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Based on interview and record review, hospital 2 failed to ensure one of three nursing staff (Registered Nurse 2) were knowledgeable of emergency evacuation equipment location. This failure had the potential to delay and negatively impact patient evacuation during an emergency.

Findings:

During an interview on 3/23/21, at 12:17 p.m., with RN 2, RN 2 stated he was a travel nurse and had worked at the hospital for "5 weeks." RN 2 stated he did not know the location of emergency evacuation equipment for the unit he was assigned to work in.

During an interview on 3/24/21, at 2:43 p.m., with Clinical Nurse Specialist (CNS), CNS stated she provided orientation to newly hired nurses, including new graduate nurses, travel nurses, and nurses with clinical experience. CNS stated all newly hired nurses receive the same information on the first day of orientation, which includes a "First Day Safety Checklist [FDSC]."

During a concurrent interview and record review on 3/24/21, at 2:49 p.m., with CNS and RN 2's, the "FDSC" dated 2/13/21 was reviewed with CNS and CNS indicated RN 2 did not receive new staff orientation on emergency patient evacuation equipment location.

During a review of the facility policy and procedure titled, "Inpatient Facilities Evacuation Plan [IFEP]," (undated), the IFEP indicated, "Purpose [:] To help ensure the safe removal of patients, staff and/or visitors in response to a situation which renders any facility, or part of a facility, unsafe for occupancy or prevents the delivery of necessary patient care."

Based on interview and record review, Hospital 1 failed to protect and promote patients' right to be free from physical and chemical restraint for two of 11 sampled patients (Patient 11 and Patient 12) when:

1. Licensed nurses (LN) and Medical Doctor (MD) 1 in the Medical Surgical Unit administered a medication that was not a standard treatment for Patient (Pt) 11, implemented 4-point locking leather restraints (applies to the 4 limbs (feet and hands) being secured), did not document the medical reason for the use of the medication and physical restraints, did not conduct wrist and ankle circulation assessments, skin injury assessment, range of motion (refers to activity aimed at improving movement of a specific joint), and did not release Pt 11's restraints every two hours in accordance with the hospital policies and procedures for Restraints and Seclusion.

2. Pt 12 wrist restraints were not released every two hours and LN did not conduct restraint circulation, skin, and range of motion assessments in accordance with the hospital policy and procedure.

These failures had the potential for Pt 11 and Pt 12 to experience hand and leg circulation problems, skin injuries and/or wounds, and cause decrease range of motion and had the potential for Pt 11 and Pt 12 to experience emotional harm from the restriction of movement.

Findings:

1. During a review of patient (Pt) 11's electronic medical record (EMR), the demographic (basic information about a patient including address, emergency contact, financial resources, dates of service, and other personal information) indicated Pt 11 was admitted to the hospital on 2/4/21 at 1:58 p.m. The space to indicate the discharge date and time was left blank. The findings in Pt 11's EMR were as follows:

During a review of an untitled document in Pt 11's EMR indicated, physician order dated 2/26/21, at 1:47 p.m., Medical Doctor (MD) 2 gave a telephone order for a one-time dose of Haldol (a strong sedative medication, commonly identified as a chemical restraint used to treat mental/mood disorders) 5mg (milligrams - a unit of measure), to be administered IM (intramuscular - injected into a muscle). Registered Nurse (RN) 12 administered the Haldol 5mg to Pt 11's left deltoid (upper arm muscle) on 2/26/21, at 1:57 p.m. The EMR did not contain documentation on the Medical Diagnosis (reason) for the Haldol order and the Medication Administration Record (MAR) did not contain the reason why Haldol was administered to Pt 11.

During a review of MD 3's Psychiatric Consult Evaluation for Pt 11, dated 3/8/21, at 1:35 p.m., indicated, MD 1 ordered a Psychiatric Consult on 3/6/21, at 7:46 p.m., the "Consult Question [ordering MD's question or reason for the consult]" indicated, "The pt [patient- Pt 11] still agitated, unable to wean off from restraints to discharge the pt." and "Current Medical Admission/Course ...Patient has had issues with episodes of agitation ...Patient was transferred out of the neuro [nervous system] ICU [intensive care unit] and subsequent management on the regular ward has been uneventful. The pt is still on restraints due to his agitation ... Current Psychiatric History Pt ...Denies recent confusion, anxiety [a feeling of worry, nervousness, or unease], depression [a mental condition characterized by feelings of loss of hope or courage, low spirits], agitation, SI [suicidal ideation (thoughts of harming self)] HI [homicidal ideation (thoughts of harming others)], AVH [audio, visual hallucinations (hearing or seeing things that aren't there)]. However, expresses discontent with being in restraints, stating he would like to get up and walk around ...Mental Status Examination ...Behavior: Calm, pleasant, cooperative with evaluation...Recommendations ...Scheduled: Haldol 1 mg bid [two times each day] PRN [as needed]: Haldol 0.5 mg q6h [every six hours] PO [orally by mouth]/IM [intramuscular (injected into the body through a muscle)] as needed for moderate/severe agitation/aggression ...Pt does not meet criteria for psychiatric inpatient admission ..."

During a review of MD 1's progress note dated 3/8/21 at 5:22 p.m., indicated, " ...The pt [Pt 11] still agitated over the night and this am. The pt is still on restraints due to his agitation. Psychiatric team note reviewed for medications adjustment, but still need further adjustments ..."

During a review of a RN Case Manager's (RNCM) progress note dated 3/9/21 at 2:03 p.m., the progress note indicated, "Patient is medically stable to be discharged to skilled nursing facility [SNF], but on 4 point restraints, [Named SNF] has accepted the patient [Pt 11] but ...need to be off restraints ..."

During a review of MD 1's progress note dated 3/10/21 at 10:42 a.m., indicated, " ...The pt is less agitated over the night, however still on restraints due to his agitation, will try to weaning [sic] off gradually. Psychiatric team note reviewed ...Noticed we do not give Haldol as instructed by psychiatric team. D/w [discussed with] nurse at bedside to follow closely with Haldol as needed [PRN] to help weaning [sic] off restraints as tolerate it ..."

During a review of physician's order titled, "Restraints Non-Violent or Non-Self Destructive (Order 292302208)," dated 3/10/21 at 11:57 a.m., indicated, MD 1 gave a telephone order to discontinue the 4-point, locking leather restraints for Pt 11, the physician's order indicated it was "Cancelled" (discontinuation of the 4-point locking leather restraints was cancelled). MD 1 electronically signed the order on 3/10/21 at 12:06 p.m.

During a review of Pt 11's flow sheets (document that contains Pt 11's medical information) dated 3/7/21 through 3/11/21, the flow sheet entry dated 3/10/21 at 12 p.m. under the "Restraint Type" indicated the 4- point locking leather restraints had been discontinued, 2-point (wrist restraints) locking leather restraints were started. The flow sheet indicated the 2-point locking leather restraints continued until 3/11/21 at 12 p.m.

During a review of a physician's order titled, "Restraints Non-Violent or Non-Self Destructive," dated 3/11/21 at 11:58 a.m., indicated MD 1 gave a telephone order for "Soft restraint: Right Wrist Left Wrist," and the restraint reason was, "Attempting to crawl out of bed." MD 1 electronically signed the order on 3/11/21 at 12:22 p.m. The soft restraint order was discontinued on 3/14/21 at 6:52 a.m.

During a review of Pt 11's flow sheets dated 3/7/21 through 3/11/21, documentation in the flowsheet for "Restraint Q2H [every two hours] Monitoring ...Visual Checks" indicated Pt 11's the following: on 3/7/21 at 8 a.m., 12 p.m., and 2 p.m. indicated "C" (calm); on 3/8/21 starting at 12 a.m., to 10 p.m., every two hours documentation indicated "AG" (agitated); on 3/9/21 at 12 a.m., 2 a.m. documentation indicated Pt 11 was calm, asleep at 6 a.m., and calm at 8 a.m., 10 a.m., and 12 p.m. On 3/10/21 documentation indicated Pt 11 was calm at 12 p.m. and 2 p.m., 6 p.m., 8 p.m., asleep at 12 a.m. and calm at 2 a.m.

During a review of Pt 11's flow sheets dated 3/7/21 through 3/11/21, documentation in the flowsheet for Restraint Q2H Monitoring and Range of Motion, indicated on 3/7/21 range of motion was "P" (performed) every two hours except at 8 p.m. "D" (declined to have range of motion performed). On 3/8/21 documentation indicated range of motions was performed every two hours. On 3/9/21 documentation indicated range of motion was performed every two hours. On 3/10/21 documentation indicated range of motion was performed every two hours up to 12 p.m.

During a review of a hospital security department document (log sheet) untitled, date range starting on 3/7/21 at 1:49 p.m. and ending on 3/10/21 at 9:29 p.m., the document indicated the times when security personnel were requested to unlock, remove, and adjust Pt 11's restraints, the time they actually adjusted (removed) the restraints for nursing staff to perform range of motion exercises (required every two hours per policy), and the time they finished the task (re-placing and locking the restraints back on Pt 11). The dates and times on the log sheet did not correspond to all the dates and times on Pt 11's flowsheets dated 3/7/21 to 3/10/21 where nursing staff indicated they performed range of motion activities every two hours for Pt 11. The security log sheet entries were as follows: the log sheet indicated on 3/7/21, security applied restraints (4-point locking leather) to Pt 11 at 1:55 p.m. and removed the restraints (for nurses to perform the required every two hours range of motion exercises) at 4:18 p.m., 6:14 p.m. Pt 11's restraints removed, at 6:16 p.m., and at 10 p.m. the task was completed. The log sheet indicated on 3/8/2, security removed Pt 11's restraints at 12:41 a.m., 7:42 a.m. (more than six hours after the previous adjustment), 10:11 a.m., 12:26 p.m., 6:34 p.m. (six hours and eight minutes after the previous adjustment), 9:48 p.m. (three hours and 14 minutes after the previous adjustment). The log sheet indicated on 3/9/21, security removed Pt 11's restraints at 3:45 a.m. (five hours and 57 minutes after the previous adjustment), 5:31 a.m., 8:26 a.m. (two hours and 55 minute after the previous adjustment), 12:10 p.m. (three hours and 44 minutes after the previous adjustment), 3:25 p.m. (three hours and 15 minutes after the previous adjustment), 6:59 p.m. (three hours and 34 minutes after the previous adjustment), and 9:43 p.m. (two hours and 44 minutes after the previous adjustment). The log sheet indicated on 3/10/21 security removed Pt 11's restraints at 1:48 a.m. (four hours and five minutes after the previous adjustment), 6:36 a.m. (four hours and 48 minutes after the previous adjustment), 10:38 a.m. (four hours and two minutes after the previous adjustment), at 11:47 a.m. the locking leather restraints were removed from Pt 11's feet (ankles); the locking restraints were left on Pt 11's wrists. The log sheet indicated their security did not log any adjustment entries for Pt 11's locking leather wrist restraints until 3/10/21 at 9:21 p.m. (nine hours and 34 minutes after the previous adjustment).

During a concurrent interview and record review on 3/25/21 at 11:30 a.m. with Registered Nurse Informaticist (RNI), Pt 11's physician's order in EMR titled, "Restraints Non-Violent or Non-Self Destructive [physician order]," dated 3/7/21 at 2:03 p.m., indicated MD 1 gave a telephone order (considered a verbal order) to RN 9, at 2:03 p.m. for continuous, locking leather 4-point (all four limbs, arms and legs) restraints for Pt 11. The reason for the restraints was noted as "Attempting to crawl out of bed." MD 1's n order included documentation to indicate, "Restraints must be removed when an alternative [less restrictive method] is available and effective and/or patient no longer meets [restraint] criteria. The MD must conduct a face-to-face assessment within 24 hours of initiation when initial restraint order is verbal." MD 1 electronically signed the order on 3/7/21 at 5:03 p.m. RNI validated Pt 11's clinical record did not contain documentation indicating least restrictive restraint and/or alternative methods such as the use of a one-to-one sitter to monitor Pt 11 had been attempted or implemented prior to applying locking leather 4-point restraints on Pt 11. RNI validated MD 1 had not conducted the required face-to-face assessment within 24 hours after the application of the restraints, in accordance with the hospital policy.

During a concurrent record review and interview on 3/25/21 at 11:49 a.m. with RNI, RNI validated the findings in Pt 11's EMR which indicated, Haldol 2 mg IM was administered to Pt 11 on 3/7/21 at 1:24 p.m., MD 1 gave a telephone order for the 4-point locking restraints which resulted in Pt 11 being placed in 4-point locking leather restraints on 3/7/21 at 2p.m. MD 1 did not perform a patient face to face assessment within 24 hours after giving order for Pt 11's restraints. The EMR did not contain documentation to indicate a one-to-one sitter was assigned to monitor Pt 11 while he was in restraints.

During an interview on 3/25/21 at 3:40 p.m., with the Vice President of Nursing (VPN), the VPN validated the findings in Pt 11's EMR which included the Haldol 2 milligram (mg - unit of measurement) that was administered to Pt 11 on 3/7/21 at 1:24 p.m. The VPN validated Pt 11 was placed in 4-point locking leather restraints starting 3/7/21 at 2 p.m. and ended on 3/10/21 at 12 p.m. The VPN validated MD 1 did not perform a face-to-face assessment for Pt 11 within the required 24 hour time period after the restraints were implemented on 3/7/21 at 2 p.m. The VPN stated nurses do not generally apply or remove the 4-point locking leather restraints, they notify security, and only security staff were permitted to apply, unlock, rotate limbs (adjust arms one restrained up and the other down) then alternate every two hours, and remove the locking leather restraints. The VPN stated nurses do not carry keys to unlock the restraints and in the event of an emergency, they call security. The VPN stated the hospital policy titled "Restraint and Seclusion," dated 1/14/20 was unclear and did not include specific criteria to determine when to use behavioral (generally 4-point locking leather) vs. medical (generally 2-point soft wrist restraints) restraints. The VPN stated ,stated, physicians were responsible for the restraint orders, and for determining if and when restraints were used for behavioral or medical purposes. The VPN stated the hospital recognized that they should have more opportunity to assess patients before placing them into 4-point locking leather restraints. The VPN stated the hospital was reviewing their current process as a result of the issue with Pt 11 having been placed in 4-point locking leather restraints for approximately three days, and 2-point locking wrist restraints on day four, and soft wrist restraints for three additional days (total of seven continuous days in restraints).

During an interview on 3/26/21 at 9:35 a.m. with MD 1 and the Director of Medical and Surgical Services (DMSS), MD 1 stated she was familiar with and provided care to Pt 11. MD 1 stated she recalled Pt 11 clearly. MD 1 stated she ordered a psychiatric evaluation for Pt 11, and chemical restraints were the first choice over physical restraints. MD 1 stated after she received a call from nursing staff (not sure when exactly or who called her) about Pt 11's aggressive behavior, attempting to elope, very agitated, and very violent when staff attempted to redirect Pt 11. MD 1 stated Pt 11 was up, getting out of bed all the time and staff were not able to control Pt 11's behavior or get him to stay in bed. MD 1 validated that on 3/7/21, she ordered 4-point locking leather restraints, "for safety reasons, keep him safe from falls." MD 1 stated she did not know Pt 11 was in 4-point locking leather restraints for three days. MD 1 stated she was not aware that she was required to conduct a patient face-to-face evaluation within 24 hours of the restraint application. MD 1 stated, "I don't put [assess the Pt] the note for that." MD 1 stated they tried everything to control Pt 11's behavior and the "sitter was for his safety, security brought him back." The DMSS validated there was no documentation in Pt 11's record to indicate a one-to-one sitter had been ordered or provided to monitor Pt 11.

During an interview on 3/26/21 at 10:55 p.m., with the Director of Security Services (DSS), the DSS stated locking leather restraints were ordered by medical staff and only security staff were permitted to apply, adjust, and remove locking leather restraints. The DSS stated they (hospital) does not call codes for out of control, aggressive patients, instead, nursing staff contacts the security dispatch office and security staff are dispatched to apply locking leather restraints, generally for a variety of types of patients, and especially when there was a concern that a patient will harm self or others. The DSS stated they do not call codes for out of control or aggressive patients, they apply, adjust, and remove restraints only when they are notified by nursing staff, they are not always called every two hours for a patient in restraints, and the process is the same throughout the hospital. The DSS stated, there was a restraint key in the pyxis (medication storage and dispensing machine) for nursing staff to access to remove the locking leather restraints in the event of an emergency and he did not know in what pyxis the spare restraint key was located. The DSS stated there was no process for tracking or monitoring storage and use of restraint keys.

During an interview on 3/26/21 at 11:20 p.m. with the Security Team Lead (STL), the STL stated he responded to a call from nursing staff one time during a night shift (does not recall exactly when) to adjust Pt 11's restraints. STL state he was aware of the process for rotating limbs, one arm pointe up and one arm pointed down, and alternating the rotation every two hours. STL stated on the night he responded to assist with Pt 11, Pt 11 was not giving staff any problems, Pt 11 was calm. STL stated he did not see any acting out behaviors' agitation, aggression, yelling out, and other disruptive behaviors from Pt 11.

During an interview on 3/26/21 at 11:55 a.m. with the Director of Consultation Psychiatric Services (DCPS), the DCPS stated generally, Psychiatric consultations are ordered for patients who are agitated and the agitation is linked to mental health related diagnosis or dementia (a permanent disorder of the mind and mental processes caused by a brain disease), delirium (a temporary disorder of the mind that causes restlessness, illogical thought and speech, that occurs from fever, or other disorders), or psychosis (a severe permanent or temporary mental disorder in which thought and emotions are so impaired that there is a loss of the sense of reality). The DCPS stated the Psychiatric Consultation Services does not generally provide recommendations for the use of restraints. The DCPS stated their primary role was medication adjustment. The decision to use restraints was left up to the primary medical care team. The DCPS stated he would not have applied restraints to any patient who was calm, and he would have used a one-to-one sitter in lieu of restraints. The DCPS stated Haldol was a chemical restraint and Haldol's main purpose was to control behavior.

During an interview on 3/26/21, at 3:15 p.m. with the DMSS, the DMSS stated she was responsible for the nursing staff on the following units: 1 East, 2 East, 2 Central, 5 Central, 5 West, and 7 West. The DMSS validated the findings in Pt 11's EMR and stated she was responsible for the nursing staff in these units, and Pt 11 was on the 5-West Unit. The DMSS stated it was her expectation for the nurses on her units to follow the hospital's policy, check patients every two hours, document in the patients EMR, Pt 11's restraints were releases and range of motion exercises were performed. The DMSS stated, "You have to rely on the documentation to ensure nurses are doing what they are assigned to do." The DMSS stated she was aware Pt 11 was in 4-point locking leather restraints for three days. The DMSS stated she was not aware of the availability of a sitter for those three days. DMSS stated, "it was a resource issue." The DMSS stated only security staff are permitted to apply, adjust, and remove locking leather restraints. The DMSS stated a one-to-one sitter should have been provided for Pt 11 prior to using restraints and "doesn't think it's normal for patients to be in restraints for three days."

During an interview on 3/26/21 at 3:29 p.m. with the Quality and Safety Specialist (QSS), the QSS stated there was a restraint key in a pyxis on the Medical Surgical Unit on the fifth floor. QSS stated she was not sure of the pyxis identification number, and if restraint key had not been accessed or used or removed from the pyxis by anyone for 806 days.

During a review of the facility policy and procedure titled, "Restraint and Seclusion," dated 1/14/20, indicated, "...II. DEFINITIONS A. Physical Restraint 1. Physical Restraint: 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 ...B. Chemical Restraint 1. Chemical Restraint: A drug [medication] used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...C. Seclusion 1. Seclusion: Involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior ...If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether the door is actually locked or not ...III. Policy ...C. Patient Rights 1. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restrain or seclusion, of any form, imposed as a means of ...convenience ...and must be discontinued at the earliest possible time ...D. Alternatives to the Use of Restraint and Seclusion ...3. The use of restraint or seclusion occurs only after alternatives to such use have been considered and/or attempted ...Such alternatives may include ...d. Increased observation and monitoring e. Use of a patient monitor f. Change in patient's physical environment ...E. Prohibitions on the Use of Restraint or Seclusion ...1 ...c. The routine use of restraints for the prevention of falls ...A history of falling without a current clinical basis for a restraint intervention is inadequate to demonstrate the need for restraint ...IV. PROCEDURE ...1. Time frames ...for restraint or seclusion used for the management of violent or self-destructive behavior ...may only be obtained and renewed in accordance with the following time limits for up to 24 hours: a. Up to four (4) hours for adults age 18 and older ...2. A new order must be obtained ...b. at the end of the time frame ...c. Orders for Restraint and Seclusion for Violent or Self-Destructive Behavior Beyond 24 Hours ...i. The physician ...must see the patient and conduct a face-to-face re-evaluation ...ii. The order must be accompanied by documentation ...describing ...re-evaluation supporting continuing restraints ...D. Violent or Self-Destructive Restraint and Seclusion: Special Requirement 1. A physician...or trained RN must see the patient face-to-face within one (1) hour after the initiation of the restraint ...2. The one(1) hour face-to-face evaluation should include both a physical and behavioral assessment ...E. Ongoing Monitoring and Assessment of a Patient in Restraint or Seclusion ... b. Minimum monitoring frequency i. Safety, non-violent, and non-destructive restraint - monitor at least every two (2) hours ... c. Ongoing assessment of patient in restraint or seclusion i. ... means that the patient will be evaluated to determine the patient's response to the restraint or seclusion, and if the patient has any care needs. This assessment shall include: I. Checking the patient's hydration and circulation; the patient's level of distress and agitation; or skin integrity, and may also provide general care needs (e.g., eating, hydration, toileting, and range of motion exercises) ... ii. Minimum assessment frequency I. Safety, non-violent, and non-destructive behavior should be assessed at least every two (2) hours ...F. Restraint Application 1. Restraint shall be applied/removed in accordance with ...c ...manufacturer's instructions ...in a manner that preserves the dignity, comfort, and well-being of the patient ...V. DOCUMENTATION A. Document the following information in the EHR [electronic health record] for each restraint or seclusion episode ... 4. Patient condition or symptom(s) that warranted restraint or seclusion use 5. Patient response to restraint/ seclusion, including the rationale for continued use 6. Individual patient assessments and reassessments 7. The intervals for monitoring ..."

During a review of the facility policy and procedure titled, "Restraints Use," dated 12/11/19, indicated, "...I. PURPOSE The purpose of this policy is to set the standards and expectations for restraint use. II. APPLICATION AUTHORIZATION A. Any authorized practitioner, as an MD designee, may provide a medical order to apply restraints to a patient ...Nurse Practitioners, Certified Nurse Midwives, Cardiovascular Nurse Clinicians, Physician's Assistants, Certified Registered Nurse, and Anesthetists...III. RESTRAINT APPLICATION A. Restraints should be applied to a patient when alternatives such as medication, structured activities, behavioral management, or verbal de-escalation have failed. Security staff is limited to only apply clinically approved restraint devices ...B. It is the general philosophy ...not to use restraints unless there are no other reasonable alternatives and the patient exhibits one or more of the following behaviors: 1. Biting 2. Kicking 3. Hitting 4. Spitting 5. Homicidal tendencies 6. Suicidal tendencies 7. Influence of a controlled substance or alcoholic beverage 8. Threat to self, staff, property or visitors C ...Staff should never apply restraints as a mere convenience ...V. RESTRAINT RE-EVALUATION A. It should be the responsibility of the clinical staff to continuously evaluate the need for continued application of restraints. The following points should be considered: 1. Release or adjustment of restraint(s) 2. Re-positioning of the patient 3. Physical condition of the patient 4. Patient's range of motion 5. Patient's personal needs 6. Patient's nutritional needs. B. Any adjustment or removal of leather restraints should be done by security staff only."

During a review of the manufacturer's instructions for restraints provided by the hospital, titled "[Brand Name] Locking Connection Straps Application Instructions," dated 2009, indicated, "...CONTRAINDICATIONS: DO NOT use this devise on a patient who is or becomes ...highly aggressive or combative, self-destructive ...UNLESS the patient is under constant supervision ...ADVERSE REACTIONS Severe emotional, psychological, or physical problems may occur: if the applied device is uncomfortable; or if it severely limits movement. If the patient is likely to cause injury to him/herself or others, get help from a qualified medical authority to find an alternative intervention or method of restraint ...MONITORING [Brand Name] recommends constant direct supervision for patient deemed to be at risk of injury to themselves or others ...No level of monitoring may avoid the risk of serious injury to highly agitated or aggressive patients. Check the patient regularly to ensure that: Circulation is not impaired. Serious injury may occur if the cuffs restrict circulation ..."


2. During a concurrent interview and record review, on 3/24/21, at 3 p.m., with the RNI and RN 11, the EMR for Pt 12's admission on 3/13/21 was reviewed with RNI and RN 11. Pt 12's EMR indicated Pt 12 was admitted with diagnosis which included weakness of lower extremities, stroke (loss of blood flow to the brain can cause lasting brain damage, long-term disability, or even death), acute (sudden) renal (kidney) failure, altered mental status (change in intellectual, emotional, psychological, and personality functioning), Coronary Artery Disease (fatty deposits inside the artery walls, thus narrowing the arteries), asthma (a respiratory condition), COVID-19 (illness that is caused by a virus that can spread from person to person, symptoms range from mild to severe). Pt 12's EMR indicated that Pt 12 was placed on bilateral wrist restraints on 3/19/21, at 2:56 p.m.

During a concurrent interview and record review, on 3/24/21, at 3:05 p.m., with the RNI and RN 11, Pt 12's Restraint Flow Sheet dated 3/21/21 was reviewed with RNI and RN 11. The Restraint Flow Sheet documentation dated 3/21/21 indicated Pt 12's bilateral wrist restraints had been released at 6 a.m. and 1:08 p.m. RNI and RN 11 confirmed Pt 12's bilateral wrist restraints were not documented as being released for 8 a.m., 10 a.m., and 12 p.m. on 3/21/21.

During an interview on 3/25/21, at 11:05 a.m., with RN 8, RN 8 stated she worked on 3/21/21 and took care of Pt 12. RN 8 stated patients while on restraints should be checked and documented that range of motion and circulation was checked every two hours. RN 8 stated she had been assigned as the nurse for Pt 12 on 3/21/21 and did not document bilateral wrist restraint release every two hours on Pt 12's Restraint Flow Sheet. RN 8 stated she was worried about Pt 12's stroke condition because Pt 12 was lethargic (sluggish) so she did not have time to document restraint release in the Restraints Flow Sheet. RN 8 stated Pt 12 was moved to the intensive care unit just after 1 p.m. on 3/21/21.

During an interview on 3/25/21, at 11:18 a.m., with the Nurse Manager for 9 West (NM), the NM stated the expectation was for the nurse to document at the same time they have performed the circulation and range of motion checks on the Restraint Flow Sheet. NM stated if the nurse was unable to document at that time of the care then the nurse was expected to document when they do have time and before they leave their shift. The NM stated RN 8 was expected to document restraint release and assessment every two hours when a patient was on restraints.

During a review of the facility's policy and procedure titled, Restraint and Seclusion, dated 01/14/2020, indicated, " ...II. DEFINITIONS A. Physical Restraint 1. Physical Restraint: 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 ... III. POLICY ... IV. PROCEDURE ... E. Ongoing Monitoring and Assessment of a Patient in Restraint or Seclusion ... b. Minimum monitoring frequency i. Safety, non-violent, and non-destructive restraint - monitor at least every two (2) hours ... c. Ongoing assessment of patient in restraint or seclusion i. ... means that the patient will be evaluated to determine the patient's response to the restraint or seclusion, and if the patient has any care needs. This assessment shall include: I. Checking the patient's hydration and circulation; the patient's level of distress and agitation; or skin integrity, and may also provide general care needs (e.g., eating, hydration, toileting, and range of motion exercises) ... ii. Minimum assessment frequency I. Safety, non-violent, and non-destructive behavior should be assessed at least every two (2) hours ... V. DOCUMENTATION A. Document the following information in the EHR [electronic health record] for each restraint or seclusion episode ... 4. Patient condition or symptom(s) that warranted restraint or seclusion use 5. Patient response to restraint/ seclusion, including the rationale for continued use 6. Individual patient assessments and reassessments 7. The intervals for monitoring ..."

During a review of the manufacturer's instructions for restraints provided by the hospital, titled "[Brand Name] Locking Connection Straps Application Instructions," dated 2009, indicated, " ...ADVERSE REACTIONS Severe emotional, psychological, or physical problems may occur: if the applied device is uncomfortable; or if it severely limits movement ....MONITORING [Brand Name] recommends ...Check the patient regularly to ensure that: Circulation is not impaired. Serious injury may occur if the cuffs restrict circulation ..."

Based on interview and record review the facility failed to follow their policy and procedures (P&P) when three of four sampled patients (Patient 5, Patient 6, and Patient 7) medical record entries were not complete for the administration of Lovenox (a blood thinning medication used to help prevent blood clots). These failures had the potential to increase the patient's risk of developing scar tissue (area of fibrous tissue that replaces normal skin after an injury) and/or bruising from repeated injection at the same injection site.

Findings:

During a concurrent interview and record review, on 3/24/21, at 1:40 p.m., with the Registered Nurse Informaticist (RNI) and Registered Nurse (RN) 11, the Electronic Medical Records (EMR) for Patient (Pt) 5's admission on 2/21/21 was reviewed. Pt 5's EMR indicated that Pt 5 was admitted for Burns generalized (over most of her body). Pt 5's EMR contained her Medication Administration Record (MAR), the MAR indicated that Pt 5 was on Lovenox, part of the Lovenox documentation is to indicate where it was given (the site). The RNI and RN 11 both confirmed that the site for the Lovenox given to Pt 5 was missing for 38 of the 39 administrations.

During a concurrent interview and record review, on 3/24/21, at 2:15 p.m., with the RNI and RN 11, the EMR for Pt 6's admission on 3/21/21 was reviewed. Pt 6's EMR indicated that Pt 6 was admitted for a Motor Vehicle Crash with burns to his body. Pt 6's EMR contained his MAR, the MAR indicated that Pt 6 was on Lovenox, part of the Lovenox documentation is to indicate where it was given. The RNI and RN 11 confirmed that the site for the Lovenox given to Pt 6 was missing for 6 of the 7 administrations.

During a concurrent interview and record review, on 3/24/21, at 2:45 p.m., with the RNI and RN 11, the EMR for Pt 7's admission on 3/14/21 was reviewed. Pt 7's EMR indicated that Pt 7 was admitted for Pedestrian versus vehicle accident causing her to have a fracture (a break) of base of skull (back bottom part of head), right side. Pt 7's EMR contained her MAR, the MAR indicated Pt 7 was on Lovenox, part of the Lovenox documentation is to indicate where it was given. The RNI an RN 11 confirmed that the site for the Lovenox given to Pt 7 was missing for 3 of the 3 administrations.

During an interview on 3/26/21, at 12:15 p.m., with the Director of Pharmacy Services (DPS) and the Director of Clinical Education and Staff Development (DCES), the DPS stated Lovenox is an anticoagulant (blood thinner) it can be given SubQ (subcutaneously- in the adipose tissue- fat) or IV (intravenously- in the vein). The DPS stated it is important to rotate sites when giving Lovenox SubQ to prevent scar tissue and prevent hematomas (bruises). The DCES stated staff are educated on orientation how to give Lovenox and to rotate and document the site given so that the next staff member knows to give it in a different location. The DCES stated if staff are not documenting sites the facility can reeducate staff on the importance of doing so.

During a review of, 'HIGHLIGHTS OF PRESCRIBING INFORMATION,' dated 05/2020, provided by the facility's pharmacy, indicated, " ...Lovenox ... for subcutaneous and intravenous use ... INDICATIONS AND USAGE Lovenox is ... indicated for: Prophylaxis [prevention of] of deep vein thrombosis [blood clots] ... FULL PRESCRIBING INFORMATION CONTENTS ... 2 DOSAGE AND ADMINISTRATION ... 2.5 Administration ... Subcutaneous Injection Technique * Position patients in supine [laying on ones back] position for Lovenox administration by deep subcutaneous injection ... * Alternate [change] injection sites between the left and right anterolateral [near the head to the side] and left and right posterolateral [near the bottom towards the side] abdominal [stomach] wall ..."

During a review of the facility's policy and procedure titled, Medications- Orders, Administration, Storage, Documentation, dated 10/10/2019, indicated, " ... I. PURPOSE To provide guidelines for the safe and accurate ordering, transcribing, labeling, administration, storage and documentation of medications ... VI. DOCUMENTATION ... C. Document the route (e.g., IVPB [Intravenous Piggy back- medication in a smaller bag used to infuse into the bigger bag of fluids], IM [intramuscular- into the muscle], subcutaneous (SubQ), sublingual (SL [under the tongue]), rectal (PR [in the bottom])) and site (e.g. vastus lateralis [muscle located on the side of the thigh], deltoid [muscle that goes around the upper arm and shoulder], abdomen [stomach]) on the MAR ..."