HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to provide care in a safe setting relative to the patient identification bracelet for one of nineteen sample patients, ID# 1.

Findings are as follows:

Review of a community reported complaint revealed that patient ID #1 was wearing the wrong identification bracelet when discharged from the hospital on 12/19/2018. The bracelet had the name, date of birth, medical record number and physician's name of another patient, ID# 2.

During an interview with patient ID #1 on 12/22/2018 at approximately 12:30 PM, the patient stated that his/her identification bracelet had been removed after a blood draw in the hospital and "they put on another one".

During an interview on 12/22/2018 at approximately 5:10 PM, the nurse manager, Staff A, confirmed that staff should determine a patients identify prior to placing an identification bracelet on the patient.

During an interview on 12/22/2018 at 4:50 PM the nurse, Staff B, who discharged patient ID #1 on 12/22/2018, stated that she did not look at the patient's identification band prior to administrating medications on 12/19/2018.

Refer to A 405.

Based upon record review and staff interview, it has been determined that the hospital has failed to develop the plan of care for the use of a restraint for 1 of 2 patients in restraints, ID# 3.

Findings are as follows:

The hospital's policy titled "Management of Patients in Restraints or Seclusion Policy # B-38" states, in part:

"...V. Ordering/Documenting Restraints

3. The Plan of Care will be modified if restraints are required.
4. The release of restraints for at least 15 minutes every 2-hours will be documented on the Restraint Assessment using the legend Released 15 minutes/Reapplied in the Restraint Status Section..."

Medical record review for patient ID# 3 revealed the patient was admitted on 12/21/2018 with rectal bleeding. The patient's medical condition deteriorated requiring intubation. The patient became disoriented and began pulling out the oxygen tubing. On 12/23/2018 and on 12/24/2018 at 7:00 AM, the physician ordered soft wrist restraints.

The record lacked evidence that the Plan of Care was modified following the initiation of restraints and that the release of restraints for at least 15 minutes every two hours was documented.

The Manager of the Intensive Care Unit, Staff C, was interviewed on 12/24/2018 at approximately 9:30 AM and was unable to produce evidence that the Care Plan was updated to include the Restraint Assessment or that the Restraint Assessments were completed every two hours documenting the restraint was released.

Based upon record review and staff interview, it has been determined that the hospital has failed to administer medications in accordance with the approved medical staff policies and procedures for 1 of 2 sample patients, ID# 1.

Findings are as follows:

Record review revealed that patient ID # 1 was admitted on 12/17/2018. He/she was discharged home on 12/19/2018 at approximately 12:30 PM.

A community reported complaint revealed that patient ID# 1 was discharged from the hospital wearing an ID bracelet belonging to another patient.

The hospital's policy titled "Transcription of Medication Orders and Medication Administration using PYXIS and MAR in PCS Policy # B-17" states, in part:

"Identify patient using 2 patient identifiers, scan COW, scan barcode on patient ID bracelet and scan barcode on medication, then give medications."

Review of the Medication Administration Record for ID # 1 revealed that on 12/19/2018, he/she was administered 11 medications without the ID bracelet having been scanned. This administration was on 12/19/2018 at 8:22 AM, by Nurse Staff B.

An interview on 12/22/2018 at 4:55 PM with Nurse Staff B revealed that she attempted to scan the patient's bracelet on 12/19/2018 prior to administering medications, however multiple attempts to scan were unsuccessful. Staff B acknowledged that she did not look at the patients ID bracelet.