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Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital's P&P for two of five sampled patients (Patients 1 and 3) when the nursing staff did not notify the patients' family members about the use of restraints for Patients 1 and 3. This failure posed the potential to result in poor health outcomes to the patients.

Findings:

Review of the hospital's P&P titled Restraints: Non Violent Behavior dated June 2024 showed in part:

* Definitions:

- Restraint: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

- Family: The person who plays a significant role in the patient's life, which may include a person(s) not legally related to the patient. The person is often referred to as the surrogate decision-maker, if authorized to make care decisions for the patient if he or she loses decision-making capacity.

* Purpose: To provide guidelines for the for the provision of a safe patient environment in which restraints are distinguished from devices not used as restraints and the least restrictive alternative to the use of restraints are pursued in order to reduce and minimize the utilization of restraints.

* Policy: The patient and family are educated to the best extent as possible. Education should include the purpose for restraint use, the criteria for termination and the monitoring/care that will be provided.

* Documentation: Use Electronic Medical Record Restraint Flow Sheet, restraint order form and narrative notes to document all pertinent information in the medical record including but not limited to physician/family notifications.

1. On 10/8/24 at 1242 hours, an interview and concurrent record review of Patient 3's medical record was conducted with the CNO.

Patient 3's medical record showed the patient was admitted to the hospital on 10/6/24.

Review of the physician's order dated 10/6/24 at 1947 hours, showed to use soft restraints to the bilateral upper extremity. The restraint reason was for the interference with the medical treatment.

However, further review of Patient 3's medical record did not show the RN notified the patient's family/responsible party of the restraint order/initiation.

On 10/2/24, the above findings were acknowledged by the CNO.


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2. On 10/8/24 at 0940 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Nursing Manager of Behavior Health.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 10/1/24.

Review of the restraint flowsheet dated 10/7/24, showed Patient 1's bilateral soft restraint on left and right wrists were started at 1100 hours.

Review of the physician's order dated 10/7/24 at 1956 hours, showed to use soft restraints to bilateral wrists. The restraint reason was for the interference with the medical treatment.

However, further review of Patient 1's medical record failed to show the nursing staff notified the patient's family/responsible party about the use of restraint for Patient 1.

The Nursing Manager of Behavior Health confirmed the above findings.

Based on interview and record review, the hospital failed to ensure the medication orders were verified and administered for one of five sampled patients (Patient 1) as per the hospital's P&P. This failure posed the risk of inappropriate care and treatment for the patient.

Findings:

Review of the hospital's P&P titled Medication Administration dated March 2024 showed the following:

* Except in an emergency, a pharmacist will review the medication order prior to administration.

* Prior to administration, the practitioner will:

- Verify the prescriber's order against the medication being administered.

- Discuss any unresolved, significant concerns about the medication with the prescriber or physician covering the patient and/or relevant staff involved with the patient's care, treatment and services.

- Review the medication administration record (MAR) for any special considerations that would influence the administration of medications, including but not limited to, clinical parameters, NPO status, medications at odd hours, one time only medications, or medications that must be given with food.

- Verify that the medication is stable based on visual examination or particulates, or discoloration and that the medication has not expired

- Verify that there is no contraindication/allergy for administering the medication.

* If the patient refuses a medication: scheduled medications may be given early or late or may be omitted under specific circumstances, such as but not limited to patient absence from unit, patient refusal, or nausea/ vomiting. If administration of a scheduled medication will be or has been delayed or administered early beyond allowable expectations:

- Document the medication that is being non administered

- Document the discussion of risks and benefits of the medication and also the refusal of the medication

- Evaluate the need to change the timing of future doses

- Notify the physician and document name of person notified and response to notification.

On 10/8/24 at 1400 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Nursing Manager of Behavior Health.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 10/1/24.

a. Review of Patient 1's laboratory blood test report dated 10/2/24 at 0102 hours, showed the TSH blood level was 0.110 µU/mL (reference ranges is 0.400 - 4.500 µU/mL).

Review of Patient 1's MAR showed the physician's order dated 10/2/24 at 1230 hours showing levothyroxine (a medication used to treat hypothyroidism) 200 mcg tablet oral before breakfast. The MAR showed the levothyroxine was not given to Patient 1 from 10/3-10/8/24.

Review of hospital pharmacy's Intervention Audit Trail showed the pharmacist tried to contact the physician on 10/4/24 at 0845 hours, about the order of levothyroxine.

The Nursing Manager of Behavior Health stated Patient 1's blood TSH level was low. The pharmacist tried to contact the physician to adjust the dose of the levothyroxine order, but the physician did not respond.

b. Review of Patient 1's MAR showed the physician's order dated 10/2/24 at 1230 hours, for vortioxetine (antidepressant) 20 mg tablet by oral in the morning. The MAR showed the vortioxetine was not given to Patient 1 from 10/3-10/8/24.

Review of hospital pharmacy's Intervention Audit Trail showed the pharmacist tried to contact the physician on 10/2/24 at 1230 hours about the order of vortioxetine.

Further review of Patient 1's medical record, there was no documentation to show the nursing staff attempted to contact the physician regarding these above missing medications.

The Nursing Manager of Behavior Health verified the above findings and stated the vortioxetine medication was not formulated by the hospital. The pharmacist tried to reach the physician for an alternative treatment or request patient's own supply, but no response from the physician.

c. Review of Patient 1's MAR showed the physician's order with the started date as of 10/2/24 and ended date as of 10/14/24, for azithromycin (antibiotic medication) 500 mg oral daily. There was no documented evidence to show azithromycin was administered to the patient on 10/7/24. Further review of Patient 1's medical record did not show if Patient 1 refused the medication.

The Nursing Manager of Behavior Health verified the above findings and stated she was not sure if Patient 1 refused medication, or the medication was not administered to Patient 1.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the physician's order of blood transfusion for one of five sampled patients (Patient 4). This failure had the potential to impact the patient's health and safety or result in in the prolonged hospitalization.

Finding:

Review of the hospital's P&P titled Blood and Blood Component Therapy, Nursing Management of Non-Emergent, Urgent, Massive dated March 2024 showed the following:

* Purpose: To assure blood/ blood component use is appropriate and the informed consent has been obtained by the patient's physician prior to blood bank release of blood/components and administration is carried. To ensure that patient care is delivered in a safe and effective manner utilizing the nursing process.

* After appropriate confirmation, blood and blood components may be administered when indicated, per physician's order, in a safe and effective manner.

On 10/8/24 at 1650 hours, an interview and concurrent review of Patient 4's medical record was conducted with the Nursing Manager of Behavior Health and Director of ED and ICU.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 9/15/24.

Review of Patient 4's laboratory blood test report showed Patient 4's hemoglobin (Hgb) level was 6.1 g/dL (normal ranges 13.5- 17.5 g/dL) on 9/25/24 at 0600 hours, 7.4 g/dL on 9/25/24 at 0925 hours, 7.2 g/dL on 9/26/24 at 0600 hours, and 8.5 g/dL on 9/26/24 at 1405 hours.

Review of the physician's order dated 9/25/24 at 1326 hours, showed to transfuse one unit of Red Blood Cell (RBC) for the Hgb level less than 8 g/dL.

Review of Patient 4's medical record failed to show documentation the nursing staff had administered one unit of RBC as per the physician's order when Patient 4' Hgb was 7.4 g/dL on 9/25/24 at 0925 hours.

Review of the Transfusion Record showed 300 ml (one unit) of RBC was transfused to Patient 4 on 9/26/24 at 1025 hours.

The Nursing Manager of Behavior Health and Director of ED and ICU verified the above findings.