HospitalInspections.org

Based on medical record review, document review, and staff interview, it was determined that in one (1) of five (5) medical records reviewed, nursing staff failed obtain a renewal order for restraint. (Patient #2).


Findings Include:

Review of the medical record for Patient # 2 identified: This 51-year old male with a past medical history of Alcohol Abuse, Bipolar Disorder, Cirrhosis of the Liver, and Seizure Disorder was admitted on 3/27/19 for Alcohol Abuse.

On 3/28/19 at 1:53 PM, the physician wrote an order for 4-point restraints and documented on the face to face assessment that patient was agitated and combative. The order noted to discontinue the 4-point restraints at
3:20 PM.
The documentation in the medical record revealed that the patient remained in 4- point restraints from 3:20 PM to 5:06 PM. There is no documented evidence of a restraint order from 3:20 PM to 5:06 PM.

The facility policy titled "Restraints," last revised on 7/18 documents: " The use of restraint must be ordered by a physician, Physician Assistant or Nurse Practitioner who is responsible for the care of the patient."

During interview on 4/12/19 at 2:26 PM, Staff D, Nurse Manager, confirmed the findings and stated the nurses are aware that they require a renewal for restraints.

Based medical record review, document review, and interview, in one (1) of five (5) medical records reviewed,
staff failed to implement the facility's policy to assess and re-evaluate a patient in restraints, to determine discontinuation of restraint at the earliest possible time. (Patient # 2).

Findings Include:

The facility's policy titled "Restraints," revised 7/18, states: "Violent/ Self-Destructive Restraints are initiated as a response to violent and potentially dangerous behavior towards self or others."
"Key Points: Restraint use must be discontinued at the earliest possible time based on an indivualized assessment and re-evaluation of the patient."
"Documentation: When restraint is used, there must be documentation in the patient's Medical Record of the following: "Description of the patient's behavior, condition or symptom (s) that warranted the use of restraint. Patient's response to the intervention (s) used, including rationale for continued use of the intervention."

Review of the medical record for Patient #2 identified: This 51-year old male with a past medical history of Alcohol Abuse, Bipolar Disorder, Cirrhosis of the Liver, and Seizure Disorder was admitted on 3/27/19 with a diagnosis of Alcohol Abuse.

On 3/28/19 at 1:53 PM, the physician wrote an order for 4-point restraints, with a start time at 1:53 PM and end time at 3:20 PM, and documented on the face to face assessment that patient was agitated and combative.

Documentation in the medical record, reflects that the patient was in 4-point restraints from 1:53 PM on 3/28/19, until 1:05 AM on 3/29/19, more than 11 hours.

Review of the "Restraint Flowsheet" identified that the nursing staff failed to document the patient's behavior, condition, or symptom (s) that warranted the continued use of 4-point restraints.

On the 15 minutes observations, the nurses documented "Done." Examples:
3/28/19 at 2:00 PM to 2:45 PM - Done
3/28/19 at 3:00 PM to 4:45 PM - Done
3/28/19 at 8:00 PM to 8:45 PM - Done
3/28/19 at 9:00 PM to 9:45 PM - Done
3/28/19 at 10:00 PM to 10:45 PM - Done.

There was no documented evidence that the patient was agitated and combative for the entire 11 hours.

There was no documented evidence to support the continued use of the restraints for 11 hours.

During interview on 4/11/19 at 2:26 PM, Staff E, Clinical Nurse Director stated, "I agree this is poor documentation, this does not tell you if the patient is agitated, and this was a long time."

Based on document review and interview, it was determined the facility failed to implement its policy to investigate and analyze incidents to identify problem prone areas and opportunities for improvement.

Findings include:

Review of documents titled "Safety and Security Keepsafe Events," for January 2018 to April 2019, revealed there were eight (8) allegations of assault, three (3) suicide attempts, 13 incidents of disorderly conduct of patients/persons, and an allegation of abuse. The documentation did not reveal that the incidents were fully investigated and analyzed to identify all problem prone areas. There was no evidence that corrective measures were developed and implemented.

Review of the policy titled "Non-Employee Adverse Event Reports," issued February 2018, revealed the facility has a web-based data entry system (KEEPSAFE) where the staff report events in categories such as; patient falls, adverse drug reactions, safety/security, and treatment/coordination of care. These events may involve actual harm or no harm. The policy states, once an event is entered, "event reviewers are responsible for monitoring, investigating, reporting, performing root cause analyses and formulating appropriate corrective action plans."

There is no documented evidence that all elements of review were completed for these incidents, and there is no evidence of reporting and incorporating these events in the facility wide quality assessment performance improvement program.

This finding was shared with Staff C, Director Quality, Safety and Regulatory Affairs, at 4:40 PM on 4/12/19.