HospitalInspections.org

Resident/Patient/Client Rights-Substantiated

Findings:
Based on observation, review of clinical records, policy and procedures, and interview, it was determined the facility failed to assure six (Pt. #8, #11-#15) of six patients in restraints had physician orders for restraint and failed to monitor the patient in restraint every two hours as ordered by the physician; Failure to follow physician orders for restraint use and monitoring did not assure patient safety. The failed practice affected six of six patients who were restrained at the time of the survey and had the potential to affect all patients. The findings were:

A. On 05/21/13, six patients were identified on the House Supervisor's Report dated 05/20/13 by the facility as restrained. (Pt. #8,#11-15.)

B. The facility policy # OC003PCS with a review/effective date of 05/13, for " Restraint Usage in Non-Behavioral health units " was received on 05/21/13 at 0935. The policy stated: " Physician orders: Restraint (or seclusion) orders must contain: reason/justification for use, type of restraint used, precautions and other considerations ... " Time limits for orders: " Medical Restraints no more than 24 hours. Renewal orders must be obtained from the physician after evaluation and at 24 hours for medical restraints. " The " Intervention " listed. Side rails should be up at all times and bed in low position when restraint is used while the patient is in bed. " " Assessment/Reassessment/Monitoring/Care of Patient " Patients in restraint/seclusion must be assessed and or attended to at least every two hours ... " " Documentation in the patient ' s medical record of this monitoring and assessment shall occur every two hours for medical restraints. "

C. Clinical record review revealed:

Patient #8 was admitted to the facility on 05/14/13. A physician order was noted for 05/15/13 at 0436 for " restraint initiate Non-Violent/Non-Self Destructive " . Order details state " for interference-medical treatment/devices, Soft. Order valid for one calendar day. " The order did not specify where the restraint was to be applied or the specific type of restraint. There was no evidence of physician order every 24 hours as required by policy for continued use of restraint for 05/17/13 and 05/22/13. There was no evidence restraint monitoring occurred every two hours as ordered by the physician and per facility policy on 05/15/13; 05/16/13; 05/18/13; 05/19/13; 05/20/13 on 05/21/13. The findings were confirmed on 05/22/13 by the Director of Quality and by Registered Nurse #12 and Information Technology analyst Registered Nurse.

Patient #11 was admitted to the facility 05/17/13. A physician order for 05/20/13 at 1823 for " restraint initiate Non violent/Non-Self Destructive " for " Actions interfere promotion of healing. Soft. Order valid for one calendar day. " The order did not specify where the restraint was to be applied or the specific type of restraint. There was no evidence restraint monitoring occurred every two hours as ordered by a physician and per facility policy on 05/21/13.

Patient #12 was admitted to the facility 05/13/13. A physician order for 05/20/13 at 0300 for " restraint initiate: Non violent/Non-Self Destructive " for " interference-medical treatment/devices, Soft. Order valid for one calendar day. " The order did not specify where the restraint was to be applied or the specific type of restraint. There was no evidence restraint monitoring occurred every two hours as ordered by a physician and per facility policy on 05/20/13 and 05/21/13. There was not an order for the use of 4 side rails. Documentation in the clinical record by nursing staff revealed " 4 side rails, to restrict patient to bed " on 05/22/13 at 0842 and 0924. .

Patient #13 was admitted to the facility 05/18/13. A physician order for 05/20/13 at 2216 for " restraint initiate: Non violent/Non-Self Destructive " for " interference-medical treatment/devices, Soft. Order valid for one calendar day. " The order did not specify where the restraint was to be applied or the specific type of restraint. There was not an order for the use of 4 side rails. Documentation in the clinical record by nursing staff revealed " 4 side rails, to restrict patient to bed " on the following date and times: 05/20/13 at 2213 and 2300; 05/21/13 at: 0100, 0305, 0322, 0500, 0545, 0700,2000,2148, and 2218 and on 05/22/13 at 0026, 0206, and 0400.

Patient #14 was admitted to the facility 05/19/13. A physician order to initiate the use of restraints was noted for 05/20/13 at 0429 for " restraint continue: Non violent/Non-Self Destructive " for " Interference-medical treatment/devices, Soft. Order valid for one calendar day. " The order did not specify where the restraint was to be applied or the specific type of restraint. There was no evidence restraint monitoring occurred every two hours as ordered by a physician and per facility policy 05/20/13.

Patient #15 was admitted to the facility 05/04/13. A physician order to initiate the use of restraints was noted for 05/05/13 at 1830 and stated: "restraint initiate: Non violent/Non-Self Destructive" for "interference-medical treatment/devices, Soft. Order valid for one calendar day." The order did not specify where the restraint was to be applied or the specific type of restraint. Clinical record review on 05/22/13 revealed no physician order for the documented use of "soft limb restraint and four side rails" on 05/07/13, 05/14/13, and 05/21/13. There was no evidence restraint monitoring occurred every two hours as ordered by a physician and per facility policy on 05/05/13, 05/07/13, 05/09/13, 05/10/13, 05/12/13, 05/16/13, 05/19/13, and 05/21/13.
On 05/05/13 Registered Nurse documentation at 1900 and 2300 revealed " bilateral wrist, bilateral ankle, and four side rails were in use. Registered Nurse documentation on 05/06/13 at 0400 revealed " bilateral wrist, bilateral ankle, and 4 side rails to restrict patient to bed. "

The findings for Patient #11-#15 were confirmed by the Director of Quality on 05/22/13 at 1325 - 1415.

Based on review of personnel files and interview, it was determined the facility failed to ensure competencies were determined prior to patient assignment for 8 (Registered Nurse #2, #3, #5, #7-#11) of 11 (Registered Nurse #1-#11) non-employee licensed (Traveler) nurses assigned to the Emergency Department and the Neurosurgery Intensive Care Unit. The failed practice did not ensure the safety of the patients and had the potential to affect all patients seen in the Emergency Department and admitted to the Neurosurgery Intensive Care Unit. The findings follow:

A. In an interview with the Risk Management/Quality Manager on 05/22/13 at 1245, when asked how Traveler Nurses were assessed for their competencies prior to assignment of patients, she stated the Traveler Nurse for the Emergency Department and their preceptor would complete an SVHS (St. Vincent Health System) Orientation Tool. She stated the Traveler Nurse for the Neurosurgery Intensive Care Unit and their preceptor would complete a similar tool. A current list of Travel Nurses was provided on 05/21/13. Travel nurses were assigned in the Neurosurgery ICU and the Emergency Department. Current Travel Nurse Contract start date range was 03/18/13 - 05/13/13.

B. Review of personnel files from the list of Traveler Nurses for the Emergency Department revealed there was no evidence of assessment of competencies for Registered Nurse #2, #3, #5, #7 and #8.

C. Review of personnel files from the list of Traveler Nurses for the Neurosurgery Intensive Care Unit revealed there was no evidence of assessment of competencies for Registered Nurse #9-#11.

D. In an interview with the Risk Management/Quality Manager on 05/22/13 at 1245, she confirmed there was no evidence of assessment of competencies for Registered Nurse #2, #3, #5, #7-#11.