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Based on medical record review and interview, the facility failed to ensure a physician's order for restraints was complete for one patient (#2) of five patients reviewed.

The findings included:

Patient #2 was admitted to the facility on November 22, 2009, for a GI (gastrointestinal) Bleed.

Medical record review of the nursing notes, physicians' progress notes, and physician's orders revealed the patient was confused, agitated, unable to comply with medical treatments, and attempting to remove medical devices, and was placed in limb restraints for safety on November 22, 2009, at 11:30 a.m. Medical record review revealed the patient was reassessed every 24 hours for continued need for restraints with a physician's order completed every 24 hours from November 22 through November 26, 2009.

Medical record review of the Medical/Surgical Physician Order For Restraint dated November 26, 2009, at 7:00 a.m., revealed the order was signed, dated, and timed by the physician, but did not indicate "Clinical Criteria (reason)" for restraints, patient's condition, patient behaviors, or the type of restraint to be utilized.

Interview with the Director of Critical Care on July 14, 2010, at 5:00 p.m., in the Corporate Responsibility Lower Administration offices, confirmed the physician had not indicated a reason for restraints, patient condition, patient behaviors, or type of restraint to be utilized, and the order for restraints was incomplete.

Based on medical record review and interview, the facility failed to implement the restraint plan of care for one patient (#1) of five patients reviewed.

The findings included:

Patient #1 was admitted to the facility on June 20, 2010, with a chief complaint of vomiting.

Medical record review of a nurse's note dated June 24, 2010, at 6:00 a.m., revealed the patient had attempted to pull out the endotracheal tube (tube placed in throat for breathing), was placed in wrist restraints, and given medications for sedation. Continued review of the nursing notes dated June 24, 2010, revealed the patient remained in restraints from 6:00 a.m., until 10:51 p.m.

Medical record review of the nursing notes dated June 24, 2010, revealed documentation family members were at the patient's bedside at 8:00 a.m., 8:15 a.m., 8:30 a.m., and 2:00 p.m. Continued review of the nursing notes revealed the family was available to talk with the physician at 11:30 a.m., 12:30 a.m., 1:00 p.m., 3:15 p.m., and 3:45 p.m.

Medical record review of the Non-Violent/Non-Self-Destructive (Non-Behavioral) Restraint Plan of Care dated June 24, 2010, 7P-7A and June 24, 2010, 7A-7P, revealed the plan of care for restraints was implemented on June 24, 2010, at 6:00 a.m. Continued review revealed the nursing staff documented on the plan of care at 6:00 a.m., 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 4:50 p.m., and 6:30 p.m., and indicated the family could not be notified of the restraints because, "...Family/SO (significant other) unavailable for notification..."

Interviews with the Director of Critical Care and the Manager of Medical and Cardiac Critical Care on July 14, 2010, at 4:40 p.m., in the Corporate Responsibility Lower Administration offices, confirmed the patient had been restrained, nursing documentation indicated family was available for notification and education regarding the restraints, and the plan of care regarding family notification and education had not been implemented.

Based on medical record review and interview, the facility failed to discontinue restraints at the earliest possible time for one patient (#1) of five patients reviewed.

The findings included:

Patient #1 was admitted to the facility on June 20, 2010, with a chief complaint of vomiting.

Medical record review of a nurse's note dated June 24, 2010, at 6:00 a.m., revealed the patient had attempted to pull out the endotracheal tube (tube placed in throat for breathing), was placed in wrist restraints, and given medications for sedation. Medical record review of the nursing notes for June 24, 2010, revealed no further documentation the patient was responsive or attempting to remove medical devices after the wrist restraints and sedation was implemented at 6:00 a.m.

Medical record review of the Glasgow Coma Scale assessments completed on June 24, 2010, at 7:00 a.m., 11:00 a.m., 3:00 p.m., and 7:00 p.m., revealed the patient only opened eyes to pain; motor response was flexion-withdrawal; and the oral response was not testable due to the endotracheal tube.

Medical record review of a nursing note dated June 24, 2010, at 6:50 p.m., revealed, "...sedated and in restraints does not respond to verbal stimulation withdraws to pain..."

Medical record review of the nursing notes, physician progress notes, and Death Record Form dated June 24, 2010, revealed the patient's medical condition continued to deteriorate and the patient expired at 10:51 p.m., while in the wrist restraints.

Interview by phone on July 14, 2010, at 5:00 p.m., with Registered Nurse #1, the author of the nursing note dated June 24, 2010, at 6:50 p.m., confirmed the patient was unresponsive at the beginning of the shift and there was no indication for wrist restraints.

Interview with the Director of Critical Care on July 14, 2010, at 4:40 p.m., in the Corporate Responsibility Lower Administration offices, confirmed unresponsive patients did not require restraints, and the wrist restraints had not been discontinued after they were no longer needed.

Based on medical record review and interview, the facility failed to document reporting of a death while in restraints to the CMS Regional Office for one patient (#2) of five patients reviewed.

The findings included:

Patient #2 was admitted to the facility on November 22, 2009, with a GI (Gastrointestinal) Bleed.

Medical record review of the nursing notes, physicians' orders, and physician progress notes dated November 22 through 26, 2009, revealed the patient was placed in restraints on November 22, 2009, at 11:30 a.m., and remained in restraints until the patient's death on November 26, 2009.

Medical record review of the Death Record Form dated November 26, 2009, revealed the patient died on November 26, 2009, at 5:24 p.m., was in restraints at the time of death, and was in restraints within 24 hours of death. Continued review revealed the House Administrator was notified of the patient's death while in restraints on November 26, 2010, at 6:30 p.m. Review of the progress notes, nursing notes, and the Death Record Form revealed no documentation CMS was notified of the death while in restraints.

Interviews with the Vice President of Corporate Responsibility and the Director of Risk Management on July 14, 2010, at 4:55 p.m., confirmed the facility had no documentation the death while in restraints had been reported to CMS.

Based on medical record review and interview, the facility failed to ensure timely communication of significant patient findings for one patient (#1) and failed to follow hospital protocols to initiate DVT (Deep Vein Thrombosis - blood clot) prophylaxis for one patient (#2) of five patients reviewed.

The findings included:

Patient #1 was admitted to the facility on June 20, 2010, with a chief complaint of vomiting.

Medical record review of the nursing notes dated June 23, 2010, revealed: "1105 (11:05 a.m.) Positive DVT...informed me from Echovasc (department completing diagnostic tests) that pt (patient) has acute and chronic DVT in (L) (left) popliteal vein...1108 (11:08 a.m.) Called MD...placed call for (physician). Waiting for (physician) to call me back. 1210 (12:10 p.m.) Called MD. Called MD again, waiting for the reply. 1340 (1:40 p.m.) Called MD. Placed call again for (physician). (Physician) called back. Order received to start Heparin (blood thinner) drip..."

Interviews with the Director of Critical Care and the Vice President of Corporate Responsibility on July 14, 2010, at 4:40 p.m., in the Corporate Responsibility Lower Administration offices, confirmed the physician did not return the call in a timely manner, and the new DVT findings had not been communicated so treatment could be implemented in a timely manner.

Patient #2 was admitted to the facility on November 22, 2009, with a GI (Gastrointestinal) Bleed.

Medical record review of the Adult DVT Prophylaxis Assessment and Orders dated November 22, 2009, revealed the patient was assessed for risk of developing a DVT and scored 15 which indicated, "...Very High Risk Score of 5+ (Risk prox DVT 10-20%+ Prophylaxis needed)..." Continued review revealed the section Physician Venous Thromboembolism Prophylaxis Orders was not completed or signed by the physician, and no prophylaxis was implemented.

Medical record review of the physician's orders dated November 25, 2009, at 4:00 p.m., revealed, "SCDs (sequential compression device - for prevention of DVT) - Knee high..."

Interviews with the Director of Critical Care and the Manager of Medical and Cardicac Critical Care on July 14, 2010, at 11:35 a.m., in the Cardiac Care Unit, and at 4:30 p.m., in the Corporate Responsibility Lower Administration offices, revealed the hospital protocol was for every patient admitted to be screened for risk of DVT development, and the physicians were to complete the assessment and order form, with implementation of prophylaxis if indicated. Continued interviews confirmed the form for patient #2 had not been completed; the patient was determined to be high risk for developing a DVT; no prophylaxis was implemented until November 25, 2009; and the facility had failed to follow up with the physician to determine if prophylaxis was needed or could be implemented.