HospitalInspections.org

Based on policy and procedure review, clinical record review and interview it was determined the Facility restrained four (#8, #10, #11 and #14) of six (#8, #10-15) patients without orders as mandated by Facility Policy and Procedure. Failure to obtain physician's orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints and prohibited the Facility from following it's policy. The failed practice affected Patients #8, #10, #11 and #14. Findings follow:
A. Review of Restraint and Seclusion Policy and Procedure, #MS.4.06, received from the Director of Quality Program for Nursing at 0915 on 04/15/15 revealed the following under PROCEDURES: 1. LIP (Licensed Independent Practitioner) Orders, All patients placed in restraint require a clinical justification of need. An order must be obtained from the treating LIP before restraint application... B. If an emergency application is needed, the order will be obtained from the LIP immediately following the application...
B. Review of Patient #8's clinical record revealed the patient was restrained from 2200 on 02/24/15 through 0430 on 02/25/15 without a physician's order to apply restraints. During an interview with the Director of Quality Program for Nursing at 1155 on 04/16/15 she verified the above findings.
C. Review of Patient #10's clinical record revealed the patient was restrained from 0030 on 04/13/15 through 0821 on 04/13/15 without a physician's order to apply restraints. During an interview with the Instructional Designer at 1330 on 04/16/15 he verified the above findings.
D. Review of Patient #11's clinical record revealed the patient was restrained from 2100 on 04/12/15 through 0422 on 04/13/15 without a physician's order to apply restraints. During an interview with the Instructional Designer at 1400 on 04/16/15 he verified the above findings.
E. Review of Patient #13's clinical record revealed the patient was restrained from 2200 on 04/04/15 through 0046 on 04/05/15 without a physician's order to apply restraints. During an interview with the Instructional Designer at 1430 on 04/16/15 he verified the above findings.

Based on policy and procedure review, clinical record review and interview, it was determined the Facility failed to monitor one (#13) of six (#8, #10-15) restraint patients every two hours per Facility policy and procedure. Failure to monitor and assess Patient #13 every two hours per Facility policy and procedure had the potential to allow patient injury or death and did not allow the patient to be assessed and released from restraints as early as safely possible. Findings follow:

A. Review of Restraint and Seclusion Policy and Procedure, #MS.4.06, received from the Director of Quality Program for Nursing at 0915 on 04/15/15 revealed the following under III. Assessment/Reassessment, ...D. Adult patients in restraints shall be observed and assessed by an RN (Registered Nurse) at a minimum of every two hours and a child every hour or more frequently if warranted based on the individual patient needs and setting...

B. Review of the clinical record of Patient #10 revealed no evidence the patient was monitored while in restraints from 0800 through 1900 on 04/13/15 and from 1500 through 1901 on 04/14/15. During an interview with the Instructional Designer at 1330 on 04/16/15 he verified the above findings.

Based on review of clinical records, physician's orders and interview, it was determined a Registered Nurse failed to supervise the care for four (#6, #9, #13 and #15) of five (#6, #8, #9, #13 and #15) patients in that care was not rendered per physician's orders. Dressing changes were not performed as ordered and patients were not turned every two hours as ordered. Failure to provide care per physician's orders did not ensure patients received the highest quality of care to facilitate the patient's attainment of the highest level of wellness. The failed practice affected five (#6, #7, #9, #13 and #15) of six (#6-9, #13 and #15) patients. Findings follow:

A. Review of Patient #6's clinical record revealed physician orders dated and timed 02/17/15 at 1132 to turn Patient #6 every two hours. Review of the nursing notes revealed no documentation Patient #6 was turned from 0500 to 1900 on 02/17/15 and from 1300 to 1901 on 02/13/15. During an interview with the Instructional Designer at 0855 on 04/16/15 he verified the above findings.

B. Review of Patient #9's clinical record revealed physician orders dated and timed 02/16/15 at 1511 for Xenaderm, Aquaphor to left calf every eight hours and to turn Patient #9 every two hours. Review of the nursing notes revealed the dressing change was not performed as ordered on 02/16/15, 02/17/15, 02/18/15, 02/19/15, 02/20/15, 02/21/15, 02/22/15, 02/23/15 and 02/24/15. Review of the nursing notes revealed no documentation Patient #9 was turned from 0300 to 0819 and from 0900 to 1917 on 02/17/15, on 02/18/15 from 0315 to 0723, from 0723 to 1200 and from 1200 to 1724, on 02/19/15 from 0335 to 0714, from 1845 to 2322, from 2322 (02/19/15) to 0449, from 0714 to 2005 on 02/20/15, from 0249 to 0710 on 02/22/15, from 0100 to 0715 on 02/23/15 and from 0317 to 0642 on 02/24/15. During an interview with the Instructional Designer at 1255 on 04/16/15 he verified the above findings.

C. Review of Patient #13's clinical record revealed physician orders dated and timed 04/04/15 at 2200 for Patient #13 to be turned every two hours. Review of the nursing notes revealed no documentation Patient #13 was turned from 2200 on 04/04/15 to 0300 on 04/05/15 and from 0300 to 0700 on 04/05/15. During an interview with the Instructional Designer at 1445 on 04/16/15 he verified the above findings.
D. Review of Patient #15's clinical record revealed physician's orders dated and timed 02/12/15 at 1521 to apply polymem pink dressing to right leg ulcer, secure with Kerlix. Review of the nursing notes revealed no dressing change documented from 02/16/15 at 1720 through discharge on 02/18/15 to the right leg ulcer. Review of the care plan initiated on 02/11/15 revealed Patient #15 was to be turned every two hours per the Braden score of 13 on 02/11/15. Review of the clinical record revealed no documentation Patient #15 was turned every two hours from 0725 to 1100, from 1100 to 1500, from 1500 to 1901 on 02/13/15, from 1901 on 02/13/15 to 1827 on 02/14/15, from 2207 on 02/16/15 through 0900 on 02/17/15 and from 2300 on 02/17/15 to 0726 on 02/18/15. During an interview with the Instructional Designer at 1055 on 04/16/15 he verified the above findings.

Based on policy and procedure review, clinical record review and interview, it was determined the Facility failed to ensure a current and comprehensive nursing care plan was developed and implemented based on the patient's needs for 4 (#5, #6, #10 and #11) of 15 (#1-15) patients. Failure to develop and maintain a current and comprehensive plan of care was likely to affect the nursing care rendered to ensure the patients received optimum care to progress and be discharged. The failed practice affected Patient #5, #6, #10 and #11 on 04/17/15. Findings follow:

A. Review of the policy and procedure titled "RN (Registered Nurse) Assessment" received from the Director of Quality Programs for Nursing at 0915 on 04/15/15 revealed under RN ASSESSMENT, the following:..
6. The analysis/interpretation of the data collected must be performed by the RN and is the assessment which proved the basis for the development of the nursing plan of care.
7. Each patient's nursing plan of care may consist of pre-determined hospital approved standards of care/practice appropriate to the patient or be developed as an individualized action plan.
8. Assessment data from the comprehensive nursing assessment and ongoing periodic reassessments of the patient by RNs will be incorporated into the interdisciplinary care planning process through the unit based interdisciplinary care meetings.
9. A plan of care will be instituted within 24 hours of admission...

B. Review of the clinical record for Patient #5 revealed a Braden score of 14 at admission on 04/12/15 and remained below 18 until the time of clinical record review on 04/16/15. Review of the care plan revealed the Skin Integrity Care Protocol was initiated on 04/15/15. During an interview with the Instructional Designer at 1345 on 04/15/15 he verified the above findings.

C. Review of the clinical record for Patient #6 revealed a Braden score of 13 at admission on 02/13/15 and remained below 18 until discharge. Review of the care plan revealed the Skin Integrity Care Protocol was not initiated. During an interview with the Instructional Designer at 0855 on 04/16/15 he verified the above findings.

D. Review of the clinical record for Patient #10 revealed a Braden score of 12 on 04/13/15 and remained below 18 until the time of clinical record review on 04/16/15. Review of the care plan revealed the Skin Integrity Care Protocol was not initiated. During an interview with the Instructional Designer at 1330 on 04/16/15 he verified the above findings.

E. Review of the clinical record for Patient #11 revealed restraints were applied and the Braden score dropped below 18 on 04/12/15. Review of the care plan revealed the Skin Integrity Care Protocol and restraints were not care planned for this patient. During an interview with the Instructional Designer 1400 on 04/16/15 he verified the above findings.

F. During an interview with the Director of Quality Programs for Nursing at 1200 on 04/16/15 she verified the Skin Integrity Impairment Risk should be initiated on the nursing care plan at any point a Braden score is below 18.