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CHI-ST VINCENT INFIRMARY TWO ST VINCENT CIRCLE LITTLE ROCK, AR 72205 Dec. 7, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to follow its policy and procedure in that one (Patient #13) of four (Patients #12-15) patients was restrained without physician's orders. Failure to obtain a physician's order for restraints did not allow the physician to be knowledgeable regarding the patients' need for restraints and did not allow the facility to be in compliance with its policy and procedure. The failed practice affected Patient #13. Findings follow:

A. Review of the policy and procedure titled "Restraint Usage in Non-Behavioral Health Units," received from the Facility Compliance Coordinator at 10:15 on 12/05/17 showed restraint orders are to be obtained from a physician prior to the initialization of restraints except in unquestionable cases of emergency.

B. Review of Patient #13's clinical record showed he was restrained from 4:00 PM to 9:45 PM on 09/17/17 and again from 1:45 PM to 7:00 PM on 09/19/17 without physician's orders.

C. The findings in A and B were verified during an interview with Registered Nurse Analyst #2 at 2:37 PM on 12/07/17.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on clinical record review and interview it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that ten (#1-7 and 9-11) of eleven (#1-11) clinical records did not contain evidence patient care was rendered as directed by physician's orders. Review of the clinical records showed no evidence vital signs were obtained, ambulation and out of bed activities were performed, nursing incentive spirometry was performed, intake and output measurements were obtained, neurological checks were performed, weights were obtained, dressing changes were performed, and supplements were given. Failure of a RN to supervise and evaluate patient care to ensure physician orders were followed had the potential for adverse events to occur leading to prolonged hospitalization . The failed practice had the likelihood to affect Patients #1-7 and #9-11. Findings follow:

A. Review of Patient #1's clinical record showed physician's orders dated 08/23/16 at 11:42 PM for vital signs with neurological checks every one hour, nursing incentive spirometry every two hours, out of bed three (TID) times per day, and intake and output measurement every one hour and to notify Physician if urine output was less than 200 mls (milliliters) over 6 hours, greater than 250 mls over 2 hours, and greater than 500 mls over one hour. Review of the clinical record showed no evidence vital signs and neurological checks were performed every one hour until discharge; no evidence nursing incentive spirometry was performed every two hours until discharge; no evidence the patient was out of the bed three times a day until discharge and no evidence hourly intake and output was recorded until discharge. During an interview with RN Analyst #2 at 11:07 AM on 12/06/17 the findings were verified.

B. Review of Patient #2's clinical record showed physician's orders dated 08/04/16 at 12:00 PM for patient to be up in a chair four times a day, nursing incentive spirometry ten times an hour while awake, strict intake and output measurement every two hours, 08/04/16 at 6:00 PM for vital signs every two hours, on 08/04/16 for daily dressing changes to surgical wound, and on 08/05/17 weight to be obtained every 24 hours. Review of the clinical record showed no evidence the patient was up in a chair four times a day; no evidence nursing incentive spirometry was performed ten times an hour while awake; no evidence intake and output was measured every two hours; no evidence vital signs were checked every two hours from 08/08/16 through discharge at 1:30 PM on 08/09/16; no evidence daily dressing changes were performed; and no evidence weights were obtained on 08/08/16 and 08/09/16. During an interview with RN Analyst #2 at 11:54 AM on 12/06/17 the findings were verified.

C. Review of Patient #3's clinical record showed physician's orders dated 08/03/16 at 6:53 PM for vital signs every four hours and orders dated 08/05/16 at 4:00 AM for weights to be obtained every 24 hours. Review of the clinical record showed no evidence vital signs were obtained every four hours on 08/06/16, 08/07/16 and 08/08/16, and no evidence daily weights were obtained on 08/06/16 through 08/09/16. During an interview with RN Analyst #2 at 9:01 AM on 12/07/17 the findings were verified.

D. Review of Patient #4's clinical record showed physician's orders dated 08/04/16 at 4:00 AM for weights to be obtained every 24 hours. Review of the clinical record showed no evidence weights were obtained on 08/05/16, 08/06/16, 08/08/16 and 08/09/16. During an interview with RN Analyst #2 at 9:56 AM on 12/07/17 the findings were verified.

E. Review of Patient #5's clinical record showed physician's orders dated 08/03/16 at 11:39 PM for vital signs to be obtained every four hours, and physician's orders dated 08/04/16 at 4:00 PM for weights to be obtained every 24 hours. Review of the clinical record showed no evidence vital signs were obtained every four hours on 08/06/16, 08/08/16 and 08/10/16 and no evidence weights were obtained from 08/05/16 through 08/10/16. During an interview with RN Analyst #2 at 10:42 AM on 12/07/17 the findings were verified.

F. Review of Patient #6's clinical record showed physician's orders dated 12/03/17 at 5:48 PM for vital signs to be obtained every four hours. Review of the clinical record showed no evidence vital signs were obtained every 4 hours on 12/04/17, 12/05/17 and 12/06/17. During an interview with RN Analyst #2 at 10:55 AM on 12/07/17 the findings were verified.

G. Review of Patient #7's clinical record showed physician's orders dated 12/01/17 at 5:00 PM for vital signs to be obtained every four hours and a dressing change to the left foot to be performed twice a day. Review of the clinical record showed no evidence vital signs were obtained every four hours on 12/04/17, 12/05/17 and 12/06/17 and no evidence a dressing change was performed to the left foot twice a day on 12/03/17, 12/04/17 and 12/06/17. During an interview with RN Analyst #2 at 11:06 AM on 12/07/17 the findings were verified.

H. Review of Patient #9's clinical record showed physician's orders dated 12/02/17 at 10:57 PM for vital signs to be obtained every four hours and at 12/06/17 at 10:32 AM for patient to receive Oral High Calorie supplement twice a day with meals. Review of the clinical record showed no evidence vital signs were obtained every four hours on 12/06/17 and 12/04/17. Review of the clinical record showed no evidence the patient received the Oral High Calorie Supplement on 12/06/17. During an interview with RN Analyst #2 at 12:35 PM on 12/07/17 the findings were verified.

I. Review of Patient #10's clinical record showed physician's orders dated 12/05/17 at 6:39 PM for nursing incentive spirometry ten times per hour while awake and intake and output measurements every two hours. Review of the clinical record showed no evidence nursing incentive spirometry was performed and no evidence intake and output was measured every two hours. During an interview with RN Analyst #2 at 1:06 PM on 12/07/17 the findings were verified.

J. Review of Patient #11's clinical record showed physician's orders dated 12/05/17 at 2:43 AM for vital signs every four hours, at 4:00 AM for weights to be obtained every 24 hours, and at 8:43 PM for strict intake and output measurement every two hours. Review of the clinical record showed no evidence the vital signs were obtained every four hours on 12/06/17; no evidence weights were obtained on 12/05/17 and 12/06/17; no evidence intake and output was measured every two hours. During an interview with RN Analyst #2 at 1:24 PM on 12/07/17 the findings were verified.