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Based on staff interview and document review, it was determined the hospital failed to ensure restraint use was in accordance with the order of the physician or other licensed practitioner in one (1) of two (2) applicable medical records reviewed and included in the survey sample. Medical record #8.

Findings:

Eight (8) medical records were reviewed 06/27/23 with the Director of Quality and Patient Safety (staff member #1) assisting in the navigation of the electronic records. Two (2) of the eight (8) medical records reviewed in the survey sample were of patients who were ordered restraints.

The medical record for patient # 8 indicated the patient was admitted due to alcohol abuse and withdrawal. On 06/12/23 at 10:33 PM the provider placed an order for bilateral soft restraints for the behavior of pulling at lines at tubes. The order failed to specify what body part the restraints should be applied to. There was no documentation in the record that the restraints were applied on around 10:33 PM on 06/12/23. The first documented restraint use was on 06/13/23 at 12:34 AM. The nurse documented that bilateral soft wrist restraints were "continued" at this time. It was unclear from the documentation in the medical record whether or not restraints were initiated at 10:33 PM on 06/12/23 and no monitoring was documented, or if restraints had been initiated on 06/13/23 and erroneously documented as continued. There was no new documented provider order for restraints on or around 06/13/23 at 12:34 AM.

On 06/13/23 at 1:27 AM, the patient became violent and soft restraints were ordered to bilateral wrists and ankles. The nurse documented at 1:58 AM that rigid restraints were applied to bilateral wrists and ankles. The medical record contained no order for the use of rigid restraints.

An interview was conducted with staff member #1 during record review on 06/27/23 who confirmed no body part was specified in the restraint order on 06/12/23 at 10:33 PM. The staff member confirmed that the first instance of restraints for patient #8 were documented at 12:34 AM on 06/13/23. The staff member confirmed if restraints were not applied until two (2) hours after the initial order as documented, a new provider order for restraints would be required. Staff member #1 confirmed the medical record for patient #8 contained no provider order for the use of rigid restraints, despite the documented use of rigid restraints.

The facility's policy, Restraint and Seclusion Management, Most Restrictive Restraints, last reviewed 05/16/23, was reviewed and read in part: "Restraint orders shall indicate the behavior, time limit of the restraint (not to exceed four hours for adults 18 and older...and the type of restraint to be used." The facility's policy, Restraint and Seclusion Management: Least Restrictive Restraints was reviewed and read in part: "Restraint must be applied within minutes of order (forward/backward) or a new order will need to be obtained."

Based on staff interview and document review, it was determined the nursing staff failed to implement interventions in the patient's plan of care to meet patient's needs. Specifically, the hospital failed to ensure appropriate interventions were in place to prevent patient falls in one (1) of eight (8) medical records reviewed in the survey sample. Medical record #1.

Findings:

Eight (8) medical records were reviewed on 06/27/23 with the assistance of the Director of Quality and Patient Safety (staff member #1) in the navigation of the electronic medical record.

The medical record for patient #1 contained documentation that the 76-year-old patient presented to the emergency department on 03/08/23 with shortness of breath. The patient had a documented past medical history of congestive heart failure, COPD (chronic obstructive pulmonary disease), and dementia.

Patient #1 was admitted to the hospital on 03/08/23 and identified by nursing staff as a high fall risk. The following interventions were documented on admission to prevent falls: bed in lowest position, bed alarm active at all times, high risk indicator outside of patient's room, fall mats - one on each side of the bed, chair alarm activated and audible via the nurse call at all times while in bed. The medical record for patient #1 indicated that the patient's cognitive and mobility status were variable throughout their admission. Some days and times the patient was alert and oriented to person, place, and time and able to walk with a walker to the bathroom and at other times, patient was confused, disorientated to person, time, and situation and required the assistance of two (2) people to get out of bed.

Documentation in the medical record for patient #1 indicated the patient was found on the floor on 03/13/23 at 05:09 AM by the Charge Nurse (staff member #7). Staff member #7's nurse's note dated and timed 3/13/23 at 5:30 AM read as follows: "Noticed patient O2 (oxygen) not reading on the monitor. Went to assess patient. Patient found on floor, high flow nasal cannula (a type of supplemental oxygen delivery device) was removed by patient. MRT (Medical Response Team) called at 05:09 for support. Bipap immediately placed on patient and increased to 100 %. Patient became more coherent and responsive to commands. BP, O2 responded well. Fall mats were in place and patient was laying on mat."

Documentation did not indicate whether or not the patient's bed alarm was set or if it had alarmed prior to the patient fall.

An interview was conducted on 06/27/23 at 3:38 PM with the charge nurse (staff member #7) who found patient #1 on the floor on 03/13/23. Staff member #7 stated that they were alerted by telemetry monitoring staff that the patient's oxygen sensor had stopped reading and the staff member went to check on patient #1. Staff member #7 stated the patient was on their knees on the fall mat next to the bed. The patient was assessed, the physician notified, and a CT scan performed of the patient's head to rule out injury. Staff member #7 stated the patient had been identified as a high fall risk. Staff member #7 stated the bed alarm had not sounded at the time of the patient's fall. The patient was moved to a room closer to the nurse's station and a 1:1 safety sitter was put in place for patient #1 after the fall. Staff member #7 confirmed the bed alarm should have been on as the patient had been identified as a high fall risk.

The facility's job aid titled, Job Aid: Adult Fall Prevention Intervention was reviewed and read in part: "Johns Hopkins Fall Risk Assessment Score of greater than or equal to 13 [Patient #1's fall risk score was documented as 14 on 03/12/23, the night before the patient's fall] shall have the following fall prevention interventions...High Risk Interventions: Place high risk indicator i.e. sign/light/chicklet outside patient's room; move patient to room near nursing station (when available); chair alarm activated and audible via the nurse call at all times while in chair; bed alarm activated and audible via the nurse call at all times while in bed...."

Staff member #1 acknowledged the failure of facility staff to engage patient #1's bed alarm prior to a fall and to implement appropriate fall prevention interventions for patient #1 during the exit conference on 06/27/23.