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KERN VALLEY HEALTHCARE DISTRICT 6412 LAUREL AVE LAKE ISABELLA, CA 93240 June 3, 2015
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to follow its policies and procedures regarding: 1. reporting an allegation of abuse within 24 hours 2. a complete physiological assessment every four hours while in the Intensive Care Unit (ICU.) 3. every patient's right to considerate, respectful care and to be made comfortable. This has the potential that all alleged abuse incidents are not reported to the Department within 24 hours. This has the potential that a critically ill patient will not be re-evaluated at timely intervals or receive considerate and respectful care.

Findings:

1. During an interview with the Director of Nurses (DON) on 3/17/15 at 1:40 PM, he stated, "I am aware that the alleged abuse incident occurred 3/10/15, and we did not notify the Department until 3/16/15."

The facility policy and procedure titled "Abuse Prevention Program--Mandatory Reporting and Investigation", dated 6/19/05, indicated: "Procedure:....1.1 Report the allegation of abuse or suspected abuse to the Department of Health Services as soon as possible or within 24 hours of the allegation of abuse or suspected abuse according to State law..."

2. During a record review of Patient 1's clinical record with the DON on 4/10/15 at 1 PM, he was unable to locate a second complete physiological assessment within the nurses' notes that was due to be done at 4 AM on 3/10/15. Patient 1 was admitted on [DATE] at 11:45 PM, with the initial assessment completed by the Registered Nurse (RN 1) 3/10/15 at 12:42 AM.

During a concurrent interview and clinical record review with RN 1 on 4/24/15 at 2:25 PM, he stated he did the 4 AM physiological systems reassessment. Reviewing Pt 1's ICU nursing notes, he was unable to locate it. RN 1 stated, "It's a computer problem."

The facility policy and procedure titled "Assessment of the Progressive Care/ICU Patient" undated, it indicated: "....Procedure:...2. Patients will receive a physiological systems reassessment every four hours...."

3. During an interview with LVN 1 on 4/24/15 at 11:10, she stated, "RN 1 never loosened Patient 1's wrist restraints once from midnight 3/10/15, until we went off duty at 7:30 AM. RN 1 never turned or repositioned the patient all night. RN 1 never spoke comfortingly to Patient 1 to explain any care or to orient him to ICU."

During a concurrent interview and review of the clinical record for Patient 1 on 4/24/15 at 2:25 PM, RN 1 stated, "Patient 1 was confused, disoriented and violent. Restraints were applied because he was pulling out his lines. I reassessed him every hour and did not feel that I could remove the restraints." RN 1 documented at 12:53 AM: "Alternative Used in Attempt to Discontinue Restraints: ...Reality orientation, verbal de-escalation." RN 1 documented he released the wrist restraints and provided range of motion every two hours throughout shift. RN 1 documentation at 5:06 AM: "combative, violent, danger to staff, pulls/removes tubes/ catheters; aggressive." At 6:28 AM, RN 1 documented: "attempting to disconnect tubes, lines, unable to comply with safety instruction, attempting to unsafely ambulate." Within the nurses' notes, it was documented that at 5:30 AM, wrist restraints were released by laboratory staff and the lab person was able to drawn blood with Patient 1's co-operation. At 8 AM, 3/10/15, the oncoming shift removed the restraints and documented: "Pt is calm, wrist restraints removed. Pt being very cooperative. Awake and alert, pleasantly confused, cooperative." RN 1 was asked if he had any explanation regarding the time frames of his documentations of aggression and confusion with other staff's finding Patient 1 cooperative. RN 1 stated, "I can't answer that."

During an interview with RN 2 on 4/24/15 at 11:45 AM, she stated, "I came on duty 3/10/15 at 7 AM. Patient 1 was tightly restrained, on his back, soldier-like. It was odd to me that he was restrained so tightly since his bed was immediately next to the nurses' station. Patient 1 was in such disarray, he was down in bed, he was lying on a plastic sheet and when we turned him, the plastic lid to the urinal was indented into his mid-back."

During an observation of the ICU with the DON on 4/24/15 at 12:15 PM, it was noted that the foot of the bed identified as occupied by Patient 1 was approximately two to three feet from the nurses' station.

During a review RN 2's written statement, it indicated: "[LVN 2] began the physical care of Patient 1 around 7:45 AM...Both wrist restraints were removed, the restraints were tightly attached to the bed, leaving the patient's arms very little ability to move. When we released the restraints, [LVN 2] tried to do ROM (range of motion) on the patient's wrists and elbows...The unusual part was that the joints seemed very stiff....Both LVN 2 and I noticed that the patient's mouth was very dry and lips were dry and scaly. Mouth care was provided. The patient was very appreciative and asked for something to drink. He drank the apple juice quickly....We both talked respectfully to the patient, he answered back and we left the restraints off. From this time the patient rested comfortably..."

The facility policy and procedure titled "Patient Rights and Responsibilities", dated 6/27/12, indicated: "Patient Rights: 1. Considerate and respectful care, and to be made comfortable...."