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Based on review of hospital policy/procedure, medical records, and staff interviews, it was determined the administrator failed to require that restraints placed for non-violent behavior, were discontinued at the earliest possible time for 3 of 4 patients (pt's #29, 30 and 42).

Findings include:

The hospital policy/procedure titled Restraint/Seclusion revealed: "...there must be documentation in the patient's medical record of...description of...patient's behavior...interventions...alternatives or other less restrictive interventions attempted...condition or symptom(s) that warranted...restraints...patient response to...intervention(s), including...rational for continued use of...intervention...."

Nursing documentation did not verify restraint rational as follows:

Patient #29: 01/22/12 at 0700 through 01/23/12 at 0600, nursing documented the patient was sleepy, oriented, no distress, "attempts to follow commands." On 01/23/12 at 2300, nursing documented the patient was "more responsive...asking to D/C (discontinue) restraints," however the restraints remained in place until 01/25/12 at 1200.

Patient #30: Restraints were applied on 01/23/12 at 2400. Nursing documented the patient was discharged to a skilled nursing center on 01/23/12 at 1545, however, the staff continued to document that the restraints were in place until 1900. It was unclear if or when the restraints were discontinued upon transfer.

Patient #42: 02/15/12 at 0800, nursing documented: "...Pt (patient) is usually well sedated but will startle awake...2/7/12 at 1600...restraints restarted as patient cont (continues) to reach for tube on occasion...1900...sedated, but will open eyes with tactile stimulus, bilateral soft wrist restraints due to occasional attempt to reach for ETT (endotracheal tube)...2100...no distress...2300 no change...0100...stable no distress...0300 no change...."

The Assistant Chief Nursing Office (ACNO), Director of Cardiovascular Intensive Care Unit (CVICU), and the Director of Quality Management (DQM) confirmed that documentation failed to confirm the reason/rationale patients remained in restraints when sedated, stable, and non-agitated, during interviews conducted on 02/09/12.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined the administrator failed to require that care plans were modified and updated for 3 of 4 patients restrained for non-violent behavior (patients #29, 30 and 42), according to policy, as demonstrated by the failure to document:

1. evaluations for 2 of 4 patients (#30 and 42);

2. interventions for 2 of 4 patients (#29 and 30);

3. goals for 1 of 4 patients (#29); and

4. patient/family informed of restraints needed for 3 of 4 patients (#29, 30 and 42).

Findings include:

The hospital policy titled Restraints/Seclusion, requires: "...there must be documentation in the patient's medical record of...interventions...alternatives...patient response...."

The Restraint Flow Sheet/Care Plan for Non-Violent Behavior requires the nurse document the following: Date, Patient Problem(s), Goal(s), Interventions, Patient Safety Check(s) every 2 hours, Revisions to Restraint Care Plan/Comments, and Evaluation (each shift).

1. Nursing did not document patients' evaluations:

Patient #30: 01/22/12, day shift.
Patient #42: 02/05/12, night shift.

2. Nursing did not document interventions:

Patient #29: 01/23/12 0700, through 01/24/12 0659 (24 hours).
Patient #30: 01/23/12 0700, through 01/23/12 1900 (12 hours).

3. Nursing did not document goals: Patient #29: 01/12/13.

4. Nursing did not document patient/family notification: Patients #29, 30 and 42 (02/07/12).

The Assistant Chief Nursing Office (ACNO), Director of Cardiovascular Intensive Care Unit (CVICU), and the Director of Quality Management (DQM) confirmed that documentation did not include patients' evaluations, interventions, goals, and patient/family notification, , during interviews conducted on 02/09/12.

Based on review of hospital policy/procedure, medical records, and staff interviews, it was determined the administrator failed to require that restraint orders included physicians' signatures, and/or dates/times, for 3 of 4 patients (Pt's #28, 29 and 42).

Findings include:

The hospital policy/procedure titled Restraint/Seclusion revealed: "...restraints...must be in accordance with the order of a physician...."

The physician's Restraint Order form requires the following documentation: Type of Restraint, Reason for Restraint, date/time, and physician's signature.

Physicians did not complete the following verbal orders to include signatures/dates/times, as follows:

Patient #28: 01/25/12 at 2000, 01/27/12 at 1300, and 01/27/12 at 2100.
Patient #29: 01/21/12 at 1900, and 01/24/12 at 1830.
Patient #42: 02/05/12 at 0100, 02/08/12 at 2215.

The Assistant Chief Nursing Office (ACNO), Director of Cardiovascular Intensive Care Unit (CVICU), and the Director of Quality Management (DQM) confirmed physicians' failure to document signature/dates/times for verbal orders according to policy, during interviews conducted on 02/09/12.

Based on Department of Surgery/Anesthesia Rules and Regulations, hospital policies and procedures, medical records, and staff interviews, it was determined the anesthesiologists failed to document and/or complete the post anesthesia assessment as required by hospital policy for 8 or 10 patients (Patients # 9, 10, 11, 31, 33, 36, 39 and 42).

Findings include:

Department of Surgery/Anesthesia Rules and Regulations revised January 2012, requires: "...Post-Anesthesia care...conducted as follows...anesthesia provider...responsible...the patient, unless arraignments with another physician have been made...monitored and discharged according to PACU (post-anesthesia care unit) policies...."

Hospital Policy/Procedure titled "Postoperative Anesthesia Care" policy #SU06.111.10 requires: "...anesthesiologist will perform and document a post-anesthesia assessment...completed...within 48 hours of patient's arrival to the designated recovery area...documentation should include respiratory function...cardiovascular function...mental status...temperature...pain...nausea and vomiting...postoperative hydration...."

The Anesthesia Record contains an area to document the surgical patient's Post-Anesthesia Evaluation. The post anesthesia evaluation contains the following standards of anesthesia care: respiratory function, nausea/vomiting, cardiovascular function, mental status, temperature, post-operative hydration, and pain score. The post anesthesia evaluation contains small boxes in front of each standard for documentation and a blank line to be filled in with a number for evaluation of pain. The evaluation also contains a large box for "comments," and three other boxes to document signature/title, date, and time by a physician.

Patient #9 was admitted to the hospital on 02/06/12, with severe degenerative joint disease. The patient underwent a surgical procedure for Right Total Knee Arthroplasty that same day. Review of the patient's medical record revealed the post-anesthesia evaluation contained no documentation.

Patient #10 was admitted to the hospital on 02/07/12, with compression fracture at T7 (thoracic level 7). The patient underwent a T7 Kyphoplasty. Review of the patient's medical record revealed the post-anesthesia evaluation contained no documentation.

Patient #11 was admitted to the hospital on 02/05/12, with a mid-shaft fracture of the right femur. The patient underwent an Intramedullary Rodding of the right femur. Review of the patient's medical record revealed the post-anesthesia evaluation was incomplete and did not contain a pain score evaluation.

Patient #31 was admitted to the hospital on 01/24/12, with small bowel obstruction. The elderly patient is a high risk for surgery, has ongoing pneumonia, and bladder carcinoma. The patient was treated with conservative therapies. The patient underwent an exploratory laparotomy and right colon resection on 01/27/12. Review of the patient's medical record revealed the post-anesthesia evaluation contained no documentation.

Patient #33 was admitted to the hospital on 02/07/12, with prostate carcinoma. The patient underwent a radical retropubic prostatectomy. Review of the patient's medical record revealed the post-anesthesia evaluation was incomplete and did not contain a pain score evaluation.

Patient #36 was admitted to the hospital on 02/07/12, with left femoral head fracture. The patient underwent a left Bipolar hemiarthroplasty. Review of the patient's medical record revealed the post-anesthesia evaluation was incomplete and did not contain a pain score evaluation.

Patient #39 was admitted to the hospital on 02/07/12, with severe coronary artery disease status post myocardial infarction. The patient underwent a triple coronary artery bypass grafting. Review of the patient's medical record revealed the post-anesthesia evaluation was incomplete and did not contain a pain score evaluation.

Patient #42 was admitted to the hospital on 02/03/12, with a history of shortness of breath (SOB) and diaphragmatic hernia. The patient underwent a left thoracotomy and diaphragmatic hernia repair. Review of the patient's medical record revealed the post-anesthesia evaluation contained no documentation.

The Chief Medical Officer (CMO) confirmed during an interview on 02/09/12, the expectations of the anesthesiologist giving anesthesia is to complete the post anesthesia record within 48 hours as required by the hospital Rules and Regulations. The CMO stated the Rules and Regulations are somewhat vague, and may need revision.

The Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) confirmed during an interview conducted on 02/09/12, that the post anesthesia evaluations in the above medical records were incomplete. The CEO confirmed he was in agreement with the Medical Director regarding the Rules and Regulations needing revision.