HospitalInspections.org

485.631 (b) Medical Staff Responsibilities
The CAH (Critical Access Hospital) must ensure that specific responsibilities of the Doctor of Medicine or Osteopathy requirements are met.

Based on review of records and interview, the Medical Staff failed to implement and enforce their own rules in that the physician's orders were not complete for 1 of 2 patients (Patient #1) who was in restraints and hospitalized between 01/11/11 and 02/18/11. This deficient practice presents a risk of potential harm to patients that may need to be restrained at the hospital in the future.

Findings included:

The "History and Physical" (01/12/11) of Patient #1, age 82, noted that Patient #1 was admitted to the hospital on 01/12/11 after a fall at a nursing home. Patient #1 "had a large hematoma over the left forehead and bruising and contusion around his left eye." History included Congestive Heart Failure, Diabetes, anxiety, and dementia with aggressive behavioral disorder. At 11:40 PM, Physician #4 ordered bilateral restraints to the upper and lower extremities of Patient #1.

The 01/13/11 10:00 AM "Protective/Restraint Need Assessment" noted, Patient #1 had attempted to pull out tubing and climb out of the bed or chair. On 01/13/11 at 10:00 AM, Physician #4 gave a verbal order for "4 point restraint for safety/behavior..." This order was signed by Physician #4 on 01/20/11 at 02:00 PM (approximately 7 days after the order was given).

The hospital's "Restraint Orders" form verbal order from Physician #4 was dated 01/13/11 at 10:00 AM by the nurse and was signed by Physician #4 on 01/14/11 at 11:00 AM (approximately 25 hours after the order was given). The order included wrist and ankle restraints with an order limitation of 24 hours.

The 01/14/11 10:00 AM "Restraint Orders" form documented wrist restraints limited to 24 hours. The "Alternatives tried and documented" and "Purpose of restraint" were not documented. This order was not complete.

The 01/15/11 (untimed with no nurse signature) "Restraint Orders" form was signed by Physician #4 on 01/17/11 at 08:30 AM (approximately 2 days after the order was dated). The 01/15/11 order did not contain the "Order limitation," "Alternatives tried and documented," and "Purpose of restraint." This order was not complete.

The 01/16/11 (untimed with no nurse signature) "Restraint "Orders" form was signed by Physician #4 on 01/17/11 at 08:30 AM. This order did not contain the "Alternatives tried and documented" and "Purpose of restraint." This order was not complete.

During an interview on 02/18/11 at approximately 02:00 PM, Physician #4 reviewed the physician's orders and physician's documentation for Patient #1 with the nurse surveyor. Physician #4 agreed that the information was missing and the orders were not all signed within the 24 hour timeframe.

The physician's "Restraint Orders" form (undated) included the Policy: "Patients who need restraints will be re-assessed and alternatives considered every 24 hours. A new order will be written every 24 hours. Times must be consistent. Orders must be signed on an hourly basis. If order not signed and effective, restraint will be removed. Restraint policy applies to all nursing units..."

The "Authorized Entries in the Medical Record" policy revised February 2004 noted, "...All restraint orders will be authenticated, dated, and timed within 24 hours. "

The Medical Staff Rules and Regulations (07/23/10) noted that all physician's orders "should be recorded on the patient's chart, timed, dated and signed by the staff member in charge of the case ...orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician giving the order and countersigned by the person recording the dictation ...The record is not complete until such an order is signed personally by the physician issuing the order."

Based on interview and record reviews, the Critical Access Hospital failed to maintain complete medical records in that the medical records of 1 of 2 patients (Patient #1) who was in restraints and hospitalized between 01/11/11 and 02/18/11 contained medical record entries that were not complete, dated, timed, and authenticated as required by 25 Texas Administrative Code (TAC) 133.41 (j)(5) and their own policy. This deficient practice presents a risk of potential harm to patients that may need to be restrained at the hospital in the future.

25 TAC 133.41 (j)(5): Medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Findings included:

The "History and Physical" (01/12/11) of Patient #1, age 82, noted that Patient #1 was admitted to the hospital on 01/12/11 after a fall at a nursing home. Patient #1 "had a large hematoma over the left forehead and bruising and contusion around his left eye." History included Congestive Heart Failure, Diabetes, anxiety, and dementia with aggressive behavioral disorder. At 11:40 PM, Physician #4 ordered bilateral restraints to the upper and lower extremities of Patient #1.

The 01/13/11 10:00 AM "Protective/Restraint Need Assessment" noted, Patient #1 had attempted to pull out tubing and climb out of the bed or chair. On 01/13/11 at 10:00 AM, Physician #4 gave a verbal order for "4 point restraint for safety/behavior..." This order was signed by Physician #4 on 01/20/11 at 02:00 PM (approximately 7 days after the order was given).

The hospital's "Restraint Orders" form verbal order from Physician #4 was dated 01/13/11 at 10:00 AM by the nurse and was signed by Physician #4 on 01/14/11 at 11:00 AM (approximately 25 hours after the order was given). The order included wrist and ankle restraints with an order limitation of 24 hours.

The 01/14/11 10:00 AM "Restraint Orders" form documented wrist restraints limited to 24 hours. The "Alternatives tried and documented" and "Purpose of restraint" were not documented. This order was not complete.

The 01/15/11 (untimed with no nurse signature) "Restraint Orders" form was signed by Physician #4 on 01/17/11 at 08:30 AM (approximately 2 days after the order was dated). The 01/15/11 order did not contain the "Order limitation," "Alternatives tried and documented," and "Purpose of restraint." This order was not complete.

The 01/16/11 (untimed with no nurse signature) "Restraint "Orders" form was signed by Physician #4 on 01/17/11 at 08:30 AM. This order did not contain the "Alternatives tried and documented" and "Purpose of restraint." This order was not complete.

During an interview on 02/18/11 at approximately 02:00 PM, Physician #4 reviewed the physician's orders and physician's documentation for Patient #1 with the nurse surveyor. Physician #4 agreed that the information was missing and the orders were not all signed within the 24 hour timeframe.

The physician's "Restraint Orders" form (undated) included the Policy: "Patients who need restraints will be re-assessed and alternatives considered every 24 hours. A new order will be written every 24 hours. Times must be consistent. Orders must be signed on an hourly basis. If order not signed and effective, restraint will be removed. Restraint policy applies to all nursing units..."

The "Authorized Entries in the Medical Record" policy revised February 2004 noted, "...All restraint orders will be authenticated, dated, and timed within 24 hours. "

The Medical Staff Rules and Regulations (07/23/10) noted that all physician's orders "should be recorded on the patient's chart, timed, dated and signed by the staff member in charge of the case ...orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician giving the order and countersigned by the person recording the dictation ...The record is not complete until such an order is signed personally by the physician issuing the order."

Based on review of records and interview, a registered nurse did not provide or assign to other nursing personnel the care of Patient #1, who was restrained during his January 2011 hospitalization, in accordance with Patient #1's needs and the specialized qualifications and competence of the staff available, in that 4 of 8 nurses (Nurses #6, #7, #8, and #9) did not receive the Critical Access Hospital's required restraint training before being assigned to care for Patient #1. This deficient practice presents a risk of potential harm to patients that may be restrained during their hospitalization.

Findings included:

The "History and Physical" (01/12/11) of Patient #1, age 82, noted that Patient #1 was admitted to the hospital on 01/12/11 after a fall at a nursing home. Patient #1 "had a large hematoma over the left forehead and bruising and contusion around his left eye." History included Congestive Heart Failure, Diabetes, anxiety, and dementia with aggressive behavioral disorder. At 11:40 PM, Physician #4 ordered bilateral restraints to the upper and lower extremities of Patient #1. The 01/13/11 10:00 AM "Protective/Restraint Need Assessment" noted, Patient #1 had attempted to pull out tubing and climb out of the bed or chair.

The 01/13/11 "Restraint Flow Chart" indicated Nurse #8 (LVN) cared for Patient #1, who was in restraints, from approximately 08:00 PM through 10:00 PM.

The 01/14/11 "Restraint Flow Chart" indicated Nurse #8 (LVN) cared for Patient #1, who was in restraints, from approximately 12:00 Midnight through 06:00 AM.

The 01/15/11 "Restraint Flow Chart" indicated Nurse #9 (RN) cared for Patient #1, who was in restraints, from approximately 08:00 AM through 12:00 Noon.

The 01/16/11 "Restraint Flow Chart" indicated Nurse #6 (RN) cared for Patient #1, who was in restraints, at approximately 08:00 AM.

The 01/17/11 "Restraint Flow Chart" indicated Nurse #7 (RN) cared for Patient #1, who was in restraints, from 08:00 AM through 06:00 PM.

The Critical Access Hospital's current training information through 02/18/11 and/or personnel files of Nurses #6, #7, #8, and #9 did not include documentation of the required restraint competency training.

During an interview on 02/18/11 at approximately 05:00 PM, the Chief Nursing Officer (Personnel #2) reviewed the training documentation of Nurses #6, #7, #8, and #9 with the surveyor. The Chief Nursing Officer (Personnel #2) agreed that Nurses #6, #7, #8, and #9 did not appear to have the required restraint training before being assigned to care for Patient #1 and could not produce documentation that reflected the training.

The "Orientation Plan-Medical/Surgical" policy effective June 2002 noted, "A one-two week orientation will be conducted for each category of nursing personnel to their assigned unit...Day Two...Competencies: Review with the nurse on duty...Restraints...Day Three...Complete Competencies...Care for 1-3 patients with nurse preceptor..."