HospitalInspections.org

Based on review of hospital policy, medical records review, and staff interviews, facility staff failed to ensure restraint orders were appropriately entered for a patient for 1 of 4 restraint records reviewed (Patient #20).

Findings included:

Review of the policy titled "Restraint and Seclusion Use" latest review date 11/2017 revealed, "...1 Rationale ...Restraints and seclusion are used only when necessary to ensure the immediate physical safety of the patient ...Restraints are used for non-violent patients who are not self-destructive but are confused ...unable to follow safety instructions or are unwilling to comply with medically necessary treatment that is administered in accordance with the law ....3. Practice a. Restraints for Non-Violent Patients ...xiii Restraints may only be employed while an unsafe condition continues ...xiv. When restraints have been discontinued, the LIP order should be discontinued by the nurse. A new LIP order is required to reinstitute restraint use ..."

Review of the medical record revealed Patient #20 was a 47 year old male admitted to the hospital on 09/03/2019 for gastrointestinal bleeding (GIB). Review of the admission history and physical dated 09/03/2019 at 1258 stated Patient #20's " ...past medical history significant for alcohol induced cirrhosis, peptic ulcer disease, esophageal varices s/p banding, history of upper GI bleed and history of complicated alcohol withdrawal ..." Review revealed Patient #20 was moved from the medical progressive care unit to the medical intensive care unit on 09/04/2019 for impaired respiratory status, underwent paracentesis (insertion of a tube and drainage of excessive fluid from the abdomen resulting from a disease process) on 09/05/2019, and was initially placed in a lap belt restraint after rolling out of bed onto the floor on 09/09/2019 at 1200. Review revealed Patient #20 was placed in bilateral wrist restraints on 09/10/2019 at 0400 for continued unsafe behaviors and removal of medical support and monitoring devices. Review of the medical record revealed Patient #20's care included the use of bilateral wrist restraints through 09/19/2019 at 2239. Review of a nursing note by registered nurse, RN #2, dated 09/20/2019 at 0231 revealed " ...Appears much improved from yesterday ...Restraints removed and pt (patient) remains compliant and calm with frequent rounding ...Will continue to monitor." Review of a physician "Progress Note" by MD #1 dated 09/20/2019 at 0620 revealed "Encephalopathy improving ...Conversation improved today ...off restraints and doing well ..." Review of the medical record revealed orders for "2 Point-Wrist Soft" restraints on 09/21/2019 at 0657 and 09/23/2019 at 0618. Review revealed the order duration for each was "Continuous" and "2 days." Chart review revealed no evidence of restraint use for Patient #20 from 09/20/2019 at 0620 until 09/25/2019 at 2359 during the orders' time frame.

Request for interview with RN #2 revealed she was not available for interview.

Interview with the Nurse Manager for 8 Bed Tower revealed there were restraint orders in the electronic medical record for Patient #20 after 09/19/2019, but there was no documentation of restraint use after 2239 on 09/19/2019.

Telephone interview on 10/04/2019 at 1420 with MD #1 revealed Patient #20 no longer needed restraints after 09/19/2019. MD #1 stated "I was probably clicking through the orders. I probably clicked renew mistakenly instead of expire ..." MD #1 indicated restraint use was not mentioned in her notes after they were discontinued on September 19, 2019.

Based on policy and procedure review, medical record reviews and staff interviews, nursing staff failed to reassess pain to ensure pain management for 2 of 4 patients with pain in the Emergency Department (ED) reviewed. (#14, #34)
The findings included:

Review on 10/08/2019 of the hospital policy and procedure titled "Medication Administration" effective 11/2017 revealed "...4. Evaluate and document the patient's pain prior to and in 60 minutes or less after administering pain medication ..."

Review on 10/08/2019 of the hospital policy titled "Pain Management", dated 08/2019, revealed "...2. Assessment a. Determine with patient/caregiver approprite assessment tool that is selected....c. Rassess pain presence within 60 minutes or less of any PRN pain intervention....utilizing a consistent tool and document results. ..."

1. Emergency Department (ED) record review, on 10/08/2018, revealed Patient #14 arrived to the ED on 10/03/2019 at 0528 with a chief complaint of Sickle Cell Pain Crisis. Review revealed a pain assessment at 0531, with a pain score of 8 (on a scale of 1-10 with 10 being the worst pain). Review of an ED Provider Note, dated 10/03/2019 at 0735, revealed "...(Named Patient) is a 20 y.o. (year old) female with a history of sickle cell disease who presents with sickle cell crisis.... I provided the patient with a (sic) initial dose of morphine. She will need to be reassessed in an hour to see if further morphine needs to be administered. ..."

Review revealed a physician order for Morphine (narcotic pain medication) 8 milligrams (mg) IV and Zofran 4 mg IV at 0619, which were administered at 0634. Record review failed to reveal a pain reassessment with a pain score noted within 60 minutes. At 0829 (2 hours 58 minutes later, a pain assessment score of 8 was noted and another 8 mg of Morphine was given at 0830. Record review again failed to reveal a numerical pain reassessment completed within 60 minutes. A pain score of 7 was obtained at 1100 (2 hours, 31 minutes after the last pain assessment). Record review failed to reveal pain reassessments per policy.

Interview, on 10/08/2019 at 1355, with Nurse Manager (NM) #9, an ED NM, revealed policy was not followed regarding pain reassessments. Interview revealed with Patient #14, NM #9 would have expected the nurse to contact the physician who may have changed the orders.


40194

2. Review on 10/08/2019 of the closed medical record for Patient #34 revealed a 40-year-old male presented to the Emergency Department on 05/20/2019 at 1416 with complaints of a right wrist injury. Review of the triage vital signs documented at 1424 revealed Temperature (T)-98.1, Pulse (P)-107, Respirations (R)-16, Blood Pressure (BP)-110/75, Oxygen (O2)-98% and Pain-7. Record review revealed Patient #34 was administered Morphine 2 milligrams intravenously (IV) on 05/20/2019 at 1512 and Fentanyl (Narcotic pain medication) 50 micrograms IV at 1526. Review of the medical record revealed no available documentation of a pain reassessment after medication intervention. Patient #34 was discharged on 05/20/2019 at 1817 (2 hours, 51 minutes after last narcotic pain medication was given)

Interview, on 10/08/2019 at 1355, with NM #9 revealed policy was not followed if 60 minute reassessments were not done.

NC00154244, NC00154855, NC00156760