HospitalInspections.org

Based on policy review, interview, and medical record review; the facility failed to follow its policy regarding the implementation of advance directives. This affected one of 15 sampled patients, Patient 9. The facility census was 43 at the time of the survey.

Findings include:

The medical record review for Patient 9 was completed on 06/16/11. The medical record review revealed the patient was brought to the emergency room on 05/30/11 by emergency medical services for a chief complaint of altered mental status. The clinical record review revealed a nursing progress note dated 05/30/11 at 3:30 AM that stated the patient was alert to his/her name only, and did not know where he/she was, where he/she worked, or what day it was. The medical record review revealed a physician's progress note dated 05/30/11 at 3:33 AM that stated the patient had gone to work and while speaking with a co-worker, put his/her head down and became momentarily unresponsive. The medical record review revealed a nursing progress note dated 05/30/11 at 3:53 AM that stated the patient "still not able to answer direct questions. Staring, moving mouth without verbalization. (Patient) told of plan to gown, receive (intravenous cannula), draw labs, obtain (electrocardiogram). Refusing all of the above." The medical record review revealed a nursing progress note dated 05/30/11 at 4:17 AM that stated an against medical advice form was signed by the patient's power of attorney, and ambulated "to lobby with mom, sister (power of attorney)" and no questions were asked. The medical record review lacked evidence to confirm the patient's sister was the power of attorney.

Review of the facility's policy entitled "Consent, Informed, for Medical/Surgical Care, Treatment, or Services" as revised on 01/1996 was completed on 06/16/11. The review revealed, "Anyone presenting as a legally authorized representative for the patient must provide appropriate documentation stating they have legal authority to make healthcare decisions for the patient."

On 01/15/11 at 10:30 AM in an interview, Staff J stated the hospital sometimes has access to a psychiatrist and/or psychologist at night. He/she said it would have been best to have had a second physician determine the patient's decision-making capacity and then consensus on whether the patient was capable of making his/her own decisions. (That would then determine whether the durable power of attorney applied at all.)

On 01/16/11 at 10:00 AM, Staff D confirmed the medical record review lacked evidence of any durable power of attorney paperwork.

Based on medical record review, policy review, and staff interview; the facility failed to ensure orders for restraint use were obtained for the use of restraints on one of two medical records reviewed with restraint usage (Patient 6). The facility census was 43 at the time of the survey.

Findings include:

The medical record for Patient 6 was reviewed on 06/15/11. Patient 6 was admitted to the facility on 06/13/11. The medical record contained documentation of bilateral soft wrist restraints from 3:05 AM on 06/13/11 through 06/15/11 at 3:30 PM. The medical record lacked documentation of an order for restraint usage until 6:15 AM on 06/13/11, three hours and ten minutes after the restraints were applied.

On 06/15/11, the policy for the Use of Restraint and Seclusion was reviewed. The policy stated the physician would be notified immediately upon application of restraints, but no later than one hour and a telephone or written order will be obtained.

On 06/15/11 at 4:13 PM, Staff I verified the medical record lacked documentation of a physician's order for restraints until 6:15 AM on 06/13/11, although the restraints were applied at 3:05 AM. Staff I stated a verbal order for the restraints should have been obtained when the restraints were applied.

Based on medical record review, observation, policy review, and staff interview; the facility failed to ensure all restrained patients were monitored according to the facility's policy for one of two medical records reviewed with restraint usage (Patient 6). The facility census was 43 at the time of the survey.

Findings include:

The medical record for Patient 6 was reviewed on 06/15/11. Patient 6 was admitted to the facility on 06/13/11. The medical record contained documentation of bilateral soft wrist restraints from 3:05 AM on 06/13/11 through 06/15/11 at 3:30 PM. The medical record lacked documentation of safety checks at least every two hours from 3:05 AM to 8:00 AM on 06/13/11, from 2:00 PM to 8:00 PM on 06/14/11, and from 12:00 PM to 3:30 PM on 06/15/11.

On 06/15/11 at 3:30 PM, Patient 6 was observed to have bilateral wrist restraints in place.

On 06/15/11, the policy for the Use of Restraint and Seclusion was reviewed. The policy stated restrained patients would be reassessed by a nurse at least every two hours to determine continued need for restraints, circulation checks, any sign of injury, and that a call light is within reach. In addition, vital signs, toileting, repositioning, range of motion, bathing, nutrition, and hydration will be performed and documented on the restraint flowsheet every two hours by nursing or any other trained staff.

On 06/15/11 at 4:13 PM, Staff I verified the medical record lacked documentation of the two hour reassessments as indicated above. Staff I stated staff should be documenting these safety checks at least every two hours.