HospitalInspections.org

Based on record review and interview, the hospital failed to ensure staff identified a physical hold that immobilized or reduced a patient's ability to move his arms, legs, body or head freely as a restraint for 1 (#3) of 1 (#3) sampled patients reviewed for restraint use out of a total sample of 5 (#1-#5) patients.

Findings:

Review of the hospital policy titled Restraints and Seclusion Use, policy number: PC-1502, revealed in part:
Purpose: The hospital uses restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others.
Policy: It is the policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate safety of the patient, staff, and others.
Definitions: Restraint is: A. Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. A physical hold is considered a restraint and requires adherence to the restraint policy and procedure.
Orders: B. Orders for the use of restraint or seclusion must be given by a Medical Doctor or Nurse Practitioner prior to their use. In an Emergency Situation, an RN can initiate the use of restraint or seclusion but the attending physician must be consulted as soon as possible (within a few minutes).

Review of Patient #3's physician's orders for 9/20/19 revealed no documented evidence of a restraint order.

Review of Patient #3's medical record revealed no documentation of consultation with the attending physician regarding use of restraint.

Review of S3RN's Multi-disciplinary Notes dated 9/20/19 read (in part): Patient had to be held (both arms) so that no further harm would be encountered, patient then went down to the floor with staff holding him. In the process of attempting to restrain the patient, the patient bit the nurse.

During interview on 10/21/19 at 3:00 p.m., S3RN confirmed S4LPN held Patient #3 in a hard hug to prevent him from continuing to swing at patients and staff and S4LPN managed to get the patient out of the day room and into the hall. S3RN said it happened really fast and next thing he knew the patient was on the floor with the LPN holding him down. S3RN said S4LPN was on the patient for approximately 2 minutes. S3RN confirmed he realized looking back now that the physical hold was a form of restraint. He confirmed the physician was not notified of the restraint and the restraint policy and procedures were not followed.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failure of the RN to assess a patient immediately after a fall, failure to notify the physician of a change in condition after a fall, and failure to complete the post-fall assessment form for 1(#3) of 1 (#3) patients reviewed for falls out of a total sample of 5 (#1-#5) patients.

Findings:

Review of the hospital policy titled Patient Falls, policy number: PC-1008, revealed in part:
Purpose: To identify patients at high risk for falls, to implement safety measures to prevent falls, and to ensure post fall care.
Policy: Fall risk is assessed continually throughout the patients stay and specifically upon admission and following a fall.
Procedure ...Post Fall: Following a fall, Physician will be notified and the post-fall assessment form will be completed to ensure identification of appropriate interventions for safety.


Review of Patient #3's Multi-Disciplinary Note documented on 9/20/19 at 10:42 p.m. read: Around 7:00 p.m. Patient began demonstrating aggressive behavior towards other patients. Pulling on patients who were in wheelchair, going from one patient to another. Redirected ...Ten minutes later patient got up and started annoying other patients, again the nurse attempted to redirect the patient away from other patients. The patient became agitated and aggressive, swinging his fist in an attempt to harm staff. Patient had to be held (both arms) so that no further harm would be encountered, patient then went down to the floor with staff holding him. In the process of attempting to restrain the patient, he bit the nurse: on the right arm ...S5MD notified of incident, orders given for Thorazine 50 mg IM. Attempted to take patient's vital signs but patient was too combative. IM medication given at 7:45 p.m.
9:30 p.m. patient asleep, upon awaking vitals obtained. Patient assessed for injuries or pain. Patient complains of left hip pain, no signs of bruising or fracture identified, however complains of pain when standing, and limps when walking. S5MD notified (left message on answering machine), waiting for call back. S2InterimDON notified. Received orders from S5MD for portable X-ray of left hip and neck area.
There was no documented evidence of a patient assessment documented as being done prior to the 9:30 p.m. assessment.

Further review revealed no documented evidence that a post fall risk assessment was conducted.

Review of Physician's Orders for Patient #3 revealed the following:
9/20/19, 8:25 p.m. Thorazine 50mg IM injection STAT ordered.
9/20/19, 10:23 p.m. STAT x-ray left hip and left neck for c/o pain.
9/20/19, 10:54 p.m. D/C STAT x-ray, ok to x-ray patient left hip and left neck for c/o pain on 9/21/19.

During an interview on 10/21/19 at 3:00 p.m., S3RN reviewed Patient #3's medical record and confirmed he was charge nurse and responsible for care of Patient #3 during the evening shift 9/20/19. He confirmed he witnessed Patient #3's fall and Patient #3 limped and unable to ambulate following the fall. He said he notified S5MD about the patient's behaviors, specifically the patient biting staff, and received an order for Thorazine, but did not notify the physician of the fall or that the patient was limping and no longer able to ambulate following the fall. He stated the patient was transferred from the location of the fall (Hall near nurse's station) to his room by wheelchair and had been able to ambulate without assistance prior to fall. He confirmed he did not assess the patient until 9:30 p.m., did not notify the physician of the change in Patient #3's condition until a couple of hours after the fall, and did not complete a post-fall assessment form.

In an interview on 10/21/19 at 3:45 p.m. S5MD said the only information he received initially from staff on 9/20/19 was the report that Patient #3 was attacking patients and staff and Thorazine was ordered. S5MD said staff called back and told him the patient was complaining of pain so he ordered a stat x-ray of left hip and neck, which is done by a portable service. S5MD said they notified him that something was wrong with the portable x-ray machine and they would come out when they got another machine or fixed. He said he took this to mean they would come in a few hours. He said he wasn't notified before 10:30 p.m. of the patient limping or being in pain. He said the results were a fracture to his left femoral neck and he was transferred to a local hospital. S5MD said he expected to be notified that the patient was in pain and was limping when he was first called.

In an interview on 10/22/19 at 8:29 a.m., S1Adm confirmed S3RN should have assessed Patient #3 immediately after the fall on 9/20/19, should have notified the physician of the change in the patient's condition immediately after the fall, and should have completed the post-fall assessment form as per policy.