained confused, and still attempted to get out of bed, despite the nursing staff utilizing a chest/vest restraint on Patient #9 to prevent Patient #9 from getting out of the bed.

5. During an interview on 10/09/19 at 10:00 AM, Registered Nurse (RN) P acknowledged the medical staff ordered a chest/vest restraint for Patient #9 on 8/26/19 at 12:53 AM because Patient #9 fall a second time during the hospitalization.

6. During an interview on 10/10/19 at 11:00 AM, RN Q stated, "We would have put a sitter on [Patient #9] if we would have had the resources, but our other [Patient Care Technician was being used as] a sitter for another patient."

7. During an interview on 10/10/19 at 1:00 PM, ARNP (Advanced Registered Nurse Practitioner) R acknowledged they ordered a chest/vest restraint on 8/26/19 at 12:53 AM. ARNP R ordered the chest/vest restraint as a method to prevent Patient #9 from falling, in response to Patient #9's fall earlier that night. ARNP R revealed, "We get a sitter when one is available. Unfortunately, during the middle of the night, it's hard to do." "If we can't keep [the patients] in bed, we order a [chest] vest [restraint] as our last resort, so the patient won't fall. It's a last ditch effort."


8. Review of Patient #5's medical record revealed an entry by RN L, dated 07/10/2019 at 5:10 AM, "Patient's bed alarm sounded, nurse in room ASAP. Found on floor with head against bedside table .... Hospitalist ordered a [chest/vest restraint] for patient safety. Large [chest/vest restraint] ordered, will initiate upon arrival. Will continue to monitor."

Review of Patient #5's Fall Incident Report, dated 07/10/2019 at 7:02 AM, revealed in part, "Fall precautions in place. All testing negative for injury. Restraint [chest/vest] initiated."


9. During an interview on 10/16/2019 at 8:00 AM, RN L revealed the nursing staff would consider using physical restraints on patients after the nursing staff tried all other fall prevention measures, to prevent the patient from falling. RN L would prefer to use a sitter if the hospital had a staff member available to use as a sitter, before using restraints as a fall prevention measure. The nursing staff frequently requested to utilize sitters for fall prevention. However, the nursing staff was frequently told that the hospital did not have a staff member available to function as a sitter for the patient. Thus, the nursing staff did their best to keep the patient from falling, which included the use of restraints.

RN L reviewed Patient #5's medical record and the event note from 7/10/19 at 5:10 AM. RN L could not remember any details about the events on 7/10/19, but acknowledged the nursing staff used a chest/vest restraint on Patient #5 after Patient #5 fell. The nursing staff used the restraint to prevent Patient #5 from falling again, instead of obtaining a sitter for Patient #5.

Based on document review and staff interview, the acute care hospital nursing staff failed to document a face to face medical and behavioral evaluation within one hour for 1 of 1 patients (Patient #2) placed in restraints due to violent or self-destructive behavior. Failure to document the staff performed a face-to-face medical and behavioral evaluation could potentially result in the staff potentially failing to identify potential medical causes for the patient's violent or self-destructive behavior. The hospital identified an average daily census of 351 patients.

Findings include:

1. Review of the policy, "Restraint/Seclusion Management", dated October 2018, revealed, in part, "An order must be obtained within 1 hour after initiation of restraint or seclusion, following a face-to-face assessment by a Licensed Independent Practitioner (LIP) or a trained registered nurse or physician assistant."

2. Review of Patient #2's medical record revealed:

-- 06/22/2019, 6:20 PM, RN O documented in part, "... holding [patient] to bed while [Patient #2] was screaming and becoming balligerent (sic), attempting to hit/bite/spit and escape from soft retraints (sic). This nurse assisted others to prevent [Patient #2] from hurting them self or others. This nurse was informed that ... security officer had left to fetch leather restraints. Leather restraints ... were applied. [Patient #2] continued to scream and fight..."

--06/22/2019, 6:30 PM, Physician S gave the nursing staff an order to place Patient #2 into restraints for violence.

--06/22/2019, 10:05 PM, RN N documented in part, "This RN went in and removed the 4-point leather restraints (leather straps used to tie down a patient's wrists and ankles to a bed and severely restrict a patient's movement of their arms and legs) from [Patient #2]. Placed soft restraints (soft cloth restraints which allow patients more freedom of movement than leather restraints) on [Patient #2]. Will continue to monitor [Patient #2]."

3. During an interview at the time of reviewing Patient #2's medical record, Clinical Educatior J acknowledged the nursing staff placed Patient #2 in restraints for violent or self-destructive behavior. Clinical Educatior J acknowledged the hospital's policy required a face-to-face assessment on patients when the nursing staff initiated restraints for violent or self-destructive behavior. Clinical Educator J confirmed the medical record lacked documentation of a face-to-face assessment by a licensed independent practitioner, trained registered nurse, or physician assistant.

Based on document review and staff interview, the acute care hospital's administration failed to ensure the nursing staff documented the ongoing assessment of the patient's response to restraints for 1 of 1 patient (Patient #2) which the nursing staff placed in restraints for violent or self-destructive behavior. Failure to document the ongoing assessment of a patient in restraints for violent or self-destructive behavior could potentially result in the nursing staff failing to detect changes in the patient's medical condition indicating the patient was experiencing life-threatening distress from the nursing staff applying restraints, potentially resulting in the nursing staff failing to provide life-saving care to the patients. The hospital identified an average daily census of 351 patients.

1. Review of the policy, "Restraint/Seclusion Management", dated October 2018, revealed in part, "Use of restraint for the management of Violent or Self-Destructive Behavior ... Assesses the patient at the initiation of restraint ... and every 15 minutes thereafter ..."

2. Review of Patient #2's medical record revealed, in part:

--06/22/2019 6:20 PM, RN O documented in part, "...holding [Patient #2] to bed while [Patient #2] was screaming and becoming belligerent (sic), attempting to hit/bite/spit and escape from soft restraints (sic). This nurse assisted others to prevent [Patient #2] from hurting them self or others. This nurse was informed that ... security officer had left to fetch leather restraints. Leather restraints ... were applied. [Patient #2] continued to scream and fight..."

--06/22/2019 at 6:35 PM, RN O documented "Restraint/Assessment Monitoring." RN O did not document any additional information about the monitoring RN O performed on Patient #2.

--06/22/2019 at 6:55 PM, RN O documented "Restraint Assessment Monitoring." RN O did not document any additional information about the monitoring RN O performed on Patient #2.

--06/22/2019 at 10:05 PM, RN N documented in part, "This RN went in and removed the 4-point leather restraints (leather straps used to tie down a patient's wrists and ankles to a bed and severely restrict a patient's movement of their arm and legs) from [Patient #2]. Placed soft restraints (soft cloth restraints which allow patients more freedom of movement than leather restraints) on [Patient #2]. Will continue to monitor [Patient #2]."

3. During an interview at the time of the review for Patient #2's medical record, Clinical Educator J confirmed the hospital's policy required the nursing staff to assess patients in restraints for violent or self-destructive behavior every 15 minutes. Clinical Educator J also confirmed Patient #2's medical record lacked documentation the nursing staff documented performing an assessment for almost 3 hours, from the last documented assessment at 6:55 PM, until 10:05 PM, when RN O removed the leather restraints from Patient #2.

I. Based on medical record review, document review, and staff interview the hospital's administrative staff failed:

1.To ensure that patients' safety needs were met by relying on restraints as part of the fall prevention and not providing nursing staff to meet those needs. Please refer to A-0392.

2. Ensure the hospital staff identified the use of restraints should not be considered a routine part of a falls prevention program. Please refer to A-0154.

The cumulative effect of these systemic failure resulted in the hospital's inability to ensure the nursing staff provided adequate nursing services to meet the patients' needs.


II. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 10/10/19 at 2:00 PM. The hospital staff removed the immediacy on 10/11/19 at 1:15 PM, prior to the survey team exiting the complaint investigation, when the administrative staff took the following actions:

a. Under no circumstances will restraints be utilized as a fall prevention strategy. If restraint ordered or recommended, initiate escalation process.

b. Escalation process: If restraint ordered or recommended, RN (Registered Nurse) caring for patient will notify charge nurse to initiate escalation process. Charge RN will then notify the Unit Director, Administrative Director or CNO (Chief Nursing Officer) who will identify a PCT (Patient Care Tech), RN or nursing leader to report to the beside to provide 1:1 patient care.

c. For all patients assessed at high risk for a fall who have bed/chair alarm intervention in place, staff will perform hourly verification that alarm is active and document on check list.

d. Unit Nursing leadership will communicate in person or via telephone with every RN and PCT prior to next shift worked. The communication of this education is specified in the attached process change alert. Documentation will include date, time and mode of communication/education.

e. CMO (Chief Medical Officer) and /or hospital leadership will communicate in person or via telephone with each Hospitalist prior to next shift worked, of the process change alert.

f. Plan for monitoring: Unit leader and/or Charge RN will review all fall risks patients every 8 hours, utilizing the Cerner fall risk report, to validate that the appropriate fall prevention interventions are in place to include 1:1 sitter when appropriate, and to exclude use of restraints for fall prevention at all times.

g. Nursing leadership will perform daily review of all patients in restraints, utilizing Cerner restraint reports, to verify that no restraints are in use for fall prevention.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure the nursing staff provided a nursing staff member to provide supervision to patients at high risk for falling, instead of relying upon mechanical restraints for staff convenience, as a fall prevention strategy for 2 of 65 patients (Patient #5 and Patient #9) reviewed. Failure to ensure the nursing staff provided a nursing staff member to provide supervision to patients at high risk for falling resulted in the nursing staff utilizing mechanical restraints as a fall prevention strategy, potentially resulting in patients suffering greater injury trying to get out of the restraints, potentially even resulting in patients strangling themselves, instead of falling. The hospital's administrative staff identified 151 patients with medical restraints and 23 patients where the staff potentially used restraints to prevent patients from falling, during the prior 6 months.

Findings include:

1. Review of the document "Corporate Policy Fall Prevention," effective 12/2018, revealed in part, "In addition to universal fall precautions, patients who score positive for injury on the ABC's (Age, Bones, Coagulation, a system used to determine which patients have a higher risk of injury from a fall) or who are at high risk for falls will have high risk fall prevention interventions in place. Mechanical restraints may increase injuries that occur with falls, and should be used with extreme caution with patients who are at high risk for falls and fall-related injuries."

2. Review of the "Corporate Policy Patient Observers (Sitters) Policy," effective 12/2018, revealed in part, "This policy provides guidelines for the use of patient observers when patient condition warrants to prevent injury to the patient, minimize the use of restraints when other alternatives have been ineffective ..."

3. Review of the document "Corporate Policy Restraint/Seclusion Management," effective 10/2018, revealed in part, "Alternatives to restraints will be used before the least restrictive method of restraint is utilized...."

4. Review of Patient #9's medical record revealed that Patient #9 presented to the hospital after falling in their garage on 8/23/19. The hospital's ED staff diagnosed Patient #9 with a fractured right hip and admitted Patient #9 to 5 North at 3:00 PM on 8/23/19.

Patient #9 underwent surgical repair of their right hip fracture on 8/24/19. Following the surgery, the nursing staff identified that Patient #9 was at high risk for falling. The nursing staff implemented measures to prevent Patient #9 from falling, including placing the top 2 side rales of Patient #9's bed in the raised position, lowering Patient #9's bed as low as possible, activating the bed's built in bed alarm, placing yellow socks on Patient #9 to increase the nursing staff's awareness of Patient #9's high risk for falling, and posting signs on the door frame of Patient #9's room to alert the hospital staff about Patient #9's high risk for falling.

On 8/25/19 at approximately 1:30 AM, the nursing staff found Patient #9 on the floor in their hospital room, by the bed. Patient #9 was confused to their location (not fully alert and oriented). During the fall Patient #9 suffered a cut above their right eyebrow, which required the hospital staff to place stitches to close the cut. The hospital's staff performed a head CT (high definition x-ray) and a regular x-ray of Patient #9's hip. Neither test showed any broken bones or other significant abnormalities.

At approximately 12:30 AM on 8/26/19, a Patient Care Technician found Patient #9 on the floor by their bed in the hospital room. The nursing staff assessed Patient #9's vital signs and performed a physical exam. An x-ray taken after the fall revealed Patient #9 suffered a fracture of their upper right arm. The physician interpreting the x-ray could not determine if the fracture occurred during the fall on 8/25/19 or 8/26/19.

The nursing staff obtained an order to place Patient #9 into a mechanical chest/vest restraint on 8/26/19 at 12:53 AM, since Patient #9 was confused, could not follow the staff's direction, and continued to get out of bed without staff assistance.

Review of the Post-Fall Huddle Analysis, conducted by the nursing staff on "8/24/19" after Patient #9's fall on 8/25/19, revealed the staff identified Patient #9 was confused, the nursing staff had not activated the alarm indicating if Patient #9 exited the bed, and would prevent Patient #9 from falling in the future by ensuring the nursing staff activated the bed alarm, to alert the nursing staff if Patient #9 attempted to exit the bed.

Review of the Post-Fall Huddle analysis, conducted by the nursing staff on 8/26/19 after Patient #9's fall on 8/26/19, revealed the staff identified Patient #9 was still confused, impulsive, forgetful, and unable to follow the nursing staff's instructions. The staff identified the nursing staff had not activated the bed alarm on Patient #9's bed. The nursing staff identified they would prevent Patient #9 from falling in the future by ensuring the nursing staff activated the bed alarm.

5. During an interview on 10/09/19 at 10:00 AM, Registered Nurse (RN) P acknowledged the medical staff ordered a chest/vest restraint for Patient #9 on 8/26/19 at 12:53 AM because Patient #9 fell a second time during the hospitalization.

6. During an interview on 10/10/19 at 11:00 AM, RN Q revealed, "We would have put a sitter on [Patient #9] if we would have had the resources, but our other [Patient Care Technician (PCT)] was already being a sitter for another patient." The nursing staff could not obtain another staff member to provide 1:1 observation for Patient #9, so the nursing staff used mechanical chest/vest restraints to prevent Patient #9 from falling.

7. During an interview on 10/10/19 at 1:00 PM, Advanced Registered Nurse Practitioner (ARNP) R acknowledged they ordered the mechanical chest/vest restraint for Patient #9 on 8/28/19 at 12:53 AM as a measure to prevent Patient #9 from falling, since the nursing unit lacked sufficient staff to provide a dedicated staff member to observe Patient #9 1:1 who could attempt to prevent Patient #9 from falling. The nursing staff used mechanical chest/vest restraints to prevent patients from falling about once a month, when the nursing units lacked sufficient staffing to provide 1:1 observation for patients at high fall risk.


8. Review of Patient #5's medical record revealed an entry by RN L, dated 07/10/2019 at 5:10 AM, "[Patient's] bed alarm sounded, nurse in room ASAP. Found on floor with head against bedside table .... Hospitalist ordered a [chest/vest] restraint for patient safety. Large [chest/vest] restraint ordered, will initiate upon arrival. Will continue to monitor."

Review of Patient #5's Fall Incident Report, dated 07/10/2019 at 7:02 AM, revealed in part, "Fall precautions in place. All testing negative for injury. Restraint chest/vest initiated."

9. During an interview on 10/16/2019 at 8:00 AM, RN L revealed that staff would consider using physical restraints on patients after the staff had tried all other prevention measures, to prevent the patient from falling. RN L would prefer to use a sitter if the hospital had a staff member available to use as a sitter, before using restraints as a fall prevention measure. The nursing staff frequently requested to utilize sitters for fall prevention. However, the nursing staff was frequently told that the hospital did not have a staff member available to function as a sitter for the patient. Thus, the nursing staff did their best to keep the patient from falling, which included the use of restraints.

RN L reviewed Patient #5's medical record and the event note from 7/10/19 at 5:10 AM. RN L could not remember any details about the events on 7/10/19, but acknowledged the nursing staff used a chest/vest restraint on Patient #5 after Patient #5 fell. The nursing staff used the restraint to prevent Patient #5 from falling again, instead of obtaining a sitter for Patient #5.

Based on document review and staff interviews, the acute care hospital failed to ensure the nursing staff followed the hospital's policies and procedures for wound prevention interventions for 1 of 1 closed inpatient (Patient #1) chart reviewed. Failure to ensure the nursing staff followed policies and procedures for wound prevention could potentially result in the patient developing skin complications, including pressure ulcers (bed sores), which could potentially result in life-threatening tissue, bone or blood infections, potentially leading to permanent disability and patient death. The hospital administrative staff identified an average daily census of 351 patients per day.

Findings include:

1. Review of nursing practice guideline, "Skin Assessment and Care (Adult): Includes Pressure Injury Prevention and Basic Wound Care", approved 3/2018, revealed in part, "...Calculate pressure injury risk using the Braden Scale (scale used to evaluate risk of skin injury, the lower the number, the higher the risk) and with any significant patient status change...Initiate Nurse-Driven Guidelines for Pressure Ulcer Prevention & Support Surfaces (Attachment B) if Braden Score is 18 or less...Initiate appropriate interventions based on Braden score...."

2. Review of nursing practice guideline, "Attachment B-Nurse-Driven Guidelines for Pressure Injury Prevention & Support Surfaces," revealed in part, "...Obtain order for Consult to Wound Services if Braden remains 12 or less for 24 hours, or if patient has wounds or areas of pressure injury...."

3. Review of Patient #1's same closed inpatient medical record revealed staff nurses assigned to Patient #1 documented the following Braden scores:

Staff Nurse A: 07/18/19 at 03:00 PM, Braden Score: 12
Staff Nurse B: 07/19/19 at 09:00 AM, Braden Score: 12
Staff Nurse C: 07/19/19 at 03:00 PM, Braden Score: 12
Staff Nurse D: 07/20/19 at 08:00 AM, Braden Score: 12
Staff Nurse A: 07/21/19 at 08:00 AM, Braden Score: 12
Staff Nurse D: 07/22/19 at 08:10 AM, Braden Score: 11
Staff Nurse E: 07/23/19 at 09:00 AM, Braden Score: 11
Staff Nurse D: 07/24 /19 at 08:07 AM, Braden Score: 11
Staff Nurse D: 07/25/19 at 08:41 AM, Braden Score: 11
Staff Nurse F: 07/26/19 at 08:00 AM, Braden Score: 12
Staff Nurse G: 07/27/19 at 09:00 AM, Braden Score: 12
Staff Nurse G: 07/28/19 at 09:00 AM, Braden Score: 9
Staff Nurse A: 07/30/19 at 03:00 PM, Braden Score: 10
Staff Nurse H: 08/01/19 at 03:00 PM, Braden Score: 12

4. Review of Patient #1's closed medical record revealed the nursing staff failed to obtain a wound consult from 7/10/19 to 7/28/19, despite the nursing staff assessing Patient #1's Braden score as 12 or lower, for greater than 24 hours.

5. During an interview on 10/10/2019 at 09:39 AM, WOCN I (Wound and Ostomy Certified Nurse, nurses with specialized training in treating pressure wounds) revealed obtaining a wound care consult order is "the basic nursing protocol" for any patient with a Braden score of 12 or less for 24 hours. WOCN I confirmed that Patient #1 should have received a wound care consult for the first assessed Braden score on 07/19/19 which remained 12 over 24 hours.