HospitalInspections.org

Based on record review, observation and interview the facility failed to ensure doctors' orders were obtained for the use of restraints in one (ID#7) of ten of patients records reviewed.

Findings include:

Record review of the facility policy "Restraint and Seclusion, revised 02/20 stated:
The restraint order may be renewed according to the above schedule for up to 24 hours at which time a face-to-face evaluation must be performed by a physician for restraint/seclusion to be continued beyond 24 hours.

Record review of patient (ID#7) medical record revealed the patient was admitted 10/24/2022 with a diagnosis of hypoxia, respiratory distress, pleura diffusion, hypotension, shock, GI bleed and was restrained 10/25, 10/26, 10/27/2022. The patient did not have an order for restraints on 10/26/2022.

Observation of the patient (ID#7) in his room on 10/27/2022 at 1030 revealed the patient was intubated and restrained.

Interview on 10/27/2022 at 1100 with nurse (ID#55) during the chart review stated, "we should have an order for restraints every day."

Based on record review and interview the nursing staff failed to develop and keep current nursing care plans to address the patients' needs for 7 out of 13 patients' (patient ID #4,5,6,7,8, 9, 12) medical records reviewed

Findings:

Record review of the current hospital policy titled "Care Planning, Nursing and Multidisciplinary" revised 09/20 stated: All inpatients at OakBend Medical Center will have an established Plan of Care that will be appropriate to diagnosis and individualized daily by the Nursing staff and other professional staff as indicated

Record review on 10/27/2022 between 10-1230 revealed the following patient's (ID #4,5,6,7,8, 9, 12) care plan with the charge nurse (#55) and nurse manager (#57).

Record review of the following patient records in the intensive care unit (ICU) revealed the following:

Patient (ID#4), admitted 10/25/2022 with a diagnosis of failure to thrive and had a wound vac. Review of the care plan did not address infection control and nutrition.

Patient (ID#5), admitted 10/12/2022 with a diagnosis of congestive heart failure, currently experiencing altered mental status, obese with respiratory, diabetic issues, skin issues and restraints. No skin issues noted in the care plans.

Patient (ID#6) admitted 10/21/2022 with a diagnosis of hypotension, on dialysis, positive for colon cancer, has colostomy and nephrostomy. The care plan does not discuss issues with electrolyte imbalance.

Patient (ID#7) admitted 10/24/2022 with a diagnosis of hypoxia, respiratory distress, pleura diffusion, hypotension, shock, GI bleed and had restraints. The care plan does not address infection control. The patient did not have an order for patient restraints on 10/26/2022.

Interview with nurse (ID#55) during the chart review stated" we should have an order for restraints every day".

Patient (ID#8), admitted 10/13/2022 with a diagnosis of metastatic disease, intubated, anemia, hypertensive. The charge nurse (ID#55) stated they didn't do much of a care plan". The care plan did not address the patients current diagnosis and issues.

Patient (ID#9) admitted 10/25/2022 with left leg cellulitis with a risk of sepsis. Infection and skin breakdown was noted on the care plan.

Patient (ID#12) admitted 10/19/2022 with history of Diabetes, congestive health failure, pain and an onset of dementia. Pain and fall risk was not noted in the care plan

Interview on 10/27/2022 at 1100 with charge nurse (Staff #55), who stated "the care plans should match the patient's medical diagnosis". The medical records, staff (ID#55) was referring to, were patients (ID#3,4,5,6,7,8) in the intensive care unit (ICU).

Interview on 10/28/2022 at 1243 with the 5th floor nurse manager (ID#57) while reviewing care plan of patients (ID#9, 12) on the floor, he stated, "It's not currently on the plan".