HospitalInspections.org

Based on record review and interview, the facility failed to;

A.
follow the policy and procedure on restraints to ensure chemical restraints/ emergency behavioral medications (EBM) were not ordered or administered as PRN (as needed), failed to ensure the face-to-face, nursing assessment, and patient care plan were performed and addressed in 1 of 1 (#11) patient charts reviewed.

Refer to Tag A0169


B.
follow its policy and procedure to ensure that non-violent restraints were applied, monitored, and released to ensure patient safety.

A. The facility failed to ensure all staff were educated on restraint use.

B. Nursing failed to document the patient's behavior in descriptive terms to evaluate the appropriateness of the interventions used, no nursing assessment after restraints were applied to ensure that restraints were properly and safely applied, and the effectiveness of the restraints.

C. Nursing failed to document the Q 4-hour assessment review of the patient restraints from 10/2/23 at 10:52 pm until 10/3/23 at 7:21 AM.

D. Quality failed to monitor all restraints to ensure appropriateness, use, and discontinuation when ordered and applied. Quality failed to ensure all restraints were logged on the restraint log and appropriately identified as non-violent (medical) vs violent restraints (behavioral).

Refer to Tag A073

The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on record review and interview, the facility failed to follow the policy and procedure on restraints to ensure chemical restraints/ emergency behavioral medications (EBM) were not ordered or administered as PRN (as needed), failed to ensure the face-to-face, nursing assessment, and patient care plan were performed and addressed in 1 of 1 (#11) patient charts reviewed.

The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.



Patient #11
A review of the physician's History and Physical (H&P) dated 10/02/23023 at 10:32 AM, stated "30 y/o Male, _____ (Patient #11), presents to the (Emergency Department) ED via EMS after being the unrestrained driver of a vehicle that was rear¿ended causing severe damage to vehicle and "breaking the drivers seat so that it lays in a flat position. EMS states that pt was c/o severe headache/neck pain, and slightly combative/concussed on scene. EMS reports perseveration. LOC in not known. Patient endorses SOB, chest pain, severe neck pain and headache. Patient is in a confused state and presents himself tearful and yelling. (sic) ...A review of the urine drug screen on 10/02/2023 at 9:19 AM revealed cocaine and cannabinoids were detected.

Patient #11 was admitted to the facility on 10/02/2023 at 9:26 AM with, "SDH (subdural hematoma), Right Subdural hematoma, Right clavicle fracture, T 4, T6 superior endplate compression fractures."

A review of the medication administration record (MAR) revealed patient #11 had received PRN chemical restraint/ EBM while in 4-point restraints, with a lap belt, and mittens. The following medications were ordered and administered.

On 10/3/23 at 10:44 am the order read, "Haldol (psychotropic) 2.5mg IM q 6 hours PRN." There was no reason on the physician's order why this medication was ordered.

A review of the Medication Administration Record (MAR) revealed that the nurse administered the medication on 10/3/23 at 10:49 AM. There was no documentation on the patient's behaviors that would require him to receive an IM psychotropic medication. A review of the nursing restraint flowsheet dated 10/30/23 revealed the patient was currently in 4-point restraints, a lap belt, and bilateral mittens when the Haldol order was written and administered. There was no face-to-face performed and no documentation of a behavioral restraint nursing assessment.

A review of the nursing flowsheet dated 10/3/23 at 5:00 PM stated the patient was, "confused, awake, and agitated." There was no documentation of what the nurse described as "agitation."

A review of the MAR dated 10/3/23 at 5:29 PM revealed patient #11 received an injection of Haldol 2.5 mg as a PRN at the nurse's discretion. There was no evidence that the physician was notified of the injection.

A review of the nursing restraint flowsheet dated 10/30/23 at 5:55 PM revealed the patient was currently in 4-point restraints, a lap belt, and bilateral mittens. The nurse documented, "Continues to attempt to remove essential lines/tubes or interfere with medical treatment; confused; Agitated." There was no further documentation on how the patient had interfered with lines and care when he was in bilateral wrist restraints, bilateral ankle restraints, a lap belt, and hand mittens. There was no documentation on how the patient was agitated and what behaviors constituted a chemical restraint/EBM.

A review of patient #11's chart revealed a face-to-face was not completed after the administration of the Haldol IM injection on 10/3/23 at 5:28 PM for agitation. There was no 15-minute nursing assessment for 1 hour after administering a chemical restraint/EBM. There was no documentation on the effectiveness of the medication nor was there any documentation on the care plan about the chemical restraint/EBM use. Nursing failed to recognize, assess for, or document the psychotropic IM/IV medications as a restraint.

A review of the facility policy and procedure "restraints" stated, " ...b) Requires the Physician to examine the patient Face-to-Face within ONE hour of restraint application with order validation within 24 hours.
As authorized by statutory regulations and this policy, the physician may delegate the ·face-to-face evaluation to an Advanced Practice Registered Nurse (APRN), a physician assistant (PA), or an RN who has current competency as demonstrated by completion of:
( 1) Study guide for Conducting the One Hour Face to Face Assessment of a Patient in Restraints for Behavioral Emergency
(2) UT Health Restraint Education Module
(3) Review of Administrative Policy 40039.4 ''Restraint Policy-NS-MKT'' ...d) There is no time limit when a single "STAT'' dose (orally, IM or IV) is administered for a behavioral emergency. The nurse will document every 15 minutes for up to one hour following the administration or longer if clinically indicated to ensure stability ..."

A review of the facility policy and procedure "restraints" stated. "1) Initial Orders
...d) The order must never be written as a standing or PRN order.
e) The use of restraint must be in accordance with the written modification to the patient's Plan of Care; and implemented in accordance with safe and appropriate restraint techniques ..."

An interview was conducted with Staff # 6 on 12/12/24. Staff #6 stated that over a year ago the hospital system had a computer program change and went from One Source to EPIC. Staff #6 stated in One Source the system was more user-friendly, helped the staff maneuver through the documentation of restraint use, and had hard stops for the pharmacy to review. The program allowed staff to make sure the reason for the medications was clear on the physician's orders. Staff #6 stated after the EPIC program was started, they found issues where things needed to be changed and added to ensure safe patient care was given. Staff #6 confirmed there was an issue with the monitoring and documentation of restraints and the process needed to be evaluated as soon as possible. Staff #6 stated that there has also been an increase in Residents practicing in the facility that had not received restraint training. Staff #6 confirmed there needs to be retraining and processes put back into place in all departments to ensure the policy for restraints was being followed and understood.

An interview was conducted with Staff # 8 and #9 on 12/12/24. Staff #8 stated the process for Quality Assessment Performance Improvement (QAPI) was to place the restraints on the restraint log. The QAPI department would review the restraint logs and pull charts to audit to ensure the patient's restraints were appropriate, safe, and documented. Staff #8 confirmed not all restraints were being logged correctly. Staff #6 confirmed that QAPI was not catching all the restraint patients. Staff #8 and #6 confirmed there was an issue with the review process in QAPI and the process would need to be reevaluated. Staff #8 stated the chemical restraints were being ordered and not placed on the restraint log due to staff not recognizing the medications as a chemical restraint/EBM.

Based on record review and interview, the facility failed to follow its policy and procedure to ensure that non-violent restraints were applied, monitored, and released to ensure patient safety.

A. The facility failed to ensure all staff were educated on restraint use.

B. Nursing failed to document the patient's behavior in descriptive terms to evaluate the appropriateness of the interventions used, no nursing assessment after restraints were applied to ensure that restraints were properly and safely applied, and the effectiveness of the restraints.

C. Nursing failed to document the Q 4-hour assessment review of the patient restraints from 10/2/23 at 10:52 pm until 10/3/23 at 7:21 AM.

D. Quality failed to monitor all restraints to ensure appropriateness, use, and discontinuation when ordered and applied. Quality failed to ensure all restraints were logged on the restraint log and appropriately identified as non-violent (medical) vs violent restraints (behavioral).

The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Patient #11

A review of the physician's History and Physical (H&P) dated 10/02/23023 at 10:32 AM, stated "30 y/o Male, _____ (Patient #11), presents to the (Emergency Department) ED via EMS after being the unrestrained driver of a vehicle that was rear¿ended causing severe damage to vehicle and "breaking the driver's seat so that it lays in a flat position. EMS states that pt was c/o severe headache/neck pain, and slightly combative/concussed on scene. EMS reports perseveration. LOC in not known. Patient endorses SOB, chest pain, severe neck pain and headache. Patient is in a confused state and presents himself tearful and yelling. (sic) ...A review of the urine drug screen on 10/02/2023 at 9:19 AM revealed cocaine and cannabinoids were detected.

Patient #11 was admitted to the facility on 10/02/2023 at 9:26 AM with, "SDH (subdural hematoma), Right Subdural hematoma, Right clavicle fracture, T 4, T6 superior endplate compression fractures."

A review of patient #11's chart revealed the nurse had obtained a verbal physician order dated 10/02/2023 at 9:47 AM. The order read, "NON-violent- Bilateral Soft wrist restraints and Lap belt/buddy (NV), Clinical Justification: Interfering with essential medical treatment".

A review of patient #11's chart revealed the restraint flowsheet dated 10/2/23 at 9:47 AM revealed the nurse applied the right and left wrist restraints due to "interfering with essential medical treatment. Nursing interventions previously ineffective- Change in environment, (pain, position, clothing); Discontinue non-essential devices, diversional activity; Reduce environmental stimuli; Reorientation." The nurse documented in the flowsheet that patient #11 was sleeping on 10/2/23 from 11:00 am until 3:00 pm. There was no documentation that he was interfering with any medical care at that time. The nurse failed to document the patient's behavior in descriptive terms to evaluate the appropriateness of the interventions used.

A review of the policy and procedure "restraint" stated, " ...5) Non-Violent Restraint/Medical is a medical restraint used for Behavior driven by a medical condition. The patient is attempting to Remove lines, tubes, surgical dressing or otherwise interfering with Essential medical treatment. (Example: The patient whose confusion Is due to a medical condition; this patient has no control over this behavior).
3) Monitoring and Documentation
a) Upon initiation and release
i) Alternatives to restraint
ii) Circulation assessed
iii) Laboratory results reviewed
iv) Medications reviewed
v) Skin assessed
vi) Date and time of restraint initiated
vii) Description of the patient's behavior
viii) Patient's condition or symptom(s) that warranted the use of
restraints
ix) Patient's response to less restrictive alternatives
b) Daily
i) Restraint type
ii) Reason for restraint
iii) Check if ordered within last calendar day
iv) Patient/family education
v) Restraint education comprehension _
c) Requires monitoring at least every four hours by a licensed nurse for the
following:
i) Signs of injury associated with restraint application
ii) Assessed for release
iii) Restraint correctly applied
iv) Circulation and respiratory status
v) Fluid and nutrition
vi) Release for range of motion
vii) Positioned, repositioned _
viii) Rationale for continued use of restraints
ix) Skin assessment
x) Emotional support provided
xi) Toileting
xii) A description of the patients' behavior and any change in intervention
required
xiii) Mental status, cognitive function, presence of agitation

4) Criteria for release:
a) Does not attempt to remove tubes, dressings, equipment, etc.
b) Least restrictive interventions are successful.
c) Under RN supervision, staff may remove restraints when criteria for release have been met.
d) Restraint use should be discontinued when there is no longer adequate and appropriate justification for continued use and before an order expires.
e) The use of restraint must be discontinued as soon as possible, based on an individualized patient assessment and re-evaluation."

A review of patient #11's chart revealed a verbal physician order on 10/2/23 at 4:20 PM. The order stated to discontinue the previous restraint order and ordered, "bilateral wrist restraints and a lap belt/buddy; interfering with essential medical treatment."

A review of the restraint flowsheet on 10/02/2023 at 4:21 PM revealed that the lap belt was applied. The nurse documented, "bilateral soft wrist restraints for interfering with essential medical treatment. Confused; Disoriented; Continues to attempt to remove essential lines/tubes or interfere with medical treatment". There is no nursing or physician note for 10/02/2023 at 4:21 PM to describe what the patient is attempting to remove or how the patient is interfering with medical treatment. There was no further documented justification on why the patient needed the added lap belt. The nurse failed to document a description of the patient's behaviors. There was no nursing documentation after restraints were applied that an assessment was immediately made to ensure that restraints were properly and safely applied.

A review of patient #11's chart revealed a verbal physician order on 10/2/23 at 10:35 PM to discontinue the previous restraint order. An order was written for "bilateral wrist restraints, bilateral ankle restraints, and a lap belt/buddy; interfering with essential medical treatment."

A review of the restraint flowsheet on 10/2/23 at 10:52 pm revealed the nurse applied patient #11's bilateral ankle restraints. The patient now had 4-point restraints on and a lap belt. There was no further documented justification on why the patient needed the added bilateral ankle restraints. The nurse failed to document a description of the patient's behaviors. There was no nursing documentation after restraints were applied that an assessment was immediately made to ensure that restraints were properly and safely applied.

A review of the restraint flowsheet revealed there was no documentation of restraints or a patient assessment for the ordered restraints from 10/2/23 at 10:52 pm until 10/3/23 at 7:21 AM. A review of the clinical note dated 10/3/23 at 3:21 AM revealed staff # 37, CT Tech, documented the "CT scan completed without complication. Patient came to CT by bed on a monitor, with nurse. No O2 or IV. Nurse will take patient to 3356A." There was no documentation that the patient restraints were removed. A review of the medication administration record (MAR) revealed the IV medication was "paused." There was no nursing documentation of the patient restraints. The nurse had previously documented the patient was interfering with lines and medical care that justified restraints.

A review of patient #11's chart revealed a verbal physician order on 10/3/23 at 7:46 AM to discontinue the previous restraint order. A physician order was written for bilateral wrist restraints, bilateral ankle restraints, mittens, and a lap belt/buddy; "interfering with essential medical treatment."

A review of the restraint flowsheet dated 10/3/23 at 7:52 AM revealed the nurse applied patient #11's bilateral mittens. The nurse documented that patient #11 had 4-point restraints on, mittens, and a lap belt. There was no further documented justification on why the patient needed the added bilateral mittens. The nurse failed to document a description of the patient's behaviors. There was no nursing documentation after restraints were applied that an assessment was immediately made to ensure that restraints were properly and safely applied.

A review of the medication administration record (MAR) revealed patient #11 had received chemical restraints/ Emergency Behavioral Medications (EBM) while in 4-point restraints, with a lap buddy and mittens. The following medications were administered.

Ativan (sedative) 0.5mg IV on 10/2/23 at 7:33 am, no reason indicated on the order.
Ativan 1 mg IV on 10/2/23 at 5:00 pm and 10:39 pm no reason indicated on the order.
Ativan 1 mg IV on 10/3 at 6:50 am and 10:05 pm no reason indicated on the order.
Haldol (psychotropic) 2mg IV 10/3/23 at 7:30 pm no reason indicated on the order.
Haldol 2.5 mg IV 10/3/23 at 5:28 pm and 10:49 am, no reason indicated on the order.
Geodon (psychotropic) 20mg IM 10/3/24 at 10:00 pm no reason indicated on the order.

A physician order on 10/3/23 at 10:39 PM revealed a sitter was ordered on 10/03/2023 at 10:39 PM for "restraint alternative". There was no found documentation or evidence that a sitter was provided at any time in this timeframe of the active order. There were no other documented interventions for PO (oral) medications before restraints were applied or the reaction of the patient when restraints were applied or administered. There was no documentation found of the effectiveness of the restraints. Multiple restraints were added to the patient within 24 hours without evidence of 1 to 1 evaluation or line of sight to ensure patient safety.


A review of the nursing notes dated 10/03/2023 at 10:23 PM stated, "Due to patient's aggressive behavior and physicality with nurses, this nurse is transferring care to _____ (staff # 35 RN) after one-time medication given to calm patient down."

A review of the nursing notes dated on 10/03/2023 at 10:25 PM revealed staff # 28 (student nurse) documented, "Patient agitation increasing. The patient had an incontinent episode and urinated on himself. While changing patient, he was yelling and cussing at staff and hit Nurse ______ (floor nurse) hard in the stomach. Attempted to redirect patient, unable to calm him down or de-escalate him."

A review of the restraint flow sheet revealed all restraints were discontinued on 10/3/23 at 10:38 PM, 13 minutes after he had a violent behavioral incident. There was no nursing documentation explaining the patient's condition, mental status, or justification for release. Patient #11 had been given a chemical restraint for his behaviors with Ativan 1 mg IV and Geodon 20mg IM at 10:00 PM before the patient was released from his physical restraints.

A review of the physician's (Staff #33) notes on 10/04/2023 at 12:59 PM revealed "24-Hour Events: Still agitated, confused to nurses. Took off his strains. (sic) Ziprasidone (Geodon) and haloperidol (Haldol) were given for sedation." The physician stated the medications of Geodon and Haldol were given to sedate the patient.

An interview was conducted with Staff # 6 on 12/12/24. Staff #6 stated that over a year ago the hospital system had a computer program change and went from One Source to EPIC. Staff #6 stated in One Source the system was more user-friendly, helped the staff maneuver through the documentation of restraint use, and had hard stops for the pharmacy to review. The program allowed staff to make sure the reason for the medications was clear on the physician's orders. Staff #6 stated after the EPIC program was started, they found issues where things needed to be changed and added to ensure safe patient care was given. Staff #6 confirmed there was an issue with the monitoring and documentation of restraints and the process needed to be evaluated as soon as possible. Staff #6 stated that there has also been an increase in Residents practicing in the facility that had not received restraint training. Staff #6 confirmed there needs to be retraining and processes put back into place in all departments to ensure the policy for restraints was being followed and understood.

An interview was conducted with Staff # 8 and #9 on 12/12/24. Staff #8 stated the process for Quality Assessment Performance Improvement (QAPI) was to place the restraints on the restraint log. The QAPI department would review the restraint logs and pull charts to audit to ensure the patient's restraints were appropriate, safe, and documented. Staff #8 confirmed not all restraints were being logged correctly. Staff #6 confirmed that QAPI was not catching all the restraint patients. Staff #8 and #6 confirmed there was an issue with the review process in QAPI and the process would need to be reevaluated.

Based on record review and staff interview, nursing staff failed to change the Peripherally Inserted Central Catheter (PICC) line dressing every 7 days as specified by hospital policy and per Centers for Disease Control (CDC) guidance in 4 (Patient #2, #10, #22 and #23) of 5 (Patient #2, #10, #22, #23, #24) patient charts reviewed. The PICC line dressing covers and protect the PICC insertion site, preventing infection and maintaining the line's position.

Findings include:

A review of the medical records for patients #2, #10, #22, #23, and #24 for proper dressing changes of PICC lines was conducted with Staff #2, on 12/11/2023 at 11:00 AM in the conference room. Record review found that four (patients # 2, 10, 22, and 23) of the five patient's charts reviewed documented dressing changes on PICC lines having occurred outside of the minimum seven-day timeframe required by facility policy, "Vascular Access and Maintenance (Adult), Policy Number: 39220.4."

A review of the hospital policy titled, "Vascular Access and Maintenance (Adult), Policy Number: 39220.4" with an "effective" date of 11/04/2022 revealed,

"Purpose: To provide guidelines and recommendations for insertion and maintenance of vascular access in the hospital setting that will reduce incidents of phlebitis, infiltration, and central venous catheter-related bloodstream infections ...

...4) Maintenance ...
... iv) Dressing change procedure:

(1) Hospital-approved dressings are to be changed at a minimum every seven days as designated by each facility's policy. Dressing must be changed if the dressing is wet, soiled, not occlusive, bloody, or not dated. Clean and intact dressing may remain in place for up to 7 days ...

...d) Patients being discharged with central venous access... Clinical practice with dressings and flushing will continue per this document until the patient is discharged. Prior to discharge, the site should be inspected, and dressing changed ..."

The hospital policy refers to CDC guidelines for dressing changes to any vascular access recommending to "Replace dressings used on short-term CVC (Central Venus Catheter) sites at least every 7 days for transparent dressings" https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf


Patient #2
A review of patient #2's medical record revealed a physician order dated 10/13/2023 for PICC line placement. The PICC line was inserted on 10/13/2023 and a new dressing was applied. Nursing documentation revealed the dressing was changed on 10/24/2023, 11 days later, there was no documented evidence the dressing was changed within 7 days of insertion per the hospital policy.

Patient #10
A review of patient #10's medical record revealed a physician order dated 10/28/2023 for PICC line placement. The PICC line was inserted on 10/28/2023, and three of the four dressing changes documented by Nursing staff occurred for more than seven days. Dressing changes were documented for the following dates: 10/31/2023 (3 days later), 11/13/2023 (13 days later), 11/21/2023 (8 days later) and 12/06/2023 (15 days later). There was no documented evidence the dressing was changed within the 7 days per the hospital policy.

Patient #22
A review of patient #22's medical record revealed a physician order dated 10/25/2023 for PICC line placement. The PICC line was inserted on 10/25/2023 and a new dressing was applied. Nursing documentation revealed the dressing was changed on 11/04/2023, 10 days later. There was no documented evidence the dressing was changed within 7 days per the hospital policy.

Patient #23 A review of patient #23's medical record revealed a physician order dated 10/31/2023 for PICC line placement. The PICC line was inserted on 10/31/2023 and a new dressing was applied. The patient was discharged seven days later, on 11/06/23, with a PICC line in place for long-term antibiotic treatment, however, there was no documented evidence the dressing was changed on or before discharge as required by facility policy.

In an interview on 12/12/2023 at 4:00 PM in the conference room, Staff #6 stated, "We used to do PICC line dressing changes every Friday and that process worked well. However, at some point, the staff decided to change that process and wanted to change the dressing on the 7th day, instead of a particular day of the week. The nurses should have been changing the dressing on the 7th day but in review of these charts, that has proven to be a problem throughout the hospital. We will go back to changing the dressings on PICC lines on certain days, such as every Friday to better monitor and ensure PICC line dressings are being changed per our hospital policy."

In an interview on 12/11/2023 at 11:00 AM in the conference room with Staff #2 and Staff #8 confirmed that the nursing staff did not follow the policy for "Vascular Access and Maintenance" consistently and acknowledged that monitoring and reporting from the quality and infection control department were "insufficient".