The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TMC- BONHAM HOSPITAL 504 LIPSCOMB STREET BONHAM, TX 75418 Feb. 18, 2011
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: C0256
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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], noted that Patient #1 was admitted on [DATE] 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."
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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], noted that Patient #1 was admitted on [DATE] 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."