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Tag No.: A0398
A. Based on medical record review and staff interview it was determined the facility failed to ensure nursing obtained an order for restraints before or immediately after restraints were applied. This failure was identified in one (1) of ten (10) medical records reviewed (patient #3). This failure has the potential to adversely affect all patient being placed in restraints without a physicians order.
Findings include:
A review of the medical record revealed patient #3 was admitted on 1/2/22 with atrial fibrillation with rapid ventricular response. Patient was documented as alert, mild tremors, and observation for DTs (delirium tremens). On 1/4/22 at 3:25 a.m. nursing documented, "Care for patient, patient is agitated sweating, tremor and auditory hallucination restlessness, pull out his IV, call MD request CIWA protocol, and Librium for patient and restraint order, no orders received. Call RT (respiratory therapy) patient received breathing treatment. Patient on 4L nasal cannula, on heparin gtt at 16 units/kg." On 1/4/22 at 8:37 a.m. the physician documented, "Very agitated in 4 point restraints now due to withdraw." No order for restraints for 1/4/22 at 8:37 a.m. was noted in the medical record.
An interview was conducted with the Regulatory Compliance Coordinator on 2/1/22 at 11:00 a.m. The Regulatory Compliance Coordinator concurred staff did not obtain an order for patient #3 before applying restraints.
B. Based on document review and medical record review it was determined the facility failed to ensure nursing staff turned patients as per policy. This failure was identified in two (2) of ten (10) medical records reviewed (patient #1 and 5). This failure has the potential for all patients to develop skin breakdown while on the Intensive Care Unit.
Findings include:
A review of the medical record for patient #1 revealed patient #1 was intubated on 12/26/21 and required wound care on 1/5/22. A review of the nursing flow sheets revealed no documentation of turning or repositioning on 1/11/22 every two (2) hours as per policy. No nursing note for patient having desaturations on 1/11/22.
A review of the medical record for patient #5 revealed patient #5 was intubated on 1/3/22. Patient #5 was documented as requiring wound care on 1/20/22. A review of the nursing flowsheets revealed no documentation on 1/4/22, 1/6/22 and 1/7/22 that patient #5 was turned every two (2) hours as per policy.
An interview was conducted with the Regulatory Compliance Coordinator on 2/1/22 at 11:00 a.m. The Regulatory Compliance Coordinator concurred staff failed to reposition as per policy.