HospitalInspections.org

Based on a review of the medical records of 17 patients, review of hospital policies and procedures, interviews with administrative staff, review of staff credentials, tours of six patient care units, and review of related documentation, it was determined that the hospital failed to protect and promote the rights of each patient:

Findings include:

1. The facility failed to ensure that patients had the right to receive care in a safe setting (Refer to Tag A 144).

2. The facility failed to ensure that the use of restraints was in accordance with a written modification to the patient's plan of care within a timeframe specified by hospital policy (Cross refer to Tag A 166).

3. The facility failed to ensure that the use of restraints was in accordance with the order of a physician or other licensed independent practitioner authorized to order restraint by hospital policy (Refer to Tag A 168).

4. The facility failed to ensure that each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient was renewed as authorized by hospital policy (Refer to Tag A 173).

5. The facility failed to ensure that restraints were discontinued at the earliest possible time (Refer to Tag A 174).

6. The facility failed to ensure that patients' condition was monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy (Refer to Tag A 175).

7. The facility failed to ensure that patients restrained for violent or self-destructive behavior were seen face-to-face by a physician within one (1) hour of the initiation of restraint (Refer to Tag A 178).

8. The facility failed to ensure that all restrained patients receive a comprehensive face-to-face evaluation within one (1) hour of the application of restraints (Refer to Tag A 179).

A. Based on tours of two patient care units, review of facility policy and procedure, and interview with administrative staff, it was determined that the facility failed to ensure that patients are provided care in a safe setting.

Findings include:

Reference: Policy and Procedure titled, "Emergency Code Carts & Emergency Drug Trays/Boxes (JSUMC Only)" states:
"Purpose:
1. To ensure security of the contents of Emergency Code Cart.
2. To ensure availability of all contents of Emergency Code Cart.
3. to [sic] ensure that all emergency code equipment is 100% operational and code cart supplies are available and ready for use.
Scope:
Jersey Shore University Medical Center
.....
Maintenance of Emergency Equipment
.....
2. The Code Cart, Emergency Drug Tray/Box, and Lifepak (LP) 20 monitor as well as supplies and equipment with the code cart will be checked on a daily basis by a nurse or team member who has been instructed in the process.
....."

1. A tour of the Pediatric Emergency Department on the morning of February 20, 2020 conducted in the presence of Administrator #1 revealed:

a. Review of the CODE CART CHECKLISTs for the month of February 2020 indicated that on February 12, 2020, the staff member assigned to check the Adult Code Cart in the Pediatric ED only documented checking "Resus Binder Present" and "Cardiac Electrodes Present." None of the other 11 required checks were documented as having been done.

b. Review of the CODE CART CHECKLISTs for the month of February 2020 indicated that on February 12, 2020 there was no documentation that anyone checked the cart.

c. Nutrition Area:

(i) There was a brown colored spill and crumbs atop the refrigerator.

(ii) There was heavy dust, grit, and crumbs behind and beneath the refrigerator. There were dust clumps on the refrigerator power cord.

(iii) There door gasket on the refrigerator door was ripped and torn away at the corner. There was a heavy accumulation of dust, grit, and food particles in the tears and folds of the gasket.

(iv) There was dust and grit on the bottom of the interior and on the shelves of the refrigerator.

(v) There were sticky stains atop the bottom bin in the refrigerator.

(vi) A drawer to the left of the sink had granulated sugar, crumbs, and food particles on the bottom and in the corners. There were also raised stains on the interior of the drawer.

(vii) A drawer containing plastic eating utensils had granulated sugar, paper scraps, and crumbs in the corners of the drawer.

(viii) The four bottom drawers had grit, granulated sugar, and crumbs in the corners.

d. Nurses Station:

(i) An unlocked metal cabinet on wheels contained:

* Three (3) 25mm 15 ga (gauge) io Needle Sets. The expiration dates were "5/2015, 7/2016, and 2/2017."

* One (1) 15mm 15 ga io Needle Set with an expiration date of "5/2017."

* Three (3) 45mm 15 ga io Needle Set with an expiration date of "2/2017."

(ii) A wooden cabinet had heavy dust, grit, paper scraps, a sock, and plastic eating utensils beneath and behind it. The top drawer of the cabinet contained a 15mL (milliliter) bottle of Hemocrit Developer with an expiration date of "2018-09." The bottom section of the cabinet contained a plastic container with bread crust and a used individual butter container with residue in it.

e. Alcove Area next to Room #7: The unlocked top drawer of a cabinet contained two (2) Ondansetron injection 4mg (milligram)/2ml (milliliter) vials and a plastic bag containing one (1) Albuterol Sulfate Inhalation Solution 3mL ampule and one Ipratroprium Bromide 0.5mg + Albuterol Sulfate 3mg nebulizer ampule pack.

2. A tour of the Prompt Care ED (Emergency Department) on the morning of February 20, 2020 conducted in the presence of Administrator #1 revealed:

a. Nurses Station:

(i) The counter behind a computer monitor had heavy dust and dust clumps on it.

(ii) There was dust, coins, shelled nuts, grit, dust, and raised tacky stains beneath a metal cabinet on wheels.

(iii) There was dust, grit, and a scarf under another metal cabinet on wheels. The bottom drawer of the cabinet contained two (2) Penrose Drain Packs with expiration dates of "2016-04" and "2016-07."

b. Medication Alcove Area:

(i) There were raised tacky stains inside a drawer under the counter with the coffee machine atop it. There were spillage stains on the drawer tracks.

(ii) A drawer contained a small plastic bin with a sticky red substance on it. There were white crystals and grit in the corner of the drawer.

(iii) The refrigerator beneath the counter had heavy dust atop it, on the condenser coils, and on the power cord. There were clumps of dust, rust, grit, food particles, candy wrappers, and raised tacky stains beneath and behind the refrigerator.

(iv) The "Salt + Pepper" drawer under the counter had raised tacky stains inside of it.

(v) The wall above the backsplash behind the sink had peeling paint and holes in it exposing crumbling sheetrock.

(vi) Room NP1010: There were two large rips in the cover fabric of the stretcher exposing the foam mattress.

3. A tour of the Main Emergency Department on the morning of February 20, 2020 conducted in the presence of Administrator #1 revealed:

a. Hallway near Ambulance Entrance:

(i) One stretcher had two rips in the cover fabric exposing the foam mattress.

(ii) One stretcher had a tear in the cover fabric exposing the foam mattress.

(iii) Two stretchers had small holes in the cover fabric exposing the foam mattresses.

(iv) A stretcher had a specimen cup with a urine-like liquid in it. The cup was in an unsealed transport bag laying on the undercarriage of the stretcher.

(v) An unsupervised WOW (Workstation on Wheels) had one BD Safety Glide Needle atop it.

b. Adult Nutrition Area:

(i) Drawers contained a heavy accumulation of white crystals in the corners, paper scraps, and crumbs.

(ii) The refrigerator had broken, cracked, and separated sections of the door gasket exposing the foam insulation. Within the folds and cracks of the gasket was grit, dust, and food particles. There were various types of stains on the exterior and interior of the refrigerator. The interior of the door had a broken sections of plastic exposing the foam insulation. There were broken floor tiles beneath the refrigerator. The floor beneath the refrigerator had heavy stains, dust, and grit on it.

4. A tour of the Emergency Department Crisis Unit on the morning of February 20, 2020 conducted in the presence of Administrator #1 revealed that the refrigerator in the Nurses Station had dust atop it. There was heavy dust clumps of dust, grit, and other refuse beneath and behind the refrigerator. There was spillage inside of the refrigerator.

5. A tour of the behavioral health unit, Rosa 2, on the morning of February 20, 2020 conducted in the presence of Administrator #1 revealed:

a. Room behind the Nurses Station: The metal vents atop the HVAC (heating, ventilation, air-conditioning) unit beneath the window had dust, grit, rust, and other refuse on them. When the vents were removed, there were shelled peanuts, dust, a dime, a ballpoint pen, grit, staples, crumbs, paper scraps, crumpled foil, and other refuse in the interior of the unit.

b. Shower Room: There was a broken floor tile and missing grout on the floor.

c. Activities Room:

(i) There were dried raised stains, a dead insect, dust, and grit beneath a metal cabinet.

(ii) Storage Closet: The wall had a gash in it and there was white powder, heavy dust, raised stains, grit, and other refuse on the floor.

B. Based on review of facility policy and procedure, medical record review of one of one patient (#8), and interview with administrative staff, it was determined that the facility failed to ensure that patients are provided care in a safe setting by notifying physicians with changes in patient status.

Findings include:

Reference: Policy and procedure titled, "Professional Chain of Command and Escalation" states: "..... Policy: RN's [sic] will follow a clearly defined and communicated method to escalate patient care concerns in order to facilitate patient safety and medical management.
Procedure:
1. RN's [sic] have the responsibility to exercise the professional chain of command and to retain responsibility to continue to escalate the issue until it is resolved in a satisfactory manner.
2. Changes in patient conditions are determined by assessment parameters defined in standards of care, policies and procedures, physician orders and previous patient measures. The RN will use critical thinking skills to assess the priority of the various assessment measures based on patient condition and patient safety.
3. If clinical assessment indicates physician notification is needed, the RN will notify the Physician in charge of the patient's care issues (such as cardiologist for cardiac issues, attending when no relevant consults are involved) using the SBAR (Situation-Background-Assessment-Recommendation) technique to communicate the information as per Hand Off Communication policy [sic]
.....
7. The RN is responsible for documenting the description of the actions and resolution of the patient care concern. Physicians are responsible for documenting their findings and to communicate to the other physicians responsible for the care of the patient.
....."

1. Upon review of the "Central Station" rhythm strips for Patient #8, the following was revealed:

a. "1/9/20 at 4:30 AM: heartrate (HR) sixty two (62) pace"

b. "1/9/20 at 5:00 AM: HR forty nine (49) pace, BRADY, PVC [premature ventricular contractions], BIGEMINY"

c. "1/9/20 at 5:05 AM: HR forty nine (49) pace, BRADY"

d. "1/9/20 at 5:45 AM: HR forty two (42) pace, BRADY"

e. "1/9/20 at 6:05 AM: HR forty eight (48) pace, ATRIAL FIB [atrial fibrillation], BRADY"

f. "1/9/20 at 6:15 AM: HR forty (40) pace, BRADY"

g. "1/9/20 at 6:25 AM: HR thirty two (32) pace, BRADY"

h. "1/9/20 at 6:25 AM: HR (unable to read value) pace, BRADY"

i. "1/9/20 at 6:26 and thirty three seconds (33) AM: HR (unable to read value) pace, BRADY"

j. "1/9/20 at 6:26 and fifty six seconds (56) AM: HR (unable to read value) pace, BRADY, ASYSTOLE"

2. Upon interview on 2/27/20 at 3:09 PM, Staff #4 confirmed there was "an absence of communication" between the registered nurse (RN) and the physician regarding the rhythm changes.

Based on review of the medical records of 2 of 2 patients who were physically restrained (#8 and #9) and interview with administrative staff, it was determined that the use of restraint was not in accordance with a written modification of the patient's plan of care.

Findings include:

1. Review of the medical record of Patient #8 indicated that he/she was in 4-point synthetic leather restraints between 10:30 AM on 2/8/20 until some time shortly after 6:30 AM on 2/9/20. There was no evidence in the medical record of a written modification to the patient's plan of care regarding the use of restraints. Administrator #2 agreed with the findings.

2. Review of the medical record of Patient #9 indicated that he/she was in synthetic leather restraints between 10:50 AM on 1/7/20 until 11:00 AM on 1/8/20. There was no evidence in the medical record of a written modification to the patient's plan of care regarding the use of restraints. Administrator #2 agreed with the findings.

Based on a review of the medical records of 3 of 3 patients who were physically restrained (Patients #8, #9, #17), review of policy and procedure, interview with administrative staff, and review of the security log, it was determined that the use of restraints was not in accordance with the order of a physician or other licensed practitioner who was responsible for the care of the patient.

Findings include:

Reference: Policy and procedure titled, "Restraints" states: "..... Key Points: .....
An order must be obtained immediately (within a few minutes) from the LIP (Licensed Independent Practitioner) for emergency application of restraints/seclusion. .....
Orders for restraints/seclusion
In an emergency, following a clinical assessment and when alternatives have been tried and determined to be ineffective, the RN may initiate restraints/seclusion. An emergency restraint procedure, beginning with the least restrictive alternative that is clinically feasible, hall be initiated by a registered professional nurse only when the safety of the patient or others is endangered or there is imminent risk that the patient will cause substantial property damage. The attending physician, another designated physician, a licensed physician assistant, or a nurse practitioner/clinical nurse specialist shall be notified immediately, and an order for restraints will be obtained immediately. ....."

1. Review of the medical record of Patient #8 revealed:

a. Nursing Progress Notes dated 1/8/2020:
".....
1030 - Patient on elevator trying to leave not cooperating with staff. Security called. Took 6 people to get patient off elevator. ANM [Assistant Nurse Manager], RN, and 2 security guards trying to deescalate the situation, patient uncooperative. Placed in 4 point restraints.
1100 - Dr. ______ (Staff #8) on floor, psych (psychiatry) saw patient for face to face. Dr. ______ (Staff #8) stated he/she will speak to psych regarding order for restraints.
1230 - Call placed to Dr. ______ (Staff #8) re; orders for restraints
1330 - Call placed to Dr. ______ (Staff #8) - still no order or clarification for restraints.
1415 - Call placed to psych re; restraints
....."

b. A "Restraints Non-Violent (To Prevent Disruption of Treatment) (Order 293551520)" order dated 1/8/20 at 14:49 directed that the patient be physically retrained in 4 point synthetic leather restraints for up to 24 hours. The start time for the order was entered as 10:30.

(i) There was no evidence of a physician order for physical restraints for the first 4 hours and 19 minutes that the patient was in 4 point restraints.

2. Review of the medical record of Patient #9 revealed:

a. A "Restraints Violent (For threat of violence; self-destructive behavior); Adult (18 years & older) (Order 294035298)" order dated 1/7/20 at 22:55 directed that the patient be physically restrained in "Locked Leather (Right Arm)" and "Locked Leather (Left Leg)" for up to 4 hours. The order included the statement: "EMERGENCY - Patient Exhibits Violent Self Destructive Behavior Yes."

b. A "Restraints Violent (For threat of violence; self-destructive behavior); Adult (18 years & older) (Order 294120306)" order dated 1/8/20 at 04:36 directed that the patient be physically restrained in "Leather - All Limbs" for up to 4 hours. The order included the statement: "EMERGENCY - Patient Exhibits Violent Self Destructive Behavior Yes."

c. A "Restraints Violent (For threat of violence; self-destructive behavior); Adult (18 years & older) (Order 294120318)" order dated 1/8/20 at 08:57 directed that the patient be physically restrained in "Locked Leather (Right Arm)" and "Locked Leather (Left Leg)" for up to 4 hours. The order included the statement: "EMERGENCY - Patient Exhibits Violent Self Destructive Behavior Yes."

d. The "Violent Restraints" flowsheet indicated that the patient was in physical restraints continuously between 2250 on 1/7/20 and 1100 on 1/8/20.

(i) There was no restraint order to cover the time between the expiration of the first order (02:50 on 1/8/20) and the start of the second order (04:36 on 1/8/20) - a total of 1 hour and 46 minutes.

(ii) There was no restraint order to cover the time between the expiration of the second order (08:36 on 1/8/20) and the start of the second order (08:57 on 1/8/20) - a total 21 minutes.

4. Review of the medical record of Patient #17 revealed:

a. An "ED Notes Addendum" entry dated 16:35 on 2/8/20 stated: "Security at bedside - Patient placed into 2 point leather restraints - left arm and right leg., [sic] by secruity [sic]. Arm brace noted to right arm - no restrained [sic] placed to right arm at this time. Patient continuing to yell and verbally abusive and threaten [sic] staff, unable to verbally de-escalate patient. Restraints properly applied and checked by this RN, skin intact. Will continue to monitor closely [sic]"

b. A "Restraints Non-Violent (To Prevent Disruption of Treatment) (Order 287111830)" order dated 2/8/20 at 16:47 directed that the patient be physically retrained in 4 point synthetic leather restraints for up to 24 hours. The start time for the order was entered as 16:46.

c. Documented nursing note entries state: ".....
16:36:16 PATIENT IN HALLWAY, SCREAMING/CURSING/THREATENING STAFF, SECURITY CALLED AND PLACED IN RESTRAINTS PER DR (Doctor) ______ (Staff #26) ORDERS
16:45 Violent Restraints ..... Patient Behavior: Agitation
16:48:26 ED Notes MD at bedside
16:52:30 Orders Acknowledged New - Restraints Non-Violent (To Prevent Disruption of Treatment)
17:00 Violent Restraints ..... Patient Behavior: Agitation
17:10:43 BREATHALYZER 0.145
17:15 Violent Restraints ..... Patient Behavior: Aggressive
17:20:43 ED Notes ..... Patient still yelling and aggressive with staff.
17:30 Violent Restraints ..... Patient Behavior: Agitation
17:45 Violent Restraints ..... Patient Behavior: Agitation
18:00 Violent Restraints ..... Patient Behavior: Agitation
18:15 Violent Restraints ..... Patient Behavior: Agitation
18:30 Violent Restraints ..... Patient Behavior: Aggressive
18:45 Violent Restraints ..... Patient Behavior: Aggressive"

(i) Although the patient's behavior was documented by nursing staff as "violent," the physician order was for "non-violent" behavior and time limited to 24 hour hours, not 4 hours. The nurse did not clarify the order.

(ii) There was no documentation in the medical record indicating that the patient was placed in two additional limb restraints when the order for 4-point restraints was entered.

Based upon observation, medical record review of 1 of 6 non-violent or non-self destructive restrained patients (Patient #5), facility document review, and staff interviews, it was determined that the facility failed to adhere to the renewal of restraints per facility policy.

Findings include:

Reference: Facility policy "Restraints" states: "..... Procedure: ..... Types of Restraints
Commonly used types of restraints include .....
.....
* Mitts
.....
* Soft Limb
.....
* Enclosed/Net Bed
.....
Orders for restraints/seclusion
.....
* The maximum time frame of the order for Non-Violent Behavior is 24 hours.
....."

1. Upon a tour of Booker 3, a Medical Surgical Unit, on 2/20/20, in the presence of Staff #2 and Staff #5, Patient #5 was observed in an enclosed net bed.

a. Staff #30 confirmed the patient was in a "posey bed," which is a type of restraint used for safety.

b. The initial "Restraints Non-Violent ..... (Order 303175897)" dated 2/12/20 at 12:43 AM states, " ..... Attempting to disrupt treatment, Prevent Unintentional Harm to Self" "Restraint Type Net Bed."

c. There was no documented evidence of restraint orders for the continued use of the net bed on the following dates: 2/13/20, 2/15/20, 2/16/20, and 2/18/20. This was confirmed by Staff #30.

d. The above findings were confirmed by Staff #4.

Based on review of facility policy and procedure and the medical record of 1 of 3 patients who were physically restrained (Patient #8), it was determined that the patient did not have restraints discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

Reference: Policy and procedure titled, "Restraints" states: "..... Key Points: .....
* Restraints/seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order
.....
Orders for restraints/seclusion
.....
Order for restraints will include the following:
* Indication for use
* Non-Violent (To prevent disruption of treatment)
* Violent (For threat of violence; self-destructive behavior)
.....
* Criteria for removal
* When agitation is decreased
.....
Removal of Restraints
* Restraints must be discontinued at the earliest possible time regardless of the length of time identified in the order.
....."

1. Review of the medical record of Patient #8 revealed:

a. Nursing Progress Notes dated 1/8/2020:
"0700 - Received [sic] Patient very agitated, standing at nursing station. Patient demanding to leave. Security with patient along with 1:1 [one-to-one observation]. Patient not cooperating with staff.
0915 - Patient at nurse station with 1:1, patient severely agitated, falling asleep standing up, refusing to listen to staff. Security called again. Call placed to Dr. ___________ (Staff #8).
1030 - Patient on elevator trying to leave not cooperating with staff. Security called. Took 6 people to get patient off elevator. ANM [Assistant Nurse Manager], RN, and 2 security guards trying to deescalate the situation, patient uncooperative. Placed in 4 point restraints.
.....
1550 - Patient extremely agitated in restraints shaking bed."

b. A PSYCHIATRY PROGRESS NOTE dated 1/8/20 at 10:19 AM: ".....
Subjective:
Chart reviewed. Patient was noted to be agitated and demanding to leave earlier in the morning. Not able to appreciate his/her current medical situation - security was called and placed [sic] was placed in four point restraint because of agitation. 1:1 at bedside.
....."

c. A "Restraints Non-Violent (To Prevent Disruption of Treatment) (Order 293551520)" order dated 1/8/20 at 14:49 directed that the patient be physically retrained in 4 point synthetic leather restraints for up to 24 hours. The start time for the order was entered as 10:30 and it was time limited to 24 hours. The order included the statement: "EMERGENCY - Pulling ET (endotracheal tube) and/or IV (Intravenous) With Life Sustaining Medication Yes."

d. Review of PATIENT OBSERVATION SHEETs indicated that the patient was "Sleeping" between 7:00 PM and 11:00 PM on 1/8/20; "Restless" at 11:15 PM and 11:30 PM on 1/8/20, and "Sleeping" between 11:45 PM on 1/8/20 and 6:30 AM on 1/9/20.

(i) Although the patient was documented to have been asleep for 4 hours between 7:00 PM and 11:00 PM on 1/8/20 and 6 hours and 45 minutes between 11:45 PM on 1/8/20 and 6:30 AM on 1/9/20, the restraints were not discontinued.

A. Based on a review of the medical records of 1 of 3 patients who were physically restrained (Patient #1), it was determined that the facility failed to ensure that the patients' condition is monitored by a physician, other licensed practitioner or trained staff at an interval determined by facility policy.

Findings include:

Reference #1: Policy and procedure titled, "Restraints" states: "..... Key Points: ..... Procedure: .....
Orders for restraints will include the following:
* Indication for use
* Non-Violent (To prevent disruption of treatment)
* Violent (For threat of violence; self-destructive behavior)
.....
* The maximum time frame of the order for Non-Violent Behavior is 24 hours
* The maximum time frame of the order for Violent behavior of seclusion is
Four (4) hours for patients 18 and over
.....
Documentation:
.....
* The clinical condition of the patient shall be evaluated and documented by medical or licensed nursing personnel.
Interventions:
Interventions while a patient is restrained shall be performed by nursing personnel in accordance with nursing policy. The patient will be assessed for assessment/response to intervention and criteria for discontinuation of restraints [sic] Each assessment and nursing intervention should be made as follows:
Every Two (2) hours:
* Mental status
* Cognitive function
* Current behaviors indicating need for restraints
* Circulation and skin assessment
* Vital Signs
* Clinical status with re-evaluation for the continuing need for restraints
* Release of Restraints to:
° Assess skin circulation and integrity
Perform skin care
Perform range of motion at a minimum of 5 minutes/limb
* Patient comfort inclusive of:
° Fluids and Nutrition offered
Repositioning
Toileting
Every Four (4) hours:
* Ambulation if clinically feasible
.....
Visual Observation:
* For Restraints for Non-Violent Behavior (Behavior Causing Disruption of Treatment), visual observation will be continuous or periodic, based on nursing assessment, and will be documented at a minimum of every two hours.
* For Restraints for Violent Behavior of Seclusion, the patient must be monitored by an assigned team member continuously via 1:1 sitter and will be documented every 15 minutes.
Removal of Restraints
* Restraint must be discontinued at the earliest possible time regardless of the length of time identified in the order.
....."

Reference #2: Policy and procedure titled, "Safety Precautions and Observation Guidelines" states: ..... Purpose:
To provide a safe environment for patients, team members, medical staff, and visitors by addressing the care of the patient who is a current risk of harm to self or others, including risk for suicide, homicide, violence, and any safety concern.
Scope:
This policy applies to all patient care departments of the Meridian Hospitals Corporation with the exception of the inpatient behavioral health units.
Policy:
All patients will be assessed for current risk of harm to self or others, including risk for suicide, homicide, violence and fall with injury. If indicated, appropriate safety precautions will be implemented. All patients determined to be at risk will be assigned one of the following observation levels based on the severity of the risks assessed:
* One to One Observation (For patients at risk for self-harm & harm to others)
.....
Procedure:
.....
C. PATIENT OBSERVATION FOR ANY SAFETY CONCERN such as FALL RISK, ELOPEMENT, WANDERING, or WITHDRAWAL
Patient observation for safety may be initiated by an RN if patient behavior indicates risk for any safety concern such as a fall, elopement, or wandering. If patient observation is needed, the RN will notify the physician, nurse manager or nursing supervisor, and the central staffing office.
Patient Observation for any Safety Concern such as Fall Risk, Elopement, Wandering, or Withdrawal includes the following levels of observation.
* One to One Observation (to be considered for those patients that require an observer to be within 2 arms' length at all times)
.....
D. Observation Levels
1. 1:1 Observation
Indication: Patients at risk for violence, harm to self or others, or a safety concern. 1:1 observation for patients with any safety concern such as fall with injury may be considered if the patient requires an observer to be within 2 arms' length at all times to maintain patient safety.
......
* The order for 1:1 Observation must be reassessed whenever clinically indicated and renewed every 24 hours by the physician/LIP.
.....
* Documentation of patient's behaviors will be recorded every 15 minutes by the team member assigned as the patient observer on the Patient Observation Sheet. The RN will round without predictability at random intervals.
....."

1. Review of the medical record of Patient #1 revealed:

a. A "Restraints Non-Violent (To Prevent Disruption of Treatment) (Order 293551520)" order dated 1/8/20 at 14:49 directed that the patient be physically retrained in 4 point synthetic leather restraints for up to 24 hours. The start time for the order was entered as 10:30 and it was time limited to 24 hours.

b. A "1:1 PATIENT MONITORING (Order 293551522)" order dated 1/8/20 at 14:49. The Order Details section of the order stated, "Frequency UNTIL DISCONTINUED." The reason/reasons for the 1:1 order was not included in the order.

(i) PATIENT OBSERVATION SHEETs dated 1/8/20 and 1/9/20 indicated that 15 minute entries did not begin until 17:00 on 1/8/20 - 2 hours and 11 minutes after the patient was placed in physical restraints.

c. "Disruption of Treatment Restraints Episode Information" entries were documented to have been done by nursing staff at 1030, 1300, 1800, 1900, 2100, and 2300 on 1/8/20 and 0100, 0300, and 0500 on 1/9/20.

(i) There was no documentation indicating that the clinical condition of the patient was evaluated by medical or licensed nursing personnel between 10:30 AM and 1:00 PM (2.5 hours) or between 1:00 PM and 6:00 PM (5 hours) on 1/9/20.


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B. Based on observation, medical record review of 2 of 3 patients on one-to-one observation, (Patients #5 and #6), review of facility documents and staff interviews, it was determined that the facility failed to adhere to their one-to-one (1:1) policy.

Findings include:

Reference: Facility policy "Safety Precautions and Observation Guidelines" states, " ..... Procedure:
... D. Observation Levels
1. 1:1 Observation Indication: .....
The order for 1:1 Observation must be reassessed whenever clinically indicated and renewed every 24 hours by the physician/LIP.
...
Documentation of patient's behaviors will be recorded every 15 minutes by the team member assigned as the patient observer on the Patient Observation Sheet.
..."

1. A tour of Booker 3, a Medical Surgical Unit on 2/20/20, revealed that restrained Patient #5 was with a 1:1 patient observer in his/her room.

a. The 1:1 order for Patient #5, dated 2/17/20 at 11:57 PM stated, "One to One Monitoring of the Patient (Order 303175922) ... Risk for Fall with injury ..."

b. There were no entries on the "Patient Observation Sheet" on 2/18/20 at 6:30 AM or 6:45 AM.

c. The above findings were confirmed by Staff #4.

Based on a a review of policy and procedure, review of the medical record of 3 of 3 patients who was physically restrained for the management of violent or self-destructive behavior (Patient #3, #7 and #17), and interview with administrative staff, it was determined that the facility failed to ensure that the patient is seen face-to-face by within 1-hour after the initiation of the intervention by a physician, other licensed practitioner, or registered nurse who has been trained.

Findings include:

Reference: Policy and procedure titled,"Restraints" states: "..... PROCEDURE: .....Evaluation by the LIP (Licensed Independent Practitioner)
Within one hour of giving the initial order, an LIP shall respond, conduct and document a face-to-face evaluation of the patient.
The patient must be evaluated regardless of whether the restraints remain in place when the attending physician designee arrives on the unit.
....."

1. Review of the medical record of Patient #3 indicated that the patient was placed in a right and left mitts restraints at 16:20 (4:20 PM) on 2/19/20 and remained in such until time of tour on 2/20/20 at 9:58 AM. There was no documentation of a physician face-to-face evaluation by an LIP related to this restraint episode.

2. The above findings were confirmed with Staff #4.

3. Review of the medical record of Patient #7 indicated that the patient was placed in right and left mitts restraints and right and left soft limb restraints at 12:44 on 2/19/20 and remained in such until time of tour on 2/20/20 at 10:20 AM. There was no documentation of a physician face-to-face evaluation by an LIP related to this restraint episode.

4. The above findings were confirmed with Staff #4.

5. Review of the medical record of Patient #17 indicated that the patient was placed in 4-point synthetic restraints at 16:47 (4:47 PM) on 2/8/20 and remained in such until at least 18:45 (6:45 PM) on 2/8/20. There was no documentation of a physician face-to-face evaluation by an LIP related to this restraint episode.

6. Administrator #17 agreed with the findings at 1:51 PM on 2/21/20.

Based upon observation, review of 3 of 6 medical records of restrained patients (#3, #7 and #16), review of facility documents, and staff interviews, it was determined that the facility failed to ensure all restrained patients receive a face to face evaluation within one (1) hour after the application of restraints to identify the patients immediate situation, the patients reaction to the intervention, the patients medical and behavioral condition and the need to continue or terminate the restraint.

Findings include:

Reference: Facility policy "Restraints" states, "..... Key Points: ...Within one hour of receiving the initial order, a face to face evaluation of the patient shall be conducted. ... Procedure: ... Evaluation by the LIP [licensed Independent Practitioner] Within one hour of giving the initial order, and LIP shall respond, conduct and document a face-to-face evaluation of the patient. ... Documentation: Upon initiation restraints, a comprehensive individual patient assessment will be performed inclusive of the behavior necessitating the restraint use. ..."

1. Upon a tour of the Neurosurgical Intensive Care Unit (NSICU) on 2/20/20 with Staff #2 and Staff #5, Patient #3 was observed with a right and left hand mitt restraint in place.

a. An initial order dated 2/19/20 at 8:20 PM states, "Restraints Non-Violent ... (Order 305041103) ... Pulling tubes/drains ... Mitts (left) Mitts (right) ..."

b. There was no evidence that the comprehensive, face to face evaluation was completed by the LIP, within one hour of the application of restraints on 2/19/20.

2. Upon a tour of the Surgical Intensive Care Unit on 2/20/20 with Staff #2 and Staff #5, Patient #7 was observed with a right and left hand mitt restraint, and a right and left soft limb restraint in place.

a. An initial order dated 2/19/20 at 12:44 AM states, "Restraints Non-Violent ... (Order 304973353) ... Pulling tubes/drains ... Mitts (left)- Mitts (right)- Soft Limb-Wrist (right)- Soft Limb-Wrist (left) ..."

b. There was no evidence that the comprehensive, face to face evaluation was completed by the LIP, within one hour of the application of restraints on 2/19/20.

3. Upon review of Medical Record #16 on 2/21/20, the following was revealed:

a. Initial orders for Patient #16 on 1/15/20 at 3:34 AM states, "Restraints Non-Violent ... (Order 296227041) ... Disoriented ... Prevent Unintentional Harm to Self ... Soft Limb Right- Soft Limb Left ..."

b. There was no evidence that the comprehensive, face to face evaluation was completed by the LIP, within one hour of the application of restraints on 1/15/20.

4. The above findings were confirmed with Staff #4.