HospitalInspections.org

The Condition of Participation for Patient Rights was not met as evidenced by:


Based on a review of clinical records, staff interviews and a review of the hospital's policies and procedures Patient's #8, #27, #29, #38, #39, #55, #56, #57, #58 and #59 were reviewed for restraint use and the hospital failed to ensure that restraints were least restrictive, ordered correctly to specify the reason for the type of restraint, justification for use of more than one restraint, reviewed daily for continued use, medications to manage behaviors were assessed for their use and effectiveness, that monitoring of the restrained patient was documented and hospital policies for the use of restaints and medications to manage behaviors were completed and/or were comprehensive.

Cross Reference A160, A164, A165, A174 and A175

1. Based on a clinical record reviews, staff interviews and a review of the hospital's policies and procedures for four of ten patients reviewed for the use of medications to manage a patient's behavior (Patient #27, #56, #57 and #58), the hospital failed to ensure that the physician or Licensed Independent Practitioner (LIP) documented a comprehensive assessment for the use of psychoactive medications and/or a response to the medication and/or failed to have a policy that defined what constituted the use of drugs or medications as a restraint and/or failed to have a policy that directed a reassessment after medication administration. The findings include:

a. Patient #27 was admitted to the hospital on 10/14/16 after a fall at home that resulted in a left comminuted fracture of the humeral neck. On 10/14/16 at 11:30 PM, physician's orders directed the use of an enclosure bed as the patient was confused and attempting to get out of bed. Review of the physician's orders dated 10/15/16 at 1:41 AM directed Haldol 2 milligrams (mg) intravenous (IV) times one. Review of the medication administration record (MAR) indicated Haldol 2 mg IV was administered on 10/15/16 at 1:46 AM. Review of the physicians and nurses notes failed to document a rationale/assessment and/or response for the administration of Haldol.

b. Patient #56 was admitted to the hospital on 9/27/18 with diagnosis that included cerebral vascular accident, acute kidney injury, intracranial atherosclerosis and carotid artery stenosis. On 10/16/18 at 6:41 PM, physician's orders directed the use of an enclosure bed as the patient was confused and interfering with medical treatment. Review of the physician's orders dated 10/17/18 at 1:14 PM directed Haldol 5 mg intramuscular (IM). Review of the MAR indicated that Haldol 5 mg IM was administered on 10/17/18 at 1:49 PM. Review of the physicians and nurses notes failed to document a rationale/assessment and/or response for the administration of Haldol.

c. Patient #57 was admitted to the hospital on 7/3/18 for sepsis secondary to aspiration pneumonia. On 7/5/18 at 10:00 PM, a physician's order directed the use of an enclosure bed due to interference with medical treatment for behaviors of confusion, agitation and restlessness. Review of the physician's orders dated 7/5/18 at 8:44 PM directed Haldol 0.5 mg IV every six hours as needed for agitation. Review of the MAR indicated Haldol 0.5 mg IV was administered on 7/5/18 at 9:48 PM. Review of the physicians and nurses notes failed to document a rationale/assessment and/or response for the administration of Haldol.

d. Patient #58 was admitted to the hospital on 5/17/18 for a small bowel obstruction, pneumonia and developed atrial fibrillation. Patient #58 became confused during the course of his/her hospitalization and a physician's orders dated 5/21/18 directed Haldol 2.5 mg IV every eight hours as needed for agitation. Review of the MAR indicated Haldol 2.5 mg IV was administered on 5/22/18 at 12:05 AM. Subsequent to the medication administration a physician's order dated 5/22/18 at 12:46 AM directed a bilateral padded mitt for interference with medical treatment. Review of the physicians and nurses notes failed to document a rationale/assessment and/or response for the administration of Haldol.

Interview with the Chief of Psychiatry on 10/24/18 indicated the physician or LIP should of documented an assessment, rationale and response for the administration of psychoactive medications to manage a patient's behavior. In addition, the Chief of Psychiatry identified the hospital failed to have a policy that defined a description of what constituted the use of medications as a restraint.

Interview and review of the medical record's # 27, #56, #57 and #58 with Nurse Manager #3 on 10/23/18 identified that the nurse should have documented a response to the administration of an as needed medication and did not. The hospital policy entitled Medication Orders and Administration failed to direct a reassessment of medication after medication administration.

Subsequent to the surveyers inquiry and findings an immediate action plan dated 10/24/18 directed that when as needed medications were administered, the physician's and LIP's would indicate the rational for the use of the medication and both the medical and nursing staff would assess the patient for their effectivness.

1. Based on a clinical record reviews, staff interviews and a review of the hospital's policies and procedures for four of ten patients reviewed for restraints (Patient #27, #55, #56 and #57), the hospital failed to correctly specify the reason for the restraint type.

a. Patient #27 presented to the hospital on 10/14/16 after a fall at home that resulted in a left comminuted fracture of the humeral neck. On 10/14/16 at 11:30 PM, physician's orders directed the use of an enclosure bed as the patient was confused, attempting to get out of bed and interfering with medical treatment.

b. Patient #55 was admitted to the hospital on 10/18/18 with an acute ischemic stroke. On 10/19/18, a physician's ordered directed an enclosure bed due to interference with medical treatment, cognitive impairment and risk for injury.

c. Patient #56 was admitted to the hospital on 9/27/18 with diagnosis that included cerebral vascular accident, acute kidney injury, intracranial atherosclerosis and carotid artery stenosis. On 10/16/18 at 6:41 PM physician's orders directed the use of an enclosure bed as the patient was confused and interfering with medical treatment.

d. Patient #57 was admitted to the hospital on 7/3/18 for sepsis secondary to aspiration pneumonia. On 7/5/18 at 10:00 PM, a physician's order directed the use of an enclosure bed due to interference with medical treatment for behaviors of confusion, agitation and restlessness.

Interview with the Director of the Hospitalist Program and Nurse Manager #3 on 10/23/18 identified an enclosure bed would not prevent interference with medical treatment such as intravenous lines, urinary catheters and oxygen equipment as the patient would still have use of their extremities and hands, therefore the order failed to correctly specify the reason for the restraint. Interview with the Chief of Psychiatry on 10/24/18 indicated a physician's order for the use of a restraint should be ordered and correlated with the proper type and justification for its use.

Subsequent to the surveyors inquiry, an immediate action plan dated 10/24/18 directed that education would be provided to clinical staff that identified the patient's behavior would match the type of restraint being utilized.

1. Based on a clinical record review, staff interviews and a review of the hospital's policies and procedures for five of ten patients reviewed for restraints (Patient #8, #27, #55, #56 and #57), the hospital failed to ensure the least restrictive measures were utilized. The finding included:

a. Patient #8 was admitted to the hospital on 6/3/17 for new onset seizure activity. Patient #8 was also being treated for hyperkalemia, metabolic acidosis, uncontrolled hypertension and delirium. On 6/4/17 at 9:00 PM, a physicians order directed bilateral wrist restraints due to interference with medical treatment for behaviors of agitation and restlessness. Review of the nursing restraint flow sheet dated 6/4/17 identified alternate measures that were attempted and unsuccessful included a bed alarm, redirection, de-escalation techniques, a safe environment and medication management.

b. Patient #27 presented to the hospital on 10/14/16 after a fall at home that resulted in a left comminuted fracture of the humeral neck. On 10/14/16 at 11:30 PM, physician's orders directed the use of an enclosure bed as the patient was confused and attempting to get out of bed. Review of the nursing restraint flow sheet dated 10/14/16 identified alternate measures that were attempted and unsuccessful included a bed alarm, comfort measures, decreased stimuli, diversion, frequent checks, reorientation, verbal limit setting and a proximity close to the nurse's station.

c. Patient #55 was admitted to the hospital on 10/18/18 who was admitted with an acute ischemic stroke. On 10/19/18 at 9:30 PM, a physician's ordered directed an enclosure bed due to interference with medical treatment, cognitive impairment and risk for injury. Review of the nursing restraint flow sheet dated 10/19/18 identified alternate measures that were attempted and unsuccessful included a bed alarm, de-escalation and relaxation techniques, redirection and a physically safe environment.

d. Patient #56 was admitted to the hospital on 9/27/18 with diagnosis that included cerebral vascular accident, acute kidney injury, intracranial atherosclerosis and carotid artery stenosis. On 10/16/18 at 6:41 PM physician's orders directed the use of an enclosure bed as the patient was confused and interfering with medical treatment. Review of the nursing restraint flow sheet dated 10/16/18 identified alternate measures that were attempted and unsuccessful included a bed and chair alarm. Interview with RN #3 on 10/22/18 indicated she had requested one to one care for Patient #56 and was told by nursing leadership that staffing would not allow that level of observation. On 10/23/18, the enclosure bed was discontinued.

e. Patient #57 was admitted to the hospital on 7/3/18 for sepsis secondary to aspiration pneumonia. On 7/5/18 at 10:00 PM, a physician's order directed the use of an enclosure bed due to interference with medical treatment for behaviors of confusion, agitation and restlessness. Review of the nursing restraint flow sheet dated 7/5/18 identified alternate measures were attempted and unsuccessful included a bed alarm, de-escalation techniques and redirection.

Interview and review of the clincial records of Patient #8, #27, #55, #56 and #57 with Nurse Manager #3 on 10/23/18 indicated that a one to one observation was not implemented as a least restrictive measure prior to the use of an enclosure bed. Further interview with Nurse Manager #3 indicated she was provided education that identified enclosure beds were the least restrictive measure.

The hospital policy entitled restraints and seclusion directed in part that restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff member or other from significant risk or harm.

The hospital policy entitlediInpatient observation directed in part that the registered nurse would assess each patient's needs and risk with the goal to provide as safe and therapeutic environment using the least restrictive interventions. Further review identified that direct observation of one patient was deemed for patients who are assessed to be high risk of injury to self or others, exhibit impulsive or who have unpredictable behaviors.

Subsequent to the surveyors inquiry, an immediate action plan dated 10/24/18 identified that nursing documentation of attempts for least restrictive interventions would include the utilization of one to one observation.

1. Based on a clinical record review, staff interviews and a review of the hospital's policies and procedures for one of ten patients reviewed for restraints (Patient #8), the hospital failed to discontinue restraints at the earliest time possible in accordance with the hospital policy.

a. Patient #8 was admitted to the hospital on 6/3/17 for new onset seizure activity. Patient #8 was also treated for hyperkalemia, metabolic acidosis, uncontrolled hypertension and delirium. On 6/5/17 at 7:38 PM the physicians order directed bilateral wrist restraints due to interference with medical treatment for behaviors of agitation and restlessness. Review of the nursing restraint flow sheet dated 6/5/17 identified from 1:00 AM to 5:00 AM Patient #8 was asleep.
Interview with Nurse Manager #3 on 10/23/18 indicated restraints should be discontinued when a patient has been asleep in accordance with the hospital policy.

The hospital policy entitled restraints and seclusion directed in part that the use of restraints would not occur longer than absolutely necessary and the criteria included an improved mental status, the behavior that led to the restraint had improved, the capacity to agree to the expected behavior, the time limit of the order had expired and the management by less restrictive measures was successful.

1. Based on a clinical record review, staff interviews and a review of the hospital's policies and procedures for three of ten patients reviewed for restraints (Patient # 55, #56, #57), the hospital failed to document supporting evidence by a physician or Licensed Independent Practitioner (LIP) for the use and/or continued use of the restraint and/or failed to have a policy that directed the provider to document the rationale and/or assessment for the use of the restraint in the clinical record. The findings include:

a. Patient #55 was admitted to the hospital on 10/18/18 with an acute ischemic stroke. On 10/19/18 at 9:30 PM, a physician's ordered directed an enclosure bed due to interference with medical treatment, cognitive impairment and risk for injury. The enclosure bed was reordered from 10/20/18-10/22/18.

b. Patient #56 was admitted to the hospital on 9/27/18 with diagnosis that included cerebral vascular accident, acute kidney injury, intracranial atherosclerosis and carotid artery stenosis. On 10/16/18 at 6:41 PM physician's orders directed the use of an enclosure bed as the patient was confused and interfering with medical treatment. The enclosure bed was re-ordered on 10/17/18-10/23/18.

c. Patient #57 was admitted to the hospital on 7/3/18 for sepsis secondary to aspiration pneumonia. On 7/5/18 at 10:00 PM, a physician's order directed the use of an enclosure bed due to interference with medical treatment for behaviors of confusion, agitation and restlessness. The enclosure bed was re-ordered on 7/6/18.

Interview and review of the physician's progress notes with Nurse Manager #3 on 10/23/18 failed to identify that daily clinical notes reflected an assessment and/or justification for continued restraint for Patients #55, #56 and #57. Furthermore, the hospital policy entitled Restraints and Seclusion failed to identify that daily restraint documentation was required by the physician or LIP.

Interview with the Chief of Psychiatry on 10/24/18 indicated a daily assessment from the physician or LIP should be conducted with documentation in the clinical record that identifies the justification for the restraint, its continued use, and that alternate methods that were not successful.

Subsequent to the surveyors inquiry, an immediate action plan dated 10/24/18 directed in part that the medical staff would receive education to ensure daily assessments and documentation regarding the rationale and continued use of restraints if applicable.



2. Based on a clinical record reviews, staff interviews and a review of the hospital's policies and procedures for two of ten patients reviewed for restraints (Patient #56 and #58), the hospital failed to monitor the patient in accordance with the hospital policy. The findings include:

a. Patient #56 was admitted to the hospital on 9/27/18 with diagnosis that included cerebral vascular accident, acute kidney injury, intracranial atherosclerosis and carotid artery stenosis. On 10/17/18 at 6:00 PM, physician's orders directed the use of an enclosure bed as the patient was confused and interfering with medical treatment. Review of the nursing flow sheets on 10/18/18 identified restraint monitoring including range of motion, circulation, sensation, movement, respiratory status, hygiene, nutrition and elimination. Further review identified that monitoring failed to be conducted on 10/18/18 from 4:01 PM through 7:59 PM.

b. Patient #58 was admitted to the hospital on 5/17/18 for a small bowel obstruction, pneumonia, and developed atrial fibrillation. Patient #58 became confused during the course of his/her hospitalization and a physician's order dated 5/22/18 at 12:46 AM directed a bilateral padded mitt for interference with medical treatment. Review of the nursing flow sheets on 5/22/18 identified restraint monitoring including range of motion, circulation, sensation, movement, respiratory status, hygiene, nutrition and elimination. Further review identified that monitoring failed to be conducted on 5/22/18 from 3:01 AM through 7:31 AM when the restraint was discontinued.

Interview with Nurse Manager #3 on 10/23/18 indicated restraint monitoring should have been conducted for Patient #56 and #58 every two hours and was not.

The hospital policy entitled restraints and seclusion directed in part restraint monitoring would be conducted and documented every two hours for signs of injury, hygiene, food, fluids, elimination, range of motion, vital signs, mental status, physical and psychological status, adequate peripheral circulation, the need for less restrictive interaction or discontinuation of restraints and proper application and release from the restraint.



3. Based on a clinical record reviews, staff interviews and a review of the hospital's policies and procedures for two of ten patients reviewed for restraints (Patient #55 and #56), the hospital failed to document adequate justification for the use of more than one restraint. The findings include:

a. Patient #55 was admitted to the hospital on 10/18/18 with an acute ischemic stroke. On 10/19/18 at 9:30 PM, a physician's ordered directed an enclosure bed due to interference with medical treatment, cognitive impairment and risk for injury. Further review identified that the enclosure bed was reordered from 10/20/18 through 10/22/18. Physician's orders dated 10/20/18 directed bilateral mitts due to interference with medical treatment.

b. Patient #56 was admitted to the hospital on 9/27/18 with diagnosis that included cerebral vascular accident, acute kidney injury, intracranial atherosclerosis and carotid artery stenosis. On 10/16/18 at 6:41 PM, physician's orders directed the use of an enclosure bed as the patient was confused and interfering with medical treatment. Further review identified that the enclosure bed was re-ordered on 10/17/18 through 10/23/18. Physician's orders dated 10/20/18 at 8:54 AM through 10/23/18 directed bilateral wrist restraints for the interference with medical treatment.

Interview with Nurse Manager #3 and the Director of the Hospitalist Program on 10/23/18 indicated that each restraint type for Patient #55 and #56 should have had it's own justification for use and did not.

The hospital policy failed to identify the procedure and/or steps to be conducted when more than one restraint was used simultaneously.

Subsequent to the surveyor's inquiry, an immediate action plan dated 10/24/18 indicated education would be provided that directed justification for the use of each restraint and the behavior would correspond with the restraint type.