HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to ensure that each episode of patient restraint was made in accordance with the order of a physician for 1 of 1 patients placed in restraints.

Findings were:

A review of medical records revealed that for 1 of 1 patients placed in restraints [Patient #1], the facility could provide no documented evidence of a physician's order for the restraints until after they had already been initiated.

A Nurse's Note in the medical record of Patient #1 entered on 7/28/14 at 6:39 a.m. included the following: "At around 0100 pt was trying to get out of bed and yelling. He was also kicking, squeezing and pinching the aide and myself. He did not want to remain in bed despite reorienting and trying to talk to patient. Pt was then restraint via hands, feet and vest for safety. Pt settled down after a few hours." The medical record included no documented evidence of a physician's order for the above restraint.

A Critical Care Progress Note in the chart of Patient #1entered on 7/30/14 at 1:18 p.m., stated in part: "He [patient] is requiring restraints- and a sitter ... "

A form entitled Type: Monitor Restraint, Non-Violent completed on 7/31/14 at 8:00 a.m. stated, in part: "Restrain Assessment Label: Hands, Restraint Type: Soft ..." There was no documented evidence in the medical record of a physician's order for this restraint.

In an interview with Staff #1, Director of Nursing, Med/Surg, on the afternoon of 10/22/14 in the office of the Standards Specialist, she stated, "I agree there wasn't an order for patient restraints in the chart until 8/1/14 at 4:52 p.m. "

Facility policy, Restraint and Seclusion (Policy PC 07, last revised 11/13) stated, in part,
"Requirements for ordering of restraint or seclusion for any reason:
This policy requires that a physician or other licensed independent practitioner responsible for the care of the patient to order restraint or seclusion prior to the application of restraint or seclusion."

The above findings were again confirmed in an interview with the Chief Nursing Officer and other administrative staff on the morning of 10/23/14 in her office.

Based on a review of facility documentation and staff interview, the facility failed ensure that patient daily weights were monitored on a patient receiving tube feedings who underwent a loss of more than 20 lbs. over a span of approximately 14 days.

Findings were:

A review of clinical records revealed that for 1 of 1 patients on tube feedings [Patient #1], nursing services failed to weigh the patient daily thus failing to monitor and address the patient's loss of over 20 lbs. over a span of approximately 14 days.

Patient #1 was admitted to the facility on 7/26/14. He was NPO for several days. A physician's order on 7/28/14 at 2:23 p.m. initiated "Tube Feeding Adult Diet ..." Patient #1 was on tube feedings until his discharge on 8/15/14. The weights documented for this patient were as follows, in total:
7/26/14 63.503 kg (bed scale) [140.0 lbs.]
7/27/14 63.503 kg (bed scale)
7/28/14 64.637 kg (bed scale) [142.5 lbs.]
7/29/14 64.637 kg (bed scale)
7/30/14 63.957 kg (bed scale) [141 lbs.]
7/31/14 63.957 kg (bed scale)
8/15/14 53.932 kg (standing scale) [118.9 lbs.]

There were no weights documented for 8/1/14 through 8/14/14 for Patient #1.

A review of the Discharge Summary for Patient #1 dictated on 8/14/14 at 4:14 p.m. revealed the following, in part:
"DISCHARGE DIAGNOSES:
1. Pneumonia, community-acquired, resolved ...
4. Severe protein energy malnutrition, status post percutaneous endoscopic gastrostomy tube.
5. Dysphagia status post percutaneous endoscopic gastrostomy tube ... "

In an interview with Staff #1, Director of Nursing, Med/Surg, on the afternoon of 10/22/14 in the office of the Standards Specialist, she stated, "...And I agree, they should have been weighing the patient. That's a nursing judgment issue. "

An interview was conducted with Staff #4, CNA on 9 South Unit, during the tour of the unit. Staff #4 stated that every patient on the unit was weighed on admission to the unit and every day; patient weights are entered into the medical record.

In an interview with Staff #2, RN, Nurse Manager on 9 South, the morning of 10/23/14, she stated that weights are not obtained on each patient every day. When Staff #2 was informed that the CNA [Staff #4] stated that weights were obtained every day on every patient, Staff #2 stated that Staff #4 may not have understood or was nervous. Staff #2 reviewed the policy, which stated, that weights are obtained on admission and as appropriate. She stated that weights are obtained if ordered by the physician, or a nurse may have weights obtained based on nursing judgment. Staff #2 stated that if a patient or family member requested a patient weight, then a weight would be obtained for the patient.

In an interview with Staff #7, RN, on the morning of 10/23/14 in the office of the Standards Specialist, she stated, "We weigh daily. It doesn't matter what unit a patient is on, that's what we do hospital-wide. No, we don't have to get an order for that ...With bed scales, you just have to be sure to take off the extra pillows and equipment from the bed ... "

In an interview with Staff #13, Clinical Dietitian, and Staff #14, Dietitian and Patient Services Senior Manager, on the morning of 10/23/14 in the office of the Standards Specialist, When asked about [Patient #1's] weight at the end of his stay, Staff #13 stated, "...those first weights were bed scales. They really tend to fluctuate. They're not always that accurate. We consider standing weights more valid, and there can be a difference in the readings for the two different types of scales ...If we could get a daily weight that was accurate, it would be really helpful for us, for pharmacy, for everyone. Diets are based on weights. Medications are based on weights. Why would a standing scale not be used if the patient could get up? "

Facility policy #II-A-7, entitled Daily Weights, last reviewed March 2014, stated in part:
"STATEMENT OF PURPOSE: To establish a uniform method of obtaining daily weights.
I. POLICY:
1. Weights will be obtained upon admission to the unit and once a day, as appropriate.
2. Weights will be documented in the EMR (electronic medical record) ...
NOTE: Daily weights are obtained on the following patients:
a. Doctor's order for daily weights...
f. Nursing judgment ... "

The above findings were again confirmed in an interview with the Chief Nursing Officer and other administrative staff on the morning of 10/23/14 in her office.