HospitalInspections.org

Based on policy review, medical record review and interview, the physician did not document an order for the use of restraint for 1 of 10 Patients (Patient #1).

Findings include:

Review of policy "Use of Restraints" last revised 05/12 indicates patients are not put in restraint without a time limited written order from the physician.

Review of the Medical Staff Rules & Regulations for 2016 indicates the Attending Physician is responsible for ordering and timing any use of restraints. Orders for restraints must give specific limitations on the use.

Review of the nursing note dated 06/24/17 during the 3-11 shift revealed Patient #1 was placed in a 4-point restraint from 07:50 PM to 09:05 PM for safety after assaulting a staff member. No evidence of a physician order was found in the medical record.

Interview on 08/02/17 at 03:00 PM with Staff (J), RN Supervisor, revealed that Staff (G), Family Medicine Physician, was on the unit for the restraint on 06/24/17 for Patient #1.

Interview on 08/02/17 at 03:35 PM with Staff (C), VP of Patient Care Services verified this finding.

Based on policy review, medical record review and interview, the facility failed to ensure ongoing assessment and monitoring of patient conditions during the use of restraint for 1 of 10 Patients (Patient # 1).

Findings include:

Review of the Medical Staff Rules & Regulations for 2016 indicates Nursing Services will be responsible for establishing and monitoring procedures for the safe use of restraints.

Review of policy "Use of Restraint" last revised 05/12 revealed the restraint record is completed while a patient remains in restraints. 1:1 observation is maintained. The patient is assessed every 15 minutes for impaired circulation and tolieting & fluids are offered. Vital signs are obtained every 30 minutes.

Review of the nursing note dated 06/24/17 during the 3-11 shift revealed Patient #1 was placed in a 4-point restraint from 07:50 PM to 09:05 PM for safety after assaulting a staff member. No evidence of ongoing monitoring of Patient #1's condition, while in restraints, including, but not limited to vital signs, circulation, hydration & elimination needs, level of distress & agitation, mental status, cognitive functioning and skin intergrity was found in the medical record.

Based on policy review, medical record review and interview, the physician did not document the face to face medical and behavioral assessment for 1 of 10 Patients (Patient #1).

Findings include:

Review of policy "Use of Restraints" last revised 05/12 indicates a physician must see and evaluate the need for restraint within 30 minutes of the initiation of the restraint and document the assessment on the Restraint/Seclusion flowsheet.

Review of the Medical Staff Rules & Regulations for 2016 indicates the Attending Physician shall personally evaluate the patient at the time the need arises or within 30 minutes of the onset of restraint. The Attending Physician is responsible for documenting the need for restraints, the outcome of use and any negative consequences of the procedure and each assessment of the patient must be documented.

Review of the nursing note dated 06/24/17 during the 3-11 shift revealed Patient #1 was placed in a 4-point restraint from 07:50 PM to 09:05 PM for safety after assaulting a staff member. No evidence of a physician assessment for the use of restraints was found in the medical record.

Interview on 08/02/17 at 03:00 PM with Staff (J), RN Supervisor, revealed that Staff (G), Family Medicine Physician, was on the unit for the restraint on 06/24/17 for Patient #1.

Interview on 08/02/17 at 03:35 PM with Staff (C), VP of Patient Care Services verified this finding.

Based on policy review, medical record review and interview, verbal orders are not authenticated promptly by the ordering physician for 3 of 10 Patients ( Patient # 7, 9 and 11). Failure of prompt authentication could potentially lead to incorrect treatments and inadequate patient care.

Findings include:

Review of policy "Physician Orders/Telephone Orders" last revised 05/11 indicates all telephone orders are co-signed by the physician within 24 hours of the given order.

Review of the Medical Staff Rules & Regulations for 2016 indicates telephone orders may be accepted by an RN from an Attending physician during an emergency. The Attending Physician must sign, date and time such orders within twenty-four (24) hours.

Review of the Physician Initial Order sheet for Patient #7 dated 07/26/17 at 06:55 PM revealed verbal telephone orders were given to the RN for safety precautions, mouth checks, routine vital signs and labs. The verbal telephone orders were not signed by the physician until 7/31/17.

Review of the Physicians Orders sheet for Patient #9 dated 07/17/17 at 09:15 (AM, PM not indicated) revealed a verbal telephone order given to the RN by the physician for Ativan 1 mg PO or IM with Prolixin 5 mg PO or IM x 1. The verbal telephone order was not signed by the physician as of 08/02/17.

Review of the Physician Orders sheet for Patient #11 dated 03/14/17 revealed a verbal telephone order was given at 12:28 AM to administer Ativan 2 mg by mouth. Another telephone order at 08:33 (AM, PM not indicated) was documented to give Suboxone 0.5 hours early to patient today. At 11:30 (AM, PM not indicated) a verbal order was given to administer Ativan 2 mg every day as needed for severe anxiety and panic attacks. Decrease Wellbutrin XL to 300 mg by mouth every day. The verbal telephone orders were not signed by the physician as of 08/02/17.

Interview on 08/02/17 at 01:15 PM with Staff (C), VP of Patient Care Services, verified these findings.