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Based on policy and procedure review, medical record review and staff interview the nursing staff failed to obtain a renewal order for behavioral restraints for an adult patient in 1 of 2 patients restrained (#6).

The findings include:

Review of policy "Restraint Management Administrative Manual #409 & II-R-1 effective 07/2010" revealed "Emergency Behavioral Restraint: (Any Setting): Applying in an emergency situation in which the patient's behavior is violent, aggressive or destructive, posing an imminent danger to the patient or others...Duration of Order...4 hours for patients over age 17".

Medical record review of patient #6 revealed a 54 year old admitted to the adult psychiatric unit on 5/13/2011. Record review revealed the patient was admitted with a diagnosis of psychoses. Record review revealed the patient was placed in restraints on 5/9/2011 at 2305 for behavior of "Danger to self/Danger to others". Record review revealed the physician ordered four point time limited restraints for four hours ( 2305-0305). Record review revealed the patient was continuously restrained from 5/9/2011 at 2305 until 5/10/2011 at 1100. Record review revealed no documentation of a physician's order for continued restraints at 0305 on 5/10/2011. Record review revealed documentation the patient was restrained with four point restraints and was monitored every 15 minutes from 0305 until 0650 (3 hours 45 minutes without a physician's order).

Interview with psychiatric administrative nursing staff on 8/17/2011 at 1500 revealed the patient was restrained approximately "12 hours" continuously. The interview revealed there was no documentation of physician's order for restraints available for 5/10/2011 from 0305 until 0650. The interview revealed the hospital policy for behavioral restraints for adults are time limited to four hours. The interview revealed if the patient continues to need restraining the nursing staff are to obtain a second order. The interview did not reveal why the staff did not obtain an order for continued restraints.

Based on policy and procedure review, medical record review and staff interview the nursing staff failed to monitor the condition of the patient who is restrained at an interval determined by hospital policy in 1 of 2 patients restrained (#7).

The findings include:

Review of policy "Restraint Management Administrative Manual #409 & II-R-1 effective 07/2010" revealed "Chemical restraint is a medication used to control the behavior or to restrict the patient's freedom of movement and is not the standard treatment for the patient's medical or psychiatric condition...chemical restraint may be necessary to control unexpected physically violent behavior the patient will be monitored per behavioral restraint procedure...NOTE: a patient in Emergency Behavioral restraint must be observed one to one for 30 minutes after restraints are removed...Document assessments immediately prior to and after the application of restraint and reassessment including vital signs at least every 1 hour (and more frequently as indicated per patient's condition)".

Medical record review of patient #7 revealed a 48 year old patient admitted on 7/10/2011 for altered mental status. Record review revealed a physician's order on 7/13/2011 at 1400 for Haldol (...) 2 mg IV (intravenous) every 2 hours as needed. Record review revealed the patient became combative trying to hit and kick the staff. Record review revealed the patient was administered Haldol 2 mg IV on 7/13/2011 at 1521, at 1726 (2 hours 5 minutes after first dose), and at 1955 (2 hours 29 minutes after second dose). Record review did not reveal any documentation of assessment of the patient's vital signs every hour during the medication administration from 1521 until 1955 (4 hours 34 minutes). Record review revealed documentation by the physician on 7/15/2011 at 1415 "Pt (patient) seen and evald (evaluated). He is sedated, in restraints staff reports violent & threatening behavior". Record review revealed the patient was removed from 4 point restraints on 7/15/2011 at 1538. Record review revealed no documentation of the patient being observed/monitored "one to one" 30 minutes after restraint removal.

Interview with the director of critical care and the director of medical services on 8/17/2011 at 1630 revealed the staff probably did not view the administration of Haldol IV on 7/13/2011 as a chemical restraint. The interview revealed the patient was not monitored per the facility policy of every one hour vital signs. The interview revealed there was no documentation of the patient being monitored for 30 minutes after restraint removal on 7/15/2011. The interview revealed the staff did not follow the hospital policy for "one to one" monitoring of the patient after restraint removal on 7/15/2011.

Based on hospital policy review, medical record review, and staff interviews the hospital's nursing staff failed to supervise and evaluate the nursing care of a patient by failing to monitor a patient's diet and fluid intake as the physician ordered for 1 of 2 sampled hemodialysis patients (#9).

The findings include:

Review of hospital policy titled, "Assessment/Reassessment of Patients (# 417.00, revised 07/10)," revealed "The goal of assessment is to determine the appropriate care, treatment, and services to meet a patient's needs as well as his or her changing needs while in the hospital...Assessment and reassessment activities involve making care, treatment, and service decisions based on information developed about each patient's needs and his or her response to care, treatment and services..."

1. Review on 08/17/2011 of the medical record of patient #9 revealed a 66 year old male admitted on 01/11/2011 for the surgical repair of a fractured hip as a result of a fall at home. Medical record review revealed the patient had a history of Type 2 Diabetes Mellitus, End Stage Renal Disease requiring hemodialysis, Chronic Obstructive Pulmonary Disease requiring oxygen therapy, Hypertension and Anemia. Record review revealed a "Nutrition Assessment" completed by a registered dietician and dated 01/12/2011 at 1631, indicating the patient's "Problem/Nutrition Diagnosis" were "(1) Inadequate protein-energy intake and (2) Altered nutrition-related (to) labs." Review of the "Nutrition Assessment" revealed the patient's renal diet would stop after midnight and the patient would receive nothing by mouth in preparation for surgery on the following day (01/13/2011). Review of the "Nutrition Assessment" revealed the dietician's "Goals" for the patient were to increase food intake by 50% or more and limit fluid intake to 1500 (milliliters) or less since the patient required hemodialysis. Further review of the "Nutrition Assessment" revealed the dietician wanted the patient to receive a "Medical food (Nepro)supplement" at meals BID (twice a day) and the dietician would follow-up 3-4 times weekly to monitor "PO adequacy" and "Labs." Medical record review revealed the physician's post-operation order set dated 01/13/2011 ordered a clear liquid diet to "advance to regular." Medical record review revealed on the "Intake and Output" assessment report the patient received "sips (of water)" on 01/14/2011 at 0509 and there are no further entries of "Oral" intake or "% Meal Eaten" for post operation day #1. Medical record review revealed a registered dietician evaluated the patient on 01/14/2011 (post op day #1) while the patient was on a clear liquid diet. Further review of the "Intake and Output" record of "% Meal Eaten" revealed "cls (clear liquids)" on 01/15/2011 at 1400, "CLQ (clear liquids)" on 01/16/2011 at 0906, "CLQ" on 01/16/2011 at 1457 and "other" on 01/17/2011 at 1455. Medical record review revealed the nursing "Assessment Reports" dated 11/13/2001 at 2128 through 01/17/2011 at 1220 documented the patient's abdomen was soft and non-distended, the patient had no vomiting, and the patient had bowel sounds. Medical record review revealed no contraindications for advancing the patient to a regular diet. Medical record review revealed the patient was not advanced to a regular diet as ordered by the physician but remained on a clear liquid diet (4 days post-operation) until discharge on 01/17/2011. Medical record review revealed the volume of oral intake (clear liquid diet) intake was not documented from 01/14/2011 at 0509 through 01/15/2011 at 0600 (no documentation oral intake was monitored for 24 hours and 51 minutes).

Concurrent interviews on 08/18/2011 between 1410-1450 with the Clinical Nurse Educator and Charge Nurse assigned to the Orthopedic Unit on the 3rd floor, a Registered Dietician, and Nurse Manager of the Hemodialysis Unit confirmed Patient #9 was not advanced to a regular diet. Interview with the registered dietician revealed a protein supplement would not have been ordered for the patient as long as he was on a clear liquid diet. Further interview with the registered dietician revealed it was the responsibility of the Orthopedic Unit's nursing staff to advance the patient's diet as ordered by the physician. Interviews confirmed the volume of oral intake (clear liquid diet) intake was not documented from 01/14/2011 at 0509 through 01/15/2011 at 0600. Further interview with Nurse Manager of the Hemodialysis Unit revealed patients receive food trays in the Hemodialysis Unit and the hemodialysis nursing staff do not document the patient's intake while in hemodialysis. Interview revealed it is the responsibility of the Orthopedic Unit's nursing staff to document the oral intake their patient's received while in hemodialysis. Interviews confirmed there was no available documentation of the patient's volume of oral intake from 01/14/2011 at 0509 through 01/15/2011 at 0600 (24 hours and 51 minutes).


NC00070594