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 July 7, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, observation, review of medical records and patient and staff interview the facility staff failed to obtain an order for restraint in 6 of 7 patients in bed with all 4 side rails in the elevated position. (Patients #1, #2, #3, #4, #5, and #6)

The findings include:

Review on 07/06/17 of policy and procedure "Non-Violent or Non-Destructive Restraint" (reviewed May 2017) revealed, "...If a side rail is used to restrict a patient's ability to leave bed, it would be classified as a restraint. ... Each episode of restraint use must be initiated in accordance with a physician's order. ..."

Observation on 07/05/17 at 1300 revealed continued observation revealed patients were lying in bed and other patients were out of bed to chair. Observation revealed care being provided to patient by the nursing staff. Continued observation revealed six patients (rooms 629, 607, 618, 626, 608 and 627) lying in bed with all four side rails in the elevated position. Observation revealed patients were restrained with all four side rails elevated.

1. Open Medical Record review for Patient #1 was assigned to room 629. Review revealed Patient #1 was a [AGE] year old man admitted on [DATE] with a chief complaint of "left ankle pain and [DIAGNOSES REDACTED] (swelling). Review revealed the patient was alert and oriented to person, place and time. Continued review revealed Patient#1 was being treated with antibiotics, pain medicine and DVT (deep vein thrombosis-blood clot) prophylaxis. Review of physician orders revealed no order for restraint, no documentation indicating the need for restraint use, and no documentation of patient request for the use of four side rails.

Interview on 07/06/15 at 0920 with RN #1 revealed four side rails was considered a restraint and evaluation of the patient as well as a physician order with indication for use was required.

Interview on 07/05/17 at 1630 with AS #1 revealed 4 side rails was considered a restraint and staff were reeducated annually at the skills fair on the definition of restraint, and appropriate use of restraint. Further interview revealed the use of restraint required a physician order and the evaluation for the need for restraint every 24 hours. The interview revealed the policy was not followed.

2. Open Medical Record review for Patient #2 was assigned to room 607. Review revealed Patient #2 was a [AGE] year old female admitted on [DATE] with a chief complaint of "chest pain and left arm pain". Review revealed the patient was alert and oriented to person, place and time. Continued review revealed Patient #2 was being treated with steroids, a nicotine patch and DVT prophylaxis. Review of physician orders revealed no order for restraint, no documentation indicating the need for restraint use, and no documentation of patient request for the use of four side rails.

Interview on 07/06/15 at with RN #1 revealed four side rails was considered a restraint and evaluation of the patient as well as a physician order with indication for use was required.

Interview on 07/05/17 at 1630 with AS #1 revealed 4 side rails was considered a restraint and staff were reeducated annually at the skills fair on the definition of restraint, and appropriate use of restraint. Further interview revealed the use of restraint required a physician order and the evaluation for the need for restraint every 24 hours. The interview revealed the policy was not followed.

3. Open Medical Record review for Patient #3 was assigned to room 618. Review revealed Patient #3 was a [AGE] year old female admitted to ICU on 07/02/17 with a chief complaint of "Respiratory failure" after a drug overdose. She was transferred to the 6th floor after extubating and medical stabilization. Patient #3 was awake and cooperative. Continued review revealed Patient #3 was being treated with insulin for diabetes, antibiotics and DVT prophylaxis. Review of physician orders revealed no order for restraint, no documentation indicating the need for restraint use, and no documentation of patient request for the use of four side rails.

Interview on 07/06/15 at 0920 with RN #1 revealed four side rails was considered a restraint and evaluation of the patient as well as a physician order with indication for use was required.

Interview on 07/05/17 at 1630 with AS #1 revealed 4 side rails was considered a restraint and staff were reeducated annually at the skills fair on the definition of restraint, and appropriate use of restraint. Further interview revealed the use of restraint required a physician order and the evaluation for the need for restraint every 24 hours. The interview revealed the policy was not followed.

4. Open Medical Record review for Patient #4 was assigned to room 626. Review revealed Patient #4 was a [AGE] year old male admitted on [DATE] with a chief complaint of "AMS (altered mental status)". Review revealed the patient was alert, oriented to person and followed commands appropriately. Continued review revealed Patient #4 was being treated with antihypertensive and DVT prophylaxis. Review of physician orders revealed no order for restraint, no documentation indicating the need for restraint use, and no documentation of patient request for the use of four side rails.

Interview on 07/06/15 at with RN #1 revealed four side rails was considered a restraint and evaluation of the patient as well as a physician order with indication for use was required.

Interview on 07/05/17 at 1630 with AS #1 revealed 4 side rails was considered a restraint and staff were reeducated annually at the skills fair on the definition of restraint, and appropriate use of restraint. Further interview revealed the use of restraint required a physician order and the evaluation for the need for restraint every 24 hours. The interview revealed the policy was not followed.

5. Open Medical Record review for Patient #5 was assigned to room 608. Review revealed Patient #5 was a [AGE] year old male admitted on [DATE] with a chief complaint of "Abdominal Pain" and a history of recurrent pancreatitis and alcoholism. Review revealed the patient was alert and oriented to person, place and time. Continued review revealed Patient #5 was being treated with analgesics (pain medicine), antiemetic's (anti-nausea), alcohol withdrawal protocol and DVT prophylaxis. Review of physician orders revealed no order for restraint, no documentation indicating the need for restraint use, and no documentation of patient request for the use of four side rails.

Interview on 07/06/15 at 0920 with RN #1 revealed four side rails was considered a restraint and evaluation of the patient as well as a physician order with indication for use was required.

Interview on 07/05/17 at 1630 with AS #1 revealed 4 side rails was considered a restraint and staff were reeducated annually at the skills fair on the definition of restraint, and appropriate use of restraint. Further interview revealed the use of restraint required a physician order and the evaluation for the need for restraint every 24 hours. The interview revealed the policy was not followed.

6. Open Medical Record review for Patient #6 was assigned to room 627. Review revealed Patient #6 was a [AGE] year old female admitted on [DATE] with a chief complaint of "woke up sweating ad had an episode of vomiting. Paramedics called and she was found to be hypoglycemic". Review revealed the patient was oriented to person, place and time. Continued review revealed Patient #6 was being treated with hydration, monitoring glucose levels and DVT prophylaxis. Review of physician orders revealed no order for restraint, no documentation indicating the need for restraint use, and no documentation of patient request for the use of four side rails.

Interview on 07/05/17 at 1500 with Patient #6 revealed she did not request all four side rails to be elevated. Interview revealed the staff "say it is a rule that rails have to be up."

Interview on 07/06/15 at 0930 with RN #1 revealed four side rails was considered a restraint and evaluation of the patient as well as a physician order with indication for use was required.

Interview on 07/05/17 at 1630 with AS #1 revealed 4 side rails was considered a restraint and staff were reeducated annually at the skills fair on the definition of restraint, and appropriate use of restraint. Further interview revealed the use of restraint required a physician order and the evaluation for the need for restraint every 24 hours. The interview revealed the policy was not followed.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, observation and staff interview, the facility staff failed to date and discard outside food brought to the hospital and to monitor and discard expired food products from the patient nourishment room in 1 of 4 nourishment rooms toured. (6 North nourishment room)

The findings include:

Review on 07/06/17 of policy and procedure "Food Brought to the Medical Center for Patients" (reviewed November 31. 2013) revealed, "... Food that is brought into the Medical Center to be stored for the patient must be covered appropriately, labeled with the patient's sticker and dated with the date the food was placed in the refrigerator. The food must be discarded after 3 days. ..."

1. Observation on 07/05/17 at 1330 during tour of the 6th floor revealed two nourishment rooms. Observation of the nourishment room on 6 North revealed a plastic bag containing fried chicken. Observation revealed the plastic bag had a patient label, but, no date indicating when it was placed in the refrigerator. Review of the patient roster during the tour revealed the patient name whom the bag was labeled was discharged .

Interview on 07/05/17 at 1330 with RN #2 (charge nurse) revealed, the Fried chicken belonged to a patient whom was discharged on [DATE]. Interview revealed the chicken had been in the refrigerator at least 26 days. Continued interview revealed the unit secretary was responsible for monitoring the patient nourishment room for food items that needed to be discarded. Further interview revealed the policy was not followed.

2. Observation on 07/05/15 at 1300 during tour of the 6th floor revealed two nourishment rooms. Observation of the nourishment room on 6 North revealed a cabinet under the sink. Observation revealed a flat of twelve (4oz) assorted fruit juices which expired in 2016. Observation revealed expired juice available for patient consumption.

Interview on 07/05/17 at 1330 with RN #2 revealed, the Fried chicken belonged to a patient whom was discharged on [DATE]. Interview revealed the chicken had been in the refrigerator at least 26 days. Continued interview revealed the unit secretary was responsible for monitoring the patient nourishment room for food items that needed to be discarded. Further interview revealed the policy was not followed.

Interview on 07/05/17 at 1400 during unit tour with AS #2 revealed there should not have been anything stored in the cabinet under the sink. Interview revealed maintenance would be contacted to secure the cabinet. Continued interview revealed the juice was expired and should have been discarded.

NC 121