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Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure nursing updated the Interdisciplinary Plan of Care in two (2) of two (2) medical records related to the use of restraints (patient #3 and #6). This has the potential to negatively affect the care of patients by nursing not evaluating the use of restraints and the removal at the earliest possible time, or the nursing assessment being completed to identify a problem.

Findings include:

1. Hospital policy titled "Restraining a Patient", last revised 8/10, states in part: "The Interdisciplinary Plan of Care is updated to reflect use per Federal Regulations."

2. Patient #3 was placed in restraints on 3/13/13, 3/14/13, 3/15/13, 3/16/13, 3/17/13, 3/18/13, 3/19/13, 3/20/13, 3/21/13, 3/22/13, 3/24/13, 3/24/13, 3/26/13, and 3/28/13 and the Interdisciplinary Plan of Care was not updated to reflect the use of restraints.

3. Patient #6 was placed in restraints on 12/4/12, 12/5/12, 12/6/12, 12/7/12 and 12/8/12 and Interdisciplinary Plan of Care was not updated to reflect the use of restraints.

4. During an interview conducted on 5/1/13 at 1300 with the Clinical Nurse Manager of 3 South, the Clinical Nurse Manager of Surgical Intensive Care Unit (SICU) and the Corporate Director of Regulatory Compliance, these medical records were reviewed and they agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure nursing obtained a physician order for the use of restraints in two (2) of two (2) medical records reviewed for restraints (patients #3 and #6). This had the potential to negatively affect all patients by staff using restraints inappropriately.

Findings include:

1. Hospital policy titled "Restraining a Patient", last revised 8/10, states in part: "All restraints require a physician time limited order."

2. Patient #3 was placed in restraints on 3/18/13, 3/26/13 and 3/28/13 without a physician order.

3. Patient #6 was placed in restraints on 12/5/12, 12/7/12 and 12/8/12 without a physician order.

4. These medical records were reviewed with the Clinical Nurse Manager of 3 South, the Clinical Nurse Manager of Surgical Intensive Care (SICU) and the Corporate Director of Regulatory Compliance on 5/1/13 at 1300 and they agreed with these findings.

A. Based on review of medical records and staff interview it was determined the hospital failed to ensure nursing completed a discharge assessment on all patients at discharge in two (2) of ten (10) medical records reviewed for discharge assessments (patients #1 and #2). This has the potential to negatively affect all patient's by nursing being unaware if a change in their status has occurred prior to leaving the hospital.

Findings include:

1. Patient #1 was discharged from the hospital at 1849 on 4/4/13. The nursing discharge summary sheet was incomplete in that there was no date or time as to when this assessment had occurred.

2. Patient #2 was discharged from the hospital at 1030 on 4/27/13. The nursing discharge summary sheet was incomplete in that the time on the discharge assessment was not documented.

3. These medical records were reviewed with the Clinical Nurse Manager of 3 South, the Clinical Nurse Manager of the Surgical Intensive Care Unit (SICU), and the Corporate Director of Regulatory Compliance at 1300 on 5/1/13 and they were in agreement with these findings.


B. Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure nursing completed a discharge assessment on all patients prior to discharge in three (3) of ten (10) records reviewed for discharge assessments (patients #6, #7 and #9). This has the potential to negatively affect patients by nursing being unaware if patients are stable to be discharged from the hospital.

Findings include:

1. Patient #6 was discharged from the hospital on 1/17/13 at 1723. Vital signs were documented at 1214, greater than four (4) hours prior to discharge.

2. Patient #7 was discharged from the hospital on 12/29/12 at 1606. Vital signs were documented at 1055, greater than four (4) hours prior to discharge.

3. Patient #9 was discharged from the hospital on 2/25/13 at 2120. Vital signs were documented at 1429, greater than four (4) hours prior to discharge.

4. During an interview with the Clinical Coordinator of 3 South on 4/30/13 at 1100, she stated the expectation is vital signs are to be done every four (4) hours. When a patient is discharged, if it has been less than four (4) hours, then the previous vital signs may be used, otherwise they must be repeated.

5. These medical records were reviewed on 5/1/13 at 1300 with the Clinical Nurse Manager of 3 South, the Clinical Nurse Manager of Surgical Intensive Care Unit (SICU) and the Corporate Director of Regulatory Compliance and they agreed with these findings.


C. Based on review of documents, medical records and staff interview it was determined the hospital failed to ensure nursing notified the physician when a patient's Braden score was below seventeen (17) in four (4) of four (4) medical records reviewed for skin assessments (patients #3, #4, #6 and #7). This has the potential to negatively affect all patient's by the potential development of decubitus ulcer's and the physician being unaware of the potential risk that may have been averted.

Findings include:

1. Hospital policy on the "Braden Skin Assessment" states in part: "Notify physician for any score below 17."

2. Patient #3 had a skin assessment done daily. On 3/11/13, 3/12/13, 3/13/13, 3/14/13, 3/15/13, 3/17/13, 3/18/13, 3/20/13, 3/21/13, 3/22/13, 3/23/13, 3/24/13, 3/25/13, 3/26/13, 3/27/13, 3/28/13, 3/29/13, 3/30/13, 3/31/13, 4/1/13, 4/3/, 4, 6, 7, 8/13 the patient's Braden score was below seventeen (17). There was no documentation in the medical record to indicate the physician had been notified.

3. Patient #4 had a skin assessment done daily. On 3/13/13, 3/14/13, 3/30/13 and 31/13 the patient's Braden score was below seventeen (17). There was no documentation in the medical record to indicate the physician had been notified.

4. Patient #6 had a skin assessment done daily. On 11/30/12, 12/1/12, 12/2/12, 12/3/12, 12/4/12, 12/5/12, 12/6/12, 12/7/12, 12/8/12, 12/9/12, 12/10/12, 12/11/12 and 12/12/12 the patient's Braden score was below seventeen (17). There was no documentation in the medical record to indicate the physician had been notified.

5. Patient #7 had a skin assessment done daily. On 12/19/12, 12/21/12, 12/24/12, 1225/12, 12/26/12 and 12/27/12 the patient's Braden score was below seventeen (17). There was no documentation in the medical record to indicate the physician had been notified.

6. During an interview conducted on 5/1/13 at 1300 with the Clinical Nurse Manager of 3 South and the Clinical Nurse Manager of Surgical Intensive Care Unit (SICU), they stated "nursing does not document notification of the physician, sometimes they just talk to the physician's in the hall and tell them if the Braden score is low."