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Based on hospital policy review, medical record review and staff interview the hospital staff failed to complete a face-to-face assessment within 1 hour after the initiation of violent/self-destructive physical restraint in 1 of 2 (Patient #18) violent/self-destructive restraint patient records reviewed.

Findings include:

Review on 01/31/2024 of the hospital policy "Restraints and Seclusion: Security Alert/Violent/Self-Destructive Behavior - PC 210.43" last revised 04/2023, states " ... F. Initiation of Violent/Self-Destructive Behavior Restraints, Medication Restraints or Seclusion: ... 5. When Violent/Self-Destructive restraints, Medication restraints or Seclusion are initiated, the MD, other LIP, or QRN must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of the restraint intervention (which includes therapeutic holds and seclusion). ..."

Closed medical record review of Patient #18 (Pt#18) revealed an 11 year old male patient that presented to the Emergency Department, with police, on 12/14/2023 at 1543 with agitation and suicidal ideation for involuntary commitment evaluation. The medical record review revealed a written Physician Order for "Restraints Violent or Self-Destructive Adolescent (Age 9 - 17)," dated 12/14/2023 at 1558. Medical record review revealed that restraints were applied on 12/14/2023 at 1600 and discontinued on 12/14/2023 at 1700. Review of the medical record revealed no documentation of a one (1) hour face-to-face assessment completed by a Medical Doctor (MD) that included the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint.

Interview on 02/01/24 with MD#1 revealed the physician did not recall Pt#18. MD#1 stated if there was no documentation in the medical record of a 1 hour face-to-face assessment for Pt#18, that he could not confirm that one was completed. Interview revealed MD#1 would have seen a juvenile patient brought into the ED by police, with violent restraints, but could not say a face-to-face was completed that included all required components. Interview confirmed hospital policy was not followed for obtaining or documenting a 1 hour face-to-face assessment after initiation of a Violent/Self-Destructive Behavior restraint.

Based on review of hospital policies, medical record reviews, and staff interviews the hospital staff failed to turn and reposition a patient to prevent skin breakdown in 1 of 5 patients (Patient # 14) identified as being at risk for skin breakdown.

Findings include:

Review on 02/01/2024 of a Lippincott policy, "Pressure Injury Prevention," revised 02/20/2023, revealed "...properly identifying whether a patient's skin damage is caused by pressure or moisture is key to providing adequate treatment. Keep in mind that incontinent patients who can't reposition themselves may have a condition that results from pressure and moisture...Turn and reposition the patient regularly and frequently unless contraindicated. Base the frequency of repositioning on the patient's tissue tolerance, skin condition, mobility, medical condition, and treatment goals..."

Medical record review revealed Patient #14 was a 69 year old female with a medical history of arthritis (joint inflammation), emphysema of lungs (gradual damage of lungs), hypertension (elevated blood pressure), neuropathy (nerve damage), and peripheral vascular disease (reduced blood flow to extremities) who was admitted to the hospital on 10/14/2023 "...after having an episode of bright red blood per rectum at home." Review also revealed "Left lower extremity is ischemic with chronic left lower extremity wound extending to posterior lateral calf." which ultimately required amputation on 11/03/2023. On 10/14/2023 at 0739, the admission nurse's skin assessment revealed "very dry scaly, several large scabbed sores to left ankle, no drainage, no redness, and lower extremity weakness." The admission assessment did not indicate any other wounds were present on admission.

Flowsheet review revealed on 10/22/2023 at 0600 the patient's level of assistance was documented as dependent. Flowsheet review revealed no evidence of repositioning of Patient #14 from 10/24/2023 at 0000 to 0800 (8 hours). Review of the flowsheet did not reveal repositioning from 10/24/2023 at 1600 to 10/27/2023 at 0920 (65 hours) with the exception of the words bed in chair and supine/back. Nurse's note by LPN #2 on 10/27/2023 at 1924 Patient #14 revealed "...found with skin tear/shear on left buttock while assisting patient with bed pan this shift. Zinc cream applied and encouraged patient to reposition every 2 hours." Further review of medical record revealed no evidence Patient #14 was repositioned from 11/01/2023 at 0800 to 11/1/2023 at 1820 (10 hours). Further medical record review revealed Patient #14 was not repositioned from 11/02/2023 1252 to 1820, 11/03/2023 at 0400 to 0811 (4 hours) and 11/03/2023 from 1240 to 11/04/2023 at 0600 (over 17 hours). Patient #14 was assessed by RN #3, wound care nurse, on 11/6/2023 at 1100, and noted "...groin area macerated and broken down in several areas. Sacrum, inner thighs has moisture associated skin damage. Review of the Discharge Summary on 11/7/2023 at 1529 revealed discharge diagnoses that included sacral pressure ulcer..."

Interview with RN #4 on 02/01/2024 at 1150 revealed bed in chair to supine redistributes pressure, it is not considered a full turn and full turns are expected to be done on dependent patients.

Interview with LPN #2 on 02/01/2024 at 1348 regarding the care of dependent patients. LPN #2 stated they should be turned every 2 hours when in bed. Interview revealed it was the responsibility of the nurse and nursing assistant to turn patients.

Based on hospital medical staff rules and regulations, medical record review, staff interview and family interview the hospital staff failed to document consult results for 1 of 8 patients (Patient #24).

Findings include:

Review on 02/02/2024 of hospital "Medical Staff Rules and Regulations" last revised 12/2021 revealed "Article V. Consultant, Consultation, ...2. Consultations ....b. Requests when feasible. Consultations should be requested as needed by written order....The attending physician is responsible for initiating the request of consultation and is also responsible for providing adequate and timely information in the patient's Hospital clinical record, or in person, sufficient for the consultant to carry out the consultation without delay in completing the consultation. All consultation requests should be initiated and documented by the consultant within 24 hours unless an alternative arrangement is agreed to by the attending physician. If not completed on the initial visit, it should be completed within 48 hours of the request....d. Required consultations. A consultation shall be requested and accomplished in the following cases: 1. When required by applicable statutes or regulations of the state or federal governments..."

Review of an open medical record on 02/01/2024 for Patient #24 revealed a 58 year old female was transported to the ED (Emergency Department) via EMS on 1/22/2024 at 1519 with a chief complaint of G-Tube problem. ED Provider Note dated 01/22/2024 at 1534 revealed Patient #24 was bedbound and non-verbal. Review revealed Patient #24 had past medical history that included Chronic respiratory failure with hypoxia, CVA (Cardiovascular Accident - Stroke), Anoxic brain damage, breakthrough seizures, and Patient #24 was G-Tube and Tracheostomy dependent. Provider note at 2145 revealed "awaiting CT scan abdomen pelvis." Review of the Provider note dated 01/23/2024 at 0444 noted "I assumed care of the patient from the previous ED provider ...at change of shift. The plan of care as discussed is pending CT A/P" and "Final Disposition: admit" Review of H&P (History and Physical) dated 01/23/2024 at 0502 revealed "Assessment/Plan:...Left femoral fracture (sic) Orthopedic surgery consultation placed (sic) X-ray femur, x-ray hip ordered" Review of the Provider Orders revealed an order for "Inpatient consult to Orthopedic Surgery (Order 1984186788) ordered at 0502. Review of the H&P note revealed the Radiologist documented "3. Comminuted and displaced fracture of the proximal left femur involving the intertrochanteric region possibly subacute as it is new since October 23, 2023. Please correlate clinically." As of 02/01/2024 there was no documentation of the Orthopedic Surgery consult having been completed.

An interview on 2/1/2024 at 1327 with Patient #24's husband revealed the patient was admitted to the hospital on 1/22/2024 and at the time of the interview the patient's husband was made aware on 2/1/2024 that Patient #24 had a broken femur by an unnamed RN. The unnamed RN told the husband the information regarding the broken femur had been in the computer since 1/24/2024. Patient #24's husband was concerned the patient had a broken femur, husband had just become aware of the patient's broken femur and no discussion regarding the broken femur plan of care.

An interview on 2/2/2024 at 1307 with the ED Medical Director (EDMD) #6 revealed Patient #24's femur fracture was identified incidentally on the CT Scan. The order showed "somehow the documentation was missed and came up as not released." Interview revealed the EDMD #6 expected all consult orders to be followed up by the specific consultant.

NC00209880, NC00203994, NC00202424, NC00199443, NC00198202