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Based on policy review, medical record review and staff interview the hospital failed to ensure a physician's order for restraint for 1 of 2 sampled restrained patients (#10).

The findings include:

Based on current hospital policy entitled, "Restraint & Seclusion Medical & Behavior, Including Behavioral Health Services" dated 08/12/2008 revealed, "...A physician/ALP (Advanced Level Practitioner) time-limited order is to be obtained for each use of restraint....Additional requirements for VIOLENT/SELF DESTRUCTIVE restraint use (Behavioral):...Physician/ALP orders for violent/self destructive (Behavioral) restraints are limited to : Adults (18 years and older) - 4 hours....The RN (registered nurse) will...obtain a new physician order in order to continue restraints every: 4 hours for adults...."

Open medical record review on 02/03/2010 for Patient # 10 revealed a 48 year-old male that was admitted to the behavioral health unit on 01/29/2010 with schizophrenia. Record review revealed documentation the patient was combative, verbally threatening, agitated and uncooperative on 01/31/2010 and was placed in 4 point restraints at 1640. Record review revealed documentation the patient continued to exhibit violent behaviors and remained in 4 point restraints until 02/02/2010 at 1500, at which time he was noted to be calm and cooperative and restraints were removed. Record review revealed no documentation of physician's orders for the patient to be restrained between 1550 on 02/01/2010 and 0750 on 02/02/2010 (16 hours).

Interview on 02/03/2010 at 0920 with the physician medical director of the behavioral health unit revealed the physician must reorder restraints every 4 hours while a patient is in restraints for behavioral reasons, such as violence and combativeness. Interview revealed the nurse calls the physician every 4 hours to report the patient's behavior and the physician reorders restraints, if the patients behavior continues to warrant restraints.

Interview on 02/03/2010 at 1030 with a registered nurse revealed the nurse had worked on the behavioral health unit for about 11 years. Interview revealed the nurse must reassess a patient in restraints for behavioral reasons at least every 4 hours and report her findings to the physician. Interview revealed the physician must then reorder restraints at least every 4 hours if the physician determines the patient's behavior continues to warrant restraints.

Interview on 02/03/2010 at 1420 with administrative nursing staff confirmed there was no documented evidence of physician's orders for the restraint of Patient #10 between 1550 on 02/01/2010 an 0750 on 02/02/2010 (16 hours).

Based on policy review, medical record review and staff interview the hospital's nursing staff failed to monitor a restrained patient per policy for 2 of 2 sampled restrained patients (#10, #5).

The findings include:

Based on current hospital policy entitled, "Restraint & Seclusion Medical & Behavior, Including Behavioral Health Services" dated 08/12/2008 revealed, "...Additional requirements for VIOLENT/SELF DESTRUCTIVE restraint use (Behavioral):...The RN (registered nurse) will perform and record a 'face to face' reassessment...every: 4 hours for adults....Patients require continuous assessment and monitoring of the physical and psychological well-being of the client, circulation, and safe use of physical restraint throughout the duration of the restrictive intervention by staff who are physically present....The monitoring for these issues will be documented at least every 15 minutes...."

1. Open medical record review on 02/03/2010 for Patient # 10 revealed a 48 year-old male that was admitted to the behavioral health unit on 01/29/2010 with schizophrenia. Record review revealed documentation the patient was combative, verbally threatening, agitated and uncooperative on 01/31/2010 and was placed in 4 point restraints at 1640. Record review revealed documentation the patient continued to exhibit violent behaviors and remained in 4 point restraints until 02/02/2010 at 1500, at which time he was noted to be calm and cooperative and restraints were removed. Record review revealed no documentation that staff assessed the patient's circulation and skin integrity while the patient was in 4 point restraints on 02/01/2010 from 0800 - 1100 (3 hours), 1430 - 1500 (30 minutes), 2230 - 2300 (30 minutes) and 2330 - midnight (30 minutes) and on 02/02/2010 from 0515 - 0600 (45 minutes), 0630 - 0700 (30 minutes), 0730 - 0800 (30 minutes) and 1330 - 1400 (30 minutes).

Interview on 02/03/2010 at 1030 with a registered nurse revealed the nurse had worked on the behavioral health unit for about 11 years. Interview revealed staff must continuously stay in the room with a patient in 4 point restraints. Interview revealed the staff must assess the patient's skin integrity and circulation around the restraints every 15 minutes and document the assessment on the restraint flowsheet.

Interview on 02/03/2010 at 1420 with administrative nursing staff confirmed there was no documented evidence that staff assessed the patient's circulation and skin integrity while the patient was in 4 point restraints on 02/01/2010 from 0800 - 1100 (3 hours), 1430 - 1500 (30 minutes), 2230 - 2300 (30 minutes) and 2330 - midnight (30 minutes) and on 02/02/2010 from 0515 - 0600 (45 minutes), 0630 - 0700 (30 minutes), 0730 - 0800 (30 minutes) and 1330 - 1400 (30 minutes).

2. Closed medical record review for Patient #5 revealed a 49 year-old male that was admitted to the behavioral health unit on 12/28/2009 with bipolar disorder. Record review revealed the patient was discharged on 01/06/2010. Record review revealed documentation the patient was combative, verbally threatening, agitated and uncooperative on 01/02/2010 and was placed in 4 point restraints at 0050. Record review revealed documentation the patient continued to exhibit violent behaviors and remained in 4 point restraints until 01/04/2010 at 1537, at which time he was noted to be calm and cooperative and restraints were removed. Record review revealed no documentation that the RN reassessed the patient while the patient was in 4 point restraints on 01/02/2010 from 0450 - 0945 (4 hours and 55 minutes) and from 2212 - 0450 on 01/03/2010 (6 hours and 38 minutes).

Interview on 02/03/2010 at 1030 with a registered nurse revealed the nurse had worked on the behavioral health unit for about 11 years. Interview revealed the nurse must reassess a patient in restraints for behavioral reasons at least every 4 hours and document the assessment in the medical record.

Interview on 02/03/2010 at 1420 with administrative nursing staff confirmed there was no documented evidence that the RN reassessed the patient while the patient was in 4 point restraints on 01/02/2010 from 0450 - 0945 (4 hours and 55 minutes) and from 2212 - 0450 on 01/03/2010 (6 hours and 38 minutes).

Based on policy review, closed medical record review and staff interview the hospital's nursing staff failed to administer medication per physician's orders for 1 or 7 sampled inpatients (#6)

The findings include:

Review of current hospital policy entitled "Medication Administration" dated 10/2009 revealed, "...Prior to administration: a. Verify that the medication selected matches the medication order and product label....f. Verify the medication if being administered at the proper time, in the prescribed dose...."

Medical record review for Patient #6 revealed a 58 year-old female that was admitted to the behavioral health unit on 12/30/2009 with major depression. Record review revealed the patient was discharged on 01/03/2010. Review of physician's admission orders dated 12/30/2009 at 1530 revealed, "morphine sulfate er (extended release narcotic pain medication) 15 mg (milligrams) - one tablet twice daily." Review of physician's orders dated 12/30/2009 at 1830 revealed, "Oxycodone (narcotic pain medication) 15 mg po prn (by mouth as needed) up to five times daily. Wait 2 hours between doses." Review of the MAR (Medication Administration Record) dated 01/03/2010 revealed, "morPHINE SULFATE 15 MG TAB....DOSE: 15 mg PO TWICE A DAY....(doses due at 0900 and 2100)....OXYCODONE HCL 5 MG TABLET...DOSE: 15 MG = 3 TABLETS PO EVERY TWO HOURS ...DOSE INSTR(UCTIONS): 15 MG = 3 TABLETS..." Record review revealed documentation on 01/03/2010 at 0741 the nurse gave the patient 45 mg of Morphine Sulfate. Review of nurse's notes dated 01/03/2010 revealed, "(0842 -) Pt (patient) was given morphine sulfate extended release 45 mg PO at 0741. Vital signs taken. Pt is alert, oriented and upset. (Name of physician) was made aware and no new orders were given....Will continue to monitor closely....(1414 - ) Pt verbalized...concerns to (name of physician). Speech was clear however complained of feeling like her periorbital area was numb. Will hold off on discharge until pt denies any side effects and feels alert enough for discharge....(1210 - ) Pt resting in bed. Easily awakens when name called. Pt states she feels 'Alright'....(1659 - ) Discharge note: Pt discharged to home at 1640....Pt was alert and oriented per assessment of writer and (name), Nursing Shift Supervisor...."

Review of a hospital document entitled, "Patient Safety Net Administrative Review" dated 01/03/2010 revealed documentation by the nurse that administered 45 mg of Morphine Sulfate ER to Patient #6 on 01/03/2010 at 0741. Document review revealed, "Pt requested dose of Roxicodone (Oxycodone) 15 mg. = 3 tabs. On the Pyxis (automated drug dispensing machine) Pt profile MS Contin (Morphine Sulfate ER) was together with Roxicodone 15 mg. Both doses had 15 mg. When I touched the screen the drawer opened for MS Contin and I removed 3 tabs which caused a dose of 45 mg. to be adm(inistered) instead of 15 mg. Both pt and pharmacy staff were in pyxis room and talking which also distracted me."

Interview on 02/03/2010 at 1230 with a pharmacist revealed the nurse that gave the patient 45 milligrams of Morphine Sulfate ER on 01/03/2010 at 0741, called the pharmacist and reported the error to her immediately after it happened. Interview revealed when staff enter the patient's name into pyxis, the screen shows all of the medications ordered for the patient. Interview revealed staff then touches the name of the medication they want to give and then the next screen shows the dose ordered for that particular medication. Interview revealed, "She was concerned the two medications showed up on the (pyxis) screen one under the other. She thought she had selected Oxycodone."

Interview on 02/03/2010 at 1430 with the Vice President (VP)of Patient Care Services confirmed available documentation showed the nurse administered the wrong dose of Morphine Sulfate ER to Patient #6. Interview revealed the nurse was not available for interview.


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