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Based on interviews, medical record and policy review, it was determined the facility staff failed to document that alternatives were attempted or that a less restrictive intervention was determined to be ineffective for one (1) of three (3) patient restraint records sampled.

The findings include:

On 4/25/2022, the surveyor reviewed three (3) medical records for restraint documentation. A review of the medical record for Patient #6 revealed that Patient #6 was in bilateral soft restraints (mitts) with an order from 4/17/2022 at 10:39 a.m. through 4/24/2022 at 12:00 p.m. The medical record provided contained no documentation of alternatives attempted or the rationale for not using alternatives.

During an review of the medical record with Staff Member (SM) #5, SM #5 confirmed that there was no documentation regarding alternatives/less restrictive alternatives attempted while Patient #6's was in restraints.

A review of the facility's policy titled, "IHS Restraints and Restraint Alternatives Policy," states in part:
...5. Documentation in the medical record includes the following:
...b. All alternatives or less restrictive interventions attempted...

Based on interviews, medical record and policy review, it was determined the facility staff failed to document monitoring of a patient in restraints every two (2) hours as per facility policy for one (1) of three (3) medical records sampled.

The findings include:

On 4/25/2022, the surveyor reviewed three (3) medical records for restraint documentation. A review of the medical record for Patient #6 contained evidence that there was no documentation of patient monitoring in restraints every two (2) hours as per the facility policy for the following time frames:

4/17/2022 at 10:39 a.m. (when order was written) until 8:00 a.m. on 4/18/2022
4/19/2022 no documentation at 8:00 a.m. until 8:00 p.m.
4/20/2022 no documentation at 2:00 a.m. until 8:00 a.m.
4/20/2022 no documentation at 2:00 p.m.
4/20/2022 no documentation at 6:00 p.m.
4/23/2022 no documentation at 6:00 a.m. until 8:00 p.m.

A review of the restraint order for Patient #6 contained evidence that "This type of restraint requires every [two] 2 hour assessments and documentation by nursing."

A review of the medical record for Patient #6 contained evidence that the patient's response to the intervention was not documented consistently at each two (2) hour monitoring and assessment.

During a review of the medical record for Patient #6, Staff Member (SM) #5 confirmed that patient monitoring documentation was missing from the record for various times throughout the time period while the patient was in restraints. SM #5 confirmed that Patient #6's order stated that the patient should be monitored every two hours and be documented in the medical record.

A review of the facility's policy titled "IHS Restraints and Restraint Alternatives Policy," states in part:
...3. Patients are monitored, assessed and reassessed at specific intervals during use
...5. Documentation in the medical record includes the following
...b. All alternatives or other less restrictive interventions attempted
...g. The patient's response to the interventions(s)
h. Individual patient assessments and reassessments...

Based on staff interview and document review, it was determined the hospital failed to ensure a Registered Nurse (RN) appropriately supervised the care of each patient. Specifically, the Registered Nurse failed to ensure physician orders were followed as ordered and failed to assess the need for oral fluids in one (1) of nine (9) medical records reviewed in the survey sample. Medical Record #1.

Findings:

Nine (9) clinical records were reviewed 04/25/22 - 04/26/22 with the assistance of the Informatics Nurse Specialist in the navigation of the electronic medical records.

The patient with medical record #1 was admitted to the hospital 2/07/22 with a diagnosis of acute respiratory failure secondary to COVID pneumonia, severe protein malnutrition, and right shoulder swelling and pain. The patient was transitioned to inpatient hospice services in the facility on 02/10/22 at approximately 4:30 PM. At the time of admission to hospice, the nursing documentation indicated the patient was alert and oriented x4. The medical record contained a physician order dated 02/10/22 at 4:44 PM for oral care to be provided every two hours to start 02/10/22 at 4:41 PM. The medical record contained no documentation that oral care was ever provided from the time the order was entered until the patient's death at approximately 4:55 AM on 02/11/22.

At the time of admission on 02/07/22, the patient was placed on a mechanical soft diet with thin liquids. The medical record contained documentation that this diet order was discontinued on 02/10/22 when the patient was admitted to hospice care and no new diet was ordered. On 02/10/22 - 02/11/22 the medical record for patient #1 contained no diet orders and no documentation of what type of foods or fluids the patient should have. The medical record for patient #1 contained no documentation that the patient was offered any PO (by mouth) fluids from the evening of 2/10/22 to the time of death the morning of 2/11/22 despite the family requesting the patient have water to drink. The medical record contained no documentation of an assessment from the nurse as to why fluids were not given to the patient. The medical record contained no documentation that the RN attempted to contact the patient's physician to obtain a diet order for the patient.

During chart review on 04/25/22 staff member #5 (Informatics Nurse) confirmed the absence of any documentation of staff performing oral care on patient #1 per the physician's order on 2/10/22 and 02/11/22. Staff member #5 also confirmed the absence of a diet order upon the patient's admission to hospice services 02/10/22 and the lack of documentation of fluid intake for the patient.

Interviews were conducted with RNs (Staff Member #'s 6 and 11) working on the Clinical Decision Unit (the unit where patient #1 received care) on 04/26/22. Both staff members confirmed all patients should have diet orders entered into the electronic medical record. The staff members stated if diet orders were absent and the patient was requesting fluid, the nurse should assess the patient and contact the physician for orders.

The lack of documentation related to oral care, a diet order, and fluid intake was discussed and acknowledged by the Regulatory Consultant (staff member #4) on 04/26/22.