HospitalInspections.org

Based on policy review, observation and interview, the Hospital failed to ensure patients had the right to be free from restraints. This deficient practice was evidenced by the hospital failing to follow its Restraint and Seclusion Utilization Policy for 3 of 3 patients observed in their beds with all four of the side rails raised. (Patients R1, R2, R3).
Findings:

Review of the hospital's Policy #81 titled, "Restraint and Seclusion Utilization revealed in part:
K - Side rails considered restraint: Using side rails to prevent a patient from voluntarily getting out of bed would be considered a restraint. In short, the patient may have an increased risk for a fall or other injury by attempting to exit the bed with the side rails raised.

Observation on 09/10/2019 at 12:12 p.m. revealed Patients R1, R2, and R3 in their beds with all four of the side rails raised.

During an interview on 09/10/2019 at 12:15 p.m., S3RN, the nurse assigned to R2, stated Patient R2 did not require all four of the side rails to be in the raised position.

During an interview on 09/10/2019 at 12:17 p.m., S2RN, the nurse assigned to R1 stated Patient R1 did not require all four of the side rails to be in the raised position.

During an interview on 09/10/2019 at 12:20 p.m., S4RN, the nurse assigned to R3, stated Patient R3 did not require all four of the side rails to be in the raised position.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current, individualize, and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to identify interventions and expected outcomes for identified problems for 5 of 5 (Patients #1, #2, #3, #4, #5) sample patients.
Findings:

Review of the hospital's Policy #303 titled, Evidence Based Clinical Documentation, revealed in part:
Plan of Care: A. The Plan of Care is interdisciplinary with each professional involved in the patient's care contributing to the plan by identifying problems, establishing goals and prescribing interventions. D: For each problem added to the Plan of Care, the electronic information system will suggest related interventions. 1. The clinician will review and edit the suggested interventions to meet the patient's needs.

Review of Patient's #1, #2, #3, #4, and #5's Plan of Care revealed a problem list with no nursing interventions or expected outcomes.

Surveyors requested S5RN provide printed copies of Patient's #1, #2, #3, #4, #5's Plan of Care with the problem list and interventions. After repeated request from the surveyors, the Plan of Care with interventions and expected outcomes were not provided to the surveyor.

During an interview on 09/10/2019 at 1:30 p.m., S1 RN acknowledged the Plan of Care did not include interventions to go with the problem sets. S1RN continued to state the interventions are from the MD orders and standards of care from nurse's training.

During an interview on 09/10/2019 at 3:45 p.m., S6RN was unable to provide the surveyor with the Plan of Care nursing interventions and expected outcomes within the medical record.

During an interview on 09/10/2019 at 3:50 p.m., S2RN was unable to provide the surveyor with the Plan of Care nursing interventions and expected outcomes for Patient #3.