HospitalInspections.org

Based on review of documentation and interview it was determined that the facility failed to ensure that restrained patients were monitored effectively.

Findings were:

Facility policy number P-19 titled "Medical Restraints: Non-Violent or Non-Self-Destructive Patient" stated, in part, "The interdisciplinary team will ensure that the patient's right's, dignity, and well-being are maintained ...
f. A care plan will be initiated related to patient restraints."

A review of the medical record for Patient #1 revealed physician orders present for medical restraints on the following dates 05/17/13, 05/18/13, 05/19/13, and 05/20/13.
? There was only one care plan entered on 05/20/13 that addressed restraints.

In an interview on 08/20/13, staff member #1 confirmed that the care plan should have been updated related to the use of restraints prior to 05/20/13.

Based on review of documentation and interview it was determined that the facility failed to ensure that restrained patients were monitored effectively.

Findings were:

Facility policy number P-19 titled "Medical Restraints: Non-Violent or Non-Self-Destructive Patient" stated, in part, "The inter disciplinary team will ensure that the patient's right's, dignity, and well-being are maintained ...
6. Documentation of all patient who are in medical/surgical restrains will be monitored no less than every 2 hours by a Nursing Associate who is competent to monitor restrained patient, unless the patient ' s condition warrants more frequent monitoring as assessed by the RN. The information collected by the Nursing Associate will be documented on the One or the Two Hour Medical/Surgical Restraint Documentation; Restraint/Face-to-Face Documentation form to include; observation of the patient ' s behavior, position changes, skin integrity, nutrition, elimination needs, activity, the education of the Patient/Family/Significant Other involved in the patient ' s care, and the status of the restraints."

A review of the medical record for Patient #1 revealed physician orders present for medical restraint on the following dates 05/17/13, 05/18/13, 05/19/13, and 05/20/13.
? There was only one "Restraint/One to One Observation Documentation" form that indicated the use of medical restraints in the medical record for 05/20/12.
? 4 "Restraint/One to One Observation Documentation" forms were present in the medical record with no date or time noted.
The lack of dated and timed "Restraint/One to One Observation Documentation" forms for 05/17/13, 05/18/13, and 05/19/13 makes it impossible to determine the monitoring status of the patient while in restraints.

In an interview on 08/20/13, staff member #1 confirmed that the "Restraint/One to One Observation Documentation" should have been dated and timed properly to establish proper monitoring of the patient while in restraints.

Based on review of documentation and interview, it was determined that the facility failed to ensure that the discharge summary included provisions for follow up care.

Findings were:

Facility policy number P-29 titled "Development and use of Interdisciplinary Plans of Care" stated, in part, "5. At the time of discharge or transfer, appropriate member of the Health care Team will initiate the following:
a. The patient will be provided instructions on the specifics of their post-discharge care in written format and if requested electronic format. The patient's understanding of the discharge instructions (to include consults, referrals, etc.) will be assessed/documented along with any clarification given as appropriate ...
c. I applicable, the appropriate agencies will be notified to initiate follow-up care for the patient after discharge."

A review of the medical record for Patient #1 revealed that the patient was to obtain a urodynamic study follow up with a urologist 3 weeks post discharge.
According to physician documentation:
? On 06/11/13, "We contacted [urologist] from urology services ...He recommends continuing intermittent catheterization for now and he mentioned that the only way to specifically diagnose the cause of the urinary retention will be a urodynamic study which we do not have here at UMC and it ' s only available in 1 place in El Paso."
? On 06/12/13, "A/P-Urinary retention-Urodynamic study to be done after D/C cont. intermittent catheterization."
A review of Patient # 1's medical record revealed no follow up appointments for the urodynamic study or urology follow up were made. There was no documentation of notifying the patient of family to follow up regarding these appointments. There was no documentation that the patient or family received contact information for the urologist to follow up. The discharge summary did not address this aspect of follow-up care.

In an interview on 08/19/13, staff member #3 stated, "the residents and social worker knew to make a urology appointment."

In an interview on 08/19/13 staff member #1 confirmed that these appointments should have been made for care post discharge, at minimum contact information provided to the family for follow up for the test and urology appointment.