HospitalInspections.org

Based on record review and interview, the hospital failed to identify use of physical restraints by staff for 1 (Patient #12) of 20 records reviewed.


This failed practice compromised the autonomy and dignity of Patient #12 by restricting the patient's freedom of movement, and had the potential to result in injury due to the lack of assessment of the patient's physical status prior to and following physical restraint use by staff.


Findings:

A policy titled "Restraint Policy" defined a physical restraint as any manual method that reduces the ability of a patient to move his or her arms, legs, body, or head freely. Assessment of the patient by a physician or RN was required, including physical health status, functional health status, alternatives to restraint, and staff behaviors that might be affecting the patient's behavior.

Patient #12

The patient was admitted to a medical unit from 06/16/17 to 06/19/17.

A review of the clinical record showed on 06/18/17 at 3:45 pm, Staff H documented the patient was agitated and struggling with security and nursing staff. Documentation showed the patient refused a PO antianxiety medication, and Staff H received an order for antianxiety medication to be given IV; the patient refused to let staff administer the IV medication and "...with the assistance of two security officers, a nurse and a nurse tech, this nurse was able to administer 1 mg Ativan IV." There was no documentation of patient assessment prior to or following the intervention of 4 staff members to restrict the patient's freedom of movement.

A review of the hospital's restraint logs for 2017 showed no documentation of the restraint.

On 08/09/17 at 3:10 pm, Staff A stated the interventions for Patient #12 on 06/18/17 were performed to keep the patient from harming himself/herself, but were not considered restraints and the restraint policy was not followed.

Based on record review and interview, the hospital failed to identify use of chemical restraints by staff for 1 (Patient #12) of 20 records reviewed.

This failed practice compromised the autonomy and dignity of Patient #12 by restricting the patient's behavior and freedom of movement, and had the potential to result in injury due to the lack of assessment of the patient's physical status prior to and following chemical restraint by staff.

Findings:

A policy titled "Restraint Policy" stated restraints were used in emergency situations to protect the patient from harming himself/herself or others. A chemical restraint was defined as a drug or medication used to restrict the patient's behavior or freedom of movement. Assessment of the patient by a physician or RN was required, including physical health status, functional health status, alternatives to restraint, and staff behaviors that might be affecting the patient's behavior.

Patient #12

The patient was admitted to the behavioral health unit from 06/16/17 to 06/19/17.

A review of the clinical record showed on 06/18/17 at 3:45 pm, Staff H documented the patient was agitated and struggling with security and nursing staff. Documentation showed the patient refused a PO antianxiety medication, and Staff H received an order for antianxiety medication to be given IV; the patient refused to let staff administer the IV medication and "...with the assistance of two security officers, a nurse and a nurse tech, this nurse was able to administer 1 mg Ativan IV." There was no documentation of patient assessment prior to or following the administration of medication to manage the patient's behavior.

A review of the hospital's restraint logs for 2017 showed no documentation of the restraint.

On 08/09/17 at 3:10 pm, Staff A stated the interventions for Patient #12 on 06/18/17 were performed to keep the patient from harming himself/herself, but were not considered restraints and the restraint policy was not followed.

Based on record review and interview, the hospital failed to ensure an RN supervised and evaluated wound care for 1 (Patient #3) of 20 records reviewed.

This failed practice resulted in the lack of treatment of a wound to Patient #3's sacrum and had the potential to adversely affect all patients with known and potential skin integrity problems due to a lack of integumentary assessments to identify problems and initiate treatment. (Refer to A0395).

Based on record review and interview, the hospital failed to ensure an RN supervised and evaluated wound care for 1 (Patient #3) of 20 records reviewed.

This failed practice resulted in the lack of treatment of a wound to Patient #3's sacrum and had the potential to adversely affect all patients with known and potential skin integrity problems due to a lack of integumentary assessments to identify problems and initiate treatment.

Findings:

A statement from the Wound, Ostomy, and Continence Nurses Society recommended specialized support surfaces for persons with Braden mobility subscale scores of 2 or 1 in addition to Braden moisture subscale scores of 4 or 3.

Patient #3

On 06/10/17 at 11:00 pm, patient was admitted for problems with feeding tube. Staff I documented "Admission Assessment- Adult" the patient had "pressure sores to the right hip and sacral area with multiple areas where skin is tight over bony prominences". The patient subsequently discharged on 06/12/17.

The patient was readmitted to the hospital on 06/14/17 for gastric tube placement. The nursing admission assessment included the following documentation:

1. The Integumentary Symptoms were "Area of Concern".
2. The patient had a sacral wound covered with a dry and intact dressing, with "Etiology Unknown" as the only description.
3. The Braden assessment resulted in a score of 1 for mobility (completely immobile) and 3 for moisture (occasionally moist).
3. The Braden Scale gave a total score of 9, indicating the patient was at high risk for developing pressure ulcers.
4. Additional Information shows cerebral palsy and scoliosis, conditions that limited the patient's mobility.
5. Precautions/Isolation was "pressure ulcer prevention".

On 06/14/17 at 4:02 pm, Staff K (a wound care nurse) documented the patient was off the floor for a procedure and the wound care team's assessment was not done. There were no orders for specialized support surfaces or wound care obtained on admission.

On 06/15/17 at 5:52 pm, Staff K documented the patient had been transferred to ICU and was not available to assess at that time; the wound care team's assessment was not done.

On 06/16/17 at 3:04 pm, Staff K documented the ICU nurse told her the patient had a Mepilex dressing and had no wounds. The wound care team's assessment was canceled.

On 06/20/17 at 4:52 am, Staff N transferred the patient to a specialty mattress (6 days after admission).

On 06/22/17 at 3:12 pm, documentation showed the Mepilex dressing was on the right hip and was removed to assess the area (8 days after admission). Staff L documented the presence of a six-month old Stage II pressure ulcer, the physician was notified and an order for a wound care evaluation was requested.

On 06/23/17 (the day of discharge), Staff J (a wound care nurse) documented the presence of a right hip Stage II pressure ulcer with a dark red area at the distal edge.

On 08/09/17 at 3:20 pm, Staff C (a Certified Wound Care and Ostomy Nurse) stated if a patient's Braden score was 18 or less, the hospital's practice was to notify the wound care team to evaluate the patient's risk for developing pressure ulcers. The patient should then be monitored by a wound care nurse between one and three times a week.