HospitalInspections.org

Based on Medical Staff Rules review, clinical record review, and interview, it was determined one (#10) of four (#7, #10, #13 and #14) patients was not restrained in accordance with a physician's order. Failure to obtain a physician's order for restraints did not allow the physician to be knowledgeable regarding the patient's need for restraints and prohibited the Facility from following policy. The failed practice affected Patient #10. Findings follow:

A. Review of the Medical Staff Rules received from the Medical Staff Coordinator at 0839 on 02/24/17 revealed the following under 13.2 VERBAL AND TELEPHONIC ORDERS, ...13.2.3.6 The ordering Practitioner shall authenticate all verbal orders and telephonic medication orders within seventy-two (72) hours and all other verbal and telephonic orders within ninety-six (96) hours; under 13.10 RESTRAINTS, 13.10.6 The use of restraint or seclusion must be in accordance with the written and signed order of a Physician Practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion ...

B. Review of Patient #10's clinical record revealed 11 (12/20/16, 12/21/16, 12/22/16, 12/23/16, 12/24/16, 12/27/16, 12/28/16, 12/31/16, 01/01/17, 01/02/17 and 01/03/17) of 13 (12/20/16, 12/21/16, 12/22/16, 12/23/16, 12/24/16, 12/25/16, 12/25/16, 12/27/16, 12/28/16, 12/31/16, 01/01/17, 01/02/17 and 01/03/17) restraint orders not signed by a physician within 96 hours.

C. During an interview with the Quality Management Analyst at 1318 on 02/23/17 she verified the findings in A and B.

Based on clinical record review, Medical Staff Rules and interview it was determined the Facility failed to ensure physicians and practitioners received restraint and seclusion training at orientation and every two years. Failure to ensure physicians and practitioners received restraint and seclusion training did not ensure the physicians and practitioners had a working knowledge of the Facility's restraint and seclusion policy to ensure the safe application of restraint and seclusion. The failed practice would likely affect all patients who were placed in restraints or seclusion. Findings follow:

A. Review of the Medical Staff Rules received from the Medical Staff Coordinator at 0825 on 02/24/17 revealed the following under 13.10.15: Physician Practitioners authorized to order restraint or seclusion must receive training at orientation and every two years thereafter so as to demonstrate a working knowledge of Medical Staff and Hospital policy regarding the use of restraint or seclusion.

B. At 0930 the restraint and seclusion training was requested from the Medical Staff Coordinator for Physicians #2-#6 and Nurse Practitioners #1-#2.

C. During interviews with the Chief Nursing Officer at 1010 and again at 1030 on 02/24/17 he stated there was no Physician or Practitioner training for restraint and seclusion.

Based on CPR (Cardiopulmonary Resuscitation) certification review, Human Resource notification, policy and procedure review, nursing schedules and interview it was determined the Facility failed to ensure one (#13) of nine (#7, #11-18) Registered Nurses (RN) had current CPR certification. Failure to ensure all staff maintained CPR certification did not ensure the availability of competent staff in the event of life saving measures or a cardiac emergency. The failed practice had the likelihood to affect all patients whose care was provided by RN #13 since 01/09/17. Findings follow:

A. Review of the CPR certification of RN #13 revealed the certification expired January 2017.

B. Review of a Human Resource letter dated 12/29/16 received from the Director of Human Resources at 1345 on 02/22/17, addressed to RN #13, revealed the following: "This letter is to inform you that your BLS (Basic Life Support) will expire 01/09/2017. In order to stay on the schedule you must renew your certification and forward a copy to Human Resources BEFORE February 1, 2017. Failure to do so will result in being removed from the KRONOS timekeeping system. ..."

C. Review of the policy and procedure titled "Licensure, Certification, Verification and Registration" received from the Chief Quality Director at 1345 on 02/22/17 revealed the following under POLICY: "It is the policy of Saline Memorial Hospital (SMH) to employ only those individuals who have proper licensure, certification or registration by the appropriate agency in those jobs requiring such status. Furthermore, SMH must obtain proof of licensure and/or registration of employees prior to employment. It is also the policy of SMH to obtain proof of renewals of licensures and/or registration of employees during their course of employement."

D. Review of the nursing schedules received from the Chief Quality Officer at 1045 on 02/22/17 revealed RN #13 worked 7a-7p (ante meridian and post meridian) on the 4th floor the following dates: 01/23/17, 01/28/17 (functioned as Charge Nurse), 01/29/17 (functioned as Charge Nurse), 02/04/17, 02/05/17, 02/11/17 (went home sick at 0800), 02/18/17, 02/19/17 and 02/20/17.

E. During an interview with the Chief Quality Officer at 1345 on 02/22/17 she verified the findings in A, B, C, and D.

Based on policy and procedure review, clinical record review and interview it was determined a Registered Nurse failed to supervise and evaluate the nursing care in that 5 (#3, #7, #8, #12 and #14) of 9 (#3, #4, #6 - #8, #10, #12-14) patients with orders for daily weights ordered by the physician did not have daily weights documented; a bath was not documented as rendered or performed for 9 (#3, #6-7, #9, #11-#15) of 15 (#1-#15) patients; three of three (#10, #13-#14) patients did not have dressing changes performed as ordered and three of three (#10, #13-#14) patients did not have the feeding tube tubing and bag changed daily as ordered. Failure to perform daily weights did not give physicians information necessary to make medical decisions; failure to give and document a bath did not afford the nursing staff the opportunity to assess the patients for changes in skin integrity, ensure the patients comfort and did not allow them to follow their policy and procedure; failure to perform dressing changes as ordered and was likely to allow for further skin deterioration; and failure to change the feeding tube tubing and bag daily did not allow nursing staff to follow physician's orders. The failed practices affected Patients #3, #4, #6 - #15. Findings follow:

A. Review of the policy and procedure titled "Bathing and Cleansing of Patients" received from the Chief Quality Officer at 1020 on 02/22/17 revealed the following under SPECIAL INSTRUCTIONS: 1. All patients will receive a bath and linen change each day, more often as needed, or as specified per unit-specific policy. 2. Baths will be documented on the graphic sheet or specified document per unit-specific policy. 3. In the event the patient of (or) family member refuses the daily bath and linen change it must be documented in the narrative nurse's notes (NNN). ... No Unit specific policies had been received by the end of the exit conference.

B. Review of Patient #3's clinical record revealed an admission date of 02/15/17. Review of physician's orders dated 02/15/17 revealed orders for daily weights. Review of the clinical record revealed daily weights not documented 5 of 7 (02/16/17, 0/2/17/17, 02/20/17 through 02/22/17) days and daily baths not documented 5 of 8 (02/17/17, 02/18/17, 02/20/17 through 02/22/17) days. The above was verified by the Quality Management Analyst at 1548 on 02/23/17.

C. Review of Patient #6's clinical record revealed an admission date of 02/20/17. Review of the clinical record revealed daily baths not documented 2 of 2 (02/21/17 and 02/22/17) days. The above was verified by the Quality Management Analyst at 1449 on 02/23/17.

D. Review of Patient #7's clinical record revealed an admission date of 02/16/17. Review of the physician's orders dated 02/16/17 revealed orders for daily weights. Review of the clinical record revealed daily weights not documented 2 of 7 (02/16/17 and 02/19/17) days and daily baths not documented 6 of 6 (02/17/17 through 02/22/17) days. The above was verified by the Quality Management Analyst at 1428 on 02/23/17.

E. Review of Patient #8's clinical record revealed an admission date of 02/20/17. Review of the physician's orders dated 02/20/17 revealed an order for daily weights. Review of the clinical record revealed no daily weights documented on 3 of 3 days (02/20/17 through 02/23/17). The above was verified by the Quality Management Analyst at 1708 on 02/23/17.

F. Review of Patient #9's clinical record revealed an admission date of 12/24/16 and a discharge date of 12/26/16. Review of the clinical record revealed daily baths were not documented 1 (12/26/16) of 2 days. The above was verified by the Quality Management Analyst at 1509 on 02/22/17.

G. Review of Patient #10's clinical record revealed an admission date of 12/20/16 and discharge date of 01/15/17. Review of the physician's orders dated 1/11/17 revealed an order for a daily dressing change to left heel using Xerofoam. Review of the clinical record revealed no documentation the dressing change was performed from the date ordered until 01/15/17. Review of the clinical record revealed an order from Physician #2 on 12/29/16 for PICC (Peripherally Inserted Central Catheter) dressing change to be performed every 7 days. Review of the clinical record revealed no PICC dressing change documented from 12/29/16 through 01/15/17. Review of the clinical record also revealed orders dated 12/25/16 for the feeding tube tubing and bag to be changed daily. Review of the clinical record revealed no documentation from 12/25/16 through 01/15/17 the feeding tube tubing and bag were changed. The above findings were verified by the Quality Management Analyst at 1303 on 02/23/17.

H. Review of Patient #11's clinical record revealed an admission date of 12/08/16 and discharge date of 01/09/17. Review of the clinical record revealed daily baths were not documented for 28 (12/09/16 through 12/28/16, 12/30/16 through 01/01/17 and 01/03/17 through 01/09/17) of 30 days (12/08/16 through 01/09/17). The above findings were verified by the Quality Management Analyst at 1226 on 02/23/17.

I. Review of Patient #12's clinical record revealed an admission date of 12/07/16 and discharge date of 12/09/16. Review of the physician's orders dated 12/07/16 revealed an order for daily weights. Review of the clinical record revealed no daily weight recorded on 12/09/16. Review of the clinical record revealed no baths documented 2 of 2 (12/08/16 and 12/09/16) days. The above findings were verified by the Quality Management Analyst at 1157 on 02/23/17.

J. Review of Patient #13's clinical record revealed an admission date of 12/16/16 and a discharge date of 12/20/16. Review of the physician's orders dated 12/17/16 revealed an order for the feeding tube tubing and bag to be changed daily. Review of the clinical record revealed no documentation from 12/17/16 through 12/20/16 the feeding tube tubing and bag were changed. Review of the clinical record revealed no documentation of a bath given 1 of 4 (12/20/16) days. The above findings were verified by the Quality Management Analyst at 1055 on 02/23/17.

K. Review of Patient #14's clinical record revealed an admission date of 02/01/17 and a discharge date of 02/10/17. Review of the physician's orders dated 02/01/17 by Physician #7 revealed an order for daily weights and orders dated 02/08/17 for the feeding tube tubing and bag to be changed daily. Review of the clinical record revealed daily weights were not documented 8 of 10 (02/04/17 through 02/06/17 and none documented after 02/07/17) days and there was no documentation the feeding tube tubing and bag were changed daily. Review of the clinical record revealed daily baths were not documented 5 of 9 (02/03/17 - 02/06/17 and 02/09/17) days. The above was verified by the Quality Management Analyst at 1000 on 02/23/17.

L. Review of Patient #15's clinical record revealed an admission date of 12/03/16 and a discharge date of 12/12/16. Review of the clinical record revealed baths were not documented 8 of 9 (12/04/16 through 12/05/16 and 12/07/16 through 12/12/16) days. The above findings were verified by the Quality Management Analyst at 0835 on 12/23/17.