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.

UNIVERSITY MEDICAL CENTER NEW ORLEANS 2000 CANAL STREET NEW ORLEANS, LA 70112 Sept. 14, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0187
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure there was documentation in the medical record of the patient's condition that warranted the use of a restraint for 1 of 3 patients (#2) with orders for restraints out of a total of 6 medical records reviewed. Findings:

Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained a gunshot wound to the abdomen which required a colostomy.

Review of the Nurses' Narrative Notes for Patient #2 revealed was not in his room and remained off of the unit on 06/28/11 from 5:20pm through 9:10pm. Further review of the nurses' notes revealed....2110 (9:10pm) Pt. in room disoriented and lethargic, no respiratory distress noted. Pt. stated he wanted pain medication and went to business "a". Notified charge nurse RN S4 of pt's condition. He assessed pt. and paged MD S5. MD S5 came up to see pt. She ordered blood and urine tox (toxicology) screen. Code White (security) was initiated at 2200 (10:00pm). Further review of the medical record revealed no documented evidence any least restrictive interventions had been implemented.

In a face to face interview on 09/13/11 at 2:10pm RN S6 the nurse assigned to the care of Patient #2 for the 7P shift on 06/28/11 verified RN S4 Charge Nurse had not documented in Patient #2's chart. Further S6 indicated the reason Patient #2 was being restrained was to obtain a urine specimen which Patient #2 refused to give. Further S6 indicated that was the reason she (S6) notified the House Manager because she felt it was not appropriate to restrain Patient #2.

Review of Policy #5032 titled "Restraints" last reviewed/revised 06/29/11 and submitted as the one currently in use revealed..... "Procedures for Application of Restraint Devices: H. The patient's medical record should include documentation of the progression of the patient's agitation, confusion and/or aggression and a clear progression of the less restrictive, non-physical alternative interventions used in an attempt to deactivate this process".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on record review and interview the hospital failed to follow their policy and procedure for obtaining an order (telephone, verbal or written) as evidenced by failing to obtain the beginning and ending time, behavior for the use of the restraints, or the criteria for early release for 1 of 3 patients (#2) out of a total of 6 sampled medical records. Findings:

Review of the Physicians' Orders dated/timed 06/28/11 at 2130 (9:30pm) for Patient #2 revealed.... "Blood and urine tox (toxicology). Blood alcohol level. In & out cath (catherization) for urine. OK to use 4-point restraints for tox-screens if pt. (patient) refuses".

Further review of the entire medical record revealed no documented evidence the order for a Restraint for Patient #2 had been clarified.

RN S4 Charge Nurse was terminated from the hospital and could not be located for an interview.

Review of Policy# 5032 titled "Restraints" last reviewed/revised 06/29/09 and submitted as the one currently in use revealed.... VIII. Procedures for Application of Restraint Devices: C. Restraint orders shall include, but not limited to: the date and time of the restraint order; time limits for the use of physical restraints specifying beginning and ending time; behavior for justifying use of physical restraints; criteria for early release from restraint devices; the specific type of restraint to use and the location of placement; and the physician's signature, printed name and the physician's hospital number".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure all patients were free of abuse as evidenced by: 1) use of four-point restraints being used to obtain a urine sample from a cognitive patient who had refused the test for 1 of 3 patients (#2) with orders for restraints out of a total of 6 sampled medical records and 2) failure to consider Federal and State Regulations in their Critical Incident Reporting policy resulting in an incident of possible abuse not being reported to the Department of Health and Hospitals within 24 hours of becoming aware of the incident. Findings:

1) 4-point restraints being used to obtain a urine sample from a cognitive patient who had refused the test
Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained gunshot wound to the abdomen which required a colostomy and was non-compliant in diet, medication and care of his ostomy which made frequent hospitalization s necessary for re-hydration and electrolyte balance.

Review of the Nurses' Narrative Notes for Patient #2 revealed.... 06/28/11 at 1720 (5:20pm) To CT (CAT Scan) via w/c (wheelchair), pt (patient) dressed abd (abdominal) fistula with 4 X 4 ABDs and tape. 2000 (8:00pm) Pt. not in room. Off floor. 2045 (8:45pm) Pt. still off floor. 2110 (9:10pm) Pt. in room disoriented and lethargic, no respiratory distress noted. Pt. stated he wanted pain medication and went to business "a". Notified charge nurse RN S4 of pt's condition. He assessed pt. and paged MD S5. MD S5 came up to see pt. She ordered blood and urine tox (toxicology) screen. Code White (security) was initiated at 2200 (10:00pm).

Review of the Physician's Orders for Patient #2 dated/timed 06/28/11 at 2130 (9:30pm) revealed a telephone order taken by RN Charge Nurse S4 for ......"Blood and urine tox (toxicology). Blood alcohol level. In and out cath (catherization) for urine. OK to use 4-point restraints for tox screens if patient refuses".

In a face to face interview on 09/13/11 at 2:10pm RN S6 assigned to the care of Patient #2 on 06/28/11 7P shift indicated she (S6) did not agree with the order for restraints to obtain the urine specimen for toxicology and reported this to Charge Nurse RN S4. Further S6 indicated S4 took over carrying out the MD orders and before she could call the House Manager to follow the chain of command to express her concern, Patient #2 was in 4-point restraints and the urine specimen was obtained.

In a face to face interview on 09/14/11 at 9:14am MD S5 indicated she was the House Officer on the night of 06/28/11 and had the responsibility for coverage of approximately 50 patients in addition to trauma call. MD S5 indicated she was called several times that night from the nurses on the floor concerning Patient #2. Further S5 indicated that she remembers the first call was informing her Patient #2 had been gone from the unit for over three hours and had returned with a pizza and seemed very lethargic. S5 asked Charge Nurse S4 what the policy was for leaving the hospital and he (S4) responded 2 hours, but it was too late because the staff had already let him back on the floor so Patient #2 could not be considered a desertion. S5 indicated she ordered a blood and urine tox screen, but did not order restraints if the patient refused the tests.

2) failure to report an incident of possible abuse to the Department of Health and Hospitals within 24 hours of becoming aware of the incident.

Review of the Louisiana Revised Statutes revealed the following in relation to the reporting of abuse/neglect: Title 40. Public Health and Safety, Chapter 11. State Department of Health and Hospitals ?2009.20. "Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report".

The hospital could not submit any documented evidence the Department of Health and Hospitals had been notified of the possible abuse of Patient #2 within 24 hours of being notified.

Review of Policy # 5065 titled "Identifying Abused and/or Neglected Adult Patients" last reviewed/revised 12/27/10, Policy # 0075 titled "Critical Events Reporting", last reviewed/revised 07/27/10, and Policy # 5067 titled "Reporting Suspected Sentinel Events and Near Misses" last reviewed/revised 06/27/11 and submitted as the ones currently in use, revealed no documented evidence the policies contained a procedure requiring the reporting of suspected abuse of a patient in the hospital to the department of Health and Hospitals.

In a face to face interview on 09/13/11 at 10:00am RN S3 QA Manager reviewed policy # 5065, #0075 and #5067 and verified there was no documented evidence of a procedure for reporting of suspected abuse of a patient in the hospital to the department of Health and Hospitals. Further he indicated he was not aware of the time line of reporting a case of suspected abuse to the State within 24 hours and because of this, the time lines were delayed.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure all patients were free from physical abuse as evidenced by restraining a patient (#2) for the purpose of obtaining a urine specimen for toxicology screening for 1 of 3 patients with orders for restraints out of a total of 6 medical records reviewed. Findings:

Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained gunshot wound to the abdomen which required a colostomy and was non-compliant in diet, medication and care of his ostomy which made frequent hospitalization s necessary for re-hydration and electrolyte balance.

Review of the Nurses' Narrative Notes for Patient #2 revealed.... 06/28/11 at 1720 (5:20pm) To CT (CAT Scan) via w/c (wheelchair), pt (patient) dressed abd (abdominal) fistula with 4 X 4 ABDs and tape. 2000 (8:00pm) Pt. not in room. Off floor. 2045 (8:45pm) Pt. still off floor. 2110 (9:10pm) Pt. in room disoriented and lethargic, no respiratory distress noted. Pt. stated he wanted pain medication and went to business "a". Notified charge nurse RN S4 of pt's condition. He assessed pt. and paged MD S5. MD S5 came up to see pt. She ordered blood and urine tox (toxicology) screen. Code White (security) was initiated at 2200 (10:00pm).

Review of the Physician's Orders for Patient #2 dated/timed 06/28/11 at 2130 (9:30pm) revealed a telephone order taken by RN Charge Nurse S4 for ......"Blood and urine tox (toxicology). Blood alcohol level. In and out cath (catherization) for urine. OK to use 4-point restraints for tox screens if patient refuses".

In a face to face interview on 09/13/11 at 2:10pm RN S6 assigned to the care of Patient #2 on 06/28/11 7P shift indicated she (S6) did not agree with the order for restraints to obtain the urine specimen for toxicology and reported this to Charge Nurse RN S4. Further S6 indicated S4 took over carrying out the MD orders and before she could call the House Manager to follow the chain of command to express her concern, Patient #2 was in 4-point restraints and the urine specimen was obtained.

In a face to face interview on 09/14/11 at 8:50am RN S9 indicated that she went into Patient #2's room when he returned to his room (not sure what time) and found him sitting on the bed holding a pizza and slumped over. Further S9 indicated Patient #2 looked lethargic and RN S6 assigned to the care of Patient #2 reported this to RN Charge Nurse S4. S9 indicated Charge Nurse S4 returned to Patient #2's room and stood in his (#2)'s space (very close to his face) and told #2 the MD had ordered a urine specimen. RN S9 indicated the patient, who was cognitive at the time, refused the request. S9 indicated the next thing she knew security was called, Patient #2 was out in restraints and the urine specimen was obtained. Further S9 indicated she felt this was not right because Patient #2 had a right not to be catherized. S9 indicated Patient #2 had not shown violent behavior prior to being put into 4-point restraints.

In a face to face interview on 09/14/11 at 9:00am CNA S10 indicated she was on duty the night
Review of the Nursing Notes for Patient #2 dated 06/28/11 revealed no documented evidence RN S4 assessed Patient #2 for behavior(s) warranting the use of restraints or least restrictive measures taken before the application of the 4-point restraints.

Review of Policy # 5032 titled "Restraint Policy" last reviewed/revised 06/29/2009 revealed...... "IV General Guidelines: B. Under no circumstances shall a patient be restrained as a method of punishment, for the convenience of the medical staff or solely due to the history of violent, disruptive behavior.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure RN supervision of care as evidenced by: 1) leaving a patient with a physician's order for 1:1 direct observation of a patient in 4-point restraints unattended resulting in the patient removing the restraints and leaving the hospital for 1 of 1 patients with orders for 1:1 observation out of a total sample of 6 medical records; 2) failing to re-assess a patient after administration of Morphine/Benadryl/Zofran IV and allowing the patient to leave the unit shortly after the drugs were pushed (#2) for 1 of 1 patients adminsitered Morphine/Benadryl/Zofran IV out of 6 sampled medical records; 3) failing to monitor the return of a transferred patient back to the unit for 1 of 1 patients (#2) transferred off the unit out of 6 total sampled medical records; and 4) failing to assess a patient in 4-point restraints every 15 minutes as per policy for 1 of 3 patients (#2) with orders for restraints out of a total of 6 sampled medical records. Findings:

1) leaving a patient with a physician's order for 1:1 direct observation of a patient in 4-point restraints unattended
Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained gunshot wound to the abdomen which required a colostomy and and was non-compliant in diet, medication and care of his ostomy which made frequent hospitalization s necessary for re-hydration and electrolyte balance.

Review of the Physicians' Orders for Patient #2 dated/timed 06/28/11 at 2215 (10:15pm) revealed a telephone order requiring the patient 1:1 direct observation at all times.

Review of the medical record for Patient #2 revealed no documented evidence a sitter or CNA (Certified Nursing Assistant) had been assigned to directly observe the patient.

In a face to face interview on 09/14/11 at 8:50am CNA S10 indicated she had been assigned to the 1:1 observation of Patient #2 on 06/28/11 7P shift. S7 indicated Patient #2 was screaming and threatening the staff, had pulled his colostomy bag off and told her (S10) he was going to get out of the restraints. Further S10 indicated Patient #2 was lying in a mess and she wanted to help clean him up, but he did not want to be touched. S10 indicated she was very upset because of the condition of the patient, so she stepped out of the room to talk to the nurse and it was at this time the patient removed the restraints and left the hospital.

Review of Policy #6097 titled "Psychiatric Patients, Care of" last reviewed/revised 07/10 revealed ...... Sitter Guidelines: 1. Maintain direct visual contact of the patient at all times. 7. NEVER leave the room until your replacement is also in the room ready to continue one on one observation. 8. NEVER leave the patient in the room alone even with the family present".

2) failing to re-assess a patient after administration of Morphine/Benadryl/Zofran IV and allowing the patient to leave the unit shortly after the drugs were pushed;
Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and a entercutaneous fistula.

Review of the Nurses' Notes for Patient #2 revealed....." 06/28/11 at 0935 (9:35am) Morphine 2mg IV (intravenous), Benadryl 25mg IV, Zofran 4mg IV given". Further review of the Nurses' Notes revealed no documented evidence the patient had been reassessed after administration of the medication; however the entry at 11:25 indicated the patient returned to his room and seemed listless and was dozing off when the nurse tried to speak with him.

In a face to face interview on 09/13/11 at 10:00am RN S1 Quality Management Staff Nurse indicated all patients should be re-assessment after receiving IV pain medication.

3) failing to monitor the return of a transferred patient back to the unit
Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula.

Review of the Physicians' Orders dated 06/28/11 for Patient #2 revealed an order for a CT scan of the abdomen and the pelvis with contrast.

Review of the "Ticket to Ride" (used to track transfers) revealed Patient #2 left the unit on 06/28/11 at 1700 (5:00pm) on a telemetry monitor, oriented, no fall precautions, pain medication received at 1615 (4:15pm). Further review revealed no documented evidence of the date and time the patient was returned to the unit after the procedure was completed.

Review of Policy #5095 titled "Policy Regarding Hand Off Communication" last reviewed/revised 04/27/11 and submitted as the one currently in use revealed... "E. Ticket to Ride form shall be completed by the patient's nurse when the patient is transported from his/her home base to a test or service and back to home base, e.g. an x-ray, a stress test, a pulmonary function test, a physician therapy visit".

Review of the "Patient Escort Department Daily Activity Log" dated 06/28/11 revealed Patient #2 was transferred from the unit on 06/28/11 at 1803 (6:03pm) to CT scan and returned to the unit at 1905 (7:05pm).

In a face to face interview on 09/13/11 at 3:25pm RN S8 Manager of 7W Unit revealed the transported is supposed to give report to the nurse caring for the patient or the charge nurse to make sure he/she was aware the patient was back on the unit. S8 indicated in the case of Patient #2, this did not happen.

4) failing to assess a patient in 4-point restraints every 15 minutes as per policy
Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and a entercutaneous fistula.

Review of the Nursing Care Flowsheet for Use of Restraints revealed patients with restraints due to behavioral reasons were to be monitored every fifteen minutes and patients restrained due to medical reason were to be assessed every two hours. Further review of the Nursing Care Flowsheet for Use of Restraints dated 06/28/11 revealed Patient #2 was monitored at 2200 (10:00pm), 2400 (12:am) and 0200 (2:00am).

In a face to face interview on 09/13/11 at 2:10pm RN S6 assigned to the care of Patient #2 on the 7P shift on 06/28/11 indicated the restraints were kept on Patient #2 after he (#2) had been catherized because he (#2) started threatening and spitting at the staff. Further S6 indicated patients with behavioral restraints were to be assessed every 15 minutes. S6 confirmed she assessed Patient #2 every two hours.

Review of Policy #5032 titled "Restraints" last reviewed/revised 06/29/10 and submitted as the one currently in use revealed.... VII. Procedures For Application Of Restraints: X: Documentation of patient assessment shall be recorded within the patient's medical record on the Nursing Care Flowsheet for Use of Restraints. Assessments shall be accomplished via a face-to-face observation....".
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure patients plans of care were
revised, interventions implemented and evaluated as evidenced by failing to implement interventions for a patient with continued non-compliance in ordered medical care for wounds, telemetry, fluids and leaving the unit (#2) and a patient identified with terminal cancer having emotional issues (#6) for 2 of 6 medical records reviewed. Findings:

Patient #2
Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained gunshot wound to the abdomen which required a colostomy and was non-compliant in diet, medication and care of his ostomy which made frequent hospitalization s necessary for re-hydration and electrolyte balance.

Review of the Physician's Progress Notes for Patient #2 dated/timed 06/23/11 at 0553 (5:53am) revealed......"Pt (patient) was set up for outpatient infusion therapy for regular IVF (intravenous fluids) with potassium but pt. has been non-compliant and now returning to the ED (Emergency Department) with complaints of feeling bad".

Review of the Nurses' Notes for Patient #2 revealed the following: 06/23/11 at 1650 (4:50pm) Patient off the floor; 06/23/11 at 2040 (8:40pm) Patient back to floor; 06/24/11 at 0400 (4:00am) Refuses dressing changes; 06/25/11 at 7:00am Patient refused 40 meq KCL (Potassium Chloride) and to wear the telemetry monitor; 06/27/11 at 11:50am Pt. not in room. Potassium run not completed. Pt. up and down the stairs often; and 06/28/11 at 10:20am Pt. not in room. 11:25am Pt. returned to room. 12noon Pt refused to have wound care performed by wound care nurse. 1600 (4:00pm) Pt. came out of bathroom from shower draining contrast and bloody drainage from fistula onto the floor on towels, very uncooperative, wanting to eat and drink, re-instructed NPO (nothing by mouth) for CT scan".

Review of the "Interdisciplinary Discharge Planning Rounds and Treatment Plan" for Patient #2 developed 06/24/11 revealed no documented evidence the identified problem of non-compliance concerning wound care, IV therapy, telemetry monitoring and leaving the unit for extended periods of time had been addressed.

Patient #6
Review of the medical record for Patient #6 revealed a [AGE] year old female admitted on [DATE] with the diagnosis of metastatic cancer of unknown origin.

Review of the Physicians' Progress Notes dated 08/24/11 at 0700 (7:00am) for Patient #6 revealed.... "Pt (Patient) states she has been in severe pain since 4:00am this morning - stresses, says PCA (Patient Controlled Analgesia) not working, says she wants a cigarette, tearful; 0800 (8:00am) Still with increased pain, not used to using PCA pump, increased anxiety, pain on movement, wants to go home.

Review of the "Interdisciplinary Discharge Planning and Treatment Plan" (Plan of Care) for Patient #6, initiated 08/26/11, revealed the following identified problems; Self-care deficit related to impaired movement; Alteration in comfort/pain/anxiety related to anxiety and psychological response to disease process with the interventions of assess patient for pain and anxiety, administration of medication, attempt alternative methods for managing pain and anxiety; alteration in breathing patterns related to immobility and compromised lung function; and Alteration in fluid electrolyte/nutritional status related to knowledge deficits and self-care deficit. Further review revealed no documented evidence the plan of care had been reviewed, revised, updated or evaluated at discharge.

In a face to face interview on 09/13/11 at 10:00am RN S1 Quality Management Staff Nurse indicated the plan of care for Patient #2 should have included interventions for his non-compliance.

In a face to face interview on 09/14/11 at 10:00am RN S3 Quality Manager indicated a problem had been recognized with Plan of Care and updating through the Root Cause Analysis.

Review of Policy #6013 titled "Nursing Philosophy, Process and Clinical Documentation" last reviewed/revised 06/10 and submitted as the one currently in use revealed.... "Planning Phase: 1. Goal setting utilizes an interdisciplinary process, incorporating nurses, physicians, other allied health professions, the patient, and the patient's family/significant other(s). 2. The teaching plan is developed, documented and implemented upon admission and re-evaluated throughout the patient's hospitalization ".
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure the rights of an admitted patient were met as evidenced by ignoring the refusal of a patient to be catherized to obtain urine for a drug screen resulting in the patient (#2) being placed in 4-point restraints to obtain the urine specimen for 1 of 1 patients with an order for a urine specimen out of a total of 6 sampled medical records. Findings:

Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained gunshot wound to the abdomen which required a colostomy and was non-compliant in diet, medication and care of his ostomy which made frequent hospitalization s necessary for re-hydration and electrolyte balance.

Review of the Nurses' Narrative Notes for revealed Patient #2 was sent to Radiology for a CT (CAT Scan) at 06/28/11 at 1720 (5:20pm) and returned to the unit at 2110 (9:10pm) Patient #2 was discovered in his room and was assessed by RN S6 to be disoriented and lethargic. Further review of the Nurses' Notes revealed Patient #2 requested pain medication and said he went to business "a" for a pizza. Charge Nurse RN S4 was notified of the patient's condition as well as MD S5.

Review of the Physicians' Orders for Patient #2 revealed a telephone order was taken by RN S4 Charge Nurse from MD S5 House Officer as follows: "06/28/11 at 2130 (9:30pm) Blood and urine tox. Blood alcohol level. In and out cath (catherization) for urine. OK to use 4-point restraints for tox screens if patient refuses".

Further review of the medical record for Patient #2 revealed no documented evidence to justify the use of 4-point restraints for behavioral activity, an emergency medical condition or a legal issue substantiating the need for a drug tox screen warranting the use of restraints.

In a face to face interview on 09/12/11 at 12:20pm RN S3 Quality Management Director verified restraints cannot be used to obtain a urine specimen against the will of a patient.

Review of the "Patient's Bill of Rights and Responsibilities" given to all patients at the time of admit revealed..... "As a patient, you have a RIGHT to...... Refuse care, treatment and services to the extent provided by law and be informed of the medical consequences if you do refuse".
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview the hospital failed to implement corrective action in a timely manner to address the problems identified in the RCA (Root Cause Analysis) performed in response to an incidence of patient abuse (Patient #2). Findings:

Review of the Root Cause Analysis Framework and Action Plan 2011-007 revealed the following: Root Cause(s)/Opportunity for Improvement: 1. Education in the Use of Restraints and the communication chain; Risk Reduction Strategy: The Department of Professional Development and the Department of Quality Management will present an on-line education program mandatory for all staff; Date of Implementation: Pending; and Measurement of Strategy: Data on compliance with the education will be tracked in Professional Development and reported to the Comprehensive Quality Management Committee. 2) Confusion related to the treatment of non-compliant patients; Risk Reduction Strategy: The Ethics Committee will present a program for all staff relating to Ethical decision making process when patients of sound mind refuse to be compliant with treatment plans; Date of Implementation: September 2011; and Measurement Strategy: Minutes and sign-in sheets will be on file with the Ethics Committee.

In a face to face interview on 09/13/11 at 112:15pm RN S3 Quality Manager indicated the addition to the Restraint education module presented at orientation and yearly (which can be accessed online) included a patient's right to refuse treatment and the nurse's role as a patient advocate.

Further S3 indicated the module was recently placed online for the staff; however the physicians cannot access the on-line program and will receive this information during Grand Rounds later this month.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure the physician evaluated a patient placed in 4-point restraints within a hour after the initiation of the restraints (#2) for 1 of 3 patients with orders for restraints out of a total of 6 medical records reviewed. Findings:

Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained a gunshot wound to the abdomen which required a colostomy.

Review of the Nurses' Narrative Notes for Patient #2 revealed was not in his room and remained off of the unit on 06/28/11 from 5:20pm through 9:10pm. Further review of the nurses' notes revealed....2110 (9:10pm) Pt. in room disoriented and lethargic, no respiratory distress noted. Pt. stated he wanted pain medication and went to business "a". Notified charge nurse RN S4 of pt's condition. He assessed pt. and paged MD S5. MD S5 came up to see pt. She ordered blood and urine tox (toxicology) screen. Code White (security) was initiated at 2200 (10:00pm).

Review of the Physician's Orders for Patient #2 dated/timed 06/28/11 at 2130 (9:30pm) revealed a telephone order taken by RN Charge Nurse S4 for ......"Blood and urine tox (toxicology). Blood alcohol level. In and out cath (catherization) for urine. OK to use 4-point restraints for tox screens if patient refuses".

Review of the medical record, including the Physician Progress Notes dated 06/28/11 revealed no documented evidence MD S5 evaluated Patient #5 within an hour after the 4-point restraints had been applied.

In a face to face interview on 09/13/11 at 2:10pm RN S6 assigned to the care of Patient #2 on 06/28/11 7P shift indicated after the urine specimen was obtained from Patient #2, his behavior escalated and he began threatening the staff and spitting so the 4-point restraints were left in place.

In a face to face interview on 09/14/11 at 9:14am MD S5 indicated she was the House Officer on the night of 06/28/11 and had the responsibility for coverage of approximately 50 patients in addition to trauma call. MD S5 indicated she was called several times that night from the nurses on the floor concerning Patient #2. Further S5 indicated that she remembers coming to the unit to talk with the patient, S5 verified she did not document in the chart concerning the use of the restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure the medical record for Patient #2 contained a complete and accurate description of the patient's behavior and the intervention used to restrain the patient for 1 of 3 patients with restraints ordered for a total of 6 medical records reviewed. Findings:

Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained a gunshot wound to the abdomen which required a colostomy.

Review of the Nurses' Narrative Notes for Patient #2 revealed was not in his room and remained off of the unit on 06/28/11 from 5:20pm through 9:10pm. Further review of the nurses' notes revealed....2110 (9:10pm) Pt. in room disoriented and lethargic, no respiratory distress noted. Pt. stated he wanted pain medication and went to business "a". Notified charge nurse RN S4 of pt's condition. He assessed pt. and paged MD S5. MD S5 came up to see pt. She ordered blood and urine tox (toxicology) screen. Code White (security) was initiated at 2200 (10:00pm).

In a face to face interview on 09/13/11 at 2:10pm RN S6 the nurse assigned to the care of Patient #2 for the 7P shift on 06/28/11 verified RN S4 Charge Nurse had not documented in Patient #2's chart. Further S6 indicated the documentation in the chart was hers; however it did not include whatever S4 had done because she (S6) had not witnessed it.

Review of Policy #5032 titled "Restraints" last reviewed/revised 06/29/11 and submitted as the one currently in use revealed..... "Procedures for Application of Restraint Devices: H. The patient's medical record should include documentation of ......a description of the patient's behavior and the restraint intervention used......".
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure least restrictive measures were documented in the medical record which were attempted before the application of restraints for 1 of 3 patients (#2) with orders for restraints out of a total of 6 medical records reviewed. Findings:

Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] with hypokalemia, acute renal failure, and an entercutaneous fistula. Further review of the medical record revealed Patient #2 had sustained a gunshot wound to the abdomen which required a colostomy.

Review of the Nurses' Narrative Notes for Patient #2 revealed was not in his room and remained off of the unit on 06/28/11 from 5:20pm through 9:10pm. Further review of the nurses' notes revealed....2110 (9:10pm) Pt. in room disoriented and lethargic, no respiratory distress noted. Pt. stated he wanted pain medication and went to business "a". Notified charge nurse RN S4 of pt's condition. He assessed pt. and paged MD S5. MD S5 came up to see pt. She ordered blood and urine tox (toxicology) screen. Code White (security) was initiated at 2200 (10:00pm). Further review of the medical record revealed no documented evidence any least restrictive interventions had been implemented.

In a face to face interview on 09/13/11 at 2:10pm RN S6 the nurse assigned to the care of Patient #2 for the 7P shift on 06/28/11 verified RN S4 Charge Nurse had not documented in Patient #2's chart. Further S6 indicated the documentation in the chart was hers; however it did not include whatever S4 had done because I had not witnessed it.

Review of Policy #5032 titled "Restraints" last reviewed/revised 06/29/11 and submitted as the one currently in use revealed..... "Procedures for Application of Restraint Devices: H. The patient's medical record should include documentation of the progression of the patient's agitation, confusion and/or aggression and a clear progression of the less restrictive, non-physical alternative interventions used in an attempt to deactivate this process".