HospitalInspections.org

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Based on record review and review of policies and procedures, the hospital failed to follow its policy and procedure for monitoring patients while in restraints for 2 of 7 patient records reviewed (Patients #12, #14).

Failure to follow established procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure entitled "Restraints" (Policy Number 8610-R-2; Revised 7/25/2008) stated that staff member who was trained and competent in the application and monitoring of patients in restraints would assess the patient at the initiation of restraint application and every 15 minutes thereafter. The assessment would include monitoring for signs of injury related to the application of the restraint; the status of nutrition and hydration; checks of adequate circulation and need for range of motion of the restrained extremity(ies); physical and psychological discomfort; and the readiness for discontinuation of the restraint. This would be documented in the patient's medical record.

Patients restrained for non-behavioral reasons (i.e. non-violent behaviors) would be assessed at least every two hours, or more frequently according to patient need, and would include the elements described above. Assessment results would be documented in the patient's medical record.

2. Review of the records of seven patients who had been restrained during their hospitalization revealed the following:

a. On 1/10/2011, Patient #14 was admitted to the ED for evaluation of self-destructive behavior related to cocaine abuse. The patient was combative on admission and was placed in 4-point soft restraints at 9:49 PM. The patient remained in restraints until 6:55 AM on 1/11/2011. There was no documentation in the patient's medical record that the patient had been assessed every 15 minutes according to the hospital's restraint policy and procedure.

b.. On 8/6/2011, Patient #12 was admitted to the ED for treatment of acute respiratory failure related to alcohol intoxication. The patient was intubated and placed in 2 point soft upper limb restraints by the ambulance crew to prevent the patient from accidentally removing the endotracheal tube. The patient remained in restraints until 6:45 AM on 8/7/2011. There was no documentation in the patient's medical record that the patient was assessed every two hours according to the hospital's restraint policy and procedure.

Based on record review and review of policies and procedures, the hospital failed to follow its policy and procedure for ordering restraints for management of patients exhibiting violent or self-destructive behavior for 3 of 7 patient records reviewed (Patients #11, #13, #14).

Failure to follow established procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy and procedure entitled "Restraints" (Policy Number 8610-R-2; Revised 7/25/2008) stated that restraints applied for management of violent or self-destructive behavior would be in accordance with an order given by a physician or Licensed Independent Practitioner who is responsible for the care of the patient and authorized to order the restraint. The order would be renewed every four hours for adults 18 of age and older.

2. Review of the records of seven patients who had been restrained during their hospitalization revealed the following:

a. On 9/4/2011, Patient #11 was admitted to the ED for evaluation of suicidal ideation and assaultive behavior. The patient was placed in 4-point soft restraints at 9:55 PM and remained in restraints until 4:45 AM on 9/5/2011. There was no physician or LIP's order after the first four hours of application to authorize continued use of the restraints.

b. On On 7/5/2011, Patient #13 was admitted to the ED for treatment of methamphetamine toxicity and renal failure. The patient was combative on admission and was placed in 4-point soft restraints at 11:32 PM. The patient remained in restraints until 6:55 AM on 7/6/2011. There was no physician or LIP's order after the first four hours of application to authorize continued use of the restraints.

c. On 1/10/2011, Patient #14 was admitted to the ED for evaluation of self-destructive behavior related to cocaine abuse. The patient was combative on admission and was placed in 4-point soft restraints at 9:49 PM. The patient remained in restraints until 6:55 AM on 1/11/2011. The physician's order authorizing continued use of the restraints did not include the time the order was written.. There was no evidence that the order had been written after the first four hours of restraint application to authorize continued use of the restraints.

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Based on record review and interview, the facility failed to develop an individualized plan for patient care for 2 of 2 obstetrical patients reviewed (Patients #15, #16); and for 3 of 3 newborn babies with complications (Patients #17, #18, #19).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patients needs.

Findings:

1. Review of the medical records of 2 obstetrical patients on 12/14/2011 and 1/25/2012 revealed the following:

a. Patient #15 was a 27 year-old patient who had been admitted to the obstetrical unit in early stages of labor on 12/13/2011. The patient delivered vaginally on 12/13/2011.

The patient's medical record included a plan of care for the patient after delivery but did not include a plan of care of the patient while she was in labor.

b. Patient #16 was a 30 year-old patient who had been admitted to the obstetrical unit on 11/9/2011 for induction of labor. The patient had a history of pregnancy-induced hypertension and low amniotic fluid. The patient was given medication to induce pregnancy at 2:04 PM on 11/9/2011 but failed to progress in labor. The patient was delivered via caesarian section on 11/10/2011 at 1:44 PM.

The patient's medical record included a plan of care for the patient after delivery but did not include a plan of care for the patient while she was in labor.

2. Review of the medical records of 3 newborn infants with complication on 1/15/2012 revealed the following:

a. Patient #17 was an infant who had been born on 11/8/2011. The newborn developed a temperature shortly after birth. Antibiotics were administered to the newborn from 11/8/2011 until 11/13/2011. The newborn's medical record included a standardized plan of care for a "routine newborn". The plan had not been individualized to reflect the care for an infant being treated for infection and possible sepsis.

Similar findings were found in the record of Patient #19.

b. Patient #18 was an infant who had been born on 11/9/2011 at 11:50 AM. The newborn had no respiratory effort and an undetectable heart rate on delivery. The newborn was resuscitated, placed on a continuous positive air pressure device, and supported with intravenous therapy. The newborn's condition deteriorated and required intubation and placement on a ventilator at 1:45 PM. The patient was transferred to a tertiary care facility at 3:00 PM. The newborn's medical record included a standardized plan of care for a "routine newborn". The plan had not been individualized to reflect the care for an infant being treated for respiratory failure.

3. On 1/25/2011 at 9:50 AM, an interview with the hospital's obstetrical unit director revealed that there was no process for planning care for patients in labor. The director confirmed that the standardized plans of care for the newborn infants with complications following birth had not been individualized to reflect the patients' needs.

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Based on record review and interview, the hospital failed to ensure that healthcare providers authenticated orders for procedural sedation given by registered nurses for 3 of 4 records reviewed (Patients #8, #9, #10)

Failure to authenticate verbal orders for medications and treatment risks medical errors and patient harm.

Findings:

1. On 1/24/2011, Surveyor #2 reviewed the medical records of four patients who underwent endoscopic diagnostic procedures during the month of November 2011. All four patients had been given medications for sedation and pain relief during the procedure by a registered nurse. Three of four of these records lacked a physician's order for the medications. The endoscopy procedure forms in these records had an area for the physician's signature but were unsigned.

2. During an interview on 1/14/2011, the CNO stated that the physician's signature on the endoscopy procedure record indicated that the physician had reviewed and authenticated the verbal orders for sedatives and pain medication given during the procedure. The interview confirmed that the verbal orders given by the physician had not been authenticated according to facility policy and procedure.

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