HospitalInspections.org

The Hospital reported a census of 29. Based on document review and staff interview the Hospital failed to ensure the physician followed the policy and procedure for use of restraints 1 of 1 sampled patient, #11, with soft wrist restraints.

Findings include:

- The hospital admitted patient #11 on 5/12/10 with a diagnosis of Gallstones and Gallbladder Sludge. Review on 5/24/10 at 3:00pm of patient #11' s medical record revealed the physician ordered soft restraints if necessary on 5/13/10 at 8:45pm. The physician failed to renew the 24-hour Medical/Surgical Restraint order on 5/14/10 and 5/15/10.

Review of the Hospital ' s Nursing Policy titled, " Restraint ' s, Initiating/Monitoring " , updated on 11/25/2009, states under " Procedure:6 ....requires a physician order ...not to exceed one calendar day (24 hours), after which new orders are required if the restraints must be continued. "

Staff A interviewed on 5/24/10 at 12:10pm acknowledged the 24 hour Medical/Surgical Restraint Orders dated 5/14/10 and 5/15/10 lacked the date or time the restraint order was received, lacked the name of the Physician who issued the order, and lacked the name of the nurse who took the order (if by telephone). Staff A confirmed the Hospital failed to follow the procedure for renewing physician ordered wrist restraints.

The Hospital reported a census of 29. Based on document review and staff interview the hospital failed to ensure the physicians follow the Hospital 's policy and procedure for use of restraints for 1 of 1 sampled patients, #11, with wrist restraints.

Findings include:

- The hospital admitted patient #11 on 5/12/10 with a diagnosis of Gallstones and Gallbladder Sludge. Review on 5/24/10 at 3:00pm of the medical record revealed the nurse received a telephone order for soft wrist restraints on 5/16/10 at 9:00pm from the physician. The medical record lacked evidence the physician assessed the patient before he ordered the wrist restraints.

Review of the Hospital 's Nursing Policy titled, " Restraint 's, Initiating/Monitoring " , updated on 11/25/2009, states under " Policy: 4. After 24 hours, before writing a new order for the use of restraints ... a physician ...must see and assess the patient.

Staff A interviewed on 5/24/10 at 12:10pm acknowledged the 24 Hour Medical/Surgical Restraint Order dated 5/16/10 at 9:00pm lacked an evaluation by the physician and confirmed they failed to follow the Hospital 's policy that requires the physician to see and assess the patient prior to the renewal of a restraint order.

The Hospital reported a census of 29. Based on document review and interview the Hospital failed to ensure all entries were complete, signed, dated and timed for 7 of 32 sampled patients (#11, 13, 15, 17, 27, 29, 30).

Findings include:

- The hospital admitted patient #27 on 5/18/10 for a mitral valve repair. Record review on 5/25/10 at 3:00pm revealed seven verbal orders dated 5/20/10, three verbal orders dated 5/22/10, and two verbal orders dated 5/23/10 that lacked the physician ' s signature, date and time. One verbal order dated 5/23/10 issued by a Physician Assistant lacked the authentication of the Physician.

- The hospital admitted patient #29 on 5/17/10 with complaints of left hip pain. Record review on 5/25/10 at 3:15pm revealed three verbal orders dated 5/18/10 and one verbal order dated 5/19/10 that lacked the physician's signature, date and time.

- The hospital admitted patient #30 on 5/09/10 with abdominal pain. Record review on 5/25/10 at 3:30pm revealed three verbal orders dated 5/09/10 lacked the physician 's signature, date and time.

Staff A interview on 5/25/10 at 4:00pm, confirmed Physicians orders for patients #27, 29, and 30, lacked the physician's signature, date and time on the verbal orders.

The hospital's policy on " Verbal/Telephone Orders ", revealed, " ...Verbal inpatient orders are reviewed and countersigned by the prescriber or another physician member of the team caring for the patient as soon as possible, .... " .

This deficient practice also effected sampled patients #11, 13, 15, and 17.