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Based on interview and record review the hospital failed to document the application of physicial restraint (means of purposely limiting or obstructing the freedom of a person's bodily movement) accordance with hospital policy for one of thirty sampled patients (Patient 1), when the licensed nurse failed to document Patient 1's physical restraint application on 8/15/24.

The lapse in documentation resulted in inaccurate record of what took place and increased the risk of restricting circulation to limbs.

Findings:

Review of Patient 1's physician progress notes, dated 8/15/24 at 4:55 p.m., indicated the patient had multiple code grays (summoning security personnel to assist with combative or aggressive persons) this afternoon for agitation. The note indicated Patient 1 required 4 point (both wrists and ankle) restraints and three medications by injection.

Patient 1 had a physician's order, dated 8/15/24 at 6:21 p.m., to apply four limb restraints for violent behavior. There was no nurses note indicating the patient had problem behaviors, was placed on 4-point restraints and duration of use, received medications, had security staff involvement and the outcome of the incident.

During an interview on 9/26/24 at 10:40 a.m., the clinical director of quality services who reviewed the record stated she spoke with the nurse manager yesterday to confirm the patient was restrained and could not find nursing assessment documentation for the restraint use.

Review of the Restraint policy, dated 11/2023, indicated for violent, self-destructive behavior to conduct an assessment to include level of distress, agitation, mental status and cognitive functioning and continuosly observe the patient. The registered nurse was to document in the patient's medical record of initial asssessment, the type of restraint used, care provided, results of assessment and monitoring and note the decsion to discontinue.

Based on interview and record review the hospital failed to ensure hospital policy was followed when a patient had the wrong lesion removed from her arm for one of seven sampled surgical patients (Patient 4). The hospital also failed to follow physician's order when a contrast (dye) was mistakenly administered to one of five sampled patients (Patient 5). These failures had the potiential to cause patient health complications.

Findings:

1. Review of Patient 4's brief operative note, dated 11/6/23 at 5:51 p.m., indicated the patient underwent a surgical procedure to remove a melanoma (type of skin cancer) to the left arm. The long operative note, dated 12/7/23 at 12:52 p.m., indicated Patient 1 had a second surgery to remove the melanoma in her left arm.

During an interview on 9/26/24 at 11:33 a.m., the quality nurse stated the patient unfortunately had two moles on her left upper arm. The surgeon marked her intials on the patient's left arm, did not circle the intended mole and took out the wrong one. The next day the patient noticed the wrong mole was removed and she informed the doctor

Review of the Universal Protocol - Patient, Procedure and Site Verification policy, dated 09/2022, indicated the policy was a risk-reduction strategy that was designed to ensure correct site for all operative or invasive procedures and indicated the mark was to be "unambiguous."

2. Review of Patient 5's progress note, dated 12/19/24 at 6:16 p.m., indicated the patient was scheduled to undergo a computed tomography (CT, a medical imaging procedure that uses X-rays to create detailed images of the body) scan of the urinary tract with non-contrast due to elevated creatinine (test of a chemical to see how well a person's kidney work). The note indicated a CT technician had notified the physician about half of the intravenous (IV) contrast had been administered during the procedure before it was noticed.

During an interview on 9/26/24 at 1:33 p.m., the assistant director of imaging services stated the CT technician who administered the IV contrast should have check the physician's order and creatinine lab results before the procedure.

Review of the undated STOP! CT Technologist Exam Checkist indicated prior to bringing the patient into the exam room to check labs, allergies and prior studies. It also indicated prior to making the first exposure to double-check the exam (physician order) to be performed.