HospitalInspections.org

Based on staff interview, medical record review, photograph review, and policy and procedure review the facility failed to follow the facility's policy and procedure for initiating and ordering restraints on two (2) of two (2) days of survey: Patient #1.

Findings Include:

Observation of photographs taken by Family Member #1 on 10/23/2022 of Patient #1's left arm and right hand on 11/01/2022 at 2:30 p.m. revealed blood-tinged wrist restraints, left arm and hand with bruising and bandaged from wrist to elbow, right hand bruised with one bandage.

A telephone interview with Family Member #1 on 10/31/2022 at 1:27 p.m., revealed he/she met Patient #1 in the Emergency Room on 10/22/2022 at 5:23 p.m. when Patient #1 arrived by ambulance from a long-term care facility with shortness of breath. Family Member #1 stated, "I had to leave around 8:30 p.m. and I told the Emergency Department Nurse of his confusion and to keep telling him where he was, and I would back tomorrow." Family Member #1 said she returned to the hospital the next morning and saw Physician #1 when she entered Patient #1's room. Family Member #1 asked Physician #1 to explain what was going on with his treatment. Family Member # 1 said Physician #1 did not go into any detail about Patient #1's status. Family Member #1 stated she saw the restraints for both hands and legs hanging from the bed. Patient #1 was bandaged all the way to the elbows and said he had been in a fight, and he did not know anything. Family Member #1 said A.M. Nurse #1 told her the evening nurses had trouble getting Patient #1 calmed down. Family Member #1 said she asked why the facility did not call her; she could have calmed him down. Surveyor unable to interview A.M. Nurse #1 due to the nurse not being available.

During an interview on 11/01/2022 at 2:00 p.m., Chief Nursing Officer (CNO) #1 revealed Charge Nurse #1 was talking to Nurse Practitioner #1, who was working on 10/22/2022, the night of this incident, and Nurse Practitioner #1 said she could not initiate a restraint order according to our facility bylaws and state regulations, but she can put in a verbal order from a physician and the physician must sign the order within 24 hours.

During an interview on 10/31/2022 at 2:45 p.m., Risk Manager #1 revealed the facility does not have documented evidence of a physician's order for the use of restraints on Patient #1.

Review of medical record, "Nursing Documentation," for Patient #1 dated 10/22/2022 at 10:30 p.m. by LPN #1, revealed patient became combative and abusive to the nurses, using profanity. Patient #1 ripped out doxycycline intravenous catheter (IV) in left hand with a 20-gauge IV catheter causing blood to be splattered all around the room. Patient #1 stated, "Don't you f-word touch me". "Security arrived in Patient #1's room and Patient #1 swung at one of them." "Patient #1 reported we were trying to poison him with IV fluids. Patient #1 became more combative and had to be put in restraints." LPN #1 documented she called Nurse Practitioner #1 and he/she put in an order for Thorazine (antipsychotic medication). Patient #1 had bilateral skin tears to lower forearms from fighting the restraints. Wounds were cleaned and dressed appropriately.

Review of physician's order date 10/22/2022 at 10:40 p.m. revealed Nurse Practitioner #1 ordered Chloropyramine (Thorazine) 25 milligrams intravenously through IV piggyback and Clonazepam (klonopin) 0.25 milligrams orally. No order was written for the use of restraints.

Review of Facility incident report (#2022008927) on 10/22/2022 at approximately 10:33 p.m., Security Officers #1 and #2 were dispatched to Patient #1's room due to a combative patient. Upon arrival Security Officers observed Patient #1, " ...sitting on edge of bed in a very upset manner." Documentation reveals Patient #1 pulled his intravenous catheter (IV) out of his arm and was cursing at the nursing staff. Security Officer #1 spoke with Charge Nurse #1 who explained Patient #1 was upset and very combative with the nursing staff. Security Officers #1 and #2 were asked by Charge Nurse #1 to assist Charge Nurse #1 and LPN #1 while soft limb restraints for the arms and legs were placed on Patient #1 to enable the nurses to continue treatment.

Review of medical record "Nurses note" for Patient #1 dated 10/23/22 at 3:00 a.m. by LPN #1 revealed Patient #1 asleep and showing no signs or symptoms of distress. Assessed arms and legs bilaterally appear pink with appropriate blood to all extremities with capillary refill less than two (2) seconds. Moderate strength in upper arms.

Review of medical record "Nurses note" for Patient #1 dated 10/23/22 at 6:15 a.m. by LPN #1, revealed Patient #1 popped IV tubing, was receiving cefepime. "Blood everywhere. Patient's brief was also off. Patient #1 reports he fell but he is in restraints." No other documentation present.

Review of facility policy entitled, "Safe Use of Restraints" (revised 08/10/2022), revealed " ...in compliance with Mississippi state law ...only a physician responsible for the care of a patient by order the use of restraints. An order must be obtained prior to the application of restraints except in urgent unsafe situations when the order is attained during restraint application or within a few minutes, no longer than 15 minutes. The order will most likely be given by the patient's attending physician. In a rare circumstance with the restraint may be ordered by a consultant physician, the attending physician will be notified within 24 hours of application. In an emergency, all their trained registered nurse be additional restraints prior to an order ...".

During exit conference on 11/01/2022 at 3:30 p.m., survey findings were discussed
and no further documentation was submitted for review.