HospitalInspections.org

Based on document review and interview, it was determined that in 1 of 5 (Pt #1) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure a written modification to the patient's care plan included restraint usage.

Findings include:

1. Hospital policy entitled "Restraints (for Medical/Surgical Purposes)," (effective date 4/11) required, "F. Documentation: Documentation of the episode of restraint, including start and stop times, is entered in the medical record utilizing the following:..4. Plan of Care."

2. The clinical record of Pt #1 was reviewed on 7/2/13 at approximately 2:00 PM. Pt #1 was a 93 year old female admitted on 3/30/13 with diagnoses of pneumonia and sepsis. Clinical documentation indicated that Pt #1 was in bilateral soft arm restraints at various intervals from 4/1/13 through 4/3/13. Pt #1's care plan dated 3/30/13 failed to include updated documentation to address usage of the restraint devices.

3. The findings were discussed with the Vice President of the Department of Nursing (VPDN) during an interview on 7/2/13 at approximately 2:00 PM. The VPDN verified that Pt #1's care plan lacked documentation to address usage of the restraint devices.

Based on review of documents and interview, it was determined that in 1 of 5 (Pt #1) clinical records reviewed of patients that were restrained, the Hospital failed to ensure a physician's order was obtained for the application of restraint devices.

Findings include:

1. Hospital policy entitled, "Restraints (for Medical/Surgical Purposes)," (effective 4/11) required, "E. Discontinuing Restraints: 1. Discontinuation from restraints is achieved by evaluating the patient for the following behaviors and safety factors: c. Availability of direct supervision, i.e. family. 3. Re-initiation of the restraints requires the entire process...physician order."

2. The clinical record of Pt #1 was reviewed on 7/3/13 at approximately 2:00 PM. Pt #1 was a 93 year old female admitted on 3/30/13 with diagnoses of pneumonia and sepsis. Clinical documentation indicated that Pt #1 was in bilateral soft wrist restraints from 8:12 AM until 10:58 AM on 4/1/13, at which time the family arrived and the restraints were removed. At 12:00 noon on 4/1/13 the restraints were reapplied and remained on until 8:30 AM on 4/2/13, without a physician's order.

3. The findings were discussed with the Vice President of the Department of Nursing (VPDN) during an interview on 7/5/13 at approximately 2:00 PM. The VPDN verified that Pt #1's record lacked a physician's order for the use of restraints during the above mentioned time frame.

Based on document review and interview, it was determined that in 3 of 3 (Pt #1, 4, and 5) clinical records reviewed of patients receiving tube feedings, the Hospital failed to ensure proper monitoring.

Findings include:

1. Hospital policy entitled, "Aspiration Precautions," (effective 5/11) required, "C. Swallowing Strategies/Safety Measures: 7. Enteral Feedings: a. Check NG or gastrostomy placement before feeding. b. Check residual before feeding, if indicated, i. check residuals every 6 hours during first 5 days of initiation. d. Keep head off bed elevated 30 degrees minimum at all times if patient receives enteral feedings. E. Documentation: 1. Related patient assessment, reassessments, interventions, care plan...must be documented in the electronic medical record.

2. The clinical record of Pt #1 was reviewed on 7/3/13 at approximately 2:00 PM. Pt #1 was a 93 year old female admitted on 3/30/13 with diagnoses of pneumonia and sepsis. Clinical documentation dated 3/30/13 at 4:30 PM included that Pt #1 was started on continuous tube feedings. Clinical documentation lacked every 6 hours gastric residual checks as required. Examples include: 4/1/13 at 1:00 AM until 4/1/13 at 5:00 PM (16 hrs); 4/2/13 at 4:30 PM until 4/4/13 at 9:48 AM (approximately 41 Hrs); and 4/5/13 at 12:00 AM until 4/5/13 at 5:00 PM (17 hrs). Pt #1's clinical record lacked documentation that the head of her bed was elevated the required 30 degrees while she was receiving her tube feedings.

3. The clinical record of Pt#4 was reviewed on 7/3/13 at approximately 9:15 AM. Pt #4 was a 93 year old female admitted on 12/16/12 with diagnoses of altered mental status and urinary tract infection. Clinical documentation dated 12/18/12 at 9:00 PM indicated that Pt #4 was started and continued on Dubhoff tube feedings with Jevity 20 milliliters per hour. Clinical documentation lacked every 6 hour gastric residual checks as required. Examples include: 12/25/12 from 2:00 AM until 10:00 AM (8 hours); 12/25/12 at 6:00 PM until 12/26/13 at 9:45 AM (15 hours 45 minutes); and from 12/26/12 at 9:49 AM until 12/29/12 at 11:53 AM (74 hours). With the exception of 12/26/12 at 2:23 AM and 12/30/12 at 4:18 AM, the clinical record lacked documentation that Pt #4's head of bed was elevated to the required 30 degrees.

4. The clinical record of Pt#5 was reviewed on 7/3/13 at approximately 9:15 AM. Pt #5 was an 81 year old male admitted on 5/13/13 with diagnoses of hypertension, diabetes mellitus and stridor. Clinical documentation dated 6/13/13 at 10:00 AM indicated that Pt #5 was started on Dubhoff tube feedings of Glucerna at 20 milliliters per hour on 5/25/13 and continued on feeding until 5/29/13. Clinical documentation lacked every 6 hour gastric residual checks as required. Examples include: 5/26/12 from 12:03 PM until 10:45 PM (10 hr 43 minutes); 5/27/13 from 12 :00 noon to 8:00 PM (8 hours); and 5/28/12 from 8:00 AM until 8:00 PM (12 hours). With the exception of 5/25/13 at 9:21 PM the clinical record lacked documentation that Pt #5's head of bed was elevated to the required 30 degrees.

5. The findings were discussed with the Vice President of the Department of Nursing (VPDN)during an interview on 7/5/13 at approximately 2:00 PM. The VPDN verified the lack of documentation as noted above, from the records of Pt. #s 1, 4, and 5.