HospitalInspections.org

Based on document review and staff interview it was determined nursing failed to ensure when a patient is restrained the plan of care is updated to address the restraint and reflect modifications to the nursing care being provided. This deficient practice was identified in one (1) of one (1) patient records reviewed who was placed in restraints (patient #23). When care plans are not updated to reflect the use of any restraints can result in inconsistent care or patient injury.

Findings include:

Review of the medical record for patient #23 revealed the patient was admitted on 8/13/14 and was placed on a ventilator due to respiratory failure. The record contained a physical restraint order dated 8/13/14 at 7:55 AM for wrist restraint which was signed by registered nurse #1 (RN 1) and signed by the physician on 8/15/14. There was no documentation in the patient's care plan addressing the restraint or special nursing care the patient is to receive.

The Regulatory Compliance Officer reviewed the record on 10/23/14 at 9:35 AM and stated she was unable to find where the care plan for patient #23 was modified to address the patient's restraint.

Based on document review and staff interview it was determined the hospital failed to ensure when a patient is placed in restraints there is a one (1) hour face to face evaluation completed by a physician or a trained registered nurse. Additionally, the hospital failed to ensure the registered nurses who perform the face to face evaluation have received training on how to perform a physical or behavioral assessment of the patient that addresses the immediate situation and the patients reaction to the intervention with assessment of the patient's medical and behavioral condition and the need to continue or terminate the restraint. This deficient practice was identified in one (1) of one (1) medical records reviewed in which a patient was restrained (patient #23). Failure to perform a face to face evaluation by a licensed person who is fully trained can result in incorrect, improper or unnecessary restraint application that could result in patient injury or adverse outcome.

Findings include:

Review of the hospital policy for restraints (revised 3/28/14) revealed in part the following. "The one hour face to face evaluation should be completed by a physician, however trained Registered Nurses and physician assistants are permitted to perform this duty but they must consult the responsible physician as soon as possible after the assessment and document this on the flow chart."

Review of the medical record for patient #23 revealed the patient was admitted on 8/13/14 and was placed on a ventilator due to respiratory failure. The record contained a physical restraint order dated 8/13/14 at 7:55 AM for wrist restraint which was signed by registered nurse #1 (RN 1). The physician signed the ordered on 8/15/14 at 6:14 AM. The record lacked documentation of a face to face evaluation.

The nurse manager of intensive care reviewed the above record on 10/22/14 at 1:00 PM. He was asked who performed the face to face on patient #23 He was unable to find documentation in the record where a face to face had been performed on patient #23 after restraint application. He stated it was probably performed by the nurse who signed the restraint orders. (RN 1).

Review of RN 1 personnel file/training record lacked documentation the nurse had received training on how to perform a face to face evaluation that included the physical or behavioral assessment of the patient, how to address their immediate situation and the patients reaction to the intervention with the patient's medical and behavioral condition and the need to continue or terminate the restraint.

On 10/22/14 at 2:06 PM The Regulatory Compliance Officer agreed there was no documentation of who performed the face to face on patient #23. she also concurred the Registered Nurse who signed the order for the restraint had no documentation in her personnel file that she had been trained on the one (1) hour face to face assessment.

Based on observations and testing during the survey conducted from October 20, 2014 through October 23, 2014 and the deficiencies issued to the Hospital for non compliance with the 2000 Edition of the Life Safety Code relating to the physical plant, it is determined the hospital failed to ensure the safety of patients, staff and the public. Therefore, the condition is not met. K062, K066 and K069.

Based on observations and interview during the survey conducted from October 20 - 23, 2014, the hospital failed to maintain the condition of the physical plant in a manner to protect the safety and well-being of patients.

Findings include:

1. The mobile Magnetic Resonance Imaging trailer located a distance from the hospital does not have a sheltered access route to protect patients from the elements of the weather when traveling between the hospital and the mobile unit.

2. These findings were discussed with the hospital director of engineering on 10/21/14 at approximately 11:40 a.m. and he agreed there was no covering to protect patients from the elements of weather when traveling between the hospital and the mobile unit.