HospitalInspections.org

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the rights of each patient is protected.

Findings include:

The facility failed to ensure that facility policy regarding DNR is implemented. (Cross refer Tag - 0131)

The facility failed to ensure that all nurses caring for overflow ICU (intensive care unit) patients in the PACU (post anesthesia care unit) are educated on the process concerning how to reach ICU residents or intensivist for urgent needs at all times. (Cross refer Tag - 0144)

The facility failed to ensure restraint monitoring is performed by nursing personnel in accordance with facility policy. (Cross refer Tag - 0167)

The facility failed to ensure that there is a restraint order for each patient placed in restraints, in accordance with facility policy. (Cross refer Tag - 0168)

Based on a review of two (2) of three (3) medical records (Patient (P) 7 and P8) of patients with a Do Not Resuscitate (DNR) status, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that the facility policy regarding DNR is implemented.

Findings include:

Facility policy titled, "DO NOT RESUSCITATE" (Reviewed Feb 2021) states, " ... POLICY: ...E. Documentation, communication, and consent. ... A decision to enter or change a DNR order requires the consent of a Competent Patient, or the Patient Care Representative as to an Incompetent Patient. Documentation of this consultation and consent shall be included in the patient record. ..."

On 12/30/22 at 2:40 PM, P7's medical record was reviewed with S28 (RN). P7 had a physician's order for a DNR status placed on 12/25/22 at 12:52 PM. Review of the medical record lacked documentation of the physician's consultation and discussion with the patient, or the patient's consent regarding code status.

On 12/30/22 at 2:45 PM, P8's medical record was reviewed with S28 (RN). P8 had a physician's order for a DNR status placed on 12/29/22 at 5:16 PM. Review of the notes section of the medical record lacked documentation of the physician's consultation and discussion with the patient or the patient's consent regarding code status.

On 12/30/22 at 4:45 PM, S2 (Chief Nursing Officer) confirmed that according to the facilities policy the physicians should have documented the communication with the patient and or patients' family regarding code status.

Based on observations, staff interviews, review of one of one medical record (Patient (P)1), and review of facility documents, it was determined that the facility failed to ensure that all nurses caring for overflow ICU (intensive care unit) patients in the PACU (post anesthesia care unit) are aware of the process on how to reach ICU residents or intensivist for urgent needs at all times.

Findings include:

On 12/30/22 at 2:00 PM, review of Patient (P) 1's medical record revealed that on 12/23/22 at 4:15 PM, P1 was transferred to the PACU as an ICU overflow patient following a right external iliac artery stent and angioplasty, left SFA [superficial femoral artery] popliteal artery angioplasty and stent graft placement, angioplasty peroneal artery, and placement of thrombolytic catheter in the Cardiac Cath Lab.

Review of the nursing documentation titled, "Flowsheets" dated 12/23/2022 at 9:12 PM by S13 (RN) revealed that at 8:20 PM P1's blood pressure dropped to 64/27. S13 ran to the ICU to locate the resident, but the resident was not in the ICU. S13 ran back to the PACU. At 8:30 PM a Code Blue was called and at 8:32 PM the code blue team and nursing supervisor was at the bedside of P1.

During an interview with S13 on 12/30/22 at 3:23 PM, in the PACU, S13 stated that P1's blood pressure (BP) had "dropped" and that he/she called the ICU but "no one answered." S13 further stated that the direct number for the ICU resident was not available and that he/she "ran to the ICU." S13 continued that the ICU resident was in the ER (Emergency Room) with another patient, so [he/she] ran back to the PACU. S13 further stated, that if the ICU was short staffed there was no one to answer the phones.

Interviews conducted on 1/3/23, during a tour of the ICU, revealed the following:

At 10:53 AM, during interview with S17 (RN) and S18 (RN) it was stated that the unit secretary leaves at 3:00 PM and that the ICU residents do not carry phones other than their personal phones. It was further stated that to reach the resident "you have to physically call the unit."

At 11:23 AM, an interview was conducted with S20 (ICU resident), S21 (Intensivist), S29 (ICU resident), and S30 (physician). During the interview S21 stated that if no ICU beds are available, patients are "boarded" outside the ICU. S21 continued that the residents sit at the desk in ICU, the contact number for the resident is posted in ICU, and the nurses "know to call the ICU" if needed. S21 further stated the nurse can also call the residents cell phone or the resident lounge to get in touch with them. S29 stated that the "majority of the time" nurses will "grab" residents from the ICU so there is "no need to page overhead." S20 added that the ICU resident rotation list was in the computer and the "Am I On call app (application)" lists the on-call residents as well as the phone numbers for "Team A and Team B," and that the phone numbers for each team were in the computer.

At 11:30 AM during tour of the ICU, observed posted on the wall behind the nurses' station, a December 2022 intensivist on-call list, with the phone numbers listed at the bottom of the page. Attached to the list was a handwritten note with the name and number of an ICU resident. It was observed that no Intensivist on-call list for January 2023 was posted. S19 (ICU Nursing Director) and S22 (RN) confirmed no list for January had been posted. Upon interview S19 stated that the list is only posted in the ICU and is not shared with other units.

At 11:47 AM, during a tour of the PACU, in the presence of S5 (Cath lab Director), S24 (RN) stated that to contact the ICU residents the nurse calls the ICU, PCU (step down unit), or the CTU (cardio-thoracic intensive care unit) or the nurse will "get up and go over to the unit." S24 further stated that the unit has a "book of hospital phone numbers". Upon request S24 was unable to provide a list of contact numbers for the ICU Intensivist or Residents. When questioned regarding the "Am I On" call app, S24 stated, "...I don't know what that is."

At 11:53 AM, in the hall outside the PACU, during interview, S19 stated in the presence of S1 and S5, that the facility does not use the 'Am I On call' system, because "not all the residents are registered in it." Upon request the facility was unable to provide a policy or education for the 'Am I On' call system.

At 5:20 PM the above findings were confirmed by S1, S2, and S33.

Based on staff interview, review of one (1) of four (4) medical records (Patient (P)4) and review of facility policy and procedure, it was determined that the facility failed to ensure restraint monitoring is performed by nursing personnel in accordance with facility policy.

Findings include:

Facility policy titled, "RESTRAINTS: NON-VIOLENT Behavior" (Reviewed 12/21) states, " ... POLICY: ...12. The use of restraint is in accordance with the order of a physician or other LIP who is responsible for the dare of the patient. 13. Orders for the use of restraint are never written as a standing order or on an as needed basis (PRN). ...MONITORING AND CARE -Patient in Non-Violent Restraints or Non-Self Destructive Restraints 1. A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient. ..."

Review of P4's Medical Record on 12/30/22, revealed that on 12/17/22 at 12:18 AM, an order for Non-Violent Bilateral Soft Wrist Restraints was in place. Review of the nursing documentation under the Non-Violent Restraints flowsheet revealed restraint monitoring was started on 12/17/22 at 4:18 AM, and then continued at 10:00 AM, 12:00 PM and 2:00 PM. There is no documentation of restraint monitoring or discontinuation of restraints from 4:18 AM until 10:00 AM. The medical record lacks evidence that restraint documentation occurred every 2 hours in accordance with the facility policy referenced above.

On 12/30/22 at 3:40 PM, during interview with Staff (S)28 (RN), who was present during the medical record review, they indicated that restraint monitoring was expected to be completed every 2 hours while the patient was in restraints. If the patient was removed from restraints, the removal was to be documented. A new physician order is obtained if the restraints were re-applied.

Based on staff interview, review of one (1) of four (4) medical records (Patient (P)3) of patients in non-violent restraints, and review of facility policy and procedure, it was determined that the facility failed to ensure that there is a restraint order for each patient placed in restraints, in accordance with facility policy.

Findings include:

Facility policy titled, "RESTRAINTS: NON-VIOLENT Behavior" (Reviewed 12/2021) states, " ... POLICY: ...12. The use of restraint is in accordance with the order of a physician or other LIP who is responsible for the dare of the patient. 13. Orders for the use of restraint are never written as a standing order or on an as needed basis (PRN). ... MONITORING AND CARE -Patient in Non-Violent Restraints or Non-Self Destructive Restraints 1. A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient. ..."

On 12/30/22 at 3:40 PM, a review of P3's Medical Record was conducted with Staff (S)28 (RN). Review of the nursing documentation under the Non-Violent Restraints flowsheet revealed documentation of Non-Violent Restraints of Bilateral Wrists and Ankles documented on 12/21/22 at 8:00 PM, 8:15 PM, 10:15 PM and documented as discontinued on 12/22/22 at 12:15 AM. On 12/25/22 there is Non-Violent Restraint of Bilateral Mitts documented at 8:15 PM and on 12/26/22 at 12:15 AM, 2:15 AM and 6:15 AM. Review of the Physician Orders revealed an order for Bilateral Mitts placed on 12/19/22 at 12:15 PM, however there were no orders for Bilateral Mitts on 12/25/22 or 12/26/22 or the Bilateral Wrist and Ankle restraints documented on 12/21/22.

The medical record lacked evidence of a physician's order for the Bilateral Wrist and Ankle restraints that was placed on 12/21/22, or the Bilateral Mitt restraints that was placed on 12/25/22 and 12/26/22.

On 12/30/22 at 3:40 PM, during interview with Staff (S)28, it was confirmed that there were no physician orders found in the medical record for the restraint episodes that were documented.