HospitalInspections.org

Based on policy review, clinical record review, and interview, it was determined the facility failed to ensure restraint monitoring was conducted every two hours per policy for one of one (#10) restrained patients. The failed practice did not ensure the patient's needs were assessed periodically, and created the likelihood the patient would remain in restraints longer than necessary. The failed practice had the potential to affect any patient in restraints. Findings follow.

A. Review of policy titled, "Restraint Usage in Non-Behavioral Health Units," showed, patients were to be monitored every two hours while in restraints and documentation should include various items including patient's condition/behavior, type of restraint, patient monitoring, and assessment/reassessment of patient's condition.
B. Review of the clinical record for Patient #10 showed an order for restraints on 12/31/18 at 1:52 PM. The clinical record revealed no evidence of restraint monitoring every two hours until the restraint was discontinued at 2:20 AM on 01/01/19.
C. During an interview on 01/23/19 at 1:00 PM, the findings in A and B were confirmed by the Clinical Informatics Educator.

Based on clinical record review and interview, it was determined the facility failed to ensure wound dressing changes were done as ordered for three (#10, #19, and #20) of six (#10, #13, and #17-#20) current patients with wounds. Failure to follow wound care orders did not ensure patients wounds were evaluated, treated, and assessed for healing status. The failed practice created the likelihood for wounds to go untreated and unhealed and could affect any patient with a wound. Findings follow.

A. Review of the clinical record of Patient #10 showed the following:
1) On 12/31/18 an order to "clean stoma daily including under the bolster using soap and water and hydrogen peroxide using a q-tip or gauze."
2) Review of Flowsheets showed the stoma was not documented as cleaned from 01/01/19 through the day of discharge on 01/14/19.
B. Review of the clinical record of Patient #19 showed the following:
1) On 01/10/19 an order for "Wound vac therapy s/p (status post) abdominal abscess drainage and washout. Dressing changes MWF (Monday Wednesday Friday)." Review of flowsheets showed the dressing was changed only one (01/21/19) out of five (01/11/19, 01/14/19, 01/16/19, 01/18/19, and 01/21/19) days.
2) On 01/10/19 an order for an abdominal wound. "Clean wound with NS (normal saline) and pat dry. Pack small opening with iodoform ribbon and cover with dry gauze." This was to be done daily. Review of flowsheets showed no documentation the wound was cleaned from 01/10/19 through 01/16/19, and 01/19/19 through 01/23/19.
C. Review of the clinical record for Patient #20 showed the following:
1) On 01/11/19 an order for left and right ischial/buttocks, "clean wounds with NS and pat dry. Pack wounds with dakins moistened kerlix." This was to be done twice per day. Review of flowsheets revealed no documentation the wound was cleaned from 01/11/19 through 01/22/19.
2) On 01/11/19 an order for left ankle and right heel, "clean wounds with NS and pat dry. Apply dakins moistened gauze." This was to be done daily. Review of flowsheets showed no documentation the wounds were cleaned from 01/11/19 through 01/21/19.
D. During an interview on 01/23/19 from 1:15 PM through 2:15 PM, the Clinical Informatics Educator confirmed the findings in A, B, and C.