HospitalInspections.org

Based on review of medical records, policies/procedures, restraint documentation, and staff interviews, it was determined the facility failed to ensure a registered nurse monitored patients in restraints for 2 of 4 patients restrained as evidenced by: non-licensed staff completing documentation for an emotional assessment and an assessment to determine whether restraints needed to be continued (Pt #'s 1 and 2).

Findings include:

The hospital policy titled Use of Physical or Chemical Restraints: General Requirements, revised 06/2011, required: "...The need for restraints must be continuously reevaluated...Discontinue use of restraints as soon as possible, based upon findings of re-assessments and reevaluations of the patient's conditions...Ongoing evaluation that assesses the potential use of less restrictive alternatives and ends use of the restraint at the earliest possible time...Documentation: Document the results of the comprehensive assessment in the Electronic Medical Record...Ongoing evaluation that assess the potential use of less restrictive alternatives and ends use of the restraint at the earliest possible time...Note: the above documentation can be made by any member of the health care team trained in restraint use (e.g. Nursing, Rehab, Respiratory Therapy, Nutrition Services, etc...."

The hospital job description and annual evaluation for the Patient Care Technician included: "...Able to release, remove, and reapply restraints to patient under the direction of a Registered Nurse. Ensures patient is in proper position and alignment...."

The hospital utilizes a flow sheet titled 24 Hour Restraint Order and Flow Sheet Documentation. This flow sheet is a paper form and not in the electronic medical record (EMR). The instructions on the flow sheet include: "...Documentation: Initial in the boxes the time the care is provided, at least every 2 hours. Note: Document any changes from the initial daily assessment in ProTouch (EMR). Sign name and Initial below...Plan of Care Interventions: Emotional Assessment: (for example agitated, confused, alert)**Initial if no change from daily assessment. If there is a change also place an asterisk * in the box and chart the information on ProTouch...Restraints removed during a temporary, directly supervised release to provide care such as toileting, feeding or bathing (NOTE...Assessment for continued use may be evaluated at this time)...."

Review of patient #1's medical record revealed the patient was admitted on 05/03/12, with a complex sternal wound requiring antibiotics.

The patient was restrained 05/07/12 through 06/06/12, intermittently.

On 06/05/12, at 1000 and 1200 hours a CNA indicated an emotional assessment and assessment for continued use of the bilateral wrist restraints was conducted. The registered nurse (RN's) indicated an assessment was conducted at 0800. The RN did not document on the restraint form for the emotional assessment and an assessment for continued restraint use at 1000 and 1200 hours.

On 06/04/12, at 0400 and 0600 hours a CNA indicated an emotional assessment and assessment for continued use of restraints was conducted. A registered nurse did not document at 0400 and 0600 hours on the restraint form for the emotional assessment and an assessment for continued restraint use.

On 05/31/12, at 0800 through 1800 hours a CNA documented an emotional assessment and assessment for continued use of restraints. A registered nurse did not document from 0800 through 1800 hours on the restraint form for the emotional assessment and an assessment for continued restraint use.

On 05/30/12, at 2000 through 0600 hours a CNA documented an emotional assessment and assessment for continued use of restraints. A registered nurse did not document from 2000 through 0600 hours on the restraint form for the emotional assessment and an assessment for continued restraint use.

On 06/07/12, the DQM confirmed CNA's documented conducting an emotional assessment and an assessment of the patients' needs for continued restraints. She confirmed a CNA may not conduct an assessment of a patient and this must be completed by an RN.

Review of patient 2's medical record revealed the patient was admitted on 04/24/12, with respiratory failure on a ventilator with multilobe pneumonia.

The patient's wrists were restrained 06/05/12 and 06/06/12.

On 06/04/12, at 0800 through 1600 hours a CNA documented an emotional assessment and assessment for continued use of restraints. A registered nurse did not document from 0800 through 1600 hours on the restraint form for the emotional assessment and an assessment for continued restraint use.

On 06/07/12, the DQM confirmed the CNA's documented conducting an emotional assessment and an assessment of the patients' needs for continued restraints. She confirmed a PCT may not conduct an assessment of a patient and this must be completed by an RN.

Based on review of policies/procedures, medical records, and staff interviews, it was determined the pharmacy failed to:

1. ensure a physician addressed an automatic stop order for sliding scale insulin therapy and contact the physician when no action was taken regarding the automatic stop order for 1 of 1 patient, whose blood sugar elevated to 355 and 385 on 06/05/12 and 06/06/12 (Pt #7);

2. implement monitoring for automatic stop orders of medications other than antibiotics, as required by policy; and

3. clarify medication orders for 1 of 1 newly admitted patient (Patient #10).

Findings include:

1. The hospital policy titled Automatic Stop Order Dates, revised 06/2011, required: "...The Facility will monitor medications for automatic stop dates to prevent interruption of medication therapy...If no action is taken by the physician on the day that the medication is expiring, pharmacy will need to contact the physician...Medication Automatic Stop Duration...Any medication not listed (includes insulin)...45 day (automatic stop)...."

Patient #7 was admitted on 04/17/12 with respiratory failure after a mitral valve replacement. The patient has a history of diabetes mellitus requiring insulin. The admitting physician ordered insulin determir 55 units daily and a sliding scale insulin for additional coverage. On 06/02/12, the sliding scale insulin no longer appeared on the medication administration record, therefore, nursing did not follow the sliding scale insulin order. Research of this order by the facility, with the Surveyor on 06/06/12 at 1530 hours, revealed that the sliding scale insulin was automatically stopped after 45 days. The Director of Quality Management (DQM) called the Director of Pharmacy to research the order. The Director of Pharmacy stated on 06/06/12 at 1545 hours, physicians are required to continue, discontinue or modify the order for the automatic stop medications. A physician has 72 hours to do this. No physician addressed the order for the sliding scale insulin and the order "went away."

The nurse caring for the patient was questioned about the elevated blood sugars and he indicated he didn't see an order for insulin, he then called the physician at 1553 hours and received a new order for the sliding scale insulin. The patient's blood sugar on 06/05/12 was 355 and on 06/06/12 the blood sugar was 385. The DQM confirmed the findings with the Surveyor while in the intensive care unit (ICU) reviewing Pt #7's medical record.

On 06/06/12, at 1600 hours, the Director of Pharmacy revealed that the hospital monitors automatic stop orders for antibiotics only and they are not monitoring other medications.

2. The hospital policy titled Automatic Stop Order Dates, revised 06/2011, required: "...An audit procedure will be implemented to monitor the effectiveness of the process, including physicians who are unresponsive to reminders, phone calls, etc. regarding this policy, and to identify opportunities for improvement. This data will be reported to the P&T (Pharmacy and Therapeutics) Committee, Quality Council and MEC (Medical Executive Committee)...."

On 06/06/12, at 1600 hours, the Director of Pharmacy verified the hospital is not auditing for all medication automatic stop orders, they are monitoring antibiotic stop orders only.

3. The hospital policy titled Medication Reconciliation, revised 06/2011, required: "...Medication Reconciliation is a multidisciplinary process involving the Licensed Independent Practitioner (LIP), Pharmacist and Nurse...Patients admitted from a short-term acute care hospital...or other health facility: The nurse/pharmacist, LIP reviews the Discharge Medication Lists provided by the transferring facility...For all admissions, address any discrepancies between the admission reconciliation list and the admitting medication orders with the LIP...."

Patient #10 was admitted on 06/06/12 at 1913 hours, with acute respiratory failure post coronary artery bypass grafting. The admitting nurse entered the following medication reconciliation orders into the computer system:
"...Potassium chloride: PO (orally) tab, 40 mEq (mili-equivalent); K (potassium) 3.6 - 4.0 q1h prn hypokalemia (every one hour, as needed, for low potassium);
Potassium chloride: PO tab, 80 mEq K (less than) 3.1 q1h prn hypokalemia;
Potassium chloride: PO tab, 20 mEq K 4.1 - 4.4 q1h prn hypokalemia;
Magnesium sulfate: IVPB (intravenous piggyback) inj(ection), 3 gm (grams) Mg (magnesium)...q1h prn magnesium replacement;
Magnesium sulfate: IVPB inj 4 gm Mg (less than 1.5) q1h prn low magnesium;
Magnesium sulfate: IVPB inj 2 gm Mg 2.1 - 2.3 q1h prn low magnesium;
Glucose tab(let): PO tab; 8 tab q1h prn hypoglycemia;
Glucose tab: PO tab; 4 tab q1h prn hypoglycemia;
Glucagon: IM (intramuscular) inj, 1 mg (milligram) q1h prn hypglycemia (sic);
Diazepam: IV push inj, 5 mg, q1h prn mild agitation, moderate agitation, severe agitation...."

The medication reconciliation recorded in the patient's medication administration record (MAR) was verified and signed-off by the pharmacist on 06/07/12 at 0933 hours. The Surveyor interviewed the pharmacist who approved the medication reconciliation for the MAR on 06/06/12 at 1012 hours. She confirmed she approved the medication reconciliation orders for the patient. She was asked to explain the q1h prn orders for the PO Potassium, Magnesium, and the IV Diazepam orders. She could not tell the Surveyor the amount of medication a nurse could give when administering q1h prn medications, the order did not include a maximum amount. She said she copied the medication reconciliation from the sending facility as it was listed. The sending facility had other protocols listed with their orders that this facility did not. She agreed she should have called the physician to clarify the orders and confirmed it was the pharmacy's responsibility to do this prior to approving the medications for the MAR.