HospitalInspections.org

Based on interviews and document review, it was determined the facility staff failed to utilize a restraint in accordance with the patient's plan of care by not having an active restraint order for one (1) out of three (3) patients (Patient #3, #8, and #9) on 10/20/21 and 10/25/21.

The findings included:

The surveyor received facility policy titled, "Restraints/Seclusion, Patient" (with last revised date of 12/20) on 12/25/21 at 12:55 pm by Staff Member #1.

Under the "Order for Restraint with Non-Violent or Non-Self-Destructive Behavior" section, the policy reads, "Renewal restraint order: If reassessment indicates an ongoing need for restraint, a renewal restraint order must be entered into the medical record within 24 hours of the initial restraint order. Subsequent renewal orders will be entered for each calendar day by the physician or other licensed practitioner, authorized by State law to order restraints".

The surveyor reviewed the restraint documentation record of Patient #8 on 10/26/21 at 11:53 am. Record review revealed Patient #8 was ordered a "Posey" enclosure non-violent restraint on 10/19/21 at 6:45 pm by the following physician (Staff Member # 28). The order shows that the restraint was ordered as getting out of bed would cause an "extreme injury risk" for Patient #8.

Note: the H&P provider note authored by Staff Member #28 on 10/19/21 at 12:15 pm indicates Patient #8 was a nonverbal autistic and mentally challenged young adult who was unable to listen to instructions and was a safety risk.

The restraint order was set to last twenty-four (24) hours, and was set to expire the next day on 10/20/21.

The surveyor was unable to find renewed orders for the Posey restraint enclosure for 10/20/21, as well as for 10/25/21, despite Patient #8 still having the restraint as evidenced by clinical documentation in the medical record confirming the restraint was still being used on both days.
At the end of day on 10/26/21, the surveyor confirmed with Staff Member #9 that Patient #8 continued to have the Posey restraint enclosure despite having renewed restraint orders on 10/20/21 and 10/25/21 by the physician, per policy.

Based on interviews and document review, it was determined the facility staff failed to monitor the non-violent restrained patient by not performing the required two-hour assessment criteria for one (1) out of three (3) patients (Patient #3, #8, and #9).

The findings included:

The surveyor received facility policy titled, "Restraints/Seclusion, Patient" (with last revised date of 12/20) on 12/25/21 at 12:55 pm by Staff Member #1.

Under "Monitoring the Patient in Restraints or Seclusion" section of Page 4, the policy states, "An RN will assess the patient at least every two hours. The assessment will include where appropriate:

1. Signs of injury associated with restraint, including circulation of affected extremities
2. Respiratory and cardiac status
3. Psychological status, including level of distress or agitation, mental status and cognitive functioning
4. Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met
5. Hydration/nutritional needs are being met
6. Hygiene, toileting/elimination needs are being met
7. The patient's rights, dignity, and safety are maintained
8. Patient's understanding of reasons for restraint and criteria for release from restraint
9. Consideration of less restrictive alternatives to restraint".

The surveyor reviewed the restraint documentation record of Patient #8 on 10/26/21 at 11:53 am. Record review revealed Patient #8 was ordered a "Posey" enclosure as a non-violent restraint on 10/19/21 at 6:45 pm by the following physician (Staff Member # 28). The order shows that the restraint was ordered as getting out of bed would cause an "extreme injury risk" for Patient #8.

Note: the H&P provider note authored by Staff Member #28 on 10/19/21 at 12:15 pm indicates Patient #8 was a nonverbal autistic and mentally challenged young adult who was unable to listen to instructions and was a safety risk.

During medical record review with Staff Member #9, the surveyor observed that the required two (2)-hour restraint monitoring section was entirely incomplete on the following occasions: 10/20/21 between 10:45 am through 8:00 pm, 10/21/21 between 9:30 am through 3:00 pm, and 10/22/21 between 2:00 pm through 8:00 pm.

The surveyor confirmed with Staff Member #9 and through clinical record that Patient #9 was under the Posey enclosure restraint during throughout these aforementioned periods.

At the end of day on 10/26/21, Staff Member #9 confirmed that the two (2) hour restraint monitoring documentation was not performed per policy for Patient #8 on the three (3) occasions.

Based on staff interview, clinical record review, and facility documentation review, it was determined the facility staff failed to monitor per facility policy, two (2) of three (3) patients in the survey sample (Patient #6 and Patient #7) who received blood transfusions.

The findings included:

On 10/26/21 at 2:05 p.m. Patient #6's electronic clinical record was reviewed with the Director of Quality (Staff #8). The review revealed Patient #6 was admitted to the facility on 10/6/21 with abdominal pain and rectal bleeding and was discharged on 10/9/21.

A review of physician's orders revealed on 10/8/21 1 unit of red blood cells (RBC) was ordered due to a low hemoglobin level of 6.6. Documentation showed the blood transfusion began on 10/8/21 at 1550 (3:50 p.m.) and ended on 10/8/21 at 1747 (5:47 p.m.).

Pre-transfusion vital signs were documented on 10/8/21 at 1504 (3:04 p.m.) however there were no vital signs documented during or at the time the transfusion was completed. Staff #8 identified a scanned blood transfusion slip within the electronic medical record and no vital signs were documented on the slip either.

On 10/26/21 at 3:00 p.m. a telephone interview was conducted with the Laboratory Manager (Staff #19). Staff #19 stated she was unable to see vitals on her end.

Facility policy titled "Blood and Blood Products, Administration of" with a revised date of 4/2020 included:
"...E. 4. Monitor patient according to policy guidelines:
a. Vital signs will be obtained prior to starting the transfusion, after 15 minutes, and at the termination of the transfusion..."

Staff #8 confirmed the vital signs should have been obtained pre transfusion, after 15 minutes and at the end of the transfusion. The administrative team was informed of the finding during exit conference on 10/27/21.

On 10/26/21 at 2:30 p.m. Patient #7's electronic clinical record was reviewed with the Director of Quality (Staff #8). The review revealed Patient #7 was admitted to the facility on 10/13/21 with abdominal pain and GI bleed and was discharged on 10/15/21.

A review of physician's orders revealed on 10/14/21 1 unit of red blood cells (RBC) was ordered due to a low hemoglobin level of 6.0. Documentation showed the blood transfusion began on 10/14/21 at 1837 (6:37 p.m.) and ended on 10/14/21 at 2209 (10:09 p.m.).

Pre-transfusion vital signs were documented on 10/14/21 at 1830 (6:30 p.m.) and at 1852 (6:52 p.m.), however there were no vital signs documented at the time the transfusion was completed.

Facility policy titled "Blood and Blood Products, Administration of" with a revised date of 4/2020 included:
"...E. 4. Monitor patient according to policy guidelines:
a. Vital signs will be obtained prior to starting the transfusion, after 15 minutes, and at the termination of the transfusion..."

Staff #8 confirmed the vital signs should have been obtained pre transfusion, after 15 minutes and at the end of the transfusion. The administrative team was informed of the finding during exit conference on 10/27/21.

Based on interviews and document review, it was determined the facility staff failed to perform a safe discharge in ensuring the appropriate provision and transmission of patient information by not notifying the post-hospital facility that a patient was sent to be admitted for (1) out of three (3) patients (Patient #1, #10, and #11).

The findings included:


The surveyor reviewed the clinical record of Patient #1 on 10/26/21 at 11:53 am. Record review revealed Patient #1 was sent to the facility Emergency Department (ED) via EMS from a psychiatric assisted living facility (ALF) on 10/23/21. On 10/27/21, orders were made to discharge to Patient #1 back to the previous ALF.

The progress notes reveal ED staff arranged for "Hospital to Home" private transportation services to take Patient #1 back to the psychiatric ALF on 10/27/21. The surveyor was unable to find any documentation pertaining to notifying the ALF of the plan for Patient #1 to be discharged back.

Staff Member #9 contacted the ED Nurse Manager (Staff Member #26) who confirmed they did not contact the ALF, nor could provide any ED staff who did contact the facility regarding the discharge plan.

Both Staff Member #9 and Staff Member #29 (Director of Case Management) confirmed at this time that there was no documentation in the clinical record of Patient #1 that the facility staff had called a report to the ALF that the patient was being dropped off at the facility.

The surveyor received facility policy titled, "Discharge Planning and the Continuum of Care" (with last revised date of 01/19) on 12/25/21 at 12:55 pm by Staff Member #1.

Under "Discharge Planning and Communication" section, the policy reads, "Appropriate information will be shared with other providers to ensure continuity of care in a timely manner. The information will be shared in a report (verbal and/or written) to the next provider of care".
The surveyor interviewed the Chief Medical Officer of the Emergency Department (Staff Member #30) on 10/27/21 at 2:10 pm. Staff Member #30 stated that it is the expectation for a staff member, such as a nurse, case manager, or provider to provide a report regarding the discharge plan to a facility post-discharge.