HospitalInspections.org

Based on medical record review, policy review and staff interview, the facility failed to inform patients of their rights (A117). The facility failed to ensure patients received care in a safe setting following physician's orders for administration of pain medications (A144). The facility failed to ensure orders were obtained during or immediately after the initiation of restraints/seclusion (A168). The facility failed to ensure orders for violent seclusion were reordered every 4 hours (A171). The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patients' rights would be protected.

Based on record review, staff interview and review of policies and procedures, the facility failed to inform a patient of their patient rights for one of ten sampled patients (Patient #7). The active census was 396.

Findings include:

Review of the policy titled Consent for Medical Treatment (I-34), revised on October of 2014, revealed the patient was to sign the consent form upon the patient's first encounter at the facility. If the patient was unable to sign, the facility may obtain a verbal consent or may obtain telephone consent from a person authorized to give consent.

Review of the medical record of Patient #7 revealed the patient was admitted on 11/05/16 with the diagnosis of traumatic bilateral lower extremity fractures. Review of the Consent for Medical Treatment form revealed the form was dated 11/05/16 and written in on the patient's signature line was "unable to sign". Patient #7, however, signed consent for a surgical procedure of open reduction and internal fixation on 11/15/16. There was no signed Consent for Medical Treatment in the medical record, which included the Patient Bill of Rights.

On 11/17/16 at 9:45 AM, Staff C confirmed there was no evidence that Patient #7 received his/her Patient Rights

Based on record review, staff interview and review of procedure, the facility failed to ensure patients received care in a safe setting and pain medications were administered as ordered for five of ten sampled patients (Patient #1, #2, #3, #6 and #9). The active census was 396.

Findings include:

Review of the policy and procedure titled Pain Management Nursing Care Procedure, with no date, revealed the nursing interventions included #15 administer pain medications based on severity of pain scale as specified in the physician's order and #27 document in medical record patient's self-report of pain or nursing assessment of pain.

1. Review of the medical record of Patient #1 revealed a physician's order, dated 03/25/16, for tramadol (narcotic medication for pain), 50 milligrams (mg), oral, every six hours prn (as needed) for severe pain (pain scale of 7, 8, 9, and 10). Review of the medication administration record (MAR) for Patient #1 revealed tramadol 50 mg was administered as follows: 03/27/16 at 9:00 PM for pain level of 6, 03/29/16 at 4:52 AM for pain level of 4, 03/30/16 at 6:14 AM with no pain assessment, 03/30/16 at 12:34 PM for pain level of 5, 03/30/16 at 7:43 PM for pain level of 5, 03/31/16 at 12:18 PM for pain level of 5, 03/31/16 at 8:56 PM for pain level of 6, 04/01/16 at 8:16 AM for pain level of 5, 04/01/16 at 9:37 PM for pain level of 6, 04/02/16 at 6:05 AM for pain level of 5, 04/02/16 at 8:58 PM for pain level of 5, 04/03/16 at 6:12 AM for pain level of 6, 04/03/16 at 10:10 PM for pain level of 6, 04/04/16 at 6:45 AM and 2:39 PM with no pain assessment, 04/05/16 at 6:17 AM with no pain assessment, 04/05/16 at 12:23 PM with pain level of 4 and 04/05/16 at 9:17 PM with pain level of 3.

2. Review of the medical record for Patient #2 revealed a physician's order for oxycodone, 15 mg, oral, every three hours, prn for severe pain (pain score of 7, 8, 9 and 10). Review of the MAR revealed oxycodone was administered on 03/30/16 at 1:54 PM and 03/31/16 at 8:43 AM and at 1:02 PM with no pain assessment. There was no evidence in the record that Patient #2 had severe pain when the medication was administered.

3. Review of the medical record of Patient #3 revealed a physician's order for oxycodone, 10 mg, oral, every six hours, prn for severe pain (pain score 7, 8, 9 and 10). Review of the MAR revealed a RN administered oxycodone 10 mg with no pain assessment on the following dates and times: on 03/16/16 at 12:58 AM; on 03/17/16 at 8:56 AM, 12:11 PM, 4:09 PM, 7:31 PM, 11:00 PM; on 03/18/16 at 3:24 AM, 11:44 AM, and 5 mg at 9:48 PM; on 03/19/16 16 at 9:11 AM, 03/22/16 at 8:54 AM, 4:01 PM and 9:51 PM; on 04/03/16 at 11:45 AM; on 04/04/16 at 1:00 AM; and on 04/05/16 at 12:49 PM and 10:05 PM.

4. Review of the medical record of Patient #6 revealed a physician's order for hydromorphone, 0.4 mg, intravenous (IV), every four hours, prn for severe pain (pain score 7, 8, 9 and 10). Review of the MAR for Patient #6 revealed hydromorphone, 0.4 mg was administered by a RN IV on 11/15/16 at 1:06 AM and at 3:25 PM, two hours and 19 minutes later.

5. Review of the medical record for Patient #9 revealed a physician's order for hydromorphone, 0.5 mg, IV, every two hours, prn for severe pain (pain score of 7, 8, 9 and 10). Review of the MAR revealed a RN administered hydromorphone 0.5 mg IV on 11/14/16 at 7:24 AM. No pain score was documented.

Staff D confirmed these findings on 11/17/16 at 9:00 AM.

Based on medical record review, policy review and staff interview, the facility failed to ensure seclusion/restraint orders were obtained during or immediately after the initiation of seclusion/restraint, the facility failed to get a new order when a type of restraint was added or changed, and the facility failed to have a restraint order reordered at least every four hours for violent restraint/seclusion for two of two restraint medical records reviewed (Patient #4 and #5). The active census was 396.

Findings include:

1. Review of the medical record for Patient #4 completed on 11/15/16, revealed an admission date of 11/14/16 with a diagnosis of Alcohol withdrawal. Nursing documentation on 11/14/16 at 12:20 PM showed Patient #4 was placed in Non-Violent soft wrist/ankle X4 restraints and the order for the restraints was not ordered until 11/14/16 at 2:43 PM. Nursing documentation revealed a waist restraint was added on 11/14/16 at 8:43 PM. A physician order adding the waist restraint was not noted until 11/15/16 at 7:58 PM.

These findings were verified by Staff E at the time of the review.

2. Review of the medical record for Patient #5 completed on 11/15/16 revealed an admission date of 11/01/16 with a diagnosis of Schizoaffective Disorder. Review of the nursing documentation revealed on 11/08/16 Patient #5 was placed in seclusion at 8:06 AM and an order was not obtained until 8:51 AM.

This finding was verified by Staff E at the time of the review.

Review of the policy titled "The Use of Restraint and Seclusion" (Policy No: III-16) completed on 11/16/16, revealed under V. General Provisions, C. The physician/LIP orders the type and number of limb restraint (e.g. wrist or ankle Restraints in leather or soft). Nurses may reduce the number or type of Restraints ordered but needed to document the reduction. If it was necessary to increase Restraint number or type (even if it was initially ordered), a new order was required at the time of the increase. VI. Initiation, A. The RN can authorize the initiation of Restraints based on appropriate assessment. A physician order was required immediately after initiation of Restraint.

Based on medical record review, policy review and staff verification, the facility failed to ensure violent seclusion orders were reordered at least every four hours for one of two restraint medical records reviewed (Patient #5). The active census was 396.

Findings include:

Review of the medical record for Patient #5 completed on 11/15/16 revealed an admission date of 11/01/16 with a diagnosis of Schizoaffective Disorder. Review of the Physician restraint/seclusion orders revealed on 11/05/16 a Restraint-Violent Adult Type: Seclusion (locked) was reordered at 10:27 AM and not again until 3:03 PM. Nursing documentation revealed the patient was in seclusion during this time period. On 11/13/16 seclusion was re-ordered at 11:40 AM and not again until 4:10 PM. Nursing documentation revealed the patient was in seclusion during this time period.

These findings were verified by Staff E at the time of the review.

Review of the policy titled "The Use of Restraint and Seclusion" (Policy No: III-16) completed on 11/16/16 revealed under VII. Duration of Restraint/Seclusion Orders, A. Orders for Restraints remain in effect until the patient's behavior or situation no longer required the use of Restraint or Seclusion, but no longer than:

2. At the frequency defined below for Violent or Self-Destructive behavior (Violent or Self-Destructive Standards):

a) 4 hours for adults 18 years of age or older.