HospitalInspections.org

Based on document review and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician for 1 of 1 patients (P3) who was ordered restraints.

Findings include:

1. Review of the policy titled Restraints, Revised & Effective 6/2019, indicated the following:
Restraint Devices: The following list includes the restraining devices which have been approved for use in the hospital: Mittens. Soft wrist or ankle restraints. Vest restraint. Velcro.
The use of restraints must be in accordance with the order of a physician or other practitioner...

2. Review of the medical record (MR) of patient P3 indicated that Physician D10 ordered restraints beginning 12/25/20 at 1309 hours as follows: Restraint reason: Pull lines/tubes. Type: Soft Restraint. Lap Belt. Side Rails Up x 4. Restraint orders on 12/26/20 by D10 and on 12/27/20 by D10 indicated restraints were continued/ordered for Lap Belt and Side Rails Up x 4. Restraint flowsheet documentation indicated the following: On 12/25/20 at 1300 hours and 1500 hours the MR lacked documentation of any "Restraint Type". Restraint type documented beginning 12/25/20 at 1900 hours indicated soft wrist restraints (right and left) "Continued". The MR lacked documentation of Lap Belt restraint and/or Side Rails Up x 4 having been implemented as restraint types and lacked documentation of the orders having been changed/clarified for use of bilateral wrist restraints and/or no use of the Side Rails Up x 4.

3. On 5/19/21, beginning at approximately 1:45 PM, A6, Application Support Analyst, verified MR documentation of P3.

Based on document review and interview, it could not be determined that the Medical Staff (MS) conducted appraisals for 8 of 8 MS members (D1, D2, D3, D4, D5, D6, D7 and D8).

Findings include:

1. Review of the Medical Staff Bylaws, Approved 10/2019, indicated the following:
The primary responsibility delegated to each department is to implement and conduct specific review and evaluating activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in the Hospital. To carry out this responsibility, each department shall (not all inclusive): Monitor, on a continuing and concurrent basis, adherence to: Staff and Hospital policies and procedures; Sound principles of clinical practice; and Other regulations designed to promote patient safety. Credentialing criteria, minimum threshold criteria, high risk or high volume procedures. Submit written reports to the Medical Executive Committee... concerning: Findings of the Department's review and evaluation activities, actions taken theron, and the results of such action... Involve members of the Department in monitoring and evaluation of the quality care provided...

2. The credential files of physicians D1, D2, D3, D4, D5, D6, D7 and D8; lacked documentation periodic appraisals/performance evaluations and/or peer review of the members.

3. Review of incident reports indicated the following regarding patient P3: Event Date: 1/13/21. Brief Factual Description: Patient became unstable in PACU (Post-Anesthesia Care Unit). Patient had to be brought back into the operating room to assess for post op (operative) bleeding. The report indicated the physician involved was D2. *Note: Follow-Up Actions had been redacted from the report. Unable to determine actions taken/recommended. Resolution and Outcome information had been redacted from the report. Unable to determine if actions were performed/completed and/or effective.

4. The following was indicated in interview on 5/18/21:
Beginning at approximately 10:30 AM, A5, Regional Director of Risk and Patient Safety, an event on 1/13/21 involving physician D2, related to patient P3, was sent for PEER review.
Beginning at approximately 11:30 AM, A2, Accreditation Coordinator, upon re-request for evidence of MS evaluations/PEER review, indicated they (the administrative staff) were waiting to hear from legal if they could provide that documentation. A2 indicated that at this point, the documentation could not be provided. No further documentation was provided prior to exit.