HospitalInspections.org

Based on hospital document review and medical record review and staff interviews, it was determined that the facility failed to renew orders for restraints per facility policy for 1 out of 3 medical records that were reviewed for patients in restraints (Patient #4).

Hospital Policy "Restraints" and "Restraints, 571" states:
"Definitions ...Emergency Behavioral Situation (Restraint) - A serious disruption which impacts the therapeutic environment in which the patient's behavior poses a serious and imminent danger to the physical safety of self, staff and others and non-physical interventions would not be effective ...Time limits ...Emergency Behavioral ...Patient's 18 and older - Order must not exceed 4 hours ...If restraint use continues to be clinically justified beyond the time limits noted above, the LIP (Licensed Independent Practitioner)/designee must issue a new time-limited order."

Medical Record Review for Patient #4 revealed:
Per ED [Emergency Department] Provider Notes on 8/10/21:
"11:10 AM ...the patient did become aggressive towards staff members and struck one of the nurses. She did require both chemical and physical restraints for the safety of herself and staff."

Per Flowsheets, Restraints:
-On 8/10/21 at 11:30 am the following restraints were applied: side rails up, soft restraint to the right and left wrists and right and left ankles.
-On 8/10/21 at 11:45 pm the following restraints were discontinued: side rails up, soft restraint to the right and left wrists and right and left ankles.

Per Order History:
-On 8/10/21 at 10:54 am a new order to "apply restraints violent or self-destructive adult" was placed with an interval of "Continuous x 4 hours". This order expired at 2:54 pm.
-On 8/10/21 at 9:22 pm a new order to "apply restraints violent or self-destructive adult" was placed with an interval of "Continuous x 4 hours". This order expired at 1:12 am on 8/11/21.
-No evidence of renewal of orders for emergency behavioral restraints between 10:54 am and 9:22 pm (10 hours and 28 minutes).
This finding was confirmed by Clinical Data Specialist A on 6/16/22 at 11:20 am.

Based on hospital document review and medical record review and staff interviews, it was determined that the facility failed to monitor patients in restraints per facility policy for 2 out of 3 medical records that were reviewed for patients in restraints (Patients #4 and 7).

Hospital Policy "Restraints" and "Restraints, 571" states:
"Time frames for monitoring are: Non-Behavioral Restraints - Every 2 hours ...Emergency Behavioral Restraints - Every 15 minutes ...the following components are reassessed/offered: ...Nutrition needs. Hydration needs. Elimination needs ....Readiness for discontinuation ...Documentation of monitoring/assessment will be on the Restraint Monitoring Flow Sheet at the timeframes noted above ...Special Requirements for Emergency Behavioral Restraint ...Staffing will be adjusted to provide 1:1 continuous monitoring for patients placed in behavioral restraints by an assigned, trained staff member ...Emergency Behavioral Restraint Re-evaluation and Reassessment Time Frames ...reassessment by competent staff ...Every 15 minutes ...Reevaluation by LIP/designee, RN, or Qualified Individual ...4 hours ....In-person Re-evaluation by the LIP/designee ...8 hours ..."

Medical Record Review revealed:
A) For Patient #4 - violent or self-destructive behavioral restraints
Per Order History:
On 8/10/21 at 10:54am a new order to "apply restraints violent or self-destructive adult" was placed with an interval of "Continuous x 4 hours".

Per Flowsheets, Restraints:
-On 8/10/21 at 11:30 am the following restraints were applied: side rails up, soft restraint to the right and left wrists and right and left ankles.
-RN reassessments were documented at: 11:30am, 12:29pm, 2:17pm, and 9:15pm on 8/10/21.
-On 8/10/21 at 11:45Pm the following restraints were discontinued: side rails up, soft restraint to the right and left wrists and right and left ankles.

No evidence of reassessment of a patient in emergency behavioral restraints by a LIP/designee, RN or qualified individual every 4 hours between 2:17pm and 9:15pm on 8/10/21 (6 hours and 58 minutes). This finding was confirmed by Clinical Data Specialist A on 6/16/22 between 11:36am and 11:48am.

Reassessments occurring at 12:29 pm and 2:17 pm show no evidence of reassessment of or offering nutrition or hydration, and elimination. This finding was confirmed by Clinical Data Specialist A on 6/16/22 at 11:36am.

Reassessments occurring at 9:15pm shows no evidence of reassessment of or offering nutrition or hydration. This finding was confirmed by Clinical Data Specialist A on 6/16/22 at 11:36am.

Per Constant Watch Flowsheet:
1:1 continuous monitoring began at 1pm on 8/10/21.

No evidence of 1:1 continuous monitoring of a patient in emergency behavioral restraints from time of application at 11:30am to 1pm [1.5 hours] on 8/10/21. This finding was confirmed by Clinical Data Specialist A on 6/16/22 at 11:11am.

No evidence of every 15 minute checks of a patient in emergency behavioral restraints from time of application at 11:30am to 1pm [1.5 hours] on 8/10/21. This finding was confirmed by Clinical Data Specialist A on 6/16/22 at 11:12am.

Per ED [Emergency Department] Provider Notes on 8/10/21:
"11:10 AM ...the patient did become aggressive towards staff members and struck one of the nurses. She did require both chemical and physical restraints for the safety of herself and staff."

Per Hospitalist - History and Physical Note on 8/10/21 at 2:27pm:
"Patient remains confused, becomes intermittently agitated, moving all 4 extremities, speaking incomprehensible words"

No evidence of in-person re-evaluation by the LIP/designee every 8 hours between 2:27pm and removal of restraints at 11:45pm on 8/10/21 (1 hour and 18 minutes late). This finding was confirmed by Clinical Data Specialist A on 6/16/22 at 11:48am.

B) Patient #7 - non-behavioral restraints
Per Order History:
On 6/12/22 at 11:29am a new order to "apply restraints non-violent or non-self-destructive" was placed with an interval of "Continuous x 24 hours". The order expired at 10:59 am on 6/13/22.

Per Flowsheets, Restraints:
-At 11:00am on 6/12/22 mitt restraints were applied to the right and left upper extremities of the patient.

No evidence of RN restraint reassessments every 2 hours between 12:00am and 8:00am on 6/13/22 (8 hours). This finding was confirmed by Clinical Data Specialist A on 6/16/22 between 2:18pm and 2:19pm.

Based on hospital document review, medical record review, employee record review, and staff interviews it was determined that the facility failed to ensure that all nurses providing services in the hospital adhered to the policies and procedures of the hospital for 3 out of 8 patient records sampled (Patients # 1, 2, and 6) and 2 out of 4 employee records sampled (RN A and Patient Care Coordinator A).

I. Hospital Policy "Hygiene, Provision of Patient, 2000" states:
"Complete/assisted/self bath including oral/denture care will be provided daily and prn [as needed]"

Medical record review revealed:
A) Patient #1 (admission 6/9/22 - 6/13/22)
No evidence of daily bath on 6/10/22 and 6/11/22.
This finding was confirmed by Stroke Coordinator A on 6/15/22 at 1:26pm.

B) Patient # 2 (admission 12/30/20 - 1/4/21)
No evidence of daily bath on 12/31/20 and 1/2/21.
This finding was confirmed by Clinical Data Specialist A on 6/14/22 between 11:31am and 12:55pm.

C) Patient # 6 (admission 8/24/21 - 8/31/21)
No evidence of daily bath on 8/28/21 and 8/29/21.
This finding was confirmed by Director ICU A on 6/16/22 at 10:43am.

II. Hospital Policy "Required Immunizations" states:
"All team members are encouraged to receive the Hepatitis B vaccine due to the potential for blood and body fluid exposure. If a team member is not receiving the vaccination, a declination is required."

Employee record review revealed:
RN A and Patient Care Coordinator A had no evidence of having received the Hepatitis B vaccine, immunity, or a declination.
This finding was confirmed by Director of Patient Safety A on 6/16/22 at 11:57am.