HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure that the rights of patients were met as follows:
A-0118- failure to provide patients using the Emergency Department entrance with information on whom to contact outside the hospital to file a grievance
A-0143- failure to protect patient privacy by displaying private patient information in the hallway outside of a patient room
A-0166-failure to provide a care plan for restraints
A-0168-failure to ensure restraint use in accordance with a physician ' s order
A-0169-failure to avoid the use of PRN orders for restraints
A-0176-failure to ensure that physicians ordering restraints have been trained in current hospital policies on restraints

Based on observation and interview the facility failed to provide patients using the Emergency Department with contact information for filing a grievance with the State agency. Findings include:
On 11/17/10 at approximately 1300 the Emergency Department entrance and exit were toured with the Director of Patient Relations/Risk Management. There was no information available, in postings or handouts, informing patients of contact information for filing a grievance with a State agency. During interview with the Director of Patient Relations/Risk Management these findings were confirmed.

Based on observation the facility failed to protect the private medical information for 1 of 4 patients (#16) on the A-3 unit. Findings include:
On 11/18/10 at approximately 1230, during a tour of the A-3 unit with the Chief Nursing Officer (CNO) and Director or Patient Relations/Risk Management, a sign with a patient #16's full name was observed posted in the hallway outside of her room beside a sign (measuring approximately 8" by 12 " ) that read: "Restraints In Use For This Patient".

Based on observation, interview and record review the facility failed to ensure that restraints were used in accordance with a plan of care for 5 of 5 inpatients (#2, #13, #14, #15, #16.) Findings include:
On 11/17/10 at approximately 1600, review of patient #2 's clinical record revealed no plan of care for restraint use in the portion of the electronic medical record where care plans were located. On 11/17/10, upon request for all of patient #2's care plans, the Unit 7A Nurse Manager (employee #5) provided the following documents: Coping/Anxiety Plan of Care, Discomfort Plan of Care, Neurological Plan of Care and Safety Plan of Care. There was no restraint care plan for the use of restraints.
On 11/18/10 at approximately 1100 the CNO (Chief Nursing Officer) provided a document titled, "Non-Violent Standard of Care for Patients with Restraints". The CNO stated that this document is triggered in the electronic medical record when restraints are ordered and functions as a care plan, listing interventions. The form lists general interventions but does not permit the entry of patient specific interventions, related to the patient's condition or type of physical restraint in use.
On 11/18/10 at approximately 1230, staff #10 and #11 (nurses on the A3 unit) were asked where (in the electronic medical record) they would find the care plan for a patient in physical restraints. Neither staff member was able to locate the care plan. The CNO stated that current restraint interventions could be found on a form/screen titled, "Non-Violent Restraint Initiation" which is completed at the time a restraint is initiated. Review of that screen, for a patient designated as non-violent, revealed a check list form of the "Non-Violent Standard Of Care for Patients with Restraints. " There were no goals listed and the form states: "DO NOT alter the Care Plan, this is a Requirement."
On 11/18/10 at approximately 1400-1500 review of care planning documents for patients #14, #15, and #16 were reviewed in the electronic medical record with the CNO and Director of Patient Relations/Risk Management. Record review revealed no document identified as a current care plan, with goals and interventions that could be updated in the electronic medical record.
Further review of patient #13's clinical record revealed that "violent restraints" had been ordered initially, followed by an order for "non-violent restraints." Despite the change, the interventions found in the clinical record were for violent restraints, not non-violent. These findings were confirmed by staff #10 and the CNO.

Based on observation, interview and record review the facility failed to ensure the use of restraints in accordance with a physician's order and to notify the patient's physician immediately after application in emergency situation for 2 of 6 inpatients in restraints (#2 and #15). Findings include:
On 11/17/10 from 1200-1600, facility policy #070.060, titled "Use of Physical Restraints - Ordering, Monitoring and Documentation Requirements" was reviewed. Under "General Order Information" the policy states: "When a restraint or seclusion is deemed necessary, it may be used only upon the order of a licensed independent practitioner (LIP), that is, a physician, physician's assistant, or nurse practitioner responsible for the patient's care." On 11/18/10 at approximately 1600 the Chief Nursing Officer confirmed that it is facility policy and practice to allow non-physician Physician Assistants and Nurse Practitioners to order restraints. Under Michigan statute, these midlevel practitioners are not authorized to order restraint in a medical hospital setting.
Further review of facility policy #070.060 revealed that the policy allows nurses to apply restraints in emergency situations and that the LIP should be notified immediately. In this scenario, the policy states: "Restraints used to ensure the physical safety or medical treatment of the non-violent or non-self-destructive patient must be electronically ordered by the LIP within 12 hours of the restraint application." The policy does not state that a physician's order must be obtained immediately after restraint initiation.
On 11/17/10 from 1200-1600, patient #2's clinical record was reviewed with the Director of Patient Relations/Risk Management (staff #7). An initial physical restraint order was dated 11/14/10, at 2346, by a nurse (staff #12). The order lists an "ordering physician" and says the "communication type" is per Protocol/Policy/Consult. It was not ordered by a physician or identified as a verbal order, as some orders are designated. Staff #7 confirmed that it was impossible to tell whether the physician had been contacted when the nurse initiated the order.
Further review of patient #2's clinical record, with staff #7, revealed that nurse #12 did not document contacting the patient's physician. In the next nursing note after restraint application, at 0500 on 11/15/10, staff #12 documented "posey vest and wrist restraints in place" but did not document physician contact. There was no documentation by a primary physician until 11/15/10 at 1400. These findings were confirmed by staff #7.
On 11/18/10 at approximately 1400 patient #15's electronic clinical record was reviewed with the Chief Nursing Officer (CNO) and Director of Patient Relations/Risk Manager. Patient #15 was initially placed in restraints on 11/14/10 at 1800. Neither a physician ' s order for physical restraints or documentation of a physician being contacted could be produced. These findings were confirmed by staff #7.

A-0169
Based on observation, record review and interview, the facility failed to prevent the use of restraint orders on a PRN (as needed) basis for 1 of 1 patients. Findings include:
On 11/17/10 at 1325 patient #2 was observed in bed in bilateral wrist restraints and a posey vest, sleeping, with a friend at bedside. On 11/17/10 at 1330 the Chief Nursing Officer stated: "Nurses decide restraint type, not physicians. We could add soft leg (restraints) to a non-violent patient without physician notification or a new order."
On 11/17/10 from 0900-1600 patient #2's clinical record was reviewed. Patient #2's physical restraints were initiated on 11/14/10 at 2315. The patient has been continuously restrained since admission. At initiation, patient #2 was placed in a vest and bilateral arm soft limb restraints. Neither the original restraint order or restraint reorders specify the type of restraint to be used or the time that the physician examined the patient. Each electronic record reorders states only: "I have examined the patient and concur with the RN assessment and care plan."
On the "Restraint Monitoring Non-Violent Patient" form, completed by nursing, the nurse chooses which restraint devices to use, without contacting the physician or doing a new Restraint Initiation form, where restraint alternatives are documented. Per Restraint Monitoring forms for patient #2, on 11/15/00 at 0800 the nurse added 4 siderails, discontinued them on 11/16/10 at 0000, then added them on 11/16/10 at 0800 without a physician's orders. On 11/17/10 at 0000 patient #2 was placed in 4-point soft limb restraints, without a physician's order. A vest was added to the 4-point restraints on 11/17/10 at 0400, without a physician's order. The only time a "Non-violent Restraint Initiation" form was done was upon restraint initiation on 11/14/10.
On 11/18/10 at 0815 patient #2 was observed sitting up in bed, smiling, conversing with staff and a friend. The patient's friend, who had spent the night at bedside, stated that the patient had been awake and oriented all morning. This was confirmed by the patient's nurse, staff #15. Patient #2 remained in bilateral wrist restraints and a vest restraint. The Nurse Educator (staff #14) was asked when the patient's restraints would be removed. Staff #14 stated: "We ask, is he impulsive? We just don't take them off without a period of doing OK." Staff #14 stated that there are no criteria for determining when it is safe to remove a patient's restraints. Per facility policy 070.060: "Restraints or seclusion may only be imposed to ensure the immediate physical safety of the patient ...and must be discontinued at the earliest possible time."

Based on record review and interview, the facility failed to ensure that physicians ordering restraints were trained in the hospital's restraint and seclusions policies. Findings include:
Facility policies titled "Philosophy of Restraint Use" (#070.059) "Use of Physical Restraints: Ordering, Monitoring and Documentation Requirements" (#070.060) had start dates of 8/5/10. On 11/18/10 at approximately 0900 the Manager of Education was asked to provide documentation that physicians received training in the hospital's restraint policies. The Education Manager stated that she was not able to provide evidence of formal training but that she was aware that some training had been done approximately two years ago and that there was some information provided in newsletters that were available to staff.
On 11/17/10 at approximately 1530 the Chief Nursing Officer stated that the facility's restraint policies had been revised within the past year. The hospital's policy titled "Philosophy of Restraint Use (#070,059)" with a start date of 8/5/10 states: "LIPs will be provided with initial information about hospital policy for the use of restraint or seclusion. They will also receive information when changes occur to the policy."