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.

SOUTHEASTERN REGIONAL MEDICAL CENTER 300 W 27 ST PO BOX 1408 LUMBERTON, NC 28359 Sept. 19, 2014
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based upon medical staff bylaws, credential file reviews and staff interview, the hospital's staff failed to ensure reappointment of clinical privileges for 1 of 3 emergency department physicians. (Physician #1)

The findings include:

Review conducted September 19, 2014 at 0930 of the hospital "MEDICAL STAFF BYLAWS Part III: Credentials Procedures Manual" revealed "....Section 4. Reappointment 4.1 Criteria for Reappointment ...All reappointments and renewals of clinical privileges are for a period not to exceed twenty-four (24) months. ..."

Review conducted September 18, 2014 at 1500 of Emergency Department Physician #1 credential file revealed Physician #1 had clinical privileges in Emergency Medicine. Further review revealed Physician #1 last reappointment was March 28, 2011. Review revealed Emergency Department Physician #1 last worked in the emergency department September 15, 2014. Review revealed no documentation that Physician #1 was reappointed within twenty-four (24) months of the last reappointment. Review revealed Emergency Department Physician #1 worked in the emergency department without being reappointed.

Interview conducted September 18, 2014 at 1500 with Administrative Staff revealed Physician #1 was not reappointed within twenty-four (24) months of the last reappointment.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on hospital policy review, medical record reviews, and staff interviews, the hospital's nursing staff failed to perform ongoing assessment of a patient's behavior in four (4) point restraints to evaluate discontinuation or less restrictive restraint at the earliest possible time for 1 of 3 restrained patients. (Patient #17)
The findings include:
Review of the hospital's policy "Patient Rights and Responsibilities" last revised date of 12/26/2012 revealed "Patient Rights: ... Keep you free from restraint of any type unless deemed necessary for safety and care..."
Review of the hospital's policy "Violent or Self-Destructive Restraint and/or Seclusion" last revised date of 05/2012 revealed "Procedure Steps: ... 7. Initiate Violent or Self-Destructive Restraint and/or Seclusion flow sheet and document continuous observation every 15 minutes ...9. Discontinue restraints immediately at any indication of risk to patient's health or safety and/or immediately after the patient gains behavioral control ...Care of Patient in Restraints: ...The RN (registered nurse) will remove restraints once the patient's behavior is controllable and no longer poses danger to self, other, or environment ...General Information: ... 2. Positive and less restrictive alternatives are to be considered and attempted whenever possible prior to the use of more restrictive interventions, and documented ..."
Closed medial record review on 09/17/2014 of Patient #17 revealed a [AGE] year old involuntarily admitted on [DATE] with diagnosis of unspecified bipolar disorder (mood disorder) with psychosis (mental disorder with abnormal thoughts).
1. Review of the Physician's Order Form for Violent Restraint and/or Seclusion for patient #17 dated 08/14/2014 at 1005 revealed an order "Restrain patient with: Leather 4 (four) limb restraint" for "Purpose for restraints and/or seclusion: High Risk injury to others; High risk for causing significant disruption to environment" with a 4 hour time limit. Review of the Nursing Assessment at 1005 revealed "Situation: Pt (patient) agitated/combative, confrontational (with) another peer pushed a female peer, attempting to fight another peer". Review of the "Violent Restraint and/or Seclusion-24 hour" flow sheet initiated on 08/14/2014 at 1005 revealed "Type of Restraint: Leather X4 (circled) limbs". Continued review revealed at 1005 "Behavior Observed: 1 (restless/agitated), 2 (combative), 5 (calm), 4 (verbally abusive)". Continued review revealed no further documented reassessment of the patient's behavior or continued need for restraints. Continued review revealed "Time Patient released: 1215" (2 hours and 10 minutes after documentation the patient was calm).
2. Review of the Physician's Order Form for Violent Restraint and/or Seclusion for patient #17 dated 08/15/2014 at 0425 revealed an order for "Restrain patient with: Leather 4 (four) limb" with "Purpose for restraints and/or seclusion: High Risk injury to others and High risk for causing significant disruption to environment" with a 4 hour time limit. Review of the Nursing Assessment at 0437 (12 minutes after restraint application) revealed "Situation: Pt woke up and became agitated, pacing the hallways yelling, cursing, stating 'I will have everyone's [profanity] and I will kick [name of physician] [profanity]. Pt started punching the glasses saying 'I will break one' wanting to get into the nurse's station. Not verbally directable." Review of the "Violent Restraint and/or Seclusion-24 hour" flow sheet initiated on 08/15/2014 at 0425 revealed no documented behavioral assessment. Continued review of the first documented behavioral assessment at 0825 revealed (4 hours after restraint application) "Behavior Observed: 5 (calm)". Continued review revealed no further documented reassessment of the patient's behavior or continued need for restraints. Continued review revealed "Time Patient released: 0935" (5 hours and 10 minutes after restraint application; 1 hour and 10 minutes after documentation the patient was calm).
3. Review of the Physician's Order Form for Violent Restraint and/or Seclusion for patient #17 dated 08/15/2014 at 2100 revealed "Restrain patient with: Leather 4 (four) limb" and "Twice as Tough (type of restraint) 4 limbs" with "Purpose for restraints and/or seclusion: High Risk of injury to self; High Risk injury to others" with a 4 hour time limit. Review of the Nursing Assessment at 2130 (30 minutes after restraint application) revealed "Situation: Pt hit wife in head (with) book during visitation. Became aggressive (and) combative (with) staff during limit setting..pt continues to be aggressive and angry ...Continue restraint: Yes". Review of the "Violent Restraint and/or Seclusion-24 hour" flow sheet initiated on 08/15/2014 at 2100 revealed "Type of Restraint: TAT (Twice-as-Tough) X4 (circled) limbs". Continued review revealed at 2100 no documented "Behavior Observed". Continued review revealed no documented reassessment of the patient's behavior or continued need for restraints. Continued review revealed "Time Patient released: 2151" (51 minutes after restraint application).
Interview on 09/17/2014 at 1325 with Administrative Staff #1 revealed reassessment by the RN of a patient's behavior while in 4 point restraints would be expected to occur more often than every two hours. Interview confirmed the patient should be released from restraints as soon as the violent and destructive behavior is no longer an issue. Interview confirmed there is no documented reassessment of the patient's behavior that justified keeping the patient in 4 point restraints on 08/14/2014 at 1005, 08/15/2014 at 0825, 08/15/2014 at 2100. Interview confirmed the staff failed to perform ongoing assessment of a patient's behavior in four (4) point restraints to evaluate discontinuation or less restrictive restraint at the earliest possible time.
Interview on 09/17/2014 at 1531 with Administrative Staff #2 revealed no evidence of documented ongoing assessment that would indicate continued use of 4 point restraints. Interview confirmed no documentation of the patient's behavior that indicated harm to self or others. Interview confirmed no ongoing reassessment of the patient's behavior to support the use of continued restraints. Interview confirmed the staff failed to perform ongoing assessment of a patient's behavior in four (4) point restraints to evaluate discontinuation or less restrictive restraint at the earliest possible time for all three events for Patient #17.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record reviews, and staff interviews the hospital's nursing staff failed to document alternatives or less restrictive interventions attempted for 1 of 3 restrained patients. (#17)
The findings include:
Review of the hospital's policy "Patient Rights and Responsibilities" last revised date of 12/26/2012 revealed "Patient Rights: ... Keep you free from restraint of any type unless deemed necessary for safety and care..."
Review of the hospital's policy "Violent or Self-Destructive Restraint and/or Seclusion" last revised date of 05/2012 revealed "Procedure Steps: 1...attempt alternatives measures prior to the initiation of restraints...Documentation: 1. The nurse will document in the patient's medical record:...B. Alternative measures attempted or considered prior to the use of the restraint..."
Closed medial record review on 09/17/2014 of Patient #17 revealed a [AGE] year old involuntarily admitted on [DATE] with diagnosis of unspecified bipolar disorder (mood disorder) with psychosis (mental disorder with abnormal thoughts).
1. Review of the Physician's Order Form for Violent Restraint and/or Seclusion for patient #17 dated 08/15/2014 at 0425 revealed an order for "Restrain patient with: Leather 4 (four) limb" with "Purpose for restraints and/or seclusion: High Risk injury to others and High risk for causing significant disruption to environment" with a 4 hour time limit. Review of the Nursing Assessment at 0437 (12 minutes after restraint application) revealed "Situation: Pt woke up and became agitated, pacing the hallways yelling, cursing, stating 'I will have everyone's [profanity] and I will kick [name of physician] [profanity]. Pt started punching the glasses saying 'I will break one' wanting to get into the nurse's station. Not verbally directable."
Review of the "Violent Restraint and/or Seclusion-24 hour" flow sheet initiated on 08/15/2014 at 1005 revealed "Type of Restraint: TAT (Twice-as-Tough) X4 (circled) limbs". Continued review revealed a check box "Alternatives tried prior to restraint (check all that apply): Verbal Redirection, Orientation, Talking Out Issues, Diversional Activities, Time Out, Relief of Pain, Environment Modified, Setting Limits". Review revealed no boxes for "alternatives tried" were checked. Continued review of the record revealed no documented alternatives or less restrictives alternatives documented prior to application of the restraint.
2. Review of the Physician's Order Form for Violent Restraint and/or Seclusion dated 08/15/2014 at 2100 revealed an order for "Restrain patient with: Leather 4 (four) limb" and "Twice as Tough (type of restraint) 4 limbs" with "Purpose for restraints and/or seclusion: High Risk of injury to self; High Risk injury to others" with a 4 hour time limit. Review of the Nursing Assessment at 2130 (30 minutes after restraint application) revealed "Situation: Pt hit wife in head (with) book during visitation. Became aggressive (and) combative (with) staff during limit setting...pt continues to be aggressive and angry ...Continue restraint: Yes".
Review of the "Violent Restraint and/or Seclusion-24 hour" flow sheet initiated on 08/15/2014 at 2100 revealed "Type of Restraint: TAT (Twice-as-Tough) X4 (circled) limbs". Continued review revealed a check box "Alternatives tried prior to restraint (check all that apply): Verbal Redirection, Orientation, Talking Out Issues, Diversional Activities, Time Out, Relief of Pain, Environment Modified, Setting Limits". Review revealed no boxes for "alternatives tried" were checked. Continued review of the record revealed no documented alternatives or less restrictives alternatives documented prior to application of the restraint.
Interview on 09/17/2014 at 1325 with Administrative Staff #1 revealed alternatives and less restrictive intervention attempted are to be documented on the violent restraint flow sheet and the boxes of the restrictions attempted are to be checked by the RN. Interview confirmed there is no documentation of the alternatives or less restrictive intervention prior to the application of 4-point restraints.
Interview on 09/17/2014 at 1531 with Administrative Staff #2. Review of the Restraint Flow Sheet by the Administrative Staff #2 revealed alternatives and less restrictive intervention attempted are to be documented on the violent restraint flow sheet and the boxes of the restrictions attempted are to be checked by the RN. Interview confirmed there is no documentation of the alternatives or less restrictive intervention prior to the application of 4-point restraints on 08/15/2014 at 0425 and 08/15/2014 at 2100.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, open record review, and staff interviews the facility staff failed to ensure 6 of 16 restraint orders were authenticated by a physician or licensed independent practitioner within 48 hours for 2 of 3 restraint records reviewed. (Patient #3, Patient #17)

The findings include:

Review of facility "Medical Staff Rules and Regulations. Article IV-Standards of Practice. 4.4.2 Verbal Orders ...d. All verbal orders must be signed by the ordering practitioner or designee within 48 hours unless State law specifies a different (either shorter or longer) time frame. "

A. Review of Patient #3's open medical record on 09/16/2014 at 1300 revealed a [AGE] year-old female admitted on [DATE] for altered mental status, catatonia, low blood pressure, and schizophrenia.

1. Review of Patient #3's "Non-Violent or Non-Self -Destructive Restraint-24 Hour Flow Sheet" revealed documentation dated 09/06/2014 at 1900 through 09/07/2014 at 1800 the patient was placed on roll belt restraint due to the patient was confused, disoriented, restless, and unsteady gait. Record review revealed documentation while in restraint, the patient was assessed every 2 hours for toileting, nutrition, and range of motion (ROM). Record review revealed while the patient in restraint, the Registered Nurse (RN) completed documentation of the patient assessment every 8 hours for mental status, circulation, skin integrity, signs of injury, vital signs, alternative measures, behavior observed. Review of Physician's Order Form Non-Violent or Non-Self-Destructive Restraint dated 09/06/2014 at 1900 revealed the RN obtained the telephone order for roll belt restraint for patient's unsafe mobility and the patient to be restrained for up to 24 hours. Record review on 09/16/2014 (10 days after restraint ordered) revealed no physician or other licensed independent practitioner authenticated the order.

Interview with the Administrative Staff #4 on 09/16/2014 at 1430 revealed the ordering physician or the designee is required to authenticate the telephone order within 48 hour per hospital policy. Interview revealed restraint was ordered and applied on 09/06/2014 at 1900. Interview revealed the order was received and there was no authentication.

2. Review of Patient #3's "Non-Violent or Non-Self -Destructive Restraint-24 Hour Flow sheet" revealed documentation dated 09/07/2014 at 1900 through 09/08/2014 at 1800 the patient was placed in roll belt restraint due to the patient was confused, disoriented, restless, and unsteady gait. Record review revealed documentation while in restraint the patient was assessed every 2 hours for toileting, nutrition, and ROM. Record review revealed while the patient was in restraint, the RN completed documentation of the patient assessment every 8 hours for mental status, circulation, skin integrity, signs of injury, vital signs, alternative measures, behavior observed. Review of Physician's Order Form Non-Violent or Non-Self-Destructive Restraint dated 09/07/2014 at 1900 revealed the RN obtained the telephone order for roll belt restraint for patient's unsafe mobility and the patient to be restrained for up to 24 hours. Record review on 09/16/2014 (9 days after restraint ordered) revealed no physician or other licensed independent practitioner authenticated the order.

Interview with the Administrative Staff #4 on 09/16/2014 at 1430 revealed the ordering physician or the designee is required to authenticate the telephone order within 48 hour per hospital policy. Interview revealed restraint was ordered and applied on 09/07/2014 at 1900. Interview revealed the order was received and there was no authentication.

3. Review of Patient #3's "Non-Violent or Non-Self -Destructive Restraint-24 Hour Flow Sheet" revealed documentation dated 09/08/2014 at 1900 through 09/09/2014 at 1800, the patient was placed in roll belt restraint due to the patient was confused, disoriented, restless, and pulling at line. Record review revealed documentation while on restraint the patient was assessed every 2 hours for toileting, nutrition, and ROM. Record review revealed while the patient was in restraint, the RN completed documentation of the patient assessment every 8 hours for mental status, circulation, skin integrity, signs of injury, vital signs, alternative measures, behavior observed. Review of Physician's Order Form Non-Violent or Non-Self-Destructive Restraint dated 09/08/2014 at 1900 revealed the RN obtained the telephone order for roll belt restraint for patient's unsafe mobility and the patient to be restrained for up to 24 hours. Record review on 09/16/2014 (8 days after restraint ordered) revealed no physician or other licensed independent practitioner authenticated the order.

Interview with the Administrative Staff #4 on 09/16/2014 at 1430 revealed the ordering physician or the designee is required to authenticate the telephone order within 48 hour per hospital policy. Interview revealed restraint was ordered and applied on 09/08/2014 at 1900. Interview revealed the order was received and there was no authentication.

4. Review of Patient #3's "Non-Violent or Non-Self -Destructive Restraint-24 Hour Flow Sheet" revealed documentation dated 09/11/2014 at 1230 through 09/12/2014 at 1230 the patient had a posey bed restraint due to the patient was confused, disoriented, and unsteady gait. Record review revealed documentation while in restraint, the patient was assessed every 2 hours for toileting, nutrition, and ROM. Record review revealed while the patient was in restraint, the RN completed documentation of the patient assessment every 8 hours for mental status, circulation, skin integrity, signs of injury, vital signs, alternative measures, behavior observed. Review of Physician's Order Form Non-Violent or Non-Self-Destructive Restraint dated 09/11/2014 at 1230 revealed the RN obtained the telephone order for posey bed restraint for patient's unsafe mobility and the patient to be restrained for up to 24 hours. Record review on 09/16/2014 (5 days after restraint ordered) revealed no physician or other licensed independent practitioner authenticated the order.

Interview with the Administrative Staff #4 on 09/16/2014 at 1430 revealed the ordering physician or the designee is required to authenticate the telephone order within 48 hour per hospital policy. Interview revealed restraint was ordered and applied on 09/11/2014 at 1230. Interview revealed the order was received and there was no authentication.





B. Closed medical record review on 09/17/2014 of Patient #17 revealed a [AGE] year old involuntarily admitted on [DATE] with diagnosis of unspecified bipolar disorder (mood disorder) with psychosis (mental disorder with abnormal thoughts).
5. Review of Patient #17's Physician Order Form for Violent Restraint and/or Seclusion dated 08/15/2014 at 0425 revealed an order obtained from the physician and written by the nurse for "Restrain patient with: Leather 4 (four) limb restraint" for "Purpose for restraints and/or seclusion: High Risk injury to others; High risk for causing significant disruption to environment" with a 4 hour time limit. Review of the order revealed physician authentication on 08/26/2014 at 0756 (9 days after restraint ordered).
Interview with the Administrative Staff #4 on 09/16/2014 at 1430 revealed the ordering physician or the designee is required to authenticate the telephone order within 48 hours per hospital policy. Interview confirmed the facility policy for authenticating orders was not followed.

6. Review of Patient #17's Physician Order Form for Violent Restraint and/or Seclusion dated 08/15/2014 at 2100 revealed an order obtained from the physician and written by the nurse for "Restrain patient with: Leather 4 (four) limb restraint" for "Purpose for restraints and/or seclusion: High Risk injury to others; High risk for causing significant disruption to environment" with a 4 hour time limit. Review of the order revealed physician authentication on 08/26/2014 at 0758 (10 days after restraint ordered).

Interview with the Administrative Staff #4 on 09/16/2014 at 1430 revealed the ordering physician or the designee is required to authenticate the telephone order within 48 hours per hospital policy. Interview confirmed the facility policy for authenticating orders was not followed.

NC 252, NC 751, NC 155, NC 849, NC 876, NC 707, NC 347, NC 539, NC 333