HospitalInspections.org

Based on record review and interview the governing body failed to must ensure the medical staff were writing restraint orders daily for two of two (ID#8,9) medical records reviewed.

Findings: Record review of facility policy "Restraints and Seclusion Policy" reviewed 06/25/2023.
Continued use of restraints beyond the first 24-hours must be authorized by a provider renewing the original order or by issuing a new order if the
restraint use is clinically justified. Such renewal or new order should be issued no less often than once each calendar day and is based on examination of
the patient by the provider

Record review on 06/16/2023 at 1155 of patient (ID#8) medical record revealed the patient was admitted 06/08/2023 with a diagnosis of cardiogenic shock and restrained. The patient was restrained 06/08/2023 to current. Chart review revealed a missing restraint order on 06/13/2023.

Record review on 06/16/2023 at 1200 of the patient (ID#9) medical record revealed the patient was admitted on 06/07/2023 for ST-elevation myocardial infarction, intubated and restrained. Chart review revealed a missing restraint order for 06/08/2023.
Interview 06/16/2023 at 1255 with nurse (ID#58) during the chart review who stated" looks like we missed an order, we should have an order for restraints every day."

Based on observation and interview patients have a right to receive care in a safe setting by ensuring the crash carts are checked consistently.

Findings Include: Facility policy "Cardiopulmonary Resuscitation/Code Blue Response", dated 02/11/2018. Verification Process: Licensed staff will check CPR emergency crash cart at least each calendar day unit is operational with patients.

Observation on 06/16/2023 at 1145 of two crash carts revealed April, 2023: not checked on April 12, 25, 29, May 3,4, 9,15,29,23,26,29, in Trauma South and a second crash cart near EMS triage area, reviewed not checked in June 3, 5,6, and 15th.

Interview with staff (ID #54) during the tour, stated "yes we are missing a few, but they would go straight to the crash cart in triage in the room" and verified the crash carts should be checked daily.