HospitalInspections.org
Bringing transparency to federal inspections
PENN STATE HEALTH HOLY SPIRIT MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0167
Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined nursing failed to implement the established hospital policy for assessing the needs of patients in restraints for two of two restraint records reviewed (MR9 and MR10).
Findings include:
A review on February 25, 2015, of facility policy "Non Violent/Non Self-Destructive Restraint Use" reviewed June 2012 revealed, " ... Assess patient's fluid, nutritional and toileting needs, monitor and attend to at least every 2 hours. The limbs and skin are assessed for function and integrity at that time. ..."
A review on February 23, 2015, of MR9 revealed the patient was ordered soft cloth restraints for November 27, 28 and 29, 2014. Nurses' notes revealed there was no documentation of the limb assessment every two hours for November 27, 28 and 29, 2014, from 6:00PM to 12:00 midnight. There was no documentation to show the restraints were discontinued during that time period. MR9 also revealed the patient was ordered soft cloth restraints for December 2, 2014. Nurses' notes revealed there was no documentation of the limb assessment every two hours for December 2, 2014, from 2:00PM to 8:00PM. There was no documentation to show the restraints were discontinued during that time period.
A review on February 23, 2015, of MR10 revealed the patient was ordered soft cloth restraints for December 1, 2014. Nurses' notes revealed there was no documentation of the limb assessment on December 1, 2014, at 6:00PM. There was no documentation to show the restraints were discontinued during that two hour time period from 4:00PM to 6:00PM.
An interview conducted on February 23, 2015, at 2:00PM with EMP3 and EMP8 confirmed the nurses failed to document they assessed the patients according to hospital restraint policy for MR9 and MR10.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on review of facility policy, medical record (MR), and interviews with staff (EMP), it was determined that the facility failed to ensure the use of restraints was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient for one of two restraint records reviewed (MR10).
Findings include:
A review on February 25, 2015, of facility policy "Non Violent/Non Self-Destructive Restraint Use" reviewed June 2012 revealed " ... Based on the assessed needs of the patient and after exhausting other options, restraints may be applied according to the process outlined in this procedure. A restraint order must be obtained prior to the application of the restraint. ..."
A review on February 23, 2015, of MR10 revealed a restraint order dated November 28, 29, and 30, 2014 and December 1 and 3, 2014, for soft cloth restraints. MR10 failed to reveal a restraint order for December 2, 2014. A review of MR10 "Nurse Notes," revealed the patient was in soft cloth restraints on December 2, 2014.
An interview conducted on February 23, 2015, at 2:00 PM with EMP 3 and EMP8 confirmed on December 2, 2014, the patient was in restraints and there was no of physician order for the use of the restraints.