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WHITE RIVER MEDICAL CENTER 1710 HARRISON STREET BATESVILLE, AR 72503 Dec. 1, 2016
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to ensure the initial physician's orders for restraints contained the type of restraint to be used for five (#1, #2, #3, #5 and #8) of five (#1, #2, #3, #5 and #8) patients. Failure to specify the type of restraint used did not ensure the restraint met the patient's needs with the least risk and most benefit to the patient. The failed practice affected Patients #1, #2, #3, #5 and #8. Findings follow:

A. Review of Patient #1's clinical record revealed an initial physician's order timed and dated 0924 on 09/25/16 for restraints which did not specify which type of restraint to be used. Review of the nursing notes for 09/25/16 and 09/26/16 revealed Patient #1 was in soft wrist restraints and four side rails up. The above was verified by the Physician Liaison Nurse at 1515 on 11/29/16.
B. Review of Patient #2's clinical record revealed an initial physician's order timed and dated 0943 on 10/20/16 for restraints which did not specify which type of restraint to be used. Review of the nursing notes from 10/20/16 1400 through 10/23/16 at 2200 revealed Patient #2 was in soft wrist restraints and four side rails up. The above was verified by the Physician Liaison Nurse at 1600 on 11/29/16.
C. Review of Patient #3's clinical record revealed an initial physician's order timed and dated 05/28/16 at 0456 for restraints which did not specify which type of restraint to be used. Review of the nursing notes from 05/28/16 through 1600 on 06/21/16 revealed Patient #3 was restrained all four extremities and an enclosure bed at various times. The above was verified by the Physician Liaison Nurse at 1351 on 11/30/16.
D. Review of Patient #5's clinical record revealed an initial physician's order timed and dated 1800 on 11/28/16 which did not specify which type of restraint to be used. Review of the nursing notes from 11/28/16 through 1000 on 11/29/16 revealed Patient #5 was in soft wrist restraints and four side rails up. The above was verified by the Physician Liaison Nurse at 1515 on 11/30/16.
E. Review of Patient #8's clinical record revealed an initial physician's order timed and dated 2140 on 11/24/16 which did not specify which type of restraint to be used. Review of the nursing notes from 11/24/16 through 1732 on 11/29/16 revealed Patient #8 was in soft wrist restraints. The above was verified by the Physician Liaison Nurse at 1613 on 11/30/16.
F. Review of the policy and procedure titled "Medical Safety Interventions" received from the Chief Nursing Officer at 1030 on 11/29/16 did not reveal a statement requiring the initial physician's order to contain the type of restraint used.
G. During an interview with the Physician Liaison Nurse at 1211 on 12/01/16 she verified the restraint orders generated by the electronic medical record did not include the type of restraint to be utilized for the patient.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of clinical records, interview and policy and procedure review, it was determined the Facility failed to obtain physician's orders for restraints for two (#3 and #8) of five (#1, #2, #3, #5 and #8) of five (#1, #2, #3, #5 and #8) patients who were restrained. Failure to obtain a physician's order for restraints did not allow the physician to be knowledgeable regarding the patient's need for restraints and prohibited the Facility from following policy. The failed practice affected Patient #3 and #8. Findings follow:

A. Review of Patient #3's clinical record revealed no physician's orders for restraints from 06/01/16 through 06/04/16, 06/05/16, 06/08/16 through 06/09/16 and 06/14/16. Review of the nursing notes revealed Patient #3 was in an enclosure bed on those dates. The above was verified by the Physician Liaison Nurse at 1351 on 11/30/16.

B. Review of Patient #8's clinical record revealed no physician's orders for restraints from 11/28/16 through 11/29/16. Review of the nursing notes revealed Patient #8 was in soft wrist restraints on those days. The above was verified by the Physician Liaison Nurse at 1613 on 11/30/16.

C. Review of the policy and procedure titled "Medical Safety Interventions" received from the Chief Nursing Officer at 1030 on 11/29/16 revealed the following under ...Acute/Medical Surgical or non-violent-self-destructive:
A. A RN (Registered Nurse) may initiate a restraint as long as a Licensed Independent Practitioner (LIP) is notified immediately and a verbal or written order is obtained ...
B. A written order based on a patient exam by an LIP must be entered in the chart within 24 hours of restraint initiation.
C. Restraints must be renewed by an LIP every 24 hours...
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on policy and procedure review, clinical record review and interview, it was determined the Facility failed to perform every two hour observations for one (#3) of five (#1, #2, #3, #5 and #8) patients. Failure to directly observe the restrained patient every two hours did not allow the patient to be assessed and released from restraints as early as safely possible. The failed practice affected Patient #3 and had the likelihood of affecting all patients in restraints. Findings follow:

A. Review of the policy and procedure titled "Medical Safety Interventions" received from the Chief Nursing Officer (CNO) at 1030 on 11/29/16 revealed the following under Monitoring: The patient in restraints will be observed directly by a staff member no less than every two hours and will document per policy #10.29. Appropriate attention must be paid to regular meals, bathing, toilet use and vital signs, food and fluid intake and medication administration. Fluid/meals and toileting must be offered every 2 hours.
B. Review of Patient #3's clinical record revealed an order for restraint at 0456 on 05/28/16 and 2304 on 05/29/16. Review of the clinical record revealed no restraint observation/monitoring from 1103 on 05/28/16 until 2256 on 05/29/16. Review of the physician's progress notes revealed the following:
05/28/16 at 1731 Physician #5's note stated "in 4 pt (point) restraints at this time."
05/29/16 at 0817 Physician #5's note stated "wants out of restraints".
05/29/16 at 0956 Physician #6's note stated "wants out of restraints".
C. During an interview with the Physician Liaison Nurse at 1351 on 11/30/16 she verified the contents of A and B.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that: six (#3, #6, #7, #9, #13 and #15) of six (#3, #6, #7, #9, #13 and #15) patient's clinical records did not contain documentation the patients received Ensure bid (twice daily) as ordered, the PCA (patient controlled analgesia) pump amount remaining was not cleared after use for one (#16) of one (#16) patient and 3 (#7, #13 and #16) of 15 (#1-16) patients did not have a RN (registered nurse) assessment every shift. Failure to document how much Ensure the patient consumed did not allow the physician, nutritionist and other patient care staff to assess and make adjustments in the patient's diet and supplements; failure to document how much, if any of the medication remained in the PCA pump did not allow for accurate recording of amount used and how often it was used, failure to ensure a RN assessed the patient every shift did not ensure the patient's care was coordinated by a professional nurse and that orders such as Ensure bid were recognized and performed. The failed practices affected Patient's #3, #6, #7, #9, #13, #15 and #16. Findings follow:

1. Review of Patient #3's clinical record revealed Ensure bid was ordered on [DATE] at 0530 by Physician #1. Review of the clinical record revealed the Ensure was not documented as given or refused, every day. Examples: 05/25/16 and 05/27/16 there is no documentation Ensure was given; 05/28/16 Ensure was documented as consumed at 100% (percent) at 1800; 06/02/16 there is no documentation Ensure was given; 06/06/16 there is no documentation Ensure was given; 06/09/16 Ensure was documented as consumed 100 % at 1400; 06/12/16 there is no documentation Ensure was given; 06/16/16 Ensure is documented as refused at 1800; and 06/18/16 Ensure is documented as consumed at 100% at 0930 and 1400. During an interview with the Physician Nurse Liaison at 1407 on 11/30/16 she verified the Ensure was not consistently documented as given, consumed or refused bid.

2. Review of Patient #6's clinical record revealed Ensure bid was ordered on [DATE] at 0530 by Physician #2. Review of the clinical record revealed no documentation Ensure was given from 11/25/16 through 0700 on 11/29/16. During an interview with the Physician Liaison Nurse at 1527 on 11/30/16 she verified the Ensure was not documented as given bid.

3. Review of Patient #7's clinical record revealed Ensure bid was ordered on [DATE] by Physician #2. Review of the clinical record revealed no documentation Ensure was given from 11/25/16 through 0700 on 11/30/16. Review of the clinical record of Patient #7 revealed no RN assessment on the day shift on 11/28/16. During an interview with the Physician Liaison Nurse at 1554 on 11/30/16 she verified the above findings.

4. Review of Patient #9's clinical record revealed Ensure bid was ordered on [DATE] at 0530 by Physician #2. Review of the clinical record revealed no documentation Ensure was given bid on 11/26/16, 11/27/16 and 11/28/16. During an interview with the Physician Liaison Nurse at 1006 on 12/01/16 she verified the Ensure was not documented as given bid.

5. Review of Patient #13's clinical record revealed Ensure bid was ordered on [DATE] at 1530 by Physician #3. Review of the clinical record revealed no documentation Ensure was given bid on 11/24/16, 11/25/16, 11/26/16, 11/27/16, 11/28/16 and 11/29/16. Review of Patient #13's clinical record revealed no RN assessment on the day shift on 11/26/16 and 11/28/16. During an interview with the Physician Liaison Nurse at 0950 on 12/01/16 she verified the above findings.

6. Review of Patient #15's clinical record revealed Ensure bid was ordered on [DATE] at 0530 by Physician #4. Review of Patient During an interview with the Physician Liaison Nurse at 1030 on 12/01/16 she verified the above findings.

7. Review of Patient #16's clinical record revealed no documentation Ensure was given bid on 08/21/16. Review of Patient #16's clinical record did not reveal how much of the medication remained in the PCA pump. Review of Patient #16's clinical record revealed no RN assessment on 08/31/16, 09/01/16, 09/02/16, and 09/07/16 night shifts. Review of the policy and procedure titled "Medication Administration" received from the Chief Nursing Officer at 1045 on 11/29/16 revealed the following under ...PROCEDURE:... I. Nurses will check the following medications with another licensed nurse prior to administration of the medication: ...6. PCA setup, replacement of syringe, and documentation of wastage. Verification by second nurse must be documented. During an interview with the Physician Liaison Nurse at 1040 on 12/01/16 she verified the above findings.