HospitalInspections.org

Based on record reviews and interviews, the Governing Body failed to ensure hospital policies were implemented in relation to training for three (3) of eight (8) Licensed Independent Providers ("LIP") who ordered restraints (LIP #1, #2 and #3). In addition, the hospital failed to ensure ensuring documentation was completed in a medical record for one (1) of ten (10) patients (Patient #2).

Findings:

1. The hospital's policy titled, "Restraint Program", last revised 7/2021, indicates, in part, the following: "Training of all staff to occur at New Employee Orientation, with a yearly review in the fall".

This policy was not implemented as evidenced by the following:

On 1/11/2022 at 11:45 AM, surveyors reviewed training documents with the Senior Director Quality & Safety. This revealed that LIP #1, #2 and #3 had no documented evidence of receiving the required annual restraint training.

On 1/11/2022 at 1:28 PM, the Senior Director Quality & Safety confirmed this finding.

2. The hospital's policy titled, "Pain and Sedation; Assessment, Treatment and Reassessment", last revised 9/2020, indicates, in part, the following: ..."Document pain scale every four hours, before and after pain medication or more often as needed...Document all assessments and interventions in the medical record".

This policy was not implemented as evidenced by the following:

Surveyors reviewed Patient #2's medical record with the Chief Medical Officer. The documentation in the record stated the following:
- On 11/26/2021 at 2:50 AM, the patient complained of pain;
- At 3:02 AM, Registered Nurse ("RN") #1 gave the patient Dilaudid, an opioid pain medication; and
- At 3:09 AM and 3:48 AM, RN #1 then gave the patient Narcan, a medication used to reverse the effects of opioid.

There was no evidence in the medical record that a pain scale was documented before and after the Dilaudid was administered. In addition, there was no evidence of an assessment that would indicate the need to administer the Narcan.

On 1/11/2022 at 11:08 AM, the Chief Medical Officer confirmed there was no documentation as to the reason why the Narcan was administered.

On 1/12/2022 at 6:52 PM, RN #1 was interviewed via phone. The RN stated that Patient #2 had been having belly pain, she administered the Dilaudid to him/her, and the patient became very somnolent and they had a concern for the airway, so the Narcan was administered twice. She verified that there was no documentation in relation to the patient's response to the Dilaudid in the patient's medical record.

Based on document reviews and interviews, the hospital failed to maintain a record that includes, in part, the assessment of the health status and health care needs of the patient, and a brief summary of the episode for one (1) of ten (10) patient records reviewed (Patient #2).

Finding:

The hospital's policy titled, "Pain and Sedation; Assessment, Treatment and Reassessment", last revised 9/2020, indicates, in part, the following: ..."Document pain scale every four hours, before and after pain medication or more often as needed...Document all assessments and interventions in the medical record".

This policy was not implemented as evidenced by the following:

Surveyors reviewed Patient #2's medical record with the Chief Medical Officer. The documentation in the record stated the following:
- On 11/26/2021 at 2:50 AM, the patient complained of pain;
- At 3:02 AM, Registered Nurse ("RN") #1 gave the patient Dilaudid, an opioid pain medication; and
- At 3:09 AM and 3:48 AM, RN #1 then gave the patient Narcan, a medication used to reverse the effects of opioid.

There was no evidence in the medical record that a pain scale was documented before and after the Dilaudid was administered. In addition, there was no evidence of an assessment that would indicate the need to administer the Narcan.

On 1/11/2022 at 11:08 AM, the Chief Medical Officer confirmed there was no documentation as to the reason why the Narcan was administered.

On 1/12/2022 at 6:52 PM, RN #1 was interviewed via phone. The RN stated that Patient #2 had been having belly pain, she administered the Dilaudid to him/her, and the patient became very somnolent and they had a concern for the airway, so the Narcan was administered twice. She verified that there was no documentation in relation to the patient's response to the Dilaudid in the patient's medical record.