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Based on hospital policy and procedure review, medical record review, and administrative staff interviews, the hospital staff failed to obtain a restraint order for 1 of 2 patients restrained (Patient #4).

The findings include:

Review of the hospital's "Patient Restraint Policy" revised September 20, 2012 revealed "....A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...X. Requires renewal of orders in accordance with applicable law and regulations. Orders for restraints must be renewed every 24 hours or calendar day, whichever is greater... XI. Document in the medical record when restraints are used or individual orders are received. All episodes of restraint utilization and the relevant order for use, will be documented in the clinical record..."

Closed record review of Patient #4 revealed a 44 year old male that arrived to the ED (Emergency Department) on 09/09/2013 at 1254 via EMS (Emergency Medical Services) with chief complaint of "POSTICTAL" (an altered state of consciousness after a seizure). Further review of medical record revealed documentation at 1300 "PT WAS STARTED ON WRIST RESTRAINTS DUE TO PULLING AT LINES AND NOT FOLLOWING COMMANDS PER MD ORDERS PT PLACED IN MEDICAL RESTRAINTS." Further review revealed the patient was discharged from the ED (Emergency Department) and admitted to the CCU (Critical Care Unit) at 2014. Review of Physician orders revealed an initial restraint order dated 09/09/2013 at 1300 and two renewal restraint orders dated 09/10/2013 at 0000 and 09/12/2013 at 0000. Further review of the medical record revealed documentation that the patient was restrained from 09/09/2013 at 1300 until 09/12/2013 at 1600. Record review revealed no physician's order for restraints on 09/11/2013. Further review of medical record revealed no documentation of restraints being terminated prior to transfer to a different facility on 09/12/2013.

Interview with Administrative Staff #2 on 10/29/2013 at 1355 revealed no documentation of a restraint order in the electronic record of patient #4 dated 09/11/2013. Interview confirmed the hospital's restraint policy was not followed.

Interview with Administrative Staff #4 and Administrative Staff #5 revealed possession of paper medical record for patient #4. Further review revealed no documentation of a restraint order dated 09/11/2013. Interview confirmed the hospital's restraint policy was not followed.

Based on hospital policy and procedure review, medical record review, and administrative staff interviews, the hospital staff failed to monitor 1 of 1 patients restrained in the Emergency Department (ED) and CCU (Critical Care Unit) per hospital policy (Patient #4).

The findings include:

Review of the hospital's "Patient Restraint Policy", revised September 20, 2012, revealed "...v. Clinical identification of specific behavioral changes that indicated that restraint is no longer necessary vi.Monitoring the physical and psychological well-being of the patient who is restrained including, but not limited to....skin integrity....I. Protects and preserves the patient's rights, dignity and well being during/use/meets needs during use. Patient will be assessed for comfort, warmth/cold, toileting and nutrition/hydration needs at least every 2 hours. Range of motion with exercise and circulation checks will be included in the assessment...XI. Document in the medical record when restraints are used or individual orders are received. All episodes of restraint utilization and the relevant order for use, will be documented in the clinical record. Additionally, the following will be documented:
-Relevant orders for use
-Results of patient monitoring
-Reassessment
-Significant changes in the patient's condition
Documentation includes events leading up to restraint initiation including patient response to nursing strategies and restraint alternatives attempted, consideration of least restrictive devices and the time the restraint were applied and terminated. ..."

Closed record review of Patient #4 revealed a 44 year old male that arrived to the ED (Emergency Department) on 09/09/2013 at 1254 via EMS (Emergency Medical Services) with chief complaint of "POSTICTAL" (an altered state of consciousness after a seizure). Further review of medical record revealed documentation at 1300 "PT WAS STARTED ON WRIST RESTRAINTS DUE TO PULLING AT LINES AND NOT FOLLOWING COMMANDS PER MD ORDERS PT PLACED IN MEDICAL RESTRAINTS." Review of restraint assessment at 1500 revealed "restraint continued". Continued review revealed no documentation of circulation check, range of motion with exercises, comfort, warmth/cold, toileting and nutrition offered, restraint released, patient repositioned, safety check, dignity/rights maintained, emotional wellbeing or patient response to intervention. Review of nurses notes at 1500 revealed "VITALS REMAIN STABLE NOT MUCH CHANGE IN PT CONDITION." Review of restraint assessment at 1700 revealed "restraint continued." Further review revealed no documentation of circulation check, range of motion with exercises, comfort, warmth/cold, toileting and nutrition offered, restraint released, patient repositioned, safety check, dignity/rights maintained, emotional wellbeing or patient response to intervention. Further review of chart revealed no documentation of restraint assessment for 1900. Further review of the chart revealed no documentation of restraints being terminated. Further review revealed the patient was discharged from the ED and admitted to the CCU at 2014. Review of documentation in CCU revealed the next restraint assessment was completed at 2100 (4 hours after last assessment).

Interview with Administrative Staff #1 and #3 on 10/30/2013 at 1430 while reviewing the electronic documentation of the restraint assessment for Patient #4 revealed areas for documentation for ADL'S offered, circulation check, nutrition offered, range of motion, repositioned, restraint released, safety checks, toileting offered, dignity/rights maintained, emotional well being, and patient response to intervention. Review of the restraint assessment on 09/09/13 at 1300, 1500, and 1700 revealed the ADL's offered, circulation check, Nutrition Offered, Range of Motion, Repositioned, Restraint Released, Safety Checks, Toileting Offered, Dignity/Rights Maintained, Emotional Wellbeing and Patient Response to intervention boxes unchecked. Further review of the chart revealed no documentation of a restraint assessment for 1900. Interview confirmed the hospital's policy for restraint monitoring was not followed.

Based on review of the hospital's policies and protocols, incident reporting, medical record review and staff interview, the hospital failed to ensure equipment needed to ensure patient safety was available for patient use.

The findings include:

Review of the hospital's protocol, "Seizure Management", revised 10/04/2013, revealed, "...When a patient has a generalized seizure, nursing care aims to protect him from injury and prevent serious complications. ...To protect the patient's limbs, head, and feet from injury if he has a seizure while in bed, cover the side rails, headboard, and footboard with side rail pads or bath blankets...".

Review of an incident report dated 09/24/2013 regarding an incident in the ED (Emergency Department) on 09/23/2013 at 1400 revealed, "...Staff had to remove seizure pads due to more critical and acute pt (patient) needing them and the dept (department) only having one set...". Further revealed the incident form was forwarded to the manager of the ED.

Closed medical record review of Patient #5 revealed a 57 year-old male who presented to the hospital's Emergency Department on 10/26/2013 at 1817 via EMS (Emergency Medical Services) after having a seizure and falling. Record review revealed Patient #3 was triaged at 1817 and an initial nursing assessment was completed by Registered Nurse #1 at 1833. Further record review revealed Patient #5 had an active seizure while a CT (computerized tomography) was being performed. Record review revealed no documentation that Patient #5 was placed on seizure precautions, including the placement of seizure pads around the stretcher.

Interview on 10/29/2013 at 1420 with RN #1 revealed, "I remember him (Patient #5). The reason I didn't place seizure pads on his stretcher was because there were no seizure pads in the cabinet. We didn't have any available". Interview further revealed, "he should have been placed on seizure precautions including placing seizure pads on the stretcher".

Interview on 10/30/2013 at 1055 with administrative emergency department staff revealed, "I was not aware we only had one set of seizure pads in the ED (Emergency Department). I had no knowledge of our shortage of seizure pads. I ordered two more sets this morning". Interview further revealed the manager had not read the incident report dated 09/23/2013 which revealed the shortage of seizure pads in the ED.

Based on hospital policy and protocol reviews, medical record reviews, observations during tours and staff interviews, the hospital's nursing staff failed to ensure a falls risk assessment for 2 of 10 patient records reviewed (#7 and #4); implement high risk fall prevention measures for 1 of 2 Progressive Care Unit patients (#9) identified as at risk for falls and 1 of 4 Emergency Department patients (#4) identified as at risk for falls; and failed to implement seizure precautions for 2 of 4 patients identified as high risk for seizures (#5 and #4).

Review of current hospital policy "Falls Reduction Program" revised October 2009, revealed ...(Name of Hospital) is committed to an ongoing comprehensive fall reduction program to decrease the incidence of patient falls with injuries. Key components of this program include: Accurate assessment and identification of patients at risk for falls...Assessment/Reassessment A fall risk assessment will be completed on each adult and pediatric patient admitted to the hospital. A re-assessment will be completed upon change in level of care, change in patient condition, change in causative factor or at the time of a patient fall. Emergency Department...patients will be assessed and re-assessed based on individual unit protocols...". III. Procedure ...Identification of Patients at risk for Falls All patients that meet the criteria for fall risk will have a yellow armband placed on their wrist to identify them as 'at risk for falling' throughout the continuum of care. ...Risk Reduction Strategies ...High Risk Prevention Measures -A yellow band will be placed on the patient's wrist...."

Review of current hospital policy "Fall Assessment Criteria for Emergency Department Patients" revised October 2009, revealed, "...Patients that meet 3 or more of these criteria are to be considered as 'at risk for falls' and should have a yellow band placed on the wrist. Based upon individual patient assessment, nurses may deem patients as 'at risk for falls' with less than 3 indicators......Recent history of falls, fainting, syncope, unresponsiveness (currently or in the last 3 months)....Diagnosis or symptoms of.....Altered Mental Status, Syncope, Dizziness, recent fainting or unresponsive episode, delirium....Use of any of the following drugs: Benzodiazepenes.. Ativan (Lorazepam).....Antiepileptics (medications that prevent seizures)....Dilantin (Phenytoin).....Keppra (Levetiracetam)....**Based upon nursing assessments, any medications with demonstrated untoward effects on patients may be considered in this group.

Review of a current "Adult Inpatient/Transitional Care Unit/Rehabilitation Unit Fall Reduction Protocol" form dated October 2009 revealed "Assessment of Patients ...*Patients that score 51 or above will be identified as at risk for falling ..."

Review of the hospital's protocol, "Seizure Management", revised 10/04/2013, revealed, "...When a patient has a generalized seizure, nursing care aims to protect him from injury and prevent serious complications. ...Patients considered at risk of seizures are those with a history of seizures and those with conditions that predispose them to seizures. ...By taking appropriate precautions, you can help protect a patient from injury, aspiration, and airway obstruction should he have a seizure. ...To protect the patient's limbs, head, and feet from injury if he has a seizure while in bed, cover the side rails, headboard, and footboard with side rail pads or bath blankets...".

1. Open medical record review of Patient #7 revealed a 60 year-old male admitted on 10/28/2013 with rectal cancer. Record review revealed Patient #7 had a laparoscopic abdominoperineal resection on 10/28/2013 and was admitted to the inpatient medical-surgical-oncology unit after surgery. Record review revealed no documented falls risk assessment on admission to the unit.

Observation during tour of the medical-surgical-oncology unit on 10/30/2013 at 1230 revealed Patient #7 had an indwelling urinary catheter, intravenous fluids with a PCA pump (Patient Controlled Analgesia) containing Morphine for pain control.

Interview on 10/30/2013 at 1430 with RN #2 revealed the RN admitted Patient #7 to the medical-surgical-oncology unit from surgery on 10/28/2013. Interview revealed a falls risk assessment was not completed for Patient #7 on admission to the unit. Interview further revealed a risk assessment for falls was completed in the pre-operative area prior to surgery. Interview further revealed the patient had experienced a change in the level of care and condition. Interview confirmed a falls risk assessment should have been completed for Patient #7 on admission to the inpatient unit. Interview revealed Patient #7 was now at risk for fall.

2. Closed medical record review of Patient #4 revealed a 44 year old male who arrived to the ED (Emergency Department) on 09/08/2013 at 0856 via EMS (Emergency Medical Services). Triage documentation revealed "PT (patient) HAD A WITNESSED SEIZURE BY ROOMMATE. POSTICTAL (the altered state of consciousness that a patient enters after having a seizure) ON EMS ARRIVAL. PT HAS HISTORY OF SEIZURES". Further review of documentation revealed Patient #4's home medication list contained Dilantin (anti-seizure medication) and Keppra (anti-epilepsy medication). Record review revealed that Patient #4 received Lorazepam (Ativan-benzodiazepine) at 1001 and 1117. Documentation on 09/08/13 at 1117 revealed "Lorazepam INJ (injection) 1 MG (milligram) SYRINGE IV (intravenous)/NOW/ONE REFRIGERATE WARNING: INCREASES FALLS-RISK. Further review of documentation revealed the pt had a fall at 1105. Review of record did not reveal documentation of a falls risk assessment on admission or reassessment after Patient #4 fell.

Interview with RN #3 on 10/30/2013 at 1030 revealed the nurse was the admitting nurse for patient #4. Further interview revealed "I did not believe the pt. was a fall risk at the time." Further interview revealed Patient #4 was not reassessed for falls after receiving medication in the ED or after the patient fell.

Interview with Administrative Staff #1 on 10/30/2013 at 1045 revealed "reassessment is currently not performed on patients for medications given after fall assessment is completed." Further interview revealed "reassessment of medications given in the ED with fall precaution flags are currently not performed in the ED."

3. Open medical record review of Patient #9 revealed an 82 year-old female admitted to the Progressive Care Unit on 10/24/2013 with altered mental status. Record review revealed a Falls Risk Assessment was completed 10/25/2013 at 0800 with the patient's score documented as 65 (at risk for falls). Observation during tour of the Progressive Care Unit on 10/30/2013 at 1230 revealed Patient #9 did not have a yellow arm-band placed to identify her as at risk for falls.

Interview on 10/30/2013 at 1230 with the charge nurse of the Progressive Care Unit confirmed Patient #9 was at risk for falls and should have a yellow-arm band on to indicate her falls risk. Interview confirmed the hospital's fall risk reduction policy was not followed.

4. Closed medical record review of Patient #4 revealed a 44 year old male who arrived to the ED (Emergency Department) on 09/08/2013 at 0856 via EMS (Emergency Medical Services). Triage documentation revealed "PT (patient) HAD A WITNESSED SEIZURE BY ROOMMATE. POSTICTAL (the altered state of consciousness that a patient enters after having a seizure) ON EMS ARRIVAL. PT HAS HISTORY OF SEIZURES". Further review of documentation revealed Patient #4's home medication list contained Dilantin (anti-seizure medication) and Keppra (anti-epilepsy medication). Record review revealed that Patient #4 received Lorazepam (Ativan-benzodiazepine) at 1001 and 1117. Documentation on 09/08/13 at 1117 revealed "Lorazepam INJ (injection) 1 MG (miligram) SYRINGE IV (intravenous)/NOW/ONE REFRIGERATE WARNING: INCREASES FALLS-RISK. Further review of documentation revealed the pt had a fall at 1105. Review of record did not reveal documentation of a falls precautions implementation on admission or reassessment after Patient #4 fell.

Interview with RN #3 on 10/30/2013 at 1030 revealed the nurse was the admitting nurse for patient #4. Further interview revealed "I did not believe the pt. was a fall risk at the time." Further interview revealed Patient #4 was not reassessed for falls after receiving medication in the ED or after the patient fell.

Interview with Administrative Staff #1 on 10/30/2013 at 1045 revealed "reassessment is currently not performed on patients for medications given after fall assessment is completed." Further interview revealed "reassessment of medications given in the ED with fall precaution flags are currently not performed in the ED."

5. Closed medical record review of Patient #5 revealed a 57 year-old male who presented to the hospital's Emergency Department on 10/26/2013 at 1817 via EMS (Emergency Medical Services) after having a seizure and falling. Record review revealed Patient #3 was triaged at 1817 and an initial nursing assessment was completed by Registered Nurse #1 at 1833. Further record review revealed Patient #5 had an active seizure while a CT (computerized tomography) was being performed. Record review revealed no documentation that Patient #5 was placed on seizure precautions, including the placement of seizure pads around the stretcher.

Interview on 10/29/2013 at 1420 with RN #1 revealed, "I remember him (Patient #5). The reason I didn't place seizure pads on his stretcher was because there were no seizure pads in the cabinet. We didn't have any available". Interview further revealed, "he should have been placed on seizure precautions including placing seizure pads on the stretcher".

6. Closed medical record of Patient #4 revealed a 44 year old male who arrived to the ED (Emergency Department) on 09/08/2013 at 0856 and 09/09/2013 at 1254 via EMS (Emergency Medical Services). Documentation on 09/08/2013 revealed "PT (patient) HAD A WITNESSED SEIZURE BY ROOMMATE. POSTICTAL ON EMS ARRIVAL. PT HAS HISTORY OF SEIZURES. Documentation on 09/09/2013 revealed pt. was "POSTICTAL" on arrival to the ED. Further review of documentation revealed no documentation the patient was placed on seizure precautions on 09/08/2013 or 09/09/2013. Documentation revealed seizure pads applied on 09/08/2013 at 0856. Further review of documentation revealed the pt had a fall on 09/08/2013 at 1105.

Telephone interview with RN #4 on 10/30/2013 at 1453 revealed the nurse heard the patient fall. Further interview revealed, "I heard a loud noise and had to pull the curtain back to see the patient lying on the floor bleeding." Further interview confirmed there was no documentation of Pt #4 being placed on seizure precautions on 09/08/2013 or 09/09/2013.

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