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Based on hospital policy and procedure review, medical record review and staff interview, the hospital staff failed to identify the need for
a chemical restraint order for 1 of 1 chemically restrained patients sampled. (Patient #12)

Findings Included:

Review of the hospital policy and procedure titled "Restraint Management Program" last revised 03/2018 revealed "Chemical Restraint: Drug or medication used as a restriction to manage the patient's behavior or restrict freedom which is not a standard treatment or dosage for the patient's medical or psychiatric condition. ...6. Restraint or seclusion renewal orders for adult Violent (behavioral) restraint are obtained every four (4) hours. 7. A provider must perform a face-to-face assessment of the patient within one (1) hour of application of Violent (behavioral) restraints... PATIENT ASSESSMENT and CARE 1. Nursing will assess the patient in restraints...every 15 minutes for violent (behavioral) restraint use..." Further review of the policy revealed no available documentation of the provider/nursing responsibilities, specific to the use of chemical restraints.

Closed medical record review on 05/15/2018 for Patient (Pt) #12 revealed a 45 year-old male that presented to the Emergency Department on 05/07/2018 at 0126 with a chief complaint of "overdose". Review of the record revealed Patient #12 was triaged by nursing staff at 0128 and a medical screening exam was completed by the physician at 0147. Review of vital signs documented at 0128 revealed Temperature (Temp) 97.0F, Heart Rate (HR) 104, Respiratory Rate (RR) 24 and Blood Pressure (BP) 178/112 with Oxygen Saturation (SPO2) of 95%. Review of the physician's orders revealed Ativan 1 milligram intravenously (IV) ordered on 05/07/2018 at 0147, 0154 and again at 0229. Further review of the physician's orders revealed Geodon 20 milligrams intramuscularly (IM) ordered on 05/07/2018 at 0154. Review of the Medication Administration Record revealed Patient #12 was administered Ativan 1 milligram IV at 0145, Ativan 1 milligram IV at 0155, Geodon 20 milligrams IM at 0158 and Ativan 1 milligram IV at 0232. Review of the Physician's Note dated 05/07/2018 at 0318 revealed Patient #12 was seen at 0147. Review of the physician note revealed Patient #12 presented with" Depression, Unclear Thinking, Suicidal Ideation, Plan: Overdose. ...HE ARRIVES TO THE ER (emergency room) AGGITATED AND STATING HE WANTS TO DIE. HE HAD TO BE RESTRAINED BY SEVERAL SECURITY PERSONELLE (sic) TO GET HIM SEDATED." Review of a nursing note documented on 05/07/2018 at 0331 by a Registered Nurse revealed "PT ARRIVED AT 0125 VIA EMS (Emergency Medical Services). EMS REPORTS PT TOOK 60 IBUPROFEN PM APPROX 30 MINUTES BEFORE ARRIVAL. PT UNCOOPERATIVE UPON ARRIVAL BUT EASILY REDIRECTED. ONCE STAFF ATTEMPTED TO GAIN IV ACCESS PT AGAIN BECAME UNCOOPERATIVE AND BEGAN SWINGING AT STAFF, UNABLE TO REDIRECT. SECURITY CALLED TO BEDSIDE. PT CONTINUED TO SWING AT STAFF, YELL AND KICK. RPD (local police department) ARRIVED TO ASSIST. PT PLACED IN HANDCUFFS BY POLICE WHO REMAINED AT BEDSIDE. PT MEDICATED PER MD ORDER. IV ACCESS OBTAINED AND I/O (In and Out) CATH. PT'S BELONGINS TO SECURITY. HANDCUFF REMOVED BY POLICE." Review of the medical record revealed a non-violent restraint order written by Physician #1 on 05/07/2018 at 0315 for soft wrist restraints, reason altered mental status and emergency situation; 4 siderails. Review of the medical record revealed no available documentation of a physician order for chemical restraints or violent (behavioral) restraints. Further review revealed no available documentation in the Emergency Department of restraint assessments or monitoring by nursing staff.

Interview on 05/17/2018 at 1105 with MD #1 while reviewing the medical record for Patient #12 revealed in his professional medical opinion, the medications given to the patient were being used as a chemical restraint to control the patient's behavior. Interview confirmed there were no orders documented for chemical restraints.

Telephone interview on 05/17/2018 at 1130 with RN #2 revealed she was the primary nurse for Patient #12 on 05/07/2018. Interview revealed the patient had an order for soft wrist restraints, which she states was never placed on patient as he was sedated after medication administration and did not warrant wrist restraints. Interview confirmed she did not document any restraint assessments or monitoring for Patient #12.

Based on hospital policy and procedure review, medical record review and staff interview, the hospital staff failed to ensure orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN) for 1 of 4 restrained patients sampled. (Patient #12)

Findings Included:

Review of the hospital policy and procedure titled "Restraint Management Program" last revised 03/2018 revealed "...RESTRAINT ORDERS AND RENEWAL ORDERS ....4. Standing orders or "prn" orders are unacceptable and are not utilized at (Name of the
Facility)..."

Closed medical record review on 05/15/2018 for Patient (Pt) #12 revealed a 45 year-old male that presented to the Emergency Department on 05/07/2018 at 0126 with a chief complaint of "overdose". Review of the record revealed Patient #12 was triaged by nursing staff at 0128 and a medical screening exam was completed by the physician at 0147. Review of vital signs documented at 0128 revealed Temperature (Temp) 97.0F, Heart Rate (HR) 104, Respiratory Rate (RR) 24 and Blood Pressure (BP) 178/112 with Oxygen Saturation (SPO2) of 95%. Review of the physician's orders revealed Ativan 1 milligram intravenously (IV) ordered on 05/07/2018 at 0147, 0154 and again at 0229. Further review of the physician's orders revealed Geodon 20 milligrams intramuscularly (IM) ordered on 05/07/2018 at 0154. Review of the Medication Administration Record revealed Patient #12 was administered Ativan 1 milligram IV at 0145, Ativan 1 milligram IV at 0155, Geodon 20 milligrams IM at 0158 and Ativan 1 milligram IV at 0232. Review of the Physician's Note dated 05/07/2018 at 0318 revealed Patient #12 was seen at 0147. Review of the physician note revealed Patient #12 presented with" Depression, Unclear Thinking, Suicidal Ideation, Plan: Overdose. ...HE ARRIVES TO THE ER (emergency room) AGGITATED AND STATING HE WANTS TO DIE. HE HAD TO BE RESTRAINED BY SEVERAL SECURITY PERSONELLE (sic) TO GET HIM SEDATED." Review of a nursing note documented on 05/07/2018 at 0331 by a Registered Nurse revealed "PT ARRIVED AT 0125 VIA EMS (Emergency Medical Services). EMS REPORTS PT TOOK 60 IBUPROFEN PM APPROX 30 MINUTES BEFORE ARRIVAL. PT UNCOOPERATIVE UPON ARRIVAL BUT EASILY REDIRECTED. ONCE STAFF ATTEMPTED TO GAIN IV ACCESS PT AGAIN BECAME UNCOOPERATIVE AND BEGAN SWINGING AT STAFF, UNABLE TO REDIRECT. SECURITY CALLED TO BEDSIDE. PT CONTINUED TO SWING AT STAFF, YELL AND KICK. RPD (local police department) ARRIVED TO ASSIST. PT PLACED IN HANDCUFFS BY POLICE WHO REMAINED AT BEDSIDE. PT MEDICATED PER MD ORDER. IV ACCESS OBTAINED AND I/O (In and Out) CATH. PT'S BELONGINS TO SECURITY. HANDCUFF REMOVED BY POLICE." Review of the medical record revealed a non-violent restraint order written by Physician #1 on 05/07/2018 at 0315 for soft wrist restraints, reason altered mental status and emergency situation; 4 siderails. Review of the medical record revealed no available documentation of a physician order to discontinue the restraint order. Further review revealed no available documentation in the Emergency Department of restraint assessments or monitoring by nursing staff.

Interview on 05/17/2018 at 1105 with MD #1 revealed they ordered restraints along with medications. Interview revealed if the restraints are never placed on the patient, the orders are left open to be used if needed after medication wears off. Interview confirmed the restraints were being ordered on an as-needed-basis.

Telephone interview on 05/17/2018 at 1130 with RN #2 revealed she was the primary nurse for Patient #12 on 05/07/2018. Interview revealed the patient had an order for soft wrist restraints, which she states was never placed on patient as he was sedated after medication administration and did not warrant wrist restraints. Interview revealed she informed the provider that she did not place the restraints on Patient #12 because of his sedation level. Interview revealed she was told by the physician to just "keep the order in case he (pt #12) wakes up again." Interview confirmed she did not document any restraint assessments or monitoring for Patient #12 and she did not discontinue the order for restraints.

Based on hospital policy and procedure review, medical record review and staff interview, the hospital staff failed to ensure documentation of restraint monitoring for 1 of 4 restrained patients sampled. (Patient #12)

Findings Included:

Review of the hospital policy and procedure titled "Restraint Management Program" last revised 03/2018 revealed "Chemical Restraint: Drug or medication used as a restriction to manage the patient's behavior or restrict freedom which is not a standard treatment or dosage for the patient's medical or psychiatric condition. ...6. Restraint or seclusion renewal orders for adult Violent (behavioral) restraint are obtained every four (4) hours. 7. A provider must perform a face-to-face assessment of the patient within one (1) hour of application of Violent (behavioral) restraints... PATIENT ASSESSMENT and CARE 1. Nursing will assess the patient in restraints every two (2) hours for non-violent (medical) restraint use and every 15 minutes for violent (behavioral) restraint use..." Further review of the policy revealed no available documentation of the provider/nursing responsibilities, specific to the use of chemical restraints.

Closed medical record review on 05/15/2018 for Patient (Pt) #12 revealed a 45 year-old male that presented to the Emergency Department on 05/07/2018 at 0126 with a chief complaint of "overdose". Review of the record revealed Patient #12 was triaged by nursing staff at 0128 and a medical screening exam was completed by the physician at 0147. Review of vital signs documented at 0128 revealed Temperature (Temp) 97.0F, Heart Rate (HR) 104, Respiratory Rate (RR) 24 and Blood Pressure (BP) 178/112 with Oxygen Saturation (SPO2) of 95%. Review of the physician's orders revealed Ativan 1 milligram intravenously (IV) ordered on 05/07/2018 at 0147, 0154 and again at 0229. Further review of the physician's orders revealed Geodon 20 milligrams intramuscularly (IM) ordered on 05/07/2018 at 0154. Review of the Medication Administration Record revealed Patient #12 was administered Ativan 1 milligram IV at 0145, Ativan 1 milligram IV at 0155, Geodon 20 milligrams IM at 0158 and Ativan 1 milligram IV at 0232. Review of the Physician's Note dated 05/07/2018 at 0318 revealed Patient #12 was seen at 0147. Review of the physician note revealed Patient #12 presented with" Depression, Unclear Thinking, Suicidal Ideation, Plan: Overdose. ...HE ARRIVES TO THE ER (emergency room) AGGITATED AND STATING HE WANTS TO DIE. HE HAD TO BE RESTRAINED BY SEVERAL SECURITY PERSONELLE (sic) TO GET HIM SEDATED." Review of a nursing note documented on 05/07/2018 at 0331 by a Registered Nurse revealed "PT ARRIVED AT 0125 VIA EMS (Emergency Medical Services). EMS REPORTS PT TOOK 60 IBUPROFEN PM APPROX 30 MINUTES BEFORE ARRIVAL. PT UNCOOPERATIVE UPON ARRIVAL BUT EASILY REDIRECTED. ONCE STAFF ATTEMPTED TO GAIN IV ACCESS PT AGAIN BECAME UNCOOPERATIVE AND BEGAN SWINGING AT STAFF, UNABLE TO REDIRECT. SECURITY CALLED TO BEDSIDE. PT CONTINUED TO SWING AT STAFF, YELL AND KICK. RPD (local police department) ARRIVED TO ASSIST. PT PLACED IN HANDCUFFS BY POLICE WHO REMAINED AT BEDSIDE. PT MEDICATED PER MD ORDER. IV ACCESS OBTAINED AND I/O (In and Out) CATH. PT'S BELONGINS TO SECURITY. HANDCUFF REMOVED BY POLICE." Review of the medical record revealed a non-violent restraint order written by Physician #1 on 05/07/2018 at 0315 for soft wrist restraints, reason altered mental status and emergency situation; 4 siderails. Review of the medical record revealed no available documentation of a physician order to discontinue the restraint order. Further review revealed no available documentation in the Emergency Department record of restraint assessments or monitoring by nursing staff.

Telephone interview on 05/17/2018 at 1130 with RN #2 revealed she was the primary nurse for Patient #12 on 05/07/2018. Interview revealed the patient had an order for soft wrist restraints, which she states was never placed on the patient as he was sedated after medication administration and did not warrant wrist restraints. Interview revealed she informed the provider that she did not place the restraints on Patient #12 because of his sedation level. Interview revealed she was told by the physician to just "keep the order in case he (pt #12) wakes up again." Interview confirmed she did not document any restraint assessments or monitoring of restraints for Patient #12 and she did not discontinue the order for restraints.

Interview on 05/17/2018 at 1045 with the Emergency Department Manager revealed the nursing staff did not follow hospital policy for identifying the appropriate type of restraint, assessment and monitoring. Interview revealed during review of medical record that the only documentation was on 05/07/2018 at 0327 when the nurse acknowledged and completed the physician order for non-violent restraints. Interview confirmed there was no available documentation of restraint assessements or monitoring in the Emergency Department record.

Based on hospital policy and procedure review, open and closed medical record review, and staff interview, the facility's nursing staff failed to ensure a plan of care was initiated for 2 of 3 patients with Diabetes (Patient #8 and #21).

Findings included:

Review of the hospital's policy titled, "Interdisciplinary Admission Assessment and Reassessment, revised 09/2016, revealed " ...POLICY: Qualified individuals initially assess each patient's need for care ... These assessments continue throughout the patient's hospital stay. ...III. Assessing the status and identifying the needs of the patient are the basis for determining the care to be provided. ...C. REGISTERED NURSE ... 5. The registered nurse will develop an individualized interdisciplinary plan of care from the findings of the admission assessment. ..."

Review of the hospital's policy titled, "Written Plan of Service & Staff Composition", revised 11/2017, revealed " ...TREATMENT PLANNING: ...Those involved in the treatment planning process include ....primary therapist nursing ... They are responsible for the development of the individualized treatment plan and the review and evaluation and ongoing treatment. ...B. The treatment plan is ... It includes the following: 1. Complete identification of physical ...problems the patient is experiencing. ...2. Achievable goals of the patient that correspond to each identified problem that will be actively treated. 3. Measurable objectives (short-term goals) ...that will reflect progress in working toward the goal achievement. 4. Therapeutic approaches used by each discipline to assist the patient in meeting the treatment goals. ...9. Reassessment of patient status and patient progress in meeting the treatment plan goals is noted in the progress notes and weekly treatment plan review. ..."

1. Open medical record review on 05/15/2018 of Patient #8 revealed a 47-year-old female was admitted on 05/11/2018 for Depression, Suicidal Thoughts, and Chronic/Acute Alcohol Use. Review revealed the patient had multiple medical problems including insulin dependent diabetes mellitus (IDDM), hypertension, and pancreatitis. Review of the "Comprehensive Treatment Plan" dated 05/11/2018 revealed " ...Axis III - IDDM, Chronic Pain, and Pancreatitis" listed as active problems. Review of the "Master Problem List" failed to reveal "IDDM, Chronic Pain, and Pancreatitis" listed as active problems and did not include "Comprehensive Multidisciplinary Treatment Goals/Interventions". Review revealed the hospital's nursing staff failed to develop an individualized plan of care based on the patient's Axis III active problems per policy.

Interview on 05/17/2018 at 1330 with Nurse Manager (NM) #1 revealed a nursing plan of care should be initiated on admission and with any changes in patient's condition or identified problems. Interview revealed problems that are actively being treated should be included in the treatment plan with identified nursing interventions and goals. Interview revealed nursing staff failed to implement a treatment plan per policy.

2. Open medical record review on 05/16/2018 of Patient #21 revealed an 85 year-old female was admitted on 05/16/2018 for Bilateral Diabetic Foot Infection, Hypotension, and Dehydration. Review revealed the patient had multiple medical problems including IDDM. Review of the Interdisciplinary Plan of Care (IPOC) "Active Problem" list revealed IDDM was not identified as an active problem and did not include multidisciplinary treatment goals/interventions. Review revealed the hospital's nursing staff failed to develop an individualized plan of care for IDDM per policy.

Interview on 05/16/2018 at 1130 with NM #2 revealed a nursing plan of care should be initiated on admission for active problems and with any changes in patient's condition. Interview revealed a plan of care should have been initiated for IDDM on admission or at some point during the patient's stay. Interview revealed nursing staff failed to initiate a plan of care for an active problem per policy.

Based on hospital policy and procedure review, medical record reviews and staff interviews, the hospital nursing staff failed to administer medication as ordered and according to hospital policy for 2 of 3 sampled diabetic patients (#8 and #21).

Findings included:

Review on 05/15/2018 of the hospital's policy titled, "Admission of Patient", revised 01/2015, revealed " ...NURSING ACTIONS: ...10. Process and carry out Physician orders ..."

Review on 05/15/2018 of the hospital's policy titled "Standard Administration Times" reviewed 05/2017, revealed "...POLICY...Medications will be administered to patients at standard times according to the directions indicated by the prescriber on the order and the unit on which the patient is located. ...Q6H (every 6 hours)...0600, 1200, 1800, 2400 ..."

1. Open medical record review on 05/15/2018 of Patient #8 revealed a 47-year-old female was admitted on 05/11/2018 for Depression, Suicidal Thoughts, and Chronic/Acute Alcohol Use. Review revealed a physician's order dated 05/11/2018 at 1016 by FNP (Family Nurse Practitioner) #1 for blood glucose (BGC) checks at 0600, 1100, 1600, and 2200 (before meals and at bedtime [ACHS]). Review of the Medication Administration Record (MAR) revealed on 05/14/2018 the 1100 BGC was missed. Review failed to reveal documentation indicating why the 1100 check was missed.

Interview on 05/16/2018 at approximately 1130 with Director of Quality, Risk Manager, and Patient Safety Organization revealed the laboratory generates a new order for blood glucose testing when the patient's ID bracelet is scanned by the nurse, "similar to a reflex order off the first order". Interview revealed if nursing staff fail to scan the patient's ID bracelet, the new order is not generated and nursing staff are not prompted to obtain a glucose test at the designated time. Interview revealed, "This seems to be a 'fluke' with the system that the result did not upload." Interview confirmed nursing staff failed to follow physician orders for ACHS BGCs.

2. Open medical record review on 05/16/2018 of Patient #21 revealed an 85 year-old female was admitted on 05/16/2018 for Bilateral Diabetic Foot Infection, Hypotension, and Dehydration. Review revealed a physician's order dated 05/12/2018 at 1625 by MD #1 for blood glucose (BGC) checks every 6 hours (0600, 1200, 1800, and 2400) and regular sliding scale insulin before meals and at bedtime (0700, 1100, 1700, and 2200). Review of the MAR revealed BGC checks were performed before meals and at bedtime and not every 6 hours as ordered. Review failed to reveal an order clarification for the desired frequency of the BGC checks. Further review revealed a BGC check was not performed on 05/15/2018 before 1159 with no documentation indicating why the morning check was missed.

Interview on 05/16/2018 at 1330 with NM #1 (the nurse manager of the unit Patient #21 was assigned) revealed the order for BGC checks every 6 hours on 05/16/2018 at 1625 should have been clarified and changed to AC and HS to align with the sliding scale insulin order. Interview revealed she could not say why the 05/15/2018 morning BGC was missed and that the nurse who missed the check was not available for interview.

Interview on 05/17/2018 at 1130 with NM #1 revealed the order for BGCs was clarified and changed to AC and HS (0700, 1100, 1700, and 2200) on 05/16/2018 during the investigation. Interview confirmed nursing staff failed to follow physician orders for every 6 hour BGC and to perform the morning BGC check on 05/15/2018 with no documented reason why.

NC00136916