HospitalInspections.org

Based on interview and record review, the hospital failed to ensure all nurses' notes were written when 1 of 18 sampled patient records (#18).

Findings:

Review of the concern log revealed patient #18 was restrained. According to the risk manager (RM), the patient was "cheeking" (holding in his cheek and not swallowing) his medications, and was asked to open his mouth so staff could check to see if he swallowed the medications. The patient became combative, a physical hold was applied, and a Code Gray was initiated. While restrained hands-on, the patient turned blue, cardiopulmonary resuscitation (CPR) was intiaited, and emergency medical services (EMS) was called. The RM said it is unknown if the patient aspirated or if it was due to the restraint hold. An investigation of all involved staff was performed, with statements obtained. The behavioral health technician (BHT) involved in the physical hold restraint was placed on administrative leave and never came back of his own will. The Department of Children and Families (DCF) was notified of the event on 11/29/17. The event was reported to the Centers for Medicare and Medicaid Services (CMS) on 12/04/17, and to the hospital accrediting organization, the Commission on Accreditation of Rehabilitation Facilities (CARF) on 12/20/17.

Patient #18's closed medical record contained a "Close Obervation Flow Record", dated 11/28/17, read, "The client hit....in the face and at 20:45 (8:45 PM), they call the Code Gray & try to handle the situation till more people came and help after that they call a Code Blue and the paramedic came and they took him to the hospital." This note was written by a BHT. A Code Gray means a patient is being restrianed and requires staff assistance. A Code Gray means the patient required CPR.

A nurse's note, dated 11/28/17 at 11:04 AM, reflected that the patient was "visable doing his usual pacing....mood is improving....does show his face at intervals....does not interact with anyone...." A nurse's note was written at 12:06 AM on 11/29/17, but at 12:14 AM, the next nurses's note read, "Previous note dated 11/29/17 @ 1206 am submitted in error." No other nurses' notes about the Code Gray and the Code Blue were reflected in patient #18's medical record.

At approximately 3 PM on 1/04/19, the director of nursing (DON) was asked to review the patient's medical record and find the last nurse's note which would reflect the occurances of the Code Gray and the Code Blue. She was unable to find any nurses' notes about the occurances of 11/28/17.

Based on interview and record review, the hospital failed to ensure all nurses' progress notes were recorded for 1 of 18 sampled patients (#18).

Findings:

Review of the concern log revealed patient #18 was restrained. According to the risk manager (RM), the patient was "cheeking" (holding in his cheek and not swallowing) his medications, and was asked to open his mouth so staff could check to see if he swallowed the medications. The patient became combative, a physical hold was applied, and a Code Gray was initiated. While restrained hands-on, the patient turned blue, cardiopulmonary resuscitation (CPR) was intiaited, and emergency medical services (EMS) was called. The RM said it is unknown if the patient aspirated or if it was due to the restraint hold. An investigation of all involved staff was performed, with statements obtained. The behavioral health technician (BHT) involved in the physical hold restraint was placed on administrative leave and never came back of his own will. The Department of Children and Families (DCF) was notified of the event on 11/29/17. The event was reported to the Centers for Medicare and Medicaid Services (CMS) on 12/04/17, and to the hospital accrediting organization, the Commission on Accreditation of Rehabilitation Facilities (CARF) on 12/20/17.

Patient #18's closed medical record contained a "Close Obervation Flow Record", dated 11/28/17, read, "The client hit....in the face and at 20:45 (8:45 PM), they call the Code Gray & try to handle the situation till more people came and help after that they call a Code Blue and the paramedic came and they took him to the hospital." This note was written by a BHT. A Code Gray means a patient is being restrianed and requires staff assistance. A Code Gray means the patient required CPR.

A nurse's note, dated 11/28/17 at 11:04 AM, reflected that the patient was "visable doing his usual pacing....mood is improving....does show his face at intervals....does not interact with anyone...." A nurse's note was written at 12:06 AM on 11/29/17, but at 12:14 AM, the next nurses's note read, "Previous note dated 11/29/17 @ 1206 am submitted in error." No other nurses' notes about the Code Gray and the Code Blue were reflected in patient #18's medical record.

At approximately 3 PM on 1/04/19, the director of nursing (DON) was asked to review the patient's medical record and find the last nurse's note which would reflect the occurances of the Code Gray and the Code Blue for patient #18. She was unable to find any nurses' notes about the occurances of 11/28/17.