HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that the restraint order form included documentation of the patient's behavior that warranted the use of restraints for two orders and failed to document the interventions attempted (prior to restraint) for one order for restraint use for 1 of 5 patients requiring the use of restraints. (pt. N3)

Findings:
1. at 12:40 PM on 12/13/11, review of the facility policy and procedure "Restraint Use" (policy number 200-25), indicated:
A. on page 3, it reads in section IV. "Restraint Orders:" "A. Non-Violent Behavior Restraint Orders The use of restraints is based on the assessed need of the patient and the failure of less restrictive interventions..."

2. review of patient medical records on 12/13/11 between 12:45 PM and 4:30 PM indicated:
A. pt. N3 had restraint orders written on 8/29/11 at 1630 hours that lacked completion on the Restraint Physician order form, in the area of behaviors, that indicated a need for restraint (no boxes are checked in this section)
B. pt. N3 had restraint orders written on 8/30/11 at 0900 hours that lack completion on the Restraint Physician order form, in the area of behaviors, that indicated a need for restraint (no boxes are checked in this section) and lacked any indication or documentation of "previous interventions attempted but unsuccessful" (no boxes are checked in this section)

3. interview with staff members NA and NC at 10:00 AM on 12/14/11 indicated:
A. the physician restraint orders for pt. N3 on 8/29/11 and 8/30/11 are lacking appropriate documentation and completion as required by the restraint policy

Based on medical staff rules and regulations review, patient medical record review, and staff interview, the medical staff failed to ensure the implementation of dating and timing authentication of restraint orders for 2 of 5 patients requiring restraint usage. (pts. N2 and N3)

Findings:
1. at 10:10 AM on 12/14/11, review of the medical staff rules and regulations, most recently approved on 5/9/11, indicated:
A. on page 7 in item 8., it reads: "All clinical entries in the patient's medical record shall be accurately timed and dated and authenticated by the author of the entry..."

2. review of patient medical records from 12:45 PM to 4:30 PM on 12/13/11, indicated:
A. pt. N2 had restraints ordered on 8/10/11 at 0500, per a telephone order, that were authenticated by the physician, but lack a date and time of the authentication
B. pt. N3 had restraint orders (by telephone) at 1630 hours on 8/29/11 that were authenticated by the physician, but lack a date and time of the authentication

3. interview with staff member NA at 10:00 AM on 12/14/11 indicated:
A. the restraint orders for pts. N2 and N3 lack a date and time with the physician's authentication of the orders
B. medical staff rules and regulations indicate that a date and time are required with all entries/authentication in the medical records

Based on patient medical record review and staff interview, the nurse executive failed to ensure that baths were documented daily for 5 of 5 patients. (pts. N1 through N5)

Findings:
1. From 12:45 PM to 4:30 PM on 12/13/11, review of patient medical records indicated:
A. pt. N1 was lacking documentation of a bath on 8/11/11 and 8/13/11
B. pt. N2 was lacking documentation of a bath on 8/13/11, 8/14/11, and 8/15/11
C. pt. N3 was lacking documentation of a bath on 8/30/11, 9/1/11, and 9/2/11
D. pt. N4 was lacking documentation of a bath on 9/5/11 and 9/7/11
E. pt. N5 was lacking documentation of a bath on 9/8/11 and 9/9/11

2. interview with staff member NA at 12:25 PM on 12/13/11 indicated:
A. the facility does not have a policy/procedure related to daily baths for patients
B. the facility expectation, and standard of practice, is that each patient will receive a daily bath while hospitalized

3. interview with staff member NC at 4:20 PM on 12/13/11 and 12/14/11 indicated:
A. the facility does not have a policy/procedure related to daily baths for patients
B. the facility expectation, and standard of practice, is that each patient will receive a daily bath while hospitalized
C. patients N1 through N5 are lacking documentation of having had a bath, either on the ICC or the med/surg nursing units, during their hospitalization on the dates as listed in 1. above