HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed regarding use of restraints, the hospital failed to ensure that the staff obtained a physician's order for the application of non-violent restraints (restraints for non-violent/non self-destructive behavior to promote medical healing or prevent injury).

Findings include:

1. On 8/31/2023, the hospital's policy titled, "Restraint and Seclusion" (2/2023) was reviewed and included, "... VI. Non-violent, non self-destructive restraints... A. Orders... 3. The restraint order must be renewed every calendar day..."

2. On 8/31/2023, the clinical record for Pt #1 was reviewed. Pt. #1 was admitted to the hospital due to worsening confusion from 5/9/2023 through 5/31/2023. Pt. #1 was placed in restraints (bilateral soft wrist restraints) due to risk of injury to self, i.e., confusion, pulling intravenous tubing/drains on the following dates: 5/11/2023, 5/12/2023, 5/13/2023, 5/14/2023, 5/15/2023, 5/16/2023, 5/17/2023, 5/18/2023, 5/19/2023, 5/20/2023, 5/21/2023, 5/22/2023, and 5/23/2023. There was no documentation that a physician's order for the application of restraints was obtained on 5/13/2023, 5/16/2023, 5/17/2023, 5/19/2023, 5/22/2023, and 5/23/2023.

3. On 9/1/2023 at approximately 10:30 AM, findings were discussed with E #13 (Manager, 3 West Unit-Medical Surgical Unit). E #3 confirmed that there was no documentation that a physician order was obtained. E #3 stated that an order should have been obtained.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed regarding use of restraints, the hospital failed to remove the non-violent restraints (restraints for non-violent/non self-destructive behavior to promote medical healing or prevent injury) when the unsafe situation was resolved.

Findings include:

1. On 8/31/2023, the hospital's policy titled, "Restraint and Seclusion Management Policy" (2/2023) was reviewed and included, "... VI... B... 2. When the unsafe situation is resolved, the restraint must be removed..."

2. On 8/31/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the hospital due to worsening confusion from 5/9/2023 through 5/31/2023. Pt. #1 was placed in restraints (bilateral soft wrist restraints) due to risk of injury to self, i.e., confusion, pulling intravenous tubing/drains on the following dates: 5/12/2023 from 6:00 AM thorough 6:00 PM, 5/14/2023 from 6:00 AM through 10:00 AM, 5/16/2023 from 8:00 PM through 5/17/2023 at 6:00 PM. However, the behavioral assessments indicated that Pt. #1 was calm or the behavior was appropriate.

3. On 9/1/2023 at approximately 10:30 AM, findings were discussed with E #13 (Manager, 3 West Unit-Medical Surgical Unit). E #3 stated that the restraints should have been discontinued when the patient was calm and the behavior was appropriate.

A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for nursing assessments, the hospital failed to ensure that the patient's weight was obtained, as required.

Findings include:

1. On 8/31/2023, the hospital's policy titled, "Assessment and Plan of Nursing Care" (1/2023) was reviewed and included, "Policy: 1. Utilize the nursing process data is collected about the health status of the patient... 4... A scaled weights are obtained every seven days..."

2. On 8/31/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the hospital due to worsening confusion from 5/9/2023 through 5/31/2023. There was no weight obtained from 5/11/2023 through 5/31/2023 (20 days).

3. On 9/1/2023 at approximately 10:30 AM, findings were discussed with E #13 (Manager, 3 West Unit-Medical Surgical Unit). E #3 stated that weights should have been taken every seven days.

B. Based on document review and interview, it was determined that the for 1 of 4 patients' (Pt. #1) clinical records reviewed for nursing care, the hospital failed to ensure the physician's order was followed.

Findings include:

1. On 8/31/2023, the job description for registered nurses (1/2023) was reviewed and included, "... Provides direct nursing care in accordance with established policies and procedures... Responsibilities... Notes and carries out physician... orders..."

2. On 8/31/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the hospital due to worsening confusion from 5/9/2023 through 5/31/2023. On 5/16/2023, a physician's order for a nutritional supplement (high protein pudding) with lunch and dinner was ordered for Pt. #1. On 5/19/2023, the order was changed to provide high protein supplement for Pt. #1 with each meal (breakfast, lunch, and dinner). The clinical record lacked documentation that nutritional supplement was given from 5/16/2023 through 5/20/2023, and from 5/22/2023 through 5/30/2023.

3. On 9/1/2023 at approximately 10:30 AM, findings were discussed with E #13 (Manager, 3 West Unit-Medical Surgical Unit). E #3 stated that the nurse should have ensured that the order for nutritional supplement was provided to Pt. #1.

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) clinical records reviewed regarding medication administration, the hospital failed to ensure that the ordering physician was notified.

Findings include:

1. On 8/31/2023, the hospital's policy titled, "Medication Administration" (3/2023) was reviewed and included, "... IV. Required Procedure. A... 3. Registered Nurse... D... 6. Medication is Refused or not Given. If medication was not administered due to patient refusal or another reason: a. Document the reason on the MAR (Medication Administration Record) and contact the (licensed independent practitioner/physician)..."

2. On 8/31/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the hospital due to worsening confusion and Parkinson's disease (brain disorder causing uncontrollable body movements) from 5/9/2023 through 5/31/2023. On 5/21/2023, a physician's order was placed to administer carbidopa/levodopa (medication for Parkinson's disease) 12.5 mg/50 mg by mouth every 8 hours. On 5/27/2023, 5/28/2023, and 5/30/2023, Pt. #1 did not receive the medication consistently. There was no documentation that a physician was notified.

3. On 9/1/2023 at approximately 10:30 AM, findings were discussed with E #13 (Manager, 3 West Unit-Medical Surgical Unit). E #3 stated that a physician should have been notified when Pt. #1 did not receive the medication. E #3 confirmed that there was no documentation that a physician was notified.