HospitalInspections.org

Based on document review and interview, the facility failed to ensure least restrictive interventions were determined to be ineffective prior to restraint application for 1 of 12 (patient #1) medical records reviewed.

Findings include;

1. Facility policy titled "USE OF RESTRAINTS AND SECLUSION" with approval date of 6/30/13 states on page 4 of 16 "C. Restraints and seclusion are used only when preventative strategies such as restraint alternatives, less restrictive interventions or de-escalation techniques have failed to protect the patient or others from harm......"

2. Review of patient #1 medical record indicated the following:
(A) The patient had restraints applied on dates including, but not limited to, 5/28/16, 6/7/16, 6/28/16 7/16/16 and 7/28/16.
(B) The record lacked evidence that least restrictive interventions were determined to be ineffective prior to the restraint application. The medical record document listing the least restrictive interventions was left blank.

3. Staff member #1 (Accreditation Specialist) verified the above in interview at 1:30 p.m. on 8/11/16.

Based on document review and interview, the facility failed to ensure the least restrictive restraint was utilized for 1 of 12 patients (patient #1).

Findings include;

1. Facility policy titled "USE OF RESTRAINTS AND SECLUSION" with approval date of 6/30/13 states on page 4 of 16 "D. When restraints cannot be avoided, the least restrictive restraint or technique that maintains the patient's safety is utilized." The definition of least restrictive listed in the policy states "allowing the greatest movement, freedom or choice. RNs and practitioners are expected to choose the least restrictive measure that preserves an maintains the patient's safety."

2. Review of patient #1 medical record indicated the following:
(A) He/she had vest restraint, bilateral wrist, and bilateral ankle restraints applied on 5/27/16 beginning at 0800 hours due to "agitation". The record lacked evidence that least restrictive restraints or techniques were attempted prior to applying the five (5) restraint devices.
(B) Nurses notes dated 6/10/16 at 2230 hours states "Patient spit out pudding and lemonade offered at RN (Registered Nurse)and began yelling. Patient was combative, kicking at RN's, shouting, and aggressively attempting to grab RNs' arm. RN was unable to communicate with patient due to language barrier (sign language), and called for a sign language interpreter. RN then gathered helping hands to safely place patient in a 4 point restraints......" An order was obtained for restraints, however the medical record lacked documentation that the least restrictive restraint was utilized prior to applying 4 point restraints.

3. Review of interpreter visit logs/forms indicated an interpreter arrived at 2345 hours on 6/10/16.

4. Staff member #2 (Clinical Informatics Coordinator) verified the medical record information for patient #1 beginning at 11:30 a.m. on 8/10/16.

Based on document review and interview, the facility failed to follow restraint and seclusion policy for 1 of 12 patients (patient #1).

Findings include;

1. Facility policy titled "USE OF RESTRAINTS AND SECLUSION" with approval date of 6/30/13 states on page 4 of 16: "G. If a restrained patient's primary means of communication is sign language, at least one hand will be released a minimum of every hour to provide for patient communication needs."

2. Review of patient #1 medical record indicated the following:
(A) The patients primary means of communication was sign language.
(B) He/she had wrist restraints applied on dates including, but not limited to, 5/28/16, 6/7/16, 6/28/16 7/16/16 and 7/28/16.
(C) The medical record lacked evidence that restraints were released at a minimum of every hour to allow for communication needs.

3. Staff member #2 (Clinical Informatics Coordinator) verified medical record information for patient #1 beginning at 11:30 a.m. on 8/10/16.

Based on document review, observation and interview, the facility failed to ensure orders were obtained for restraints for 2 of 12 patients (patients #1 and #11).

Findings include;

1. Facility policy titled "USE OF RESTRAINTS AND SECLUSION" with an approval date of 6/30/13 states on page 4 of 16: "H. Restraints or seclusion are only used when ordered by a practitioner."

2. Review of Posey Self-releasing roll belt application instructions states "If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician."

3. Review of patient #11 medical record indicated the following:
(A) The patient was admitted on 8/5/16 and had a roll belt utilized beginning on 8/5/16.
(B) The record lacked an order for a restraint.

4. Review of patient #1 medical record indicated the following:
(A) The nursing flowsheets indicated the patient was in restraints at 0200 hours on 5/29/16 through 1600 hours on 5/30/16 and 1800 hours on 5/3/16 to 0038 on 6/1/16.
(B) The medical record lacked an order for restraints for the above dates/times.
(C) The patient had an order for wrist restraints and not ankle/leg restraints on the evening of 6/4/16 when the wrist restraint was removed and placed on leg per staff.

5. Facility document review indicated that an incident report was completed for 10:30 p.m. on 6/4/16 indicating that a staff member (staff member #8, Licensed Practical Nurse) took one of the wrist restraints off of patient #1's arm and put on his/her leg.

6. During observation on the B8 Medical/Surgical unit at 11:45 a.m. on 8/11/16, patient #11 was observed with a Posey roll belt on while in bed. In the presence of staff member #6 (Patient Care Tech), the patient was requested to remove the belt. He/she worked with the belt and could not release the buckle. He/she stated "I can't."

7. Staff member #7 (Registered Nurse [RN]) indicated in interview at 12:05 p.m. on 8/11/16 that he/she went back to the patients room (patient #11) and the patient could not release the belt because the patient had not been shown how. He/she indicated that is how the facility keeps the patient safe and keeps them from falling. He/she indicated that they explained to the patient how to release the belt and it took the patient a couple times and then they could release the buckle. He/she indicated now the patient would probably be releasing the belt. He/she voiced understanding that if the patient cannot release the device, it would be a restraint. He/she verified the medical record for patient #11 lacked an order for a restraint.

8. Staff member #2 (Clinical Informatics Coordinator) verified the restraint orders/documentation for patient #1 beginning at 11:30 a.m. on 8/10/16.

Based on document review and interview, the facility failed to ensure meals were provided and meal consumption documented per policy for 11 of 12 patients (patients #1-10 and #12) , failed to ensure supplements were provided and consumption documented for 2 of 12 patients (patients #1 and 6) and failed to accurately document patients weights for 1 of 12 patients (patient #1).

Findings include;

1. Facility policy titled "DOCUMENTATION STANDARDS: INPATIENT" effective date of 3/31/16 states on attachment titled "Daily Assessments and Care Standards" under Nutrition/All Intake and Output....."Document Percentage of meal or snack eaten....."

2. Review of patient #1 medical record for visit #1 indicated the following:
(A) He/she had an order written on 5/19/16 at 0957 hours for Ensure to be given with lunch and dinner. The medical record lacked documentation that the Ensure was given at lunch and dinner on 5/19/16, lunch on 5/20/16, lunch or dinner on 5/21/16 and 5/22/16, and lunch on 5/23/16.
(B) The medical record lacked documentation of meal consumption for breakfast, lunch, and dinner on 5/20/16, lunch on 5/21/16, lunch on 5/22/16, and dinner on 5/23/16,
(C) The patients admission weight was documented as 70.0 kg on admission date of 5/15/16. His/her weight was documented as 67.3 kg on discharge date of 5/24/16.

3. Review of patient #1 medical record for visit #2 indicated the following:
(A) The medical record lacked of documentation of meal consumption for dates including, but not limited to, lunch and dinner on 5/27/16, dinner on 5/28/16, breakfast, lunch, and dinner on 6/5/16, lunch on 6/9/16, breakfast, lunch and dinner on 6/10/16, breakfast, lunch and dinner on 6/14/16, lunch on 6/25/16, breakfast and lunch on 6/27/16, breakfast, lunch, and dinner on 7/2/16, breakfast, lunch and dinner on 7/4/16, breakfast, lunch, and dinner on 7/14/16, breakfast, lunch, and dinner on 7/24/16.
(B) An order was written at 1350 hours on 7/5/16 for Ensure pudding to be given tid (three times a day) with meals. The medical record lacked documentation that the pudding was given 7/5/16 through 7/18/16 and from 7/20/16 through 7/24/16.
(C) The patients admission weight was documented as 62.0 kg on 5/25/16, a 5.3 kg loss in 24 hours from discharge on 5/24/16. His/her weight was documented as 60.9 kg on discharge date of 7/29/16.

4. Review of patient #2 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for dinner on 5/11/16, and breakfast and lunch on 5/12/16.

5. Review of patient #3 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for breakfast, lunch, and dinner on 5/10/16, lunch and dinner on 5/11/16, breakfast, lunch, and dinner on 5/12/16, dinner on 5/13/16, breakfast, lunch, dinner on 5/14/16 through 5/16/16, and dinner on 5/17/16.

6. Review of patient #4 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for the hospital stay despite an order for a regular diet written at 0850 hours on 5/12/16. The patient had a documented weight loss. His/her weight at 1521 hours on 5/11/16 was 75.5 kg. His/her weight at 0600 on 5/13/16 was 73.7 kgs. The patient was discharged on 5/14/16.

7. Review of patient #5 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for hospital stay after diet order was placed at 1410 hours on 5/13/16. The patient was discharged on 5/15/16.

8. Review of patient #6 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for hospital stay after diet order was placed on 5/16/16 at 0414 hours except for a 20% intake documented at 10:28 a.m. on 5/18/16. Additionally, Ensure plus with meals was ordered on 5/19/16 at 0946 hours. The medical record lacked evidence that the Ensure plus was given.

9. Review of patient #7 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for hospital stay after diet order was placed on 5/10/16 at 1946 hours. The patients weight was documented as 82.6 kg on admission date of 5/10/16 and 78.5 kg on discharge date of 5/12/16.

10. Review of patient #8 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for lunch and dinner on 8/6/16 and breakfast, lunch, and dinner on 8/7/16 through 8/10/16.

11. Review of patient #9 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption including, but not limited to, breakfast, lunch, and dinner on 7/25/16-7/28/16 and breakfast, lunch, and dinner on 8/7/16-8/9/16. The patients weight was documented as 95.9 kg on 7/24/16 and 92.6 on 8/1/16.

12. Review of patient #10 medical record indicated the following:
(A) The medical record lacked documentation of meal consumption for dinner on 8/10/16.

13. Review of patient #12 medical record indicted the following:
(A) The medical record lacked documentation of meal consumption for lunch and dinner on 8/8/16, and breakfast, lunch and dinner on 8/9/16.

14. Staff member #2 (Clinical Informatics Coordinator) verified medical record information beginning at 11:30 a.m. on 8/10/16.