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Based on record review, observation, and interview the hospital failed to ensure restraints were applied according to accepted standards of care. This deficient practice was evidenced by the application of restraints without a physician's order for 1 (#5) of 2 (#2, #5) sampled patients reviewed for restraint use from a total patient sample of 6.

Findings:

Review of the hospital policy titled, "Restraint and /or Seclusion and Safe Patient Behavioral Management", reviewed 02/08/2021, revealed in part, "In the absence of a physician or other authorized licensed practitioner, a Registered Nurse, trained and competent, may initiate restraint.
i. The attending physician must be notified immediately, informing him/her of the rationale for use and the patient's immediate physical and psychological status.
ii. The physician may provide a telephone order.

Review of the transfer record from emergency medical transport revealed the patient was transferred to the hospital on 03/14/2022 between 3:35 a.m. and 4:27 a.m. During the transport the patient was given Diprovan 50 mcg/kg/min and then I.V. Ketamine because she was "moving and breathing over the vent" and "the patient's arms were restrained to the stretcher."

Review of the EMR for Patient #5, navigated by S2RN, revealed the patient was admitted to the hospital at 4:37 a.m. and transferred to the floor at 6:16 a.m.

Review of the restraint flow sheet for Patient #5 revealed monitoring of the restraints began on 03/14/2022 at 8:00 a.m.

Review of orders for Patient #5 revealed an order for "Restraints non-behavioral" was placed on 03/14/2022 at 11:23 a.m.

On 03/14/2022 at 11:15 a.m. and 03/15/2022 at 8:36 a.m., Patient #5 was observed to be asleep in her room. Patient #5 was intubated and in restraints at the time of both observations.

In an interview on 03/15/2022 at 11:04 a.m., with S2RN, he verified Patient #5 was in restraints for over 5 hours without an order for the restraints.

Based on record review, observation, and interview the hospital failed to ensure patient restraints were applied and monitored according to accepted standards of care. This deficient practice was evidenced by failure to maintain documentation of restraint use, the reason for placement of the restraints, the need for continued restraint use, and failure to ensure a patient in restraints was monitored for safety, for 1 (#5) of 2 (#2, #5) sampled patients reviewed for physical restraint use from a total patient sample of 6.

Findings:

Review of the policy titled, "Restraint and/or Seclusion and Safe Patient Behavior Management," revealed, in part: 1. Assessment: May include, but is not limited to the following: a. Patient's understanding/ability to use the call bell., b. Causes of pain/discomfort, .c. Range of Motion, d. Mental status and ability to comprehend and follow instruction., e. The need for food/ fluids, .f. Proper placement of medical devices., g. Patient's ability to control his or her behavior., h. Any pre-existing medical conditions or physical disabilities or limitations that would place the patient at a greater risk during restraint., i. History of sexual, physical, verbal or financial abuse which increases psychological risk of restraint.The policy also revealed in part: 5. Monitoring and Documentation: Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff. Documentation of the patient will occur every 2-3 hour intervals.

Review of the transfer record from emergency medical transport revealed the patient was transferred to the hospital on 03/14/2022 between 3:35 a.m. and 4:27 a.m. During the transport the patient was given Diprovan 50 mcg/kg/min and then I.V. ketamine because she was "moving and breathing over the vent" and "the patient's arms were restrained to the stretcher."

Review of the EMR for Patient #5, navigated by S2RN, revealed the patient was admitted to the hospital at 4:37 a.m. and transferred to the floor at 6:16 a.m.

Review of the initial nursing assessment for Patient #5 revealed no documentation of the patient's restraints or the indication for continued use.

Review of the restraint flow sheet for Patient #5 revealed monitoring of the restraints began on 03/14/2022 at 8:00 a.m.

On 03/14/2022 at 11:15 a.m. and 03/15/2022 at 8:36 a.m., Patient #5 was observed to be asleep in her room. Patient #5 was intubated and in restraints at the time of both of the observations.

In an interview on 03/15/2022 at 8:36 a.m., with S8RN, he verified Patient #5 was in restraints when she arrived to the floor.

In interview on 03/15/2022 at 11:04 a.m., S2RN verified Patient #5 was in restraints on the floor for over 1 1/2 hour without initiation of documentation of restraint use, the reason for placement, or monitoring for safety.

Based on record review and interview, the RN failed to supervise the nursing care provided for each patient to ensure care was provided according to physician's orders. This deficient practice was evidenced by:
1. failure to ensure wound care was provided as ordered for 1 (#6) of 3 (#2, #4, #6) sampled patients reviewed for wound care from a total patient sample of 6.;
2. failure to ensure the RN assessed a patient every 4 hours, as ordered per MD, for 1 (#2) of 6 (#1- #6) total sampled patient records reviewed.; and
3. failure to ensure a patient scheduled for PEG tube placement was kept NPO resulting in the PEG placement procedure being delayed for 24 hours, for 1 (#2) of 2 (#2, #5) sampled NPO patient records reviewed from a total patient sample of 6 (#1-#6).

Findings:

1. Failure to ensure wound care was provided as ordered.

Review of the EMR for Patient #6, navigated by S2RN, revealed the patient was admitted on 03/05/2022 with a diagnosis of Non-ST elevation myocardial infarction and sepsis.

Review of the orders for Patient #6 revealed an order placed 03/07/2022 at 11:37 which read, "Staff nurse to cleanse moisture related skin dermatitis under pannus with foaming soap, rinse well, pat dry and apply single layer of Interdry cloth to the skin fold, allow cloth to hang out approximately 2 inches. Nurse to change daily and prn." and " Staff nurse to cleanse sacrococcygeal area, perineum, scrotum, penis and bilateral buttocks with foam cleanser, pat dry, and apply clear zinc bid with each toileting episode."

Review of the nurses' notes revealed no documentation the ordered wound care was performed on 03/08/2022, 03/09/2022 and 03/12/2022.

In interview on 03/15/2022 at 1:35 p.m., S9Comp verified the orders were not followed and there was no documentation the wound care was performed on 03/08/2022, 03/09/2022 and 03/12/2022.


2. Failure to ensure the RN assessed a patient every 4 hours, as ordered per MD.

Review of Patient #2's EMR revealed the following, in part: Patient #2 was admitted on 05/19/2021. Further review revealed Patient #2 had a left heart catheterization performed on 05/19/2021 and developed acute neurologic symptoms. Patient #2 was sedated with Precedex and intubated to allow for further work-up due to being too agitated to tolerate a stat diagnostic CT scan. Additional review revealed the patient was extubated to BiPAP on 05/21/2021, re-intubated due to progressive hypoxemia despite maximum BiPAP support on 05/23/2021, and extubated to Vapotherm on 05/26/2021.

Review of Patient #2's nursing assessments on 05/31/2021 revealed a nursing assessment was performed at 4:00 p.m. Further revealed another assessment was not performed until 9:16 p.m. on 05/31/2021 when the patient stopped breathing, was coded and required intubation.

Review of a significant event narrative nursing note dated 05/31/2021 at 9:16 p.m., completed by S10RN, revealed the following: In patient's room prepping meds and placed patient back on heart monitor due to him removing it in his agitated state. Patient stopped breathing, a Code Blue was called and chest compressions begun. Patient found to be in PEA (pulseless electrical activity) and dose of epi (epinephrine) was given. Code team arrived and took over.

S1RN, chart navigator, verified during the EMR review on 03/15/2022, that there was an RN assessment at 4:00 p.m. and no further RN assessments were documented until 9:16 p.m. S1RN further verified the ordered frequency of nursing assessments was every 4 hours.

3. Failure to ensure a patient scheduled for PEG tube placement was kept NPO.

Review of Patient #2's EMR revealed the patient was admitted on 05/19/2021 after exhibiting signs of a TIA post heart catheterization procedure.

Review of Patient #2's EMR revealed MD orders dated 06/03/2021 at 5:09 p.m., to be effective on 06/04/2021 at 00:01 a.m., to place the patient NPO for PEG tube placement procedure.

Further review of Patient #2's EMR revealed the following progress note completed by S3MD (Gastroenterology), dated 06/04/2021 at 12:29 p.m.: Tube feeds not held. Will reschedule.

Review of Patient #2's discharge summary, dated 06/17/2021, revealed Patient #2's PEG tube placement procedure was performed on 06/05/2021.

S1RN, chart navigator, confirmed the above referenced findings at the time of the record review on 03/15/2022.










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