HospitalInspections.org

Based on review of patient's clinical record and and hospital policy and procedure, the hospital failed to ensure the Behavioral Health Unit's Master Treatment Plan was updated when a patient was placed in restraint or seclusion for 2 of 37 sampled patients (#36 and 37). The findings are:

A. Review of Patient #36's seclusion order dated 08/24/10 revealed the patient was placed in seclusion for being physically violent. Review of the patient's Master Treatment Plan revealed no updates or entries regarding justification for seclusion for violent behavior.

B. Review of Patient #37's restraint order dated 09/23/10 revealed the patient was placed in restraints. Review of the patient's Master Treatment Plan revealed no updates or entries regarding justification for the restraint.

C. Review of the hospital's policy and procedure titled, "Restraint and Seclusion," effective 02/2010, revealed "General Provision #8" that read, "Care Plan: The restrained or secluded patient's written plan of care shall be modified to address appropriate interventions implemented..."

Based on review of patient's clinical record and staff interview, the hospital failed to ensure chemical restraint orders were not written as "PRN [as needed]" for 2 of 37 sampled patients (#33 and 34). The findings are:

A. Review of Patient #33's physician's orders revealed an order dated 10/10/10 written by the doctor that read, "Ativan 1 mg [milligram] IV [intravenous] q [every] 4h [four hours] prn [as needed] aggitation [sic]."
1. Further review of the physician's orders revealed a telephone order dated 10/27/10 that read, "1 mg Ativan IV q 4 hrs PRN."
2. On 11/04/10 at 9:15 am, during an interview, Registered Nurse #2 confirmed the orders were written as PRN and stated that they should not have been written in that manner.

B. Review of Patient #34's physician's orders revealed an order dated 10/31/10 written by the doctor that read, "change Ativan to 1-2 mg IV q 4 hours prn, agitation/anxiety."
1. Further review of the physician's orders revealed an order dated 11/01/10 written by the doctor that read, "Haldol 5 mg IV Q 4 hours prn agitation."
2. On 11/04/10 at 11:30 am, during an interview, the ICU Assistant Manager confirmed the orders were written as PRN and stated that they should not have been written in that manner.

C. Review of the hospital's policy and procedure titled, "Restraint and Seclusion," effective 02/2010, revealed "General Provision #4" that read, "4. PRN Orders: "As needed" orders for restraint or seclusion shall not be used."

Based on record review, facility medical staff bylaws, policies and procedures, and staff interviews, the facility failed to ensure that all patient medical record entries, including physician order entries and progress notes were either dated, timed or authenticated in written form within the 72-hour time frame in accordance with state law for 3 of 32 sampled patients (#17, 18 and 31). The findings are:

A. Review of the facility's Bylaws of the Medical Staff Organization, approved on 05/26/10 by the governing body, revealed the following: "All verbal orders shall be transcribed in the proper place in the medical record, shall include the date, time, name and signature of the person transcribing the order and the name of the practitioner, and shall be countersigned by the practitioner within 72 hours in accordance with state law...All clinical entries in the patient's record must be accurately dated, timed and individually authenticated...The following areas of the medical record require the responsible practitioner's signature: Admission progress notes and orders, history and physical examination, narcotic orders and all clinical entries, diagnoses, order, reports and progress notes personally given or written by him."

B. Review of Patient #17's medical record revealed that 7 out of 55 physician order entries were not signed by a physician in a timely manner. Record review of progress notes revealed that 14 out of 48 physician entries were either not signed nor timed by the physician in a timely manner.

C. Review of Patient #18's medical record revealed that 5 out of 56 physician order entries were not signed by a physician in a timely manner. Record review of progress notes revealed that 3 out of 35 were either not signed nor timed by the physician in a timely manner.

D. On 11/03/10 at 12:00 pm, during interview the Clinical Director of Patient Care Services and the Surgical Floor Nurse Manager, both confirmed that physician order and progress note entries were either not signed nor timed by the physicians in a timely manner for Patients #17 and 18.


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E. Review of Patient #31's electronic medical record revealed two documents that had not been electronically signed by the patient's physician. The first was a verbal order for normal saline, 75 ml/hr. The order was dated 09/01/10, 2005 hours. The second was the patient's discharge summary, transcribed 09/06/10, 5:27 pm.
1. On 11/04/10 at 10:00 am, the Manager, Health Information Management, verified the absence of the physician's electronic signature on these two documents.

Based on record review and interview, the facility failed to ensure that a medical history and physical examination was completed no more than 30 days before or 24 hours after admission and prior to a surgical procedure for 1 of 32 sampled patients (#32). The findings are:

A. Review of patient #32's electronic medical record revealed a presurgical history and physical examination that was performed on 07/06/10. Further medical record review revealed that the surgical procedure was not performed until 08/23/10. Additionally, the patient's medical record contained no documentation that a presurgical update was performed prior to the procedure.
1. On 11/04/10 at 10:00 am, the Manager, Health Information Management, verified that greater than 30 days had elapsed between the patient's presurgical history and physical examination and the date of surgery. She also verified that the record contained no documentation of a presurgical update.