HospitalInspections.org

Based on medical record review, policy review, and staff interview the Hospital failed to follow their policy to perform an in-person assessment of the physically restrained patient at least daily and if required re-order the use of the physical restraint for 24 hours for 1 of 3 patients with restraints (patient #28). The failure to follow hospital policy for daily re-assessment of the need for physical restraints created the potential that physical restraints were not discontinued as soon as possible.

Findings include:

- The Hospital policy titled "Restraint Utilization" reviewed on 7/20/11 at 12:55pm stated,
"the licensed independent practitioner (LIP) shall perform an in-person assessment of the restrained patient at least once every calendar day at which time restraint shall be either re-ordered or discontinued as indicated " .

- Patient #28's closed medical record reviewed on 7/20/11 at 10:00am revealed an admission date of 3/17/11 with diagnoses of congestive heart failure (fluid in the heart tissue) and atrial fibrillation (abnormal heart rhythm). The physician ordered soft limb restraints on 3/18/11 at 8:00am for safety of the patient. The medical record lacked evidence of a re-assessment by the physician or renewal of orders for physical restraints on 3/19/11, 3/20/11, 3/21/11 and 3/22/11 while the patient remained in the soft limb restraints.

- Staff B interviewed on 7/20/11 at 10:00am acknowledged patient #28's medical record lacked four days of the required restraint orders and re-assessments.

Based on medical record review, policy review and staff interview the Hospital failed to report deaths associated with use of restraints by the close of the next business day to the Centers for Medicare and Medicaid Services (CMS) for 3 of 3 sampled patients whose death occurred while in or within 24 hours after the patient was removed from physical restraints (Patients #'s 28, 29 and 30).

Findings include:

- The Hospital policy titled "Restraint Utilization" reviewed on 7/20/11 at 12:55pm states, "The time and date patient's death associated with the use of restraints is reported to CMS must be documented in the patient's medical record ...within one business day following knowledge of patient death".

- Patient #28's medical record reviewed on 7/20/11 revealed an admission date of 3/17/11 with diagnoses of congestive heart failure (fluid in the heart tissue) and atrial fibrillation (abnormal heart rhythm). The medical record revealed the physician ordered patient #28's soft limb restraints on 4/1/11 at 8:00am. The soft limb restraints were removed by staff on 4/1/11 at 11:45am. Patient #28 died on 4/1/11 at 12:15pm. The medical record lacked evidence the hospital notified CMS within one business day of patient #28's death which occurred within 24 hours after the patient was removed from physical restraints.

- Patient #29's medical record reviewed on 7/20/11 of revealed an admission date of 5/9/11 with a diagnosis of severe sepsis (blood infection). The medical record revealed the physician ordered soft limb restraints for patient #29 on 5/9/11 at 5:00am. Staff untied the soft restraints left them in place on 5/9/11 at 8:00am and removed the soft restraints from patient #29 on 5/9/11 at 11:00pm. Patient #29 died on 5/9/11 at 11:00pm. The medical record lacked evidence the hospital notified CMS within one business day of patient #29's death which occurred within 24 hours after the patient was removed from physical restraints.

- Patient #30's medical record review on 7/20/11 revealed an admission date of 4/5/11 with a diagnosis of congestive heart failure. The medical record revealed the physician ordered soft limb restraints for patient #30 on 4/6/11 at 9:00am. The restraints were removed on 4/6/11 at 5:55pm. The medical record lacked evidence the hospital notified CMS within one business day of patient #30's death which occurred within 24 hours after the patient was removed from physical restraints.

- Staff C interviewed on 7/20/11 at 3:40pm acknowledged the medical records for patient #'s 28, 29 and 30 lacked evidence of the required notification to CMS within one business day of the patient deaths which occurred within 24 hours after the patient was removed from physical restraints.

Based on observation, policy review, and staff interview, the Hospital failed to ensure drugs and biologicals remain secured and stored in such a manner to prevent unmonitored access by unauthorized individuals. The Hospital failed to develop and implement a policy to meet the regulation. The failure to secure 5 of 5 crash carts with medications stored in the Materials Management (Central Supply) area created a potential for diversion or theft of medications and biologicals.

Findings include:

- The Hospital's policy titled, "Code Blue - Emergency Medications", stated, "After an emergency and after material management has completed restocking of all non-medication items, the Pharmacy Department will restock all the medications and finally lock the cart. The cart (crash cart) will be stored in Materials Management where it is ready for rotation." The policy failed to meet the regulation that all drugs and biologicals remain in a secure area

- Observation of the Materials Management department (Central Supply) on 7/20/11 at 3:00pm revealed five Code Blue crash carts stored in an area next to one of the entrances of the Materials Management department. The entrance door remained unlocked from 7:00am until 4:30pm, with uncontrolled access by anyone entering the department and not visible by staff unless they were in the immediate area. After 4:30pm the locked doors were accessible by the Hospital Unit Coordinator (HUC) runner, maintenance, and security. The crash carts contained a drawer of medications used for emergency purposes.

Staff A interviewed on 7/20/11 at 3:00pm acknowledged the crash carts contained medications, and the hospital failed to secure and store all medications in a manner to prevent unmonitored access by unauthorized persons.