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Based on observation, interview, and record review, the facility failed to:

A. Follow their own policy and procedures for Use of Restraints and Seclusion for 2 (#2 and # 15) of 20 patients;

B. Ensure less restrictive interventions had been determined to be ineffective and documented appropriately;

C. Ensure restraints or seclusion were removed at the earliest possible time;

refer to tag A-0154

Based on observation, interview, and record review, the facility failed to:

A. Follow their own policy and procedures for Use of Restraints and Seclusion for 2 (#2 and # 15) of 20 patients;

B. Ensure less restrictive interventions had been determined to be ineffective and documented appropriately;

C. Ensure restraints or seclusion are removed at the earliest possible time;

This deficient practice had likelihood to cause harm to all patients placed in restraints:

Patient # 2

A review of the patient's history and physical revealed, the patient was brought to the emergency room on 12-10-2019 for recurrent episodes of seizures and noted to have a fever of 106 degrees Fahrenheit. The patient had a history of seizure disorder, neurosarcoidosis (an inflammatory disease that effects the brain and spinal cord), high blood pressure, depression, kidney stones, bronchial asthma, and paroxysmal atrial fibrillation. Documentation revealed, the patient was sedated and placed on mechanical ventilation and admitted to the intensive care unit (ICU).

Review of a document titled "Patient Assessment Report - Nursing Restraint Initiation," documented 12-10-2019 at 6:00 p.m. revealed, restraints were initiated on 12-10-2019 at 1:00 p.m., under the section "List Reason (s) Restraints Are Required," the nurse documented "Behavior interfering with medical care, devices, tubes or drains, ventilator management." Documented under the heading "Alternatives to restraints to treat and eliminate the cause" on the same form, the nurse documented "comfort measures, diversional activities, environmental measures, medication, increased frequency of monitoring." Documented under the heading "Were any of the Alternatives effective" the nurse documented "no-continue to assess for restraints."

Further review of a nurse narrative note on 12-10-2019 at 1:00 p.m. revealed the nurse documented the patient was admitted to ICU, " ....sedated and intubated and nonresponsive to stimuli ...."

Review of the "Patient Assessment Report-Nursing Restraint Monitor- Non Violent" dated 12-10-2019 at 6:00 p.m., revealed " ...restraints applied 12-10-2019 at 1300 (1:00 p.m.) (Type) soft wrist, (Location) wrist bilateral, (Reason) ventilator management, (Alternative Measures attempted) comfort measures, diversional activities, interpersonal skills, medication, (Discontinue restraints if alternative measures become effective) No-alternative not effective," There was no nursing restraint monitoring documentation found from 1:00 p.m. to 5:00 p.m. that indicated the patient was monitored while restrained, until the 6:00 p.m. entry.

Review of a document titled "Restraint, Non-Violent, Non Self-Destructive" dated 12-10-2019 at 1:00 p.m., revealed an order to initiate soft wrist restraints while patient is intubated. A box is checked titled "Discussed alternative interventions with nursing." This document is signed as a telephone order dated 12-10-2019 at 1:00 p.m., however the document is not signed by a physician, the following "RBTO (physician name)/(nurse name), 12/10/2019 at 1300," no physician signature is found.

Review of the "Patient Assessment Report-Nursing Restraint Monitor - Non Violent" dated 12-10-2019 at 8:00 p.m., revealed "restraints applied 12-10-19 at 1800 (6:00 p.m.), (Type) soft wrist, (Location) wrist bilateral, (Reason) ventilator management, (Alternative Measures attempted) comfort measures, diversional activities, education, medication, (Discontinue restraints if alternative measures become effective) No-alternative not effective,"

Review of the same assessment form dated 12-10-2019 at 10:00 p.m. revealed ""restraints applied 12-10-19 at 1800 (6:00 p.m.), (Type) soft wrist, (Location) wrist bilateral, (Reason) ventilator management, (Alternative Measures attempted) comfort measures, diversional activities, environmental measures, medication, (Discontinue restraints if alternative measures become effective) No-alternative not effective," Further review of the restraint monitoring documentation from 12-11-2019 through 12-18-2019 8:00 p.m. documents the reason for restraints as only "ventilator management." Review of this assessment form dated 12-18-2019 10:00 a.m. revealed " (Type) soft wrist, soft ankle, (Location) wrist bilateral, ankle bilateral, (Reason) behavior interfering with medical care, devices, tubes or drains, (Alternative Measures attempted) comfort measures, education, increased frequency in monitoring."

Review of nursing narrative documentation from 12-11-2019 at 6:00 p.m. through 12-14-2019 at 2:48 p.m., revealed no documentation that the patient was interfering with medical care, devices, tubes, or drains.

Documentation on 12-11-2019 revealed patient was intubated and sedated. Documentation on 12-12-2019 9:28 a.m. revealed " ....pt not awake, or following commands ..." Documentation on 12-13-2019 at 3:45 p.m., revealed " ....patient remains off sedation, moves all extremities but does not open eyes or follow commands ...," 12-13-2019 at 7:00 p.m. " ....Pt resting, intubated and restrained, easily arousable and attempting to move all extremities ..."

Documentation on 12-14-2019 at 3:00 p.m., revealed the first documentation of the patient's behavior interfering with medical care "..Pt agitated, coughing against ett, sitting up in bed, kicking arms against restraints, does not follow commands ..."

Review of the physician progress note dated 12-11-2019, 12-12-2019, and 12-13-2019, revealed the patient remained sedated on mechanical ventilation. Review of a physician progress noted dated 12-14-2019 revealed the patient had been taken off sedation at 7:00 a.m. " ....but is still not awake or following commands ..." There was no documentation found in the physician progress notes that indicated the patient had behaviors that required restraints. There was no documentation found in the physician progress note that described the patient as attempting to remove medical devices, lines, tubes, or drains, or that the patient's activities required restraints.


Patient # 15

A review of the patient's history and physical revealed the patient was brought to the emergency room on 1-5-2020 for respiratory distress. The patient was admitted to the ICU on 1-5-2020 sedated and mechanically intubated with a diagnosis septic shock, secondary to right lower lobe pneumonia, urinary tract infection, hypotension, acute on chronic systolic and diastolic congestive heart failure, critical aortic valve stenosis, acute exacerbation of chronic obstructive pulmonary disease. The patient has a past medical history of congestive heart failure, chronic obstructive pulmonary disease with oxygen dependency, Parkinson's disease, high blood pressure, cardiac arrest twice, peripheral vascular disease, high cholesterol.

A review of the nursing assessment dated 1-5-2020 at 2:00 p.m., revealed the patient was admitted to the ICU, sedated, intubated and restrained on mechanical ventilation. The documentation revealed the patient was in bilateral soft wrist restraints and was calm and cooperative. Nursing assessments dated 1-5-2020 at 6:00 p.m. through 1-8-2020 at 6:00 a.m. revealed the patient was intubated, mechanically ventilated, calm and cooperative.

Review of document titled "Restraint, Non-Violent, Non Self-Destructive," revealed documentation every two hours beginning 1-5-2020 at 3:00 p.m. through 1-8-2020 7:00 a.m., as follows: "restraints applied 1-5-2020 at 1400 (2:00 p.m.), (Type) soft wrist, (Location) wrist bilateral, (Reason) ventilator management, (Alternative Measures attempted) comfort measures, diversional activities, environmental measures, medication, nutrition, toileting, increased frequency of monitoring, (Discontinue restraints if alternative measures become effective) No-alternative not effective," Review of a document titled "Nursing Restraint - Discontinued," dated 1-8-2020 at 9:00 a.m. revealed patient " ...calm, family at bedside, pt knods (sic) head in understanding to not pull at tubing or lines, family bedside to assist."

Review of physician documentation from 1-5-2020 through 1-7-2020, revealed no documented behaviors that indicated the patient was or required restraints.

Review of a physician ordered entered into the electronic medical record on 1-5-2020 at 2:25 p.m. by the nurse was discontinued on 1-5-2020 at 6:06 by the attending physician. No other documentation was found where the physician ordered for the patient to be restrained for ventilator management.

Review of nursing narrative documentation revealed no documentation of patient behaviors that interfered in medical care, devices, tubes, lines or drains, to justify the patient being restrained. Documentation was found from 1-5-2020 through 1-8-2020, the patient was calm, cooperative, sedated on mechanical ventilation.

An interview with staff # 8 was conducted on 1-8-20 after 11:00 a.m. in the conference room. Staff # 8 was asked why people, documented as sedated on ventilators, were placed in bilateral restraints. Staff # 8 stated, they "restrained vent patients because they might pull on lines or tubes, during sedation vacations."


Review of facility policy tiled "Restraint and Seclusion Policy" with the latest review date of 10/2018 revealed the following:

" ... ...Policy:

It is the policy of this facility to:

A. Protect he patient and preserve the patient's rights, dignity, and well being during restraint use by:

i. Respecting the patient as an individual.

ii. Maintain a clean and safe environment.

iii. Encouraging the patient to continue to participate in own care.

iv. Maintain the patient's modesty, preventing inappropriate visibility to others and maintaining comfortable body temperature.

v. Implementing the policy that convenience is not an acceptable reason to restrain a patient nor can restraint use serve as a substitute for adequate staffing to monitor a patient.

B. Prevent, reduce, eliminate the use of restraints by basing use on patient's assessed needs:

i. preventing emergencies that have the potential to lead to the use of restraints.

ii. the rational that a patient should be restrained because he/she "might" fall does not constitute an adequate basis for using a restraint.

iii. limiting the use of restraints and seclusion to emergencies where there is a risk to the patient harming himself/herself or others. Though patient's have the right to refuse treatment, under certain circumstances if serious bodily harm is judged to be imminent, (e.g.. Violent patient) an R.N. , after assessment of the patient, should institute the use of restraint, which he/she believes will protect the patient and/or others, effectively, but alternatives must be considered.

iv. using the least restrictive method. Restraint use shall not be the first choice solution. The choice of device shall be the least restrictive restraint needed to accomplish this purpose and in consideration of the patient condition when the restraint is used.

v. All efforts should be made to avoid restraints if patient safety may be maintained without the use of restraints. The nurse who is caring for a patient who is at high risk for confusion/possible use of restraints should be concentrate on attempts at preventing the need for restraints by initiating the items listed in Limiting the Use of Restraints or Seclusion in this policy ... ... ...


Procedure:

B. Assessment of risk factors

A comprehensive assessment of the patient that the risks associated with the use of restraints outweigh the risk of not using it. The use of anatomical, physiological and psychological assessment for risk factors by the RN and/ or physician LIP facilitates the limited and justified use of restraints/seclusion. Planning for being proactive rather than reacting to the patient's behavior protects the patient's health and safety and allow for the implementation of preventable strategies that would be of the greatest benefit to the patient.

Factors to consider as part of the assessment include, but are not limited to:

Degree of orientation to person, time and place

Memory disturbances

Fluctuating levels of awareness

Alteration in sleep/wake cycle

Perceptual disturbance

Pain or other discomfort

Victims of sexual, physical or emotional abuse


Type and/or combination of medications which may be contributing to the behavior

Type and/or combination of treatment modalities

Physiological changes such as, oxygen perfusion, blood glucose changes, blood chemistry, etc.., which may be causing or contributing to the altered behavior patterns

Techniques, methods or tools that would assist the patient control his/her behavior.

Risks associated with vulnerable patient populations, such as emergency, pediatric, pregnant and cognitively or physically limited patients, or patients with certain pre-existing medical conditions.

Restraint or seclusion use is limited to situations where imminent risk of a patient is physically harming himself or herself, staff or others and nonphysical interventions would not be effective.

Situations in which restraints/seclusion are clinically justified include:

i. harmful to self or others and alternative methods have been attempted.

ii. threatens placement and or patency of necessary therapeutic lines/tubes, interfering with medically necessary medical treatment and alternative measures have been attempted, and

iii. patient is unable to follow directions to avoid self-injury and protective, alternative measures have been attempted

C. Limiting the Use of Restraints or Seclusion

Our facility believes nonphysical techniques are the preferred interventions in the management of behavior. Attempts should be made to evaluate and use intervention/alternatives when possible and in response to the patient's assessed needs ... ....

E. Orders for Restraint

i. The physician or Licensed Independent Practitioner (LIP) responsible for the care of the patient is authorized to order restraints ... .....Orders should:

a. Before each use of the restraints and related to a specific episode of the patient's behavior and not for an unspecified future time or episode.

b. At Woodland Heights Medical Center the following categories of LIPs are allowed to order restraint or seclusion:
Physicians
iii. Orders for restraints may never be written as Standing Orders or PRN orders. Each episode of restraint or seclusion must be initiated in accordance with an order by a physician or other LIP.

v. Staff is expected to continually assess and monitor the patient to ensure the patient is released from restraint or seclusion at the earliest possible time ....

H. Periodically assessing, assisting and monitoring the patient in restraint or seclusion .....

v. Care is provided at lease every 2 hours to include:

offer of fluids

nourishment

hygiene care as required

toileting as required

Release of extremities and range of motion provided

I. Documentation

Each episode of restraint is documented in the patient's medical record consistent with policies and procedures

i. Circumstances and patient condition or symptoms that led to restraint use; description of patient's behavior

ii. consideration or failure of alternative interventions

iii. rational for the type of interventions selected

v. written order for use

x. Patient response to the intervention including rationale for continues use of the intervention.

The facility failed to follow it's own policy.

Based on observation, interview, and record review, the facility's Nursing RN failed to provide care in an organized and safe environment for 2 ( #2 and # 15) out of 20 patient's reviewed. This had the potential to cause harm to the patient when nursing failed to:

A. Report abnormal vital signs to the physician in a timely manner resulting in a delay in care.

B. Follow all doctors' orders or notify the physician when the doctors' order could not be carried out:

Refer Tag A-0392

C. Obtain clarification of a titrated medication:

Refer Tag A-0410

Based on observation, interview, and record review, the facility's Nursing RN failed to provide care in an organized and safe environment for 1 (# 15) out of 20 patients reviewed, when nursing failed to:

A. Report abnormal vital signs to the physician in a timely manner resulting in a delay in care. This had the potential to cause harm to the patient.

B. Follow all doctors' orders or notify the physician when the doctors' order could not be carried out:


Findings:

Patient # 15

A review of the patient's history and physical revealed the patient was brought to the emergency room on 1-5-2020 for respiratory distress. The patient was admitted to the ICU on 1-5-2020 at 2:00 p.m., sedated and mechanically intubated with a diagnosis septic shock, secondary to right lower lobe pneumonia, urinary tract infection, hypotension, acute on chronic systolic and diastolic congestive heart failure, critical aortic valve stenosis, acute exacerbation of chronic obstructive pulmonary disease. The patient has a past medical history of congestive heart failure, chronic obstructive pulmonary disease with oxygen dependency, Parkinson's disease, high blood pressure, cardiac arrest twice, peripheral vascular disease, high cholesterol.

The medical record revealed, the patient's vital signs on admission to the ICU were: Temperature 101.1 degrees Fahrenheit, pulse 116, respirations 12 breaths per min, blood pressure 126/39 and oxygen saturation 91% on ventilator. The patient's pulse remained between 105 and 119 from 2:00 p.m. on 1-5-20 through midnight on 1-06-20. On 1-6-20 at 1:00 a.m. the patient's pulse began to trend up as follows:

1-6-20
1:00 a.m. - 120
2:00 a.m. - 121
3:00 a.m. - 124
4:00 a.m. - 125
4:59 a.m. - 135
5:01 a.m. - 127
6:00 a.m. - 125
7:00 a.m. - 123
9:00 a.m. -122
10:00 a.m. - 129
11:00 a.m. - 127
12:00 p.m. - 123
1:00 p.m. - 125

Nursing documentation was reviewed. There was no documentation found that the nurse notified the physician of the patient's heart rate over 120 beats per minute until 1:30 p.m. on 1-6-20. The nurse documented "(Proper Name) updated to patient HR sustaining in 120's -130's throughout shift. Telephone order received to start diltiazem 30 mg via OG tube q 8 hours PRN HR above 100. Orders carried out."

A review of the medication administration record revealed the nurse documented administration of "Cardizem 30 mg OG tube q 8 hours PRN Heart Rate above 100," on 01-6-20 at 1:30 p.m.

Review of documentation from 1-6-20 2:00 p.m. to 9:00 p.m. revealed the following heart rates:

1-6-20
2:00 p.m.-129
3:00 p.m. - 121
4:00 p.m. - 124
4:57 p.m. - 122
5:00 p.m. - 120
6:00 p.m. - 125
7:00 p.m. - 126
8:00 p.m. - 125
9:00 p.m. - 123

01-07-20
6:00 a.m. - 122
7:00 a.m. - 131
8:00 a.m. - 125
8:32 a.m. - 125
9:00 a.m. - 128

Nursing documentation was reviewed. There was no documentation found that the nurse notified the physician of the patient's sustained heart rate over 120 and that the prescribed medication to be given for heart rate of 100 had not been effective in controlling the patient's heart rate. A nurse note dated 1-7-20, at 9:30 a.m., revealed, the nurse contacted the physician regarding the patient's heart rate sustained in the 120's to 130's and an order for Digoxin 0.25 mg IV now was given. However, documentation revealed the nurse did not administer the medication until 10:48 a.m., the patient's heart rated was noted to be 129 at 10:30 a.m., there was no documentation found that he nurse notified the physician that the "now" order for the Digoxin 0.25 mf IV was not given for 1 hour after it was ordered.

The physician ordered for the patient to be weighed on admission and daily after that. On 1-5-20, the patient's weight was noted to be 94 pounds at 9:58 a.m. On 1-6-20 at 6:29 a.m., the patient's weight was recorded as 115.6 pounds. On 1-7-20 at 6:26 a.m., the patient's weight was recorded as 110.4 pounds. On 1-8-20 at 5:14 a.m., the patient's weight was recorded as 126.8 pounds. There was no documentation found that the nurse notified the physician on 1-6-20 of a 21.6 pound weight gain, or of a 16.4 pound weight gain on 1-8-20. The record showed a total weight gain of 32.8 pounds in 3 days and no documentation was found the nurse discussed the weight gain with the physician. The patient had a diagnosis of acute on chronic systolic and diastolic congestive heart failure and daily weights were used as an indication of fluid volume status and worsening condition for patients with congestive heart failure.


The facility policy titled "Routine Vital Signs," was reviewed. The policy gives guidance on how frequently vital signs are to be measured based on the level of care the patient is receiving, and when to notify the physician regarding temperature. This policy however has no guidance to staff of when to notify the physician of abnormal vital signs, no set parameters of when pulse, blood pressure, weight gain or weight loss, or oxygen saturation should be reported to the physician. There is no guidance for staff to report abnormal vital signs if the physician does not set specific parameters on each patient.

Based on observation, interview, and record review, the facility's Nursing RN failed to provide care in an organized and safe environment when nursing failed to obtain clarification of a titrated medication order when parameters were not entered into the electronic medical record physician order entry system for 1 (#2 ) out of 20 patients reviewed. This had the potential to cause harm to the patients.

Findings:

Patient # 2

A review of the patient's history and physical revealed, the patient was brought to the emergency room on 12-10-2019 for recurrent episodes of seizures and noted to have a fever of 106 degrees Fahrenheit. The patient had a history of seizure disorder, neurosarcoidosis (an inflammatory disease that effects the brain and spinal cord), high blood pressure, depression, kidney stones, bronchial asthma, and paroxysmal atrial fibrillation. Documentation revealed the patient was sedated and placed on mechanical ventilation and admitted to the intensive care unit (ICU).

The medical record revealed the patient was in ICU from 12-10-19 through 12-23-19, when he was transferred out to the floor. The patient remained out of ICU from 12-23-19 until 12-29-19, when he began experiencing respiratory distress with at respiratory rate of 52 breaths per minute and hypotension with a blood pressure of 77/27. The patient was transferred back to ICU for closer monitoring. When the patient arrived in ICU, he was started on a vasoactive drip of Levophed (norepinephrine) to increase his blood pressure.

Physician orders for Levophed were reviewed and revealed an order entered in the electronic medical record on 12-29-19 at 4:43 p.m. that read: "Norepinephrine Bitartrate 8 mg/250 ml: Titration detail: Titrate for blood pressure systolic between ______ and _______mmHg. Begin infusion at 0.5 mcg/min. Increase by 0.5 mcg/min for blood pressure systolic between _____ and ______mmHg to dose of 0. Comment: Rate per chart instruction."

There was no documentation found that the nurse asked for clarification of the Levophed order entered into the physician order system without specific titration parameters for goal systolic blood pressure.

A copy of the facility titration policy related to titration of medications was requested, however the facility did not provide a copy of this policy or documentation that there were specific guidelines/orders or protocols for nurses to titrate this vasoactive medication.