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Based on interviews and record reviews the facility failed to ensure patient safety was maintained in 2 of 3 records for patients who had procedures conducted (Patients #6 and #11).

This failure created the potential for patient harm when a time out to verify correct patient, site and procedure was not performed.

FINDINGS:

POLICY:

According to the facility policy, Documentation Requirements for Invasive Procedures with and without Sedation (Universal Protocol), the following steps are required before any procedure may proceed ... "a time out completed." No procedure may proceed if the above required steps are not followed. A timeout is the last stage immediately before an invasive procedure begins. No procedure may begin without a complete "Timeout" to ensure the correct procedure is being performed in the correct location on the correct patient.

1. The facility failed to utilize the time out process prior to conducting patient procedures.

a) Review of Patient #11's record revealed an Operative/Procedure Report, dated 05/07/15, in which the patient received a lumbar puncture with intrathecal injection of Lioresal.

Review of the accompanying, undated, Invasive Procedures Without Sedation form, showed no documentation that a time out was performed prior to the invasive procedure. Specifically, there was no documentation to show a timeout was conducted to ensure the correct procedure was being performed on the correct patient.

b) Review of Patient #6's record showed an Operative/Procedure Report, dated 05/14/15, in which the patient had bilateral gluteal wounds with slough requiring debridement (where tissue was removed with the use of a sharp instrument). Review of the Invasive Procedures Without Sedation form, dated 05/14/15, contained no documentation to show the facility conducted a timeout prior to the procedure.

c) On 5/28/15 at 3:24 p.m. an interview was conducted with Chief Clinical Officer #1 (CCO) in which s/he stated the requirement that a time out was documented for every procedure on the Invasive Procedures without Sedation form. CCO #1 acknowledged the lack of documentation in Patient #6's record which indicated a time out was performed.

Based on interview and document review, the facility failed to ensure patients who were placed in physical restraints were monitored and assessed to ensure the physical and emotional safety of the patients in 1 of 4 restraint records reviewed (Patient #3).

This failure created the potential for an unsafe patient care environment in which the physical and emotional safety and needs of patients were not met.

FINDINGS:

POLICY

According to the policy, Physical Restraints (Violent and Non-Violent Behavior) and Seclusion, a Registered Nurse (RN) will perform assessment/reassessment at established intervals and as needed. The RN determines if the current restraint should be continued, if less restrictive methods could be used or if restraints could be discontinued based on monitoring data.

The clinical team work collaboratively to observe the patient and remove the restraints as soon as possible, based on an assessment. This includes documentation that indicates the unsafe situation is resolved and determination is made that the patient's behavior is no longer a threat to the patient's safety and/or safety of others.

1. Review of Patient #3's History and Physical, dated 02/05/15, showed the patient was admitted to the hospital on 02/05/15 for malnutrition, urine leak, high-output fistula and wound care.

According to a Restraint Initiation/Order form, dated 04/23/15, bilateral soft wrist restraints were applied at 2:15 a.m. for risk of injury to self, disturbing monitoring equipment, lack of safety awareness and unsuccessful attempts to redirect behavior.

Review of a Restraint Monitoring form, dated 04/23/15, showed Registered Nurse #12 (RN) conducted safety checks and monitoring at 2:00 a.m., 4:00 a.m. and 6:00 a.m. Under the section, titled "Is the need for Restraint Resolved", RN #12 documented "No" and that there had been "No change."

There was no subsequent documentation to show the patient received safety checks and monitoring at least every 2 hours or was evaluated for the continued necessity of physical restraints.

Additionally, there was no documentation to show when the restraints were discontinued and that the restraints were removed and discontinued as soon as possible based on assessments and a collaborative decision by the clinical team.