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Based on policy and procedure review, medical record review, and staff interview the facility failed to ensure physicians' orders for restraint use were routinely obtained. This affected four (Patient's #3, #5, #7 and #10) out of ten medical records reviewed (A168). This deficient practice had the potential of affect all patients admitted to the hospital. The hospital census was 427 patients.

Based on policy and procedure review, medical record review, and staff interview the facility failed to ensure physicians' orders for restraint use were routinely obtained. This affected four (Patient's #3, #5, #7 and #10) out of ten medical records reviewed. The hospital census was 427 patients.

Findings Include:

1. Review of the medical record for Patient #4 documented the use of bilateral soft wrist restraints on 02/18/15 at 9:00 PM due to the patient pulling on medical devices. Further, the nursing flow sheets documented on 02/19/15 at 2:00 PM soft restraints were applied bilaterally to the lower extremities. The nursing flow sheets documented the patient remained in restraints until 02/25/15 at 12:00 PM. Review of the physician's orders lacked evidence of a signed restraint order from 02/21/15 through 02/25/15. This finding was confirmed with Staff D on 05/21/15 at 2:30 PM.

2. Review of the medical record for Patient #7 documented the use of bilateral soft wrist restraints to the upper extremities on 04/15/15 at 6:29 PM due to the patient pulling on medical devices. The restraints were discontinued on 04/16/15 at 9:18 AM. The medical record revealed restraints were reapplied on 04/16/15 at 2:00 PM. The medical record lacked a signed physician's order for the restraint application on 04/16/15 at 2:00 PM. This finding was confirmed with Staff G on 05/20/15 at 3:10 PM.

3. Review of the medical record for Patient #10 documented the daily use of a soft wrist restraint to the right upper extremity beginning 05/07/15 at 12:00 AM. Nursing flow sheets documented the restraint being used 05/08/15 through 05/12/15. Review of the physician's orders lacked evidence of a signed physician's order for restraints until 05/12/15 at 1:12 AM. This finding was confirmed with Staff D on 05/21/15 at 10:03 AM.

4. On 05/21/15 the medical record for Patient #3 was reviewed including the restraint flow sheet and restraint orders. The restraint flow sheet documented soft wrist restraints to the upper extremities used daily from 01/24/15 through 02/16/15. Review of restraint orders lacked signed physician orders on 01/28/15 and 01/29/15.


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Review of the Policy and Procedure for Restraint and/or Seclusion: Non-Violent/Non- Self Destructive Behavior and Violent/Self Destructive Behavior, Policy No. UCH-PCS-Admin-001-02 states the purpose of the policy was to define procedures regarding the use of restraints and seclusion to prevent patients from harming themselves, staff, or others while preserving the dignity and rights of the patient.

The expectation was that renewal orders for non-violent restraints were placed in the electronic medical record before noon. A physician's order was required for all restraints. The order was to include the rationale for the restraint, the type of restraint, date/time and the duration of the order. If a non-violent restraint was to be continued beyond twenty four hours, its use was ordered once each calendar day or every twenty four hours, whichever was greater, by a physician/LIP based on the examination of the patient.

On 05/21/15 at 2:30 PM, Staff D stated the facility identified a system issue with obtaining physician's orders for restraints. An electronic communication note dated 05/19/15 and 05/20/15 confirmed the facility had acknowledged the problem during the survey, but had not implemented a plan of correction to fix the system issue of obtaining physician's orders for restraints according to hospital policy.

Based on medical record review, staff interview, and policy and procedure review the facility failed to supervise nursing care for an intensive care unit patient including hygiene care. This affected one, Patient #3, of 10 medical records reviewed from the hospital's intensive care units. This deficient practice has the potential to affect all patients admitted to the hospital. The hospital census was 427.

Findings include:

On 05/20/15 the medical record of Patient #3 was reviewed. The record documented an admission on 01/24/15 and a discharge on 02/19/15 for a total of 26 days as an inpatient. The emergency resident physician documented that the clinical impression included a pedestrian hit by a train with traumatic brain injury, fractures of the skull, and diffuse axonal brain injury. Patient #3 was admitted in-patient in the surgical intensive care unit (SICU) for further care on 01/24/14 at 4:43 AM.

Patient #3's hygiene care was identified in the daily flow chart of the medical record. The documentation including notations including complete bed bath, partial bed bath, and hair washing.

The medical record lacked documentation Patient #3 was bathed or hair washed during the seven days prior to discharge (02/13/15 through 02/19/15).

On 05/21/15 at 11:00 AM Staff D confirmed the electronic medical record lacked documentation of hygiene care including bed baths and hair washing for the last seven days of Patient #3's admission.

On 05/21/15 the hospital's electronic record documentation (EPIC) procedures for the intensive care units were reviewed. The EPIC guidelines indicated documentation of daily care every four hours.

This deficiency substantiates Substantial Allegation OH00078631.

Based on medical record review, staff interview, and policy and procedure review the facility failed to implement a nursing care plan for skin integrity per facility policy for a bed bound intensive care unit patient with a Braden score below 14. This affected one, Patient #3, of 10 medical records reviewed in the hospital's intensive care units. The hospital census was 427.

Findings include:

On 05/20/15 the medical record of Patient #3 was reviewed. The record documented an admission on 01/24/15 and a discharge on 02/19/15 for a total of 26 days as a surgical intensive care unit (SICU) patient. The emergency resident physician documented clinical impression included a pedestrian hit by a train with traumatic brain injury, fractures of the skull, and diffuse axonal brain injury. Patient #3 was admitted in-patient in the surgical intensive care unit (SICU) for further care on 01/24/14 at 4:43 AM.

Further review of the medical record documented Patient #3 was in soft wrist restraint from 01/24/15 to 02/16/15 due to pulling of IV lines, ventilator tubes, feeding tubes, and chest tubes. On 02/16/15, day 23 of the admission, a wound care assessment documented the right elbow was found with a yellow wound base that required autolytic debridement with wound gel. The recommendation was to cleanse the wound with saline, apply a small amount of Silvasorb gel and cover with a Mepilex Border every three days and as needed. On 02/19/15 Patient #3 was discharged from the hospital.

A review of Patient #3's care plan lacked documentation of a care plan for "Potential for Skin Breakdown". The care plan documented occupational and physical therapy started on 01/28/15, non-violent/non-self-destructive restraints and non-violent restraint safety started on 01/30/15, inadequate airway clearance and inadequate gas exchange started on 02/11/15, and knowledge deficit and compromised skin integrity started on 02/17/15. The "compromised skin integrity" care plan was not added until the SP experienced a skin breakdown of the right elbow.

On 05/21/15 the hospital policy titled Skin Care: Prevention and Treatment, revised 05/2013 was reviewed. The policy outlined nursing management for skin and wound care of the patient with potential for and actual alterations in skin integrity. The policy documented the use of the Braden Scale to identify patients at risk for pressure ulcer development and to provide data for initiation of a plan of care. The scores included: 9 and below = severe risk for breakdown, 10 to 12 = high risk for breakdown, 13 to 14 = moderate risk for breakdown, 15 to 18 = mild risk for breakdown, and 19 to 23 = low risk for breakdown.

On 05/21/15 at 11:00 AM, Staff J indicated a skin integrity care plan would be initiated for a patient with a Braden score below 16.

Review of Patient #3's medical record documented a Braden score of 11, 12, or 13 for nine days including 01/24/15, 01/25/15, 01/26/15, 01/27/15, 01/28/15, 01/29/15, 01/30/15, 01/31/15, 02/01/15. No care plans for skin integrity or potential for skin integrity breakdown was initiated. The first skin integrity care plan initiated for Patient#3 was on 02/17/15 after the skin breakdown of the right elbow.

This deficiency substantiates Substantial Allegation OH00078631.