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Based on staff interviews, medical record reviews, and during the investigation of a complaint, it was determined the facility staff failed to ensure Medicare beneficiaries were provided a copy of the signed document titled, "Important Message from Medicare (IM)" no more than two days before the patient's discharge in one (1) of three (3) Medicare beneficiaries' medical records reviewed within the survey sample. (Patient #3).

The findings were:

Patient #3's electronic medical record was reviewed throughout the survey with various facility staff navigators. The patient was admitted to the facility on 7/01/17 and discharged on 7/19/17. The record contained evidence the patient's representative signed the document titled "IMPORTANT MESSAGE FROM MEDICARE ABOUT YOUR RIGHTS" on 7/2/17, the day after Patient #3 was admitted to the facility. This standardized document informed inpatient Medicare beneficiaries of their rights, including discharge rights and how to appeal a discharge should the patient or patient representative feel the planned discharge was too soon. The medical record contained a copy of the patient's power of attorney (POA) for medical decisions and that document listed two of Patient #3's family members (adult children), one of the adult children was the one who signed the IM on 7/2/17. The signed POA designated one of Patient #3's adult children as the patient's "Healthcare Agent" (Adult Child #1) and designated a second adult child (Adult Child #2) if the first designee was unwilling or unable to serve.

On 9/21/17 at 3:20 PM, the facility's director of regulatory affairs provided the surveyor a copy of the IM signed on 7/2/17 and acknowledged there was no evidence the patient or patient representative had received a copy of the IM no more than two days prior to discharge. The director also acknowledged the patient or patient representative should have received a copy of the signed IM no more than two days prior to discharge.

Based on a review of clinical records, interviews with facility leadership staff, and a review of facility policies, it was determined the nursing documentation process, related to restraint use, failed to provide evidence the least restrictive restraint intervention necessary for the patient's protection was implemented for two (2) of two (2) patients reviewed related to restraints, (Patient #5 and #6).

The findings were:

The surveyor conducted a review of the closed clinical records of Patient #5 and Patient #6 on 09/21/17 beginning at 11:15 am. The facility's Director of Professional Practice, hereafter referred to as the DOPP, assisted the surveyor by navigating the electronic health records for both clinical record reviews. The findings related to each clinical record were as follows:
· The clinical record of Patient #5 contained evidence the patient was intubated (had a tube leading into the airway) to allow for mechanical ventilation. The physician ordered restraint interventions dated 08/12/17 at 8:00 pm, of soft extremity restraints to both arms and gave the reason for the restraint as "Pulling out/at lines/tubes." The record contained evidence the restraint orders were discontinued the next day, on 08/13/17 at 3:05 pm. The clinical record failed to contain documentation or evidence of the specific type of restraint implemented and/or monitored by the patient care staff. In the absence of that documentation, there was no evidence the specific restraint type in use was the least restrictive restraint necessary.
· The clinical record of Patient #6 contained evidence the patient was seen in the Emergency Department (ED) 08/27/17 at midnight. The physician's History and Physical examination dated 08/27/17 documented the patient had a history of substance abuse, was found with a needle in [his/her] arm, was given Narcan (a reversal agent for narcotic overdose), was "agitated" and "combative" with an "AMS" (altered mental status), and was "intubated" (had a tube leading into the airway to allow for mechanical ventilation). The ED record contained evidence the patient was receiving a continuous drip (infusion) of Propofol (a medication used for sedation/anesthesia) and received two (2) additional bolus doses of Propofol for "sedation and tube safety." The ED record contained orders from the physician for restraint interventions on 08/27/17 at 2:31 am of soft extremity restraints to all extremities (both arms and both legs) and listed the reason the restraint was necessary as "Unable to remain safe in environment." The ED record failed to contain documentation addressing the restraint(s) again other than the aforementioned order. The patient was admitted to the Neuro-Science Intensive Care Unit on 08/27/17 at approximately 3:00 am. That unit's documentation included a note by an RN (registered nurse) on 08/27/17 at 3:00 am which documented the patient "arrived from ED in restraints." However, that note did not address the specific type of restraint which was in use for the patient. From 08/27/17 to 09/03/17 (eight [8] days), the record contained additional orders each day for the specific type of restraint intervention of soft extremity restraints to all 4 extremities and gave the reason for the restraint as "unable to remain safe in environment." There was no documentation describing the reason why the patient was unable to remain safe in the environment, i.e., a description of the patient's specific behavior(s) which justified the use of restraints to all four (4) extremities. There was no documentation or evidence that the restraint intervention ordered from 08/27/17 to 09/03/17 was, in fact, the restraint intervention implemented and monitored during that time frame. The clinical record failed to contain any documentation or evidence of the specific type of restraint implemented and/or monitored by the patient care staff during that time frame. In the absence of the aforementioned documentation, there was no evidence the specific restraint type in use was the least restrictive restraint necessary. The Nurse Manager of the ED was present for a short time during the review of Patient #6's record to attempt to find the lacking documentation of restraint implementation and/or monitoring while the patient was in the ED. The Nurse Manager of the ED stated being unable to locate the documentation but that he/she wasn't that familiar with the particular computer being used. The surveyor informed the Nurse Manager of the ED that he/she could search using another computer and provide the surveyor with copies of anything found.

The surveyor interviewed the DOPP during the record reviews for Patient #5 and Patient #6, occurring on 09/21/17 beginning at 11:15 am. The DOPP stated the nurses weren't expected to document the specific type of restraint implemented and monitored because the hospital's process doesn't require them to. The DOPP stated, "they are only allowed to apply the type ordered" by the physician.

The surveyor reviewed the facility's Policy titled "Restraint and Seclusion" (PC.PS.004) last updated 12/22/14, on 09/21/17 at 1:00 pm. The policy did not address the process described above by the DOPP related to restraint documentation. The policy at the heading titled "Policy" included, in part,........."C. The least restrictive form of restraint or seclusion that provides for the patient's safety is employed." The policy included as well, at the heading titled, "Documentation Requirements" in part, "Documentation of restraint and seclusion in the medical record includes the following: ...........2. A description of the patient's behavior and the intervention used" and "The patient's behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of the restraint or seclusion."

The surveyor met with the Nurse Manager of the ED on 09/21/17 at 1:30 pm. He/she stated being unable to find any additional documentation for Patient #6 related to the aforementioned ED restraint documentation. The Nurse Manager stated he/she called the nurse assigned to Patient #6 during the ED visit on 08/27/17 and asked about the restraint orders. The Nurse Manager stated the ED nurse recalled requesting orders for bilateral wrist restraints but had no recollection of asking for restraints for all 4 extremities.

The surveyor met with the DOPP again on 09/21/17 at 4:20 pm. The surveyor discussed the concerns that, for both Patient #5 and Patient #6 there was no documentation that the specific type of restraint ordered by the physician was, in fact, the specific type of restraint the staff applied or noted to be in use for the patients. The surveyor also discussed with the DOPP the concern that Patient #6 had physician's orders for restraints to all 4 extremities for eight (8) consecutive days, and if that was the type of restraint applied and maintained for eight (8) days, there was no evidence or documentation provided describing the specific behaviors which warranted that level of restriction. The surveyor discussed with the DOPP that the documentation process currently in place, leaves no mechanism for the clinical record to reflect errors such as the wrong restraint having been in use, nor does it clearly document that the least restrictive restraint necessary was implemented.

Based on a review of clinical records, interviews with facility leadership staff, and a review of facility policies, it was determined the nursing documentation related to restraint use failed to provide evidence the specific type of restraint intervention(s) implemented, were in accordance with the restraint orders from the physician(s) for two (2) of two (2) patients selected for restraint review, (Patient #5 and #6).

The findings were:

The surveyor conducted a review of the closed clinical records of Patient #5 and Patient #6 on 09/21/17 beginning at 11:15 am. The facility's Director of Professional Practice, hereafter referred to as the DOPP, assisted the surveyor by navigating the electronic health records for both clinical record reviews. The findings related to each clinical record were as follows:
· The clinical record of Patient #5 contained evidence the patient was intubated (had a tube leading into the airway) to allow for mechanical ventilation. The physician documented orders for a specific type of restraint intervention dated 08/12/17 at 8:00 pm. That physician's order was for soft extremity restraints to both arms and the reason the restraint was necessary was documented as "Pulling out/at lines/tubes." The record contained evidence the restraint orders were discontinued the next day, on 08/13/17 at 3:05 pm. The clinical record failed to contain documentation or evidence that the specific type of restraint intervention ordered by the physician was, in fact, the restraint intervention implemented and monitored during the time the patient was being restrained. The nursing staff documented the ongoing monitoring and safety assessments related to restraints on the "Care Flowsheet." However, that documentation failed to address what type of restraint was implemented or in use at any point during the ongoing monitoring. The clinical record failed to contain evidence that the specific type of restraint intervention ordered by the physician, was the restraint intervention implemented for the patient.
· The clinical record of Patient #6 contained evidence the patient was seen in the facility's Emergency Department (ED) on 08/27/17 at midnight. The physician's History and Physical examination dated 08/27/17 documented the patient had a history of substance abuse, was found with a needle in [his/her] arm, was given Narcan (a reversal agent for narcotic overdose), was "agitated" and "combative" with an "AMS" (altered mental status), and was "intubated" (had a tube leading into the airway to allow for mechanical ventilation). The ED record contained evidence the patient was receiving a continuous drip (infusion) of Propofol (a medication used for sedation/anesthesia) and received two (2) additional bolus doses of Propofol for "sedation and tube safety." The ED record contained orders from the physician for a specific type of restraint intervention on 08/27/17 at 2:31 am of soft extremity restraints to all extremities (both arms and both legs) and listed the reason the restraint was necessary as "Unable to remain safe in environment." There was no ED documentation describing the reason why the patient was unable to remain safe in the environment, i.e., a description of the patient's specific behavior(s) which warranted the use of restraints to all four (4) extremities. The ED record failed to contain documentation addressing the restraints again, other than the aforementioned order. There was no documented evidence that the physician's order for a specific restraint intervention was implemented while the patient was in the ED. The patient was admitted to the Neuro-Science Intensive Care Unit on 08/27/17 at approximately 3:00 am. That unit's documentation included a note by an RN (registered nurse) on 08/27/17 at 3:00 am which documented the patient "arrived from ED in restraints." However, that note did not address the specific type of restraint which was in use for the patient. For eight (8) consecutive days, from 08/27/17 to 09/03/17, the record contained additional orders each day from the physician for the specific type of restraint intervention of soft extremity restraints to all 4 extremities with the reason for the restraint listed as "unable to remain safe in environment." The record failed to contain documentation or evidence that the specific type of restraint interventions ordered by the physician from 08/27/17 to 09/03/17 were, in fact, the restraint interventions implemented and monitored during that time frame. On 09/04/17 the physician ordered the restraint intervention of soft extremity restraints to both arms and listed the reason as "Pulling out/at lines or tube." On 09/06/17 at 10:00 am the physician ordered the restraint intervention of splints to both arms and listed the reason as "Unable to remain safe in environment." On 09/06/17 at 2:39 pm the restraints were discontinued and the nurse documented "no further cause" for restraints. The Intensive Care Unit's nursing staff documented the ongoing monitoring and safety assessments related to restraints from 08/27/17 to 09/06/17 on the "Care Flowsheet." That documentation failed to address what type of restraint was initially applied or present when the patient was received to the unit, nor did it identify the specific type of restraint in use at any point during the ongoing monitoring. The clinical record failed to contain evidence that the specific type of restraint intervention ordered by the physician, was the restraint intervention implemented and monitored for the patient.

The surveyor interviewed the DOPP during the record reviews for Patient #5 and Patient #6, occurring on 09/21/17 beginning at 11:15 am. The DOPP stated the nurses weren't expected to document the specific type of restraint implemented and monitored because the hospital's process doesn't require them to. The DOPP stated, "they are only allowed to apply the type ordered" by the physician. He/she explained the facility's process for restraint documentation was purposefully developed with the intent that nurses would only be allowed to apply the type of restraint ordered and therefore the nurses would not be required to document the specific type of restraint applied and/or monitored. The DOPP stated, "we let the order stand on its own." The surveyor requested a copy of the policy/procedure or other written process addressing the aforementioned process described by the DOPP.

On 09/21/17 at 1:00 pm, the surveyor reviewed the facility's Policy titled "Restraint and Seclusion" (PC.PS.004) last updated 12/22/14. The policy did not address the process described above by the DOPP related to restraint documentation. The policy at "Documentation Requirements" included, in part, "Documentation of restraint and seclusion in the medical record includes the following: ........... 2. A description of the patient's behavior and the intervention used."

Based on a review of clinical records, interviews with facility leadership staff, and a review of facility policies, it was determined the patient care staff failed to document specific patient behaviors and/or the restraint interventions used for two (2) of two (2) patients selected for restraint review, (Patient #5 and #6).

See also Tag A-0168.

The findings were:

The surveyor conducted a review of the closed clinical records of Patient #5 and Patient #6 on 09/21/17 beginning at 11:15 am. The facility's Director of Professional Practice, hereafter referred to as the DOPP, assisted the surveyor by navigating the electronic health records for both clinical record reviews. The findings related to each clinical record were as follows:
· The clinical record of Patient #5 contained evidence the patient was intubated (had a tube leading into the airway) to allow for mechanical ventilation. The physician ordered restraint interventions on 08/12/17 at 8:00 pm, of soft extremity restraints to both arms and gave the reason for the restraint being necessary as "Pulling out/at lines/tubes." The record contained evidence the restraint orders were discontinued the next day, on 08/13/17 at 3:05 pm. The clinical record failed to contain documentation or evidence that the specific type of restraint intervention ordered by the physician was, in fact, the restraint intervention implemented and monitored during the time the patient was being restrained. The nursing staff documented the ongoing monitoring and safety assessments related to restraints on the "Care Flowsheet." However, that documentation failed to address what type of restraint was implemented or in use at any point during the ongoing monitoring. The clinical record failed to contain documentation of the specific type of restraint intervention implemented and monitored for the patient.
· The clinical record of Patient #6 contained evidence the patient was seen in the Emergency Department (ED) on 08/27/17 at midnight. The physician documented in the History and Physical the patient had a history of substance abuse, was found with a needle in [his/her] arm, was given Narcan (a reversal agent for narcotic overdose), was "agitated" and "combative" with an "AMS" (altered mental status), and was "intubated" (had a tube leading into the airway to allow for mechanical ventilation). The ED record contained evidence the patient was receiving a continuous drip (infusion) of Propofol (a medication used for sedation/anesthesia) and received two (2) additional bolus doses of Propofol for "sedation and tube safety." The ED record contained orders from the physician on 08/27/17 at 2:31 am for the restraint intervention of soft extremity restraints to all extremities (both arms and both legs), and listed the reason the restraint was necessary as "Unable to remain safe in environment." The ED record failed to contain documentation of the patient's specific behaviors warranting the use of restraints to all 4 extremities. There was no evidence in the ED record of what specific type, if any, restraint intervention the patient care staff applied/implemented. The ED record failed to address restraints (other than the order) while the patient was in the ED. The patient was admitted to the Neuro-Science Intensive Care Unit on 08/27/17 at approximately 3:00 am. That unit's documentation included a note by an RN (registered nurse) on 08/27/17 at 3:00 am which documented the patient "arrived from ED in restraints." However, that note did not address the specific type of restraint which was in use for the patient. From 08/27/17 to 09/03/17 (eight [8] days), the record contained additional orders each day for the specific type of restraint intervention of soft extremity restraints to all 4 extremities and the reason for the restraint was listed as "unable to remain safe in environment." The record failed to contain documentation describing the reason why the patient was unable to remain safe in the environment, i.e., a description of the patient's specific behavior(s) which warranted the use of restraints to all four (4) extremities for eight (8) days. The record contained evidence that on 09/04/17 the physician ordered the restraint intervention of soft extremity restraints to both arms because the patient was pulling out/at tubes and lines. On the morning of 09/06/17 the physician ordered the restraint intervention of splints to both arms and listed the reason as "Unable to remain safe in environment."

The record did not contain a description of specific patient behaviors causing him/her to be unsafe in the environment and warranting use of the restraint. On the afternoon of 09/06/17 the restraints were discontinued and the nurse documented "no further cause" for restraints. The Intensive Care Unit's nursing staff documented the ongoing monitoring and safety assessments related to restraints from 08/27/17 to 09/06/17 on the "Care Flowsheet." That documentation failed to address what type of restraint was initially applied or present when the patient was received to the unit, nor did it identify the specific type of restraint in use at any point during the ongoing monitoring. The clinical record failed to contain documentation of the specific type of restraint intervention(s) implemented for the patient and the specific behaviors exhibited which warranted the use of those restraints.

The surveyor interviewed the DOPP during the record reviews for Patient #5 and Patient #6, occurring on 09/21/17 beginning at 11:15 am. The DOPP stated the nurses weren't expected to document the specific type of restraint implemented and monitored because the hospital's process didn't require them to. The DOPP stated, "they are only allowed to apply the type ordered" by the physician.

On 09/21/17 at 1:00 pm, the surveyor reviewed the facility's Policy titled "Restraint and Seclusion" (PC.PS.004) last updated 12/22/14. The policy did not address the process described above by the DOPP related to restraint documentation. The policy included a heading titled, "Documentation Requirements" and that section included, in part, "Documentation of restraint and seclusion in the medical record includes the following: ...........2. A description of the patient's behavior and the intervention used" and "The patient's behavior and staff concerns regarding safety risks to the patient, staff, and others that necessitated the use of the restraint or seclusion."

The surveyor met with the DOPP again on 09/21/17 at 4:20 pm. The surveyor discussed the concerns that, for both Patient #5 and Patient #6 there was no documentation of the specific type of restraint the patient care staff applied or noted/observed to be in use for the patients. The surveyor also discussed with the DOPP the concern that Patient #6 had physician's orders for restraints to all 4 extremities for eight (8) consecutive days, and if that was the type of restraint applied and maintained for eight (8) days, there was no evidence or documentation provided describing the specific behaviors which warranted that level of restriction.