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Based on interviews and record reviews, the hospital failed to ensure the use of restraints were in accordance with the order of a physician and/or licensed practitioner who is authorized per hospital policy to order restraints for one of three patients (P1) reviewed for restraints. Specifically, the hospital failed to ensure an order for restraint was recorded per policy; documentation that patient was informed of the use of restraints; documentation less restrictive interventions were implemented; and failed to keep an internal log or mechanism recording the death of the patient in restraints. This deficient practice places all patients requiring restraints at risk for harm.

Findings include:
In a review of the "Restraint/Seclusion Policy," last revised on 03/2017, read in pertinent parts, "The use of restraint must be in accordance with the order of a Physician or other licensed independent practitioner (LIP) defined herein as a Nurse Practitioner (NP) or Physician's Assistant (PA)."
"Documentation of restraint use, documentation must include the following: b. Patient informed of the changes in his/her treatment plan/plan of care or documentation supporting why not informed; c. a description of the patient's behavior and the intervention used; d. Less restrictive interventions attempted or considered."
The policy further read in the pertinent part, "Exceptions to death reporting requirements: When no seclusion has been used and the only restraint used was a soft, cloth-like two-point wrist restraints, the hospital staff must record in an internal log (or other system)"; The following must be documented in the patient's medical record: a. The date and time the death was recorded in the internal log (or other system) for deaths related to soft wrist restraints as described above; i. Each entry must be made not later than seven days after the date of death of the patient; ii. Each entry must document the patient's name, date of birth, date of death, name of attending Physician or other licensed independent practitioner who is responsible for the care of the patient, medical record number, and primary diagnosis (es)."

Review of the medical record titled "INPT [inpatient] H&P [history and physical] Adult. Patient (P1) was a 25-year-old male admitted on 4/15/22 with a diagnosis of alcoholic pancreatitis.

In a review of the order summary dated 4/15/22, P1 was a full code (should breathing or heart cessation occurs, P1 requests implementing emergency efforts).

In a review of the order summary dated 4/17/22 at 10:38 AM, it stated the order to discontinue restraints.

In a review of the "RN [Registered Nurse], Clinical Note" dated 4/17/22 at 10:36 AM, authored by RN3, read in pertinent part, "0820 AM Pt agitated combating restraints." Further read, "0815 AM verbal order to place restraints."; "0830 AM Restraints secured."
Note: There was no documentation that the patient was informed of the use of restraints or that less restrictive measures were implemented, and RN3 received an order for restraints but did not follow the hospital policy for verbal orders.

In a policy review, "Verbal and Telephone Orders: Medication and Non-Medication" was revised on 05/2022.
Read in pertinent part, "A verbal/telephone communicated order must contain all components of a valid written order as outlined in this policy. In addition, it must bear the name of the person who issued the order and the name and title of the person who received it." Further, "The prescribing practitioner must sign the written or electronic health record (EHR) of the verbal/telephone order within 24 hours of giving the order and include the date and time."
Note: There were no orders for restraints signed in the EHR.

In a review of the "Discharge Summary" dated 4/17/22 at 3:35 PM authored by Medical Doctor (MD) 9, read in pertinent part, "Wrist restraints and Haldol were also administered to prevent patient from getting out of bed, pulling at IVs"; further read, "While setting up for intubation, the patient became unresponsive and lost pulses."; CPR was started immediately at the time of code.."; "Patient was pronounced dead at 0946 AM."

During an interview on 9/1/22 at 12:48 PM, RN3 stated she provided care for P1 the day of 4/17/22 and remembered his agitation was increasing, as evidenced by P1's attempt to leave the room. RN3 said they were told they could restrain him but could not identify who had given the order to use restraints.
Note: No documentation of the less restrictive interventions was attempted or considered.

During an interview with the Director of Nursing (DON) on 9/1/22 at 1:30 PM, the DON stated there is an internal log where all the patients who had restraints are kept. The DON then submitted the internal record for April 2022.
P1 was not listed on the "Restraint Log" the DON gave. Note: According to policy, hospital staff must record in an internal log (or other system) the date and time the death was recorded related to soft restraints, and each entry must be made no later than seven days after the patient's death date.

Review of professional reference from American Nursing Association retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/reduction-of-patient-restraint-and-seclusion-in-health-care-settings/
Read in pertinent part, "When restraint is necessary, documentation should be done by more than one witness." Retrieved on 9/7/22.

During the survey, no documentation was submitted indicating an order was given for the restraints.

Based on interviews and record reviews, the hospital failed to ensure staff were evaluating the care for each patient when appropriate and in accordance with standards of nursing practice and hospital policy. Specifically, the staff were not following doctor orders; and did not reassess the Patient (P)1 with a change of condition. This failure places all patients at risk for less than optimal outcomes.

Findings include:

In a review of the "Nursing-Assessment-Reassessment" policy last revised 07/2019, read in pertinent part, "Reassessments will be performed by the RN at least every shift and more frequently as patient's condition/circumstances warrant and as specified in standards of care/procedures or by physician orders."

Professional reference from the National Institute of Health (NIH) read in pertinent part, "Monitoring of blood pressure and frequent measurement can in large number prevent progression of hypertension, which can often remain unnoticed if the blood pressure is not measured regularly." Further read, "High blood pressure increases the workload of the heart and thus leads to instability in the hemodynamics and physiology of blood flow which often leads to stroke, myocardial infarction, and in severe forms leads to decompensation, kidney failure and congestive heart failure." Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804429/

A review of "INPT [inpatient] H &P [History and Physical] dated 4/15/22 revealed Patient (P)1 was a 25-year-old admitted on 4/15/22 with alcoholic pancreatitis. The report also indicated that P1 has a history of heavy ETOH (alcohol) use and currently drinks.

A review of the "Order Summary" dated 4/15/22 revealed that P1 was admitted to the inpatient ward with vital signs per CIWA ( Clinical Institute Withdrawal Assessment) Protocol or "at a minimum of at least every four hours". The order further read to call the physician for systolic BP (Blood Pressure) greater than 160 or less than 100; Diastolic BP greater than 90 or less than 50.

A review of the CIWA flow sheet for 4/16/22 indicated the following:
1:00 AM BP 150/85
4:30 AM BP 169/91
8:15 AM BP 174/105
12:15 PM BP 184/116
4:15 PM BP 176/124
6:50 PM BP 174/116

Review of the "Progress Notes" authored by Registered Nurse (RN) 3 on 4/16/22 revealed no documentation that the physician was made aware of the elevated blood pressure at 8:15 AM. There was no evidence that RN3 did a reassessment to evaluate the elevated pressure. At 12:15 PM, RN3 indicated in progress notes the BP was 184/116; a report was given to the physician, but no subsequent BP was documented until 4:15 PM. At 4:15 PM, P1's BP was 176/124. There was no documentation of a reassessment following the upward trending of high BP.

During the interview on 9/1/22 at 12:50 PM, RN3 stated "yes" she believes an elevated pulse and a BP is considered a change in condition. When asked why more frequent assessments were not completed for P1, she stated, "his door was open the whole time where I could see him, and I went in every four hours." RN3 said she worked in the long-term care setting last year and was new to the hospital.

On 9/1/22 at 3:15 PM, I shared findings with the Director of Nursing (DON), and she acknowledged.

Based on policy review, record review, and interviews, the hospital failed to ensure the staff members who were delegated by the registered nurse (RN) to one-to-one observe a patient in the emergency department (ED) had received training and had been assessed for competency for two (Radiology Tech 1, Registered Nurse 3) of three personnel files reviewed for training and competency; and the hospital failed to ensure staff (RN3) designated to respond in a code blue emergency had training and was competent. The deficient practices had the potential to affect all patients receiving services in the hospital who required one-to-one observation by hospital staff; and all patients and staff requiring emergency services offered by the Code Blue Team.

Findings include:

I. Review of the hospital policy titled, "Observer Policy for Emergency Department," revised August 2020, indicated, "This policy sets forth the Observer Procedures for the [name of hospital] Emergency Department and Observers to ensure that the level of patient care services is maintained for the safety and well-being of at-risk patients who are in need of higher level care that our facility cannot offer, until a transfer is arranged. . . Definitions: . . . Observer: An individual assigned to provide one to one observation to ensure the safety of the patient. . . 1. A patient who is admitted to the ED is identified as needing an Observer by the ED triage/bay nurse assigned to the patient. . . Continuous Observation Record tool will be utilized by staff for all patients meeting the Observation Policy definition. . . 4. The assigned ED nurse will be responsible to complete the following duties: . . . Document the use of Observer in the patient's medical record. Orient the Observer to the patient's room and introduce them to the patient/family. Review the purpose and function of the Continuous Patient Observation Record with the Observer. Review the Observer Hand-off tool with the Observer. Complete yearly Observer Competency. . ."

Review of Patient (P) 2's medical record, under the "Visit Selection" tab, indicated P2 presented to the ED on 03/08/22 at 3:53 PM. Review of P2's ED provider progress notes documented by Physician 1 on 03/08/22 at 4:21 PM, located under the "Notes" tab, indicated P2 presented with "concern for suicidal ideation. Patient has thoughts of taking pills to overdose. Told a school counselor about this today. Has been feeling suicidal since [he/she] was released from JDC [juvenile detention center] 2/18 [February 2018] . . ." Further review indicated P2 was ordered to be on "Direct 1:1 [one-to-one] observation . . ."

Review of P2's "Observation/Restraint Flow Sheet," dated 03/08/22 and located under the "Scanned Images" tab, indicated Radiology Tech (RT) 1 provided one-to-one observation for P2 on 03/08/22 from 5:00 PM to 5:31 PM. Further review of the flow sheet indicated RT1 signed the flow sheet on 03/08/22 (no time documented). Review of the section on the flow sheet that read "I have read and understand the above Observer Responsibility Guidelines" indicated RT 1's signature was not documented, dated, and timed.

Review of RT1's personnel file indicated the "Hospital Wide Orientation" was dated 02/07/22 with no documentation of RT1's signature. The list of orientation topics did not include observation of patients one-to-one.

Review of "Memo To: All Radiology Staff: Re: [regarding] Radiology Staff Responsibilities" signed by RT1 on 02/08/22 indicated '. . . Specialties: Each of the technologists in Radiology may have their areas of expertise, however, each and everyone in the department does have "Duties as Assigned" parts of which may be assisting other specialties/services. . ." The list of duties did not include providing one-to-one observation of patients in the ED. There was no documentation in RT1's personnel file that RT1 had been trained on providing one-to-one observation of patients in the ED and had been assessed for competency of providing such observation.

In an interview on 9/1/22 at 11:57 AM, Registered Nurse (RN) 1 stated "they pull from everywhere" for observers. RN1 stated if an ED nurse is not available to observe the patient one-to-one, they get anyone who is free in the hospital to provide the observation.

An unsuccessful attempt was made on 9/1/22 at 2:01 PM to contact RT1 to discuss RT1's observation of P2. There was no answer to the phone call.

In an interview on 9/1/22 at 2:55 PM, Director of Nursing (DON) confirmed there was no documentation in the personnel file of RT1 of education and competency evaluation as a one-to-one observer of patients in the ED. DON stated they send out an email for anyone who is available to do observations if ED staff is not available to do it. DON stated he/she could not explain why RT1 did not sign as having been trained on the observation sheet.


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II. In a review of the hospital policy titled, "Code Blue Team Response", revised 9/2019, read in pertinent part, "Upon completion of Code, the patient disposition is appropriately recorded on the "Code Blue/Critical Care Flow Sheet and a statement in EHR in reference to the forms used." Further read, "The Unit charge nurse involved with the code is responsible for notifying the Unit Nursing Supervisor or Nursing Administrator On-call, completing and submitting the Code Blue Evaluation Form within 72 hours and providing a copy to the Code Blue/Critical Care Flow Sheet to the Accreditation Specialist for review and filing."

Review of the Patient (P) 1's medical record titled "INPT [inpatient] H&P [history and physical] Adult revealed P1 was a 25-year-old male admitted on 4/15/22 with a diagnosis of alcoholic pancreatitis.

In a review of P1's "Discharge Summary" dated 4/17/22 at 3:35 PM authored by Medical Doctor (MD) 9, read in pertinent part," "While setting up for intubation, the patient became unresponsive and lost pulses." Further stated, "CPR was started immediately at the time of the code"; "Patient was pronounced dead at 09:46 AM."

During an interview with the Director of Nursing (DON) on 8/31/22 at 11:30 AM, when asked where was P1's Code Blue form used to record the events, the DON stated the nurse recorded the event in the EHR and said they could choose to use the Code Blue form or document in the EHR.

During an interview with the DON on 9/1/22 at 12:10 PM, when reference to the "Code Blue Team Response" policy was made, the DON stated, "we have identified we were not following our policy and have addressed this."

Review of the Registered Nurse (RN) 3 progress notes dated 4/17/22, revealed in pertinent part, "0832: Pt unresponsive and pulseless. Compressions started. CODE BLUE called overhead."

During an interview with RN3 on 9/1/22 at 12:50 PM, RN3 stated she was the recorder for the Code Blue response involving P1. When asked why the "Code Blue/Critical Care Flow Sheet" was not completed and not referenced in the Electronic Health Record, RN3 stated she was not aware of the Code Blue Policy when she began working in January of 2021 and had no training since then. RN3 said that "they [hospital]" do not do competency evaluations for Code Blue teams. Also, RN3 stated she is often assigned to respond to Code Blue activations in the hospital.

In a review of RN3's personnel files, there was no documentation of competency about the Code Blue Team Response policy or acknowledgment that RN3 read the policy.

During an interview with the Director of Nursing (DON) on 9/1/22 at 1:30 PM, the DON acknowledged the findings.