HospitalInspections.org

The Hospital reported a census of 58 patients. Based on medical record review, policy review and staff interview the Hospital failed to assure nursing staff obtained physician orders for the use of restraints for four of four medical records reviewed of patients with restraint (patient #'s 15, 21, 22, and 23). The failure of nursing staff to obtain a physician's order for the use of restraints could potentially cause harm to the patients.

Findings include:
- The Hospitals policy titled "Restraint/Seclusion (SCH)" reviewed on 11/19/15 at 7:45am directed, "...the registered nurse may initiate the restraint. The physician must be notified within 12 hours of the initiation of restraint and a written order obtained ...restraint orders must be renewed every 24 hours after a physician ' s face-to-face evaluation validates the continued need for restraints ..."

- Patient #15's medical record reviewed on 11/18/15 revealed an admission date of 11/7/15 with diagnoses of chest pain and alcoholism to the intensive care unit. Patient #15's medical record revealed on 11/8/15 the patient had respiratory failure and placed on the ventilator and applied soft wrist restraints for the patient's safety. The medical record lacked evidence of physician orders for the use of restraints. Currently, (11/18/15) the patient continues to have wrist restraints applied because they are still on the ventilator. The hospital failed to assure there was a physician order for the use of restraints for the past 10 days the hospital used the soft wrist restraints.
Administrative staff B, Registered Nurse (RN), interviewed on 11/18/15 at 5:00pm confirmed the medical record lacked evidence of a physician's order for the use of restraints after review of the patient's medical record.
Registered Nurse staff R, interviewed on 11/19/15 at 2:15pm acknowledged that the patient is on the ventilator and the medical record lacked physician orders for the use of the restraints. Staff R Explained they are to enter the reminder in the computer to prompt the physician they need an order and the staff failed to follow-up to assure the physician ordered the use of the restraints.

- Patient #21's closed medical record reviewed on 11/19/15 revealed an admission date of 5/19/15 for surgery of left renal cancer. Patient#21's medical record revealed they admitted the patient to the intensive care unit post operatively because they were on the ventilator. The medical record revealed the patient had soft wrist restraints applied for patient safety. They was discontinued the ventilator on 5/20/15. The medical record lacked evidence of physician orders for the use of restraints. The hospital failed to assure there was a physician's order for the use of the restraints.

- Patient #22's closed medical record reviewed on 11/19/15 revealed an admission date of 8/31/15 with diagnoses of gastrointestinal bleed (bleeding in the intestines), and rectal pain. Patient #22's medical record revealed they developed respiratory distress on 9/8/15 that required they the use of the ventilator and use of soft wrist restraints for patient safety and they discontinued the ventilator on 9/9/15 and the use of the soft wrist restraints. On 9/14/15 the patient had surgery, was on the ventilator and had soft wrist restraints applied for patient safety. They discontinued the ventilator and soft wrist restraints on 9/15/15. The medical record lacked evidence of physician orders for the use of restraints both times. The hospital failed to assure there was a physician's order for the use of the restraints.

- Patient #23's closed medical record reviewed on 11/19/15 revealed an admission date of 8/22/15 with a diagnosis of respiratory failure. Patient #23's medical record revealed the patient required to be placed on the ventilator on 8/22/15 and the use of soft wrist restraints for patient safety were applied. They discontinued the ventilator and soft wrist restraints on 8/23/15. The medical record lacked evidence of physician orders for the use of restraints. The hospital failed to assure there was a physician's order for the use of the restraints.
Administrative staff B RN, interviewed on 11/19/15 at 9:30am acknowledged the medical records for patient's #21, #22, and #23 lacked evidence of physician orders for the use of the restraints.

The hospital reported a census of 58 patients. Based on record review, document review, and staff interview the facility failed to ensure that nursing staff's orientation documentation accurately reflected their competency to care for patients on the medical-surgical (med/surg) unit and Rehabilitation (rehab) unit for five of seven nursing staff personnel records reviewed. The hospital failed to ensure one of three CNA's personnel records reviewed were certified/licensed and completed their orientation checklist on the med/surg and rehab unit. This has the potential to cause injury to all patients receiving care on the med/surg and rehab units.Findings:
Policy titled "Orientation Policy", reviewed on 11/19/2015 at 8:00am, directed staff "... All new nursing associates will participate in a planned orientation program. The orientation process will have components of: 1. Individual review, 2. Nursing unit orientation, 3. Hospital A's orientation, 4. Clinical orientation, 5. Hospital Safety Orientation, 6. Independent study, 7. LEARN ... and ... The nursing unit orientation is a planned program of conferences and learning experiences scheduled by the director ..."

The facility's "RN's Competency Validation Checklist" states the following directions for completion: " It is the new associates responsibility to have this skills checklist completed around your evaluation ... and ... have your preceptor sign off each competency item upon demonstration and/or verbalization with the date and initial ... " and " ... These Essential Patient Safety Competencies are to be achieved at the COMPETION of orientation ...1) Patient centered care ...2) Teamwork and Collaboration ...3) Evidence-Based practice ...4) Quality Improvement ...5) Safety ...6) Informatics ... " Nursing Staff E' s personnel record, reviewed on 11/19/2015 at 5:00pm, revealed Nursing Staff E started working as a Registered Nurse (RN) at the hospital on 6/24/2015. The personnel file lacked evidence Nursing Staff E was validated as competent on the required Competency Validation Checklist. Nursing Staff E began working independently on 7/6/2015. Nursing Staff E began acting as a preceptor on 11/6/2015.

Nursing Staff E, interviewed on 11/17/2015 between 4:40am and 5:30am, indicated they are currently independently working on their unit. Staff E revealed management took people off orientation after a couple of weeks. "There were several nurses crying because they weren't ready and were just treated like warm bodies".

Administrative Staff C, interviewed on 11/18/15 at 3:30pm, acknowledged Nursing Staff E has still not completed their required Competency Validation Checklist.

Nursing Staff M's personnel record, reviewed on 11/19/2015 at 5:00pm, revealed Nursing Staff M started working at the hospital on 7/29/2014. The personnel file flacked evidence Nursing Staff M was validated as competent on the required Competency Validation Checklist.
Nursing Staff N's personnel record, reviewed on 11/19/2015 at 5:00pm, revealed Nursing Staff N started working at the hospital on 6/8/2015. The personnel file flacked evidence Nursing Staff N was validated as competent on the required Competency Validation Checklist and Nursing Staff N has been working independently since 7/26/2015 and began acting as a preceptor on 9/9/2015.

Nursing Staff Q's personnel record, reviewed on 11/19/2015 at 5:00pm, revealed Nursing Staff Q started working at the hospital on 6/2/2015. The personnel file flacked evidence Nursing Staff Q was validated as competent on the required Competency Validation Checklist and Nursing Staff Q has been working independently on the unit since 8/22/2015.

Nursing Staff G's personnel record, reviewed on 11/19/2015 at 5:00pm, revealed Nursing Staff G started working at the hospital on 11/19/2013. The personnel file flacked evidence Nursing Staff Q was validated as competent on the required Competency Validation Checklist nursing.

Nursing Staff G, interviewed on 11/18/15 at 4:40pm, revealed they were acting as a preceptor for a new nurse (Nursing Staff T) on 11/16/15 and was unaware if they had a Competency Validation Checklist to ensure they were competent in the required skills. Staff G acknowledged the Staff T should have had one. Staff G indicated they received orientation when they started in 2013, but was not sure if they ever completed a Competency Validation Checklist.
Preceptor program documentation, reviewed on 11/18/2015 at 10:00am, revealed the orientation program is a six-week program to include a weekly orientation conference and completion of the orientation workbook. The preceptor is "... Responsible for the orientation of the newly employed nurse to the nursing process. The preceptor will provide didactic and clinical information for the new associate until competency level is reached ..."

Administrative Nurse Staff B, interviewed on 11/18/15 at 5:30pm, indicated an RN's orientation might last between 4-6 weeks depending on how they are doing. Staff B revealed a manager or department director would speak with the orientating nurse and evaluate their readiness to become independent on the unit. Staff B acknowledged they failed to document this evaluation for five of seven personnel records reviewed.

Nursing Staff S, interviewed on 11/18/2015 at 4:00pm, indicated they were hired on 6/24/2015 and only received a couple of days of orientation at hire and then was assigned to another unit. Staff S acknowledged they have not completed the required Competency Validation Checklist and have been working independently on 7/10/2015, but had not worked shifts between orientation date and date they were independent. Staff S revealed they expressed concerns to manager, not currently employed by the hospital; they did not have sufficient training to be on the unit independently. Staff S indicated they were an experienced nurse and was concerned about the hospital's lack of appropriate orientation.

Nursing Staff U, interviewed on 11/19/2015 at 2:10pm, indicated there have been instances of traveler nurses orienting new nurses, but was unable to give a time or date of these occurances.

CNA Staff K's personnel file, reviewed on 11/17/2015 at 11:30am, revealed a hire date of 3/2015 with a licensure date of 8/2015. The hospital failed to follow their job description requirement for CNA's to have a current CNA certification/license prior to hire. The hospital failed to ensure Staff K was competent to perform the duties of a CNA prior to patient care assignments.

Daily Schedule Worksheet for the months of 5/15/2015- 11/15/2015, reviewed on 11/19/2015 at 9:20am, revealed CNA Staff K assigned as a nurse aid without a preceptor beginning on 5/15/2015, the first day of the review period, prior to Staff K obtaining the required CNA certification/license.

CNA Job description, reviewed on 11/17/2015 at 11:50am, revealed CNA job requirement "...Current KS Certified Nursing Assistant License ... and ... Basic Life Support at time of hire ..."


Administrative Staff B interviewed on 1/18/2015 at 7:45am acknowledged staff hired as CNA's must have a current license prior to hire and start date.