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Based on interviews and the review of documents, it was determined the facility staff failed to clearly document the behaviors that justify the continued use of restraints for one (1) of two (2) patients selected for review of restraint use. (Patient #3).

The findings include:

Patient #3's clinical documentation was reviewed with Staff #12 (a registered nurse) and SM #2 and in the presence of Staff #1 and Staff #10. An order for the use of non-violent restraints (left and right soft wrist) was entered for Patient #3 on 4/29/22 at 9:45 PM. Patient #3 was documented as having an altered mental status, acutely agitated, thrashing, hitting staff and not allowing medical treatment to be delivered. The patient required sedation and intubation for their safety. Patient #3 remained restrained until 5/1/22 at 8:34 AM a period of approximately 35 hours. While Patient #3 was restrained, restraint documentation was entered 21 times. For 17 of the 21 restraint documentations completed, the patient's behavior was documented as "asleep". Restraint discontinuation criteria included the following"Cognitive status improved and no longer interferes with medical care; No interference with medical devices, tubes, dressings, etc.; Medical devices, tubes, dressings, etc. removed; Responds to safe limit settings; Follows commands; Behavior no longer present/patient oriented; Alternatives identified; Restraints are determined to be more harmful than helpful." Documentation of the patient's behavior in the section of the record dedicated to restraint documentation failed to justify the continued use of restraint. Staff #12 was unable to find other documentation (nursing notes, etc.) that explained the continued use of restraint.

The following information was found in a facility policy titled "Restraint and Seclusion" (last reviewed 3/5/2021): "4. Care of the Patient in Non-Violent Restraint...b.i. The restraint should be discontinued as soon as the patient meets the behavior criteria for its discontinuation c. Ongoing assessments and monitoring of the patient's condition will be completed to ensure restraints are utilized in support of the plan of care and discontinued at the earliest possible time."

The above information was shared with Staff present during the review of the documentation and with the management team prior to exit on 5/3/2022.

Based on interviews and review of documents it was determined hospital staff failed to administer drugs in accordance with the orders of the practitioner for 1 of 4 patients included in the sample with a) orders for alcohol detoxification and b) immediate medication administration. (Patient #5)

The findings include:

1. Patient #5 presented to the hospital's emergency department on 03/09/22 at 5:20 PM in acute alcohol withdrawal, had a seizure and was subsequently admitted for observation. Patient #5's electronic health record (EHR) was reviewed on 5/3/22 with the assistance of Staff #12, a navigator provided by the hospital.

a) An order was placed on 3/10/22 at 2:18 AM for CIWA (Clinical Institute Withdrawal Assessment from Alcohol) monitoring. The order read as follows: "Calculate CIWA score every 4 hours while awake for CIWA score of less than or equal to 10. Every 2 hours while awake for CIWA score of 11-19. Every 1 hour while awake for score equal to or greater than 20. Notify physician if score greater than 20 and for transfer to cardiorespiratory-monitored bed. Routine PRN 03/10/22 0210-until specified. Automatic Discharge Provider 03/11/22 1327." A correlating order for lorazepam (a benzodiazepine, can be used to treat symptoms of alcohol withdrawal) was placed at the same time which read in part: "Frequency: Every 2 hour PRN: CIWA Score less than 10: Give 0.5 mg every 4 hours PRN until CIWA Score < 8 or RASS -1 to 0. CIWA-Ar Score 10-12: Give 1 mg every 2 hours PRN until CIWA Score < 8 or RASS -1 to 0. CIWA Score 13-15: Give 2 mg every 2 hours PRN until CIWA Score < 8 or RASS -1 to 0. CIWA-Ar Score 16-17: Give 3 mg every 2 hours PRN until CIWA Score < 8 or RASS -1 to 0. CIWA-Ar Score 18-19:: Give 4 mg every 2 hours PRN until CIWA Score < 8 or RASS -1 to 0."
First documentation of the CIWA score was found at 00:58 AM as a 9; (2 mg of lorazepam was given at 00:58 AM during a shoulder reduction procedure). Next CIWA score recorded at 2:44 AM was 6; no medication indicated. Succeeding CIWA documented at 5:38 AM was 12; 1 mg lorazepam given by mouth. CIWA score recorded at 8:05 AM was 12; 1 mg lorazepam was given by mouth at 9:55 AM (1 hour 55 minutes later); Following CIWA score recorded at 10:49 AM was 2; no medication indicated. Next CIWA score at 12:14 PM was 16; 3 mg lorazepam given by mouth at 12:45 PM; Next CIWA at 13:54 "patient asleep"; Next assessment at 4:09 PM documented CIWA Score as 10; no medication given (per order, based on score 10, patient should have been administered lorazepam 1 mg ); CIWA at 5:22 PM was 16; 3 mg lorazepam were given by mouth at 5:29 PM; Next CIWA score at 7:53 was 17; 3 mg lorazepam given by mouth. The clinical record failed to provide evidence of a CIWA score after last documented score at 7:53 PM on 3/10/22. The order remained in effect until 3/11/22 at 1:27 PM when the patient was discharged. The failure to continue CIWA calculations and administer medication as ordered was discussed with Staff #12 at the time of discovery and with the management team prior to exit. The risk of adverse effects on a patient who had suffered an earlier seizure was discussed as well. Staff were unable to provide the surveyor with any additional documentation.

b) On 3/14/22 at 6:31 PM, Patient #5 presented to the hospital emergency department with concerns related to pain and bruising related to a left shoulder dislocation sustained on 3/9/22 while receiving care at the hospital. Patient #5 was noted to have elevated blood pressure (199/104) at 8:25 PM during triage, blood pressure of 139/102 at 9:00 PM and blood pressure of 159/94 at 9:37 PM. Patient #5 was discharged at 10:39 PM on the same day. On 3/14/22 at 9:30 PM an order was entered for clonidine (given for elevated blood pressure) 0.2 mg to be given STAT (at once). Instructions on the order are to hold dose for heart rate less than 45 or SBP (systolic blood pressure) less than 90. Documentation on 3/14/22 at 9:25 PM by the nurse states the medication was not administered with the comment "BP too low". Staff assisting the surveyor were unable to find additional documentation of blood pressure and agreed documented blood pressures would not have indicated to hold the medication. Staff #1 was asked what the hospital's time frame for the administration of a STAT order would be. Staff #1 replied (after confirming with pharmacy) that it would be immediately or within 30 minutes. Staff #12 who assisted with record review confirmed the STAT medication had not been administered as ordered and should have been given.

The above findings were reviewed with Staff #1, #4, #10 and #12 when discovered by the surveyor and with the management team prior to exit.

Based on interview and document review it was determined that nursing staff failed to obtain vital signs at the required intervals for two (2) of two (2) patients in the survey sample who were administered blood or blood products. (Patients #1 and #2)

The findings include:

The clinical record for Patient #1 was reviewed on 5/3/22 with the assistance of a navigator provided by the hospital (Staff # 12).

An order for Patient #1 was entered on 4/26/22 at 8:48 PM for transfusion of 1 unit of red blood cells. Review of the clinical record revealed nursing staff failed to obtain the patient's vital signs one hour after the administration of blood products is completed as defined by hospital policy. The absence of documented vital signs one hour after completion of the transfusion was confirmed by Staff #12. Vital signs were documented at the beginning of the transfusion as 11:46 PM on 4/26/22. Vital signs were obtained within 30 minutes of the start and hourly until completion of the transfusion at 3:15 AM on 4/27/22. Staff failed to obtain vital signs one hour post transfusion with the next recorded vital signs at 8:41 AM 4/27/22 (5 hours and 26 minutes post-transfusion).

The clinical record for Patient #2 was reviewed on 5/3/22 with the assistance of a navigator provided by the hospital (Staff # 12).

An order for Patient #2 was entered on 4/20/22 at 6:21 AM for a transfusion of 1 unit of red blood cells. Review of the clinical record revealed nursing staff failed to obtain the patient's vital signs hourly during the administration of blood products and at the conclusion of blood transfusion as it is defined by the hospital policy. The absence of documented vital signs during and at the end of the transfusion was confirmed by Staff #12. Vital signs were documented at the beginning of the transfusion as 7:46 AM on 4/20/22. Vital signs were obtained within 30 minutes of the start at 8:00 AM. Succeeding vital signs were obtained during the transfusion at 8:45 AM, 9:45 AM and 12:05 PM. The transfusion was documented as complete at 11:45 AM. Staff failed to obtain vital signs at 10:45 AM during the transfusion and at 11:45 AM at the completion of the transfusion.

Hospital policy "Transfusion of Red Blood Cells and Blood Components" and attachments revised 11/5/21 contained the following in part: "3. The Registered Nurse will monitor the patient during and after the transfusion. a. Record blood pressure, pulse, and temperature prior to transfusion and fifteen (15) minutes after initiation of transfusion. b. Document additional vital signs in EMR at one (1) hour, two (2) hours, and post transfusion."
Attachment titled "Blood Product Administration" read under part "Red Blood Cells and Vital sign check frequency" the following: "Prior to administration, within 30 minutes of start of transfusion, at least every hour from start of transfusion, and at completion of transfusion. Assess vital signs one hour post transfusion." Review of the policy and the attachment found inconsistency in guidelines for vital signs when transfusing blood products.

The failure of nursing staff to obtain vitals signs for patients receiving blood or blood products was confirmed by SM # 12 confirmed in a discussion conducted during record review that nursing staff failed to obtain vitals signs for patients receiving blood or blood products and could not explain the inconsistent guidance contained within hospital policy and attachment related to blood product transfusion.

The above noted findings were shared and discussed with the management team prior to exit but no new or additional information was provided to the surveyor.