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Based on clinical record review, policy review and staff interview, the facility failed to ensure that the use of restraints for 1 of 8 sampled patients (#7) was in accordance with the order of the physician or other licensed independent practitioner who was responsible for the care of the patient and that the order was updated each day.
The findings include:

Review on 11/23/10 of the medical record for sampled Patient #7 revealed the patient was admitted to the facility on 11/12/10 with abdominal pain, nausea vomiting and a history significant for obstructive sleep apnea, chronic obstructive pulmonary disease. The patient underwent a laparotomy on 11/16/10 for lysis of adhesions. Post operatively, the patient was unable to be extubated and was transferred to the intensive care unit for continued monitoring. Bilateral soft wrist restraints were initiated on 11/17/10 at 00:00 per the rationale that they were needed because patient was interfering with medical therapies. The medical record revealed the initial physician's order for restraints was written on 11/18/10 at 14:25. Subsequent physician orders were missing from the medical record for the dates of 11/20/10 and 11/21/10.

The facility policy was reviewed on11/23/2010 at 12:55 pm. Per the policy, a physician's written order is required within 12 hours of initiation for each episode of restraint and the order of restraint must be re-ordered each calendar day.

Interview on 11/23/10 with the nurse manager at 11:25 am revealed that she was aware that physician orders were missing for this patient. She agreed that physicians orders were to be completed for patients on restraints each calendar day.

Based on clinical record review , staff interview and policy review, the facility failed to ensure 2 of 8 sampled patients (#7, #8) were monitored and assessed for the use of restraints per the hospital policy.

The findings include:

Review on 11/23/2010 of the medical record for sampled Patient #7 revealed the patient was admitted to the facility on 11/12/10 with abdominal pain, nausea vomiting and a history significant for obstructive sleep apnea, chronic obstructive pulmonary disease. The patient underwent a laparotomy on 11/16/10 for lysis of adhesions. Post operatively, the patient was unable to be extubated and was transferred to the intensive care unit for continued monitoring. Bilateral soft wrist restraints were initiated on 11/17/10 at 00:00 for the rationale of interfering with medical therapies. Of the 76 opportunities for monitoring since the initiation of restraints, 13 were missing from the medical record. Those missing include monitoring on 11/17/10 at 02:00, 04:00 and 06:00, on 11/18/2010 at 04:00, 06:00, on 11/20/10 at 02:00, 04:00, 06:00, on 11/22/10 at 10:00, 12:00, 14:00, 16:00, 18:00.

Patient #8 was admitted to the facility 11/15/2010 with small bowel obstruction. ON 11/19/2010, the patient had a lysis of adhesions and laparotomy and was transferred to the intensive care unit post-operatively for altered mental status. The medical record reflects the patient was placed on restraints on 11/19/2010 at 08:00 for the reason of interfering with medical devices. Of the 51 opportunities for monitoring the patient two were missing on the dates of 11/19/2010 at 10:00 and 11/20/10 at 06:00.

Review of the facility policy for physical restraints on 11/23/2010 at 1:10 pm revealed that the condition of the restrained patient must be continually monitored and reevaluated. The standard is that the patient should be monitored every two hours.

Interview with the nurse manager on 11/23/2010 at 1:13 pm revealed that she was not aware that the monitoring for restraints was missing from the medical record of these two patients. She agreed the monitoring needs to be done every two hours.

Based on clinical record review, staff interview and policy review, the facility failed to ensure that drugs and biologicals were administered in accordance with federal and state laws and in accordance with accepted standards of practice for 1 of 8 sampled patients (#1).

The findings include:

Review on 11/23/2010 of the medical record for sample Patient #1 revealed the patient was admitted to the facility on 10/6/10 at 2025 via ambulance with complaints of chest pain lasting approximately one hour, rated as a 2 (1-10 scale). Vital signs were stable at triage and a twelve lead EKG, completed by emergency medical services found the patient to have sinus rhythm, with frequent premature ventricular contractions and intermittent hypertension. After a medical evaluation by the physician an order was written for Morphine 2mg along with Benadryl 12.5mg and Zofran 4mg intravenously, which the patient received at 23:18. At 23:44 on 10/06/10 the electronic medical record documented that the patient 's allergy list was updated to reflect an allergy to Morphine. On 10/07/10 at 01:53, the following morning, the patient received again, Morphine 2mg along with Benadryl 12.5mg intravenously.

Review of facility policy on medication administration guidelines on 11/23/2010 at 9:15am revealed that nurses are to observe patients rights when giving medications, which include the right patient, time, medication, dosage, route of administration, rate of administration and documentation of administration. Any error in medication administration or adverse drug reaction is to be immediately reported to the supervisor of the unit or area, the physician who ordered the drug and the pharmacy. An adverse drug event will be completed and submitted to Risk Management via the on-line Risk Master program. Pharmacy is to be notified by phone.

The nurse manager for the ED was interviewed on 11/23/2010 at 9:00am regarding this patient being listed as having an allergy to Morphine prior to the administration of the medication. Per the nurse manager, she was not aware the patient had received a medication listed on the patient medical record as an allergy. She also did not know whether the physician and/or pharmacy were notified, as there was no documentation of the error.

Based on clinical record review, staff interview and policy review, the facility failed to ensure for 1 of 8 sampled patients (#1) that drug administration errors were immediately reported to the attending physician.

The findings include:


Patient #1 was admitted to the facility on 10/6/10 at 2025 via ambulance with complaints of chest pain lasting approximately one hour, rated as a 2 (Wong Baker-Scale). Vital signs were stable at triage and a twelve lead EKG, completed by emergency medical services found the patient to have sinus rhythm, with frequent premature ventricular contractions and intermittent hypertension. After a medical evaluation by the physician an order was written for Morphine 2mg along with Benadryl 12.5mg and Zofran 4mg intravenously, which the patient received at 23:18. At 23:44 the electronic medical record documents that the patient 's allergy list was updated to reflect an allergy to Morphine. On 10/07/10 at 1:53, the following morning, the patient received again, Morphine 2mg along with Benadryl 12.5mg intravenously.

Review of facility policy on medication administration guidelines on 11/23/2010 at 9:15am revealed that nurses are to observe patients rights when giving medications, which include the right patient, time, medication, dosage, route of administration, rate of administration and documentation of administration. Any error in medication administration or adverse drug reaction is to be immediately reported to the supervisor of the unit or area, the physician who ordered the drug and the pharmacy.

The nurse manager for the ED was interviewed on 11/23/2010 at 9:00 am regarding this patient being listed as having an allergy to Morphine prior to the administration of the medication. Per the nurse manager, she was not aware the patient had received a medication listed on the patient medical record as an allergy. She also was not aware if the physician and/or pharmacy were notified, as there was no documentation of the error.