HospitalInspections.org

Based on review of 11 medical records, the Hospital failed identify a physician order was not documented for a Soma Bed (a restraint) in two of 11 records reviewed.

Findings included:

1.) The Hospital failed to identify stickers required for use of a restraint (use of Soma bed) were not signed by a physician.

2.) Review of Hospital policies and procedures for restraints indicated the use of a restraint must be authorized by a physician or Licensed Independent Practitioner affiliated with the Hospital.

Based on interview and documentation review the Hospital failed to ensure that the plan of care was updated for 1 of 11 patients (Patient #1).

Findings included:

1.) Review of medical record documentation indicated that upon admission Patient #1 was assessed to have a severe developmental disability and was non verbal.

2.) Review of the Care Plan indicated a plan for an Orthopedic patient and the documented goal was that Patient #1's activity level will be optimized. Patient #1's plan of care was not individualized and updated to include interventions required for activities of daily living such as bathing and toileting because of Patient #1's developmental disabilities. Also, Patient #1's behavior of noncompliance with nursing care, was not identified in Patient #1's care plan.

3.) The plan of care did not include to feeding meals to Patient #1, as identified on the initial nursing assessment, dated May 11, 2011.

Based on documentation review the Hospital failed to ensure that a physician's order was obtained per policy for each physical restraint applied to two of eleven patient records reeviewed (Patient #10 and #11).

Findings included:

1.) Review of Hospital policies and procedures for restraints indicated the use of a restraint must be authorized by a physician or Licensed Independent Practitioner affiliated with the Hospital.

2.) Medical record documentation dated 3/2/11, indicated that Patient # 10's record contained a sticker used for restraint orders. The sticker indicated the type of restraint was for an enclosure bed, however the order was not signed by a physician.

3.) Medical record documentation dated 4/28/11, indicated that Patient #11's record contained a sticker that was used for restraint orders. The sticker dated 4/28/11 was not signed by a physician.