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Based on interview and record review, the hospital failed to ensure the patient received care in a safe setting when the nursing staff did not administer the medication to one of five sampled patients (Patient 5) as per the physician's order. This failure had the potential to create an adverse health outcome to the patient.

Findings:

Review of the hospital's P&P titled Medication Administration dated 2/1/21, showed the following:

* Administering the medications is defined as the administration of the medications as ordered by a prescriber.

* The assessment of the patient's condition is performed related to administration of medication. The assessment required is dependent on the type of medication (indication and side effect profile) to be administered and the patient's condition.

* All medications are documented in the electronic health record with the time of administration. If patient refuses medication, this is documented as refused.

On 9/13/23, Patient 5's closed medical record was reviewed and showed the patient was admitted to the hospital on 8/10/23.

Review of the ED Provider Note dated 8/10/23 at 1058 hours, showed Patient 5 was presented to the ED with a chief complaint of inability to stand or move his left side.

Review of the History and Physical examination dated 8/10/23 at 1146 hours, showed Patient 5 was admitted on 8/10/23, with a chief complaint of acute onset left hemiparesis. The patient had continuous repetitive shaking of the left side consistent with partial complex seizure. The patient was to be admitted to ICU for further care.

Review of the Pulmonary/Critical Care Medicine Consultation dated 8/10/23 at 1310 hours, showed Patient 5 had "Focal seizure, ongoing...with brain metastasis..." The physician was called "for consult for above and SBP control in ICU."

Review of the Hospitalist Progress Note dated 8/14/23 at 1916 hours, showed Patient 5 "had an unwitnessed fall today, no apparent injury."

Review of the Hospitalist Progress Note dated 8/15/23 at 2030 hours, showed Patient 5 remained "very agitated, frequently paranoid, sometimes hallucinating. Discussed with neurology, likely due to combination of steroids, brain metastases, and possible ongoing seizures."

Review of the physician's order dated 8/20/23 at 1837 hours, showed hydralazine (a medication used to treat high blood pressure) 20 mg, intravenous, every six hours PRN for SBP greater than 160 mmHg.

Review of the Patient Recent Data dated 8/23/23, showed Patient 5's vital signs. Further review of the Patient Recent Data showed the following:

* At 1200 hours, Patient 5's BP was 183/106 mmHg. However, there was no documented evidence to show the patient was medicated for the SBP greater than 160 mmHg as per the physician's order.

* At 1300 hours, Patient 5's BP was at 233/125 mmHg. However, there was no documented evidence to show the patient was medicated for the SBP greater than 160 mmHg as per the physician's order.

* At 1324 hours, Patient 5 expired.

On 9/14/23 at 1035 hours, the ICU Manager verified the above findings.

Based on interview and record review, the hospital failed to identify the rationale for the use of posey or vest restraint for one of five sampled patients (Patient 5). This failure had the potential for unnecessary use of restraints for the patient and the potential for adverse health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraint and Seclusion dated 4/29/21, showed the following:

* Policy: It is our policy that all patients have the right to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation. Restraints will not be used for the routine prevention of falls or if a patient "might fall." The condition of the patient who is in restraint or seclusion must be assessed, monitored and re-evaluated.

* Physical Restraint is defined as any physical or mechanical device, manual method, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. In addition, the following are considered restraint:

- The use of side rails to restrict the patient's freedom from exiting the bed.

* For Non-Violent, Non-Self-Destructive Restraint Orders, orders must contain reason for restraint and type of restraint. Restraints will be discontinued when it is assessed that alternative measures may be used.

* Documentation: At a minimum and for non-violent/non-self-destructive restraints and seclusion, the following should be documented in the patient's medical record:

- The patient's behavior, condition, or symptoms that necessitated the use of restraint or seclusion and/or staff concerns regarding safety risks to the patient, staff, and others.

- The patient's response to the intervention(s) used.

- Revision to the plan of care.

On 9/13/23, Patient 5's closed medical record was reviewed and showed the patient was presented to the ED on 8/10/23 at 1047 hours.

Review of the ED Provider Notes dated 8/10/23 at 1058 hours, showed Patient 5 was brought in by EMS via code stroke. The patient stated approximately at 0900 this morning, the patient was unable to stand or move his left side. The patient would be evaluated for possible CVA.

Review of the History and Physical examination dated 8/10/23 at 1146 hours, showed Patient 5 was admitted on 8/10/23, with a chief complaint of acute onset left-sided hemiparesis.

Review of the Post Fall Note dated 8/14/23 at 1431 hours, showed the bedside RN was in her other patients' room. The social worker was passing by Patient 5's room and saw the patient was laying on the floor at the foot of the bed and yelled out for help.

Further review of Patient 5's closed medical record showed on 8/15/23 at 0456 hours, Patient 5 was transferred to Med Surg/Neuro unit.

Review of the physician's order dated 8/15/23 at 1559 hours, showed the physician ordered to apply the bilateral soft wrist and cloth vest restraints to Patient 5. The reasons for restraints were due to pulling lines and removal of equipment. The duration of restraint order was not to exceed three days.

Review of the Hospitalist Progress Note dated 8/15/23 at 2030 hours, showed Patient 5 remained "very agitated, frequently paranoid, sometimes hallucinating. Discussed with neurology, likely due to combination of steroids, brain metastases, and possible ongoing seizures."

Review of the physician's order dated 8/18/23 at 1616 hours, and 8/21/23 at 1921 hours, showed the physician ordered to apply the bilateral soft wrist and cloth vest restraints to Patient 5. The reasons for these restraints were due to pulling lines and tubes, and removal of equipment and dressing. The duration of restraint order was not to exceed three days.

Review of RN 1's End of Shift Summary dated 8/20/23 at 1600 hours, showed Patient 5 was alert and oriented. The patient was agitated, confused, disoriented to situation. The patient denied pain. The restraints were in place. The patient was on seizure precautions. The patient was transferred to ICU.

Review of RN 2's End of Shift Summary dated 8/20/23 at 1834 hours, showed Patient 5 had increased agitation. Versed (a sedative) 4 mg was given to the patient. Precedex (sedative medication) was started for the patient. The patient was resting comfortably.

Review of RN 3's End of Shift Summary dated 8/21/23 at 0559 hours, showed Patient 5's RASS score was minus 2 to minus 3. The patient woke up at some point, puling on restraints, but fell back asleep. The patient had bilateral wrist restraints, posey, and mittens on.

There was no documented evidence to show the physician's order was obtained for the use of mittens tied to the two elevated upper siderails and Patient 5's inability to freely remove the mittens due to left-sided hemiparesis.

Review of RN 6's End of Shift Summary dated 8/22/23 at 1817 hours, showed Patient 5 had period of lucidity today, but mental status continued to fluctuate. When the patient was oriented, he continuously asked to go home.

Review of RN 4's End of Shift Summary dated 8/23/23 at 0626 hours, showed Patient 5 had periods of agitation and restlessness. The patient could occasionally tell his name and the current year. The patient had periods of lucidness. Patient became agitated, angry and was medicated with Ativan (a medication used to treat anxiety) 1 mg Precedex was increased to 0.3 mcg.

Review of the nursing documentation dated 8/23/23, showed no activity from 0800 to 1000 hours, and the restraints were not removed until 1145 hours.

On 9/13/23 at 1020 hours, a concurrent interview and Patient 5's closed medical record was conducted with the ICU Manager. When asked about the indication for the use of bilateral wrist and cloth vest restraints on Patient 5 who had left-sided hemiparesis, the ICU Manager stated the patient was pulling on lines, tubes, and equipment.

On 9/13/23 at 1105 hours, an interview was conducted with the ICU Manager. When asked, the ICU Manager stated no physician's order was required for the use of mittens.

Based on interview and record review, the hospital failed to ensure a physician's order for the use of restraint was obtained for one of five sampled patients (Patient 2). This failure could lead to an injury and unnecessary use of restraints for the patient.

Findings:

Review of the hospital's P&P titled Restraints and Seclusion dated 4/29/21, showed the restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time. Restraints or seclusion orders will be initiated and renewed by a physician or other licensed independent practitioner responsible for the care of the patient.

On 9/12/23, Patient 2's medical record review was initiated and showed the patient was admitted to the hospital on 9/1/23.

Review of the physician's order dated 9/8/23 at 1402 hours, showed to apply the bilateral soft wrist restraints for Patient 2. The reason for restraint was due to pulling lines and tubes.

Review of the restraint flowsheet for Patient 2 dated 9/8/23 at 1402 hours, showed the non-violent restraints had been placed on Patient 2's right and left wrists and continued to be on Patient 2's right and left wrists through 9/10/23 at 0000 hours, when the restraints had been discontinued. Further review of the restraint flowsheet for Patient 2 showed the right and left wrist restraints were reapplied by the nursing staff on 9/10/23 at 0330 hours; however, there was no new physician's order for the reapplication of the right and left wrist restraints obtained on 9/10/23.

On 9/12/23 at 1311 hours, an interview and concurrent record review was conducted with the Executive Director of Acute Care Services and Operations Manager of the Telemetry Unit. The Executive Director of Acute Care Services and Operations Manager of the Telemetry unit reviewed the physician's order dated 9/8/23 and Patient 2's restraint flowsheet dated 9/8/23. The Executive Director of Acute Care Services and Operations Manager of the Telemetry Unit verified Patient 2's had the physician's order for the use of restraint dated 9/8/23. The Executive Director of Acute Care Services and Operations Manager of the Telemetry Unit verified the nursing staff had implemented this restraint order on 9/8/23 at 1402 hours. The Executive Director of Acute Care Services and Operations Manager of the Telemetry Unit reviewed the restraint flowsheet and verified the bilateral soft wrist restraints were discontinued on 9/10/23. The Executive Director of Acute Care Services and Operations Manager of the Telemetry Unit verified after an order was placed and discontinued, a new order was needed to apply the restraints again to Patient 2.

The Executive Director of Acute Care Services stated the expectation was for the nursing staff to implement an order once received and once the order was implemented, the order was considered completed. If the completed order was discontinued, and the restraints were removed, a new order would need to be obtained to reapply the restraints to the patient. The Executive Director of Acute Care Services stated once Patient 2's order for the use of restraint was discontinued on 9/10/23 at 0000 hours, a new order was needed to apply the restraints again to Patient 2 on 9/10/23 at 0330 hours. The Executive Director of Acute Care Services stated no new physician's order was obtained to place Patient 2 back in the soft wrist restraints on 9/10/23 at 0330 hours, after the physician's order had been implemented on 9/8/23, and discontinued on 9/10/23 at 0000 hours. A new physician's order was needed to reapply the right and left wrist restraints to Patient 2, but none was obtained on 9/10/23.

The Quality Director was made aware of the above findings.