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UPMC ALTOONA 620 HOWARD AVENUE ALTOONA, PA 16601 Aug. 22, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on a review of facility documents and staff interview (EMP) it was determined that the facility failed to ensure that physician orders were obtained for the use of restraints in 2 of 2 records (MR14 & MR15).

Findings include:

UPMC Policy and Procedure Manual Policy: Hs-NA0416. Index title: Nursing Subject: Restraint and Seclusion. Date: February 29, 2016. "I. Policy It is the policy of UPMC to create an environment that minimizes circumstances that give rise to the application of restraint and use of seclusion for patients and maximizes safety when utilization is necessary. Restraints or Seclusion is not used as a disciplinary measure, a means of coercion, a substitute for patient care, or as a convenience for the staff. ... VIII. Use of Restraint for Non Violent/Non Self-Destructive Behavior (previously identified as "Medical Management") A. Order (written/Computerized Provider Order Entry OR "CPOE") A physican order, order of a CRNP or a PA is required for restraint use. 1. The order will include: a. Type of restraint (if mechanical restraint or drug, dose, route, and frequency for chemical restraint) b. Reason for the use or continuation c. Date and time of order ... 3. Standing or PRN (as needed) Orders for any Restraint are not accepted. 4. Orders for use of restraint for non-violent -destructive patients are renewed every calendar day. Restraint reorders are preferentially obtained during a face to face examination of the patient by the physician although a verbal or telephone order is acceptable ... ."

1. MR15 revealed that restraints were initiated on August 18, and were discontinued on August 21, 2017. MR15 failed to include documented evidence of a physican order for restraint use on August 20, 2017.

2. MR14 revealed that restraints were on August 15, and were removed on August 16, 2017. The restraints were reapplied on August 16, 2017, at 8:00 PM. MR14 failed to include documented evidence of a physician order for restraint use on August 20, 2017, and failed to include a new physician restraint order when restraints were reapplied on August 16, 2017 at 8:00 PM.


3. An interview was conducted with EMP2, On August 22, 2017, at approximately 11:30 AM. EMP4 confirmed the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on a review of facility documents and staff interview (EMP), it was determined that the facility failed to discontinue restraint use at the earliest possible time in 2 of 2 medical records in which the patients were restrained. (MR14 & MR15)

Findings include:

UPMC Policy and Procedure Manual Policy: Hs-NA0416. Index title: Nursing Subject: Restraint and Seclusion. Date: February 29, 2016. "... VIII. Use of Restraint for Non Violent/Non Self-Destructive Behavior (previously identified as "Medical Management") ... 2. Restraint use is to be discontinued at the earliest possible time, based on individualized assessment that the individual needs can be addressed using less restrictive methods, regardless of the length of time identified in the order ... D. Ongoing Patient Assessment and Care Interventions 1. Patient's need for toileting, food and nutrition, hygiene, personal and medical care including mental and neurological status will be met while in restraint ... 4. The continued need for the use of restraint for Non- Violent/Non Self-Destructive behavior will be addressed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. Non Violent/Non Self-Destructive behavior - every 2 hours. 5. a. Release of restraint b. Color, sensation and movement of the involved extremity(ies) c. Skin integrity. signs of injury d. Readiness for restraint discontinuation based on observed behaviors e. Alternatives provided tot he patient E. Discontinuation of Restraint 1. The RN or physician, CRNP, or PA may discontinue the restraint if the criteria for discontinuation have been met. 2. The time and criteria for release will be documented when the restraint is removed ... ."

1. MR15 failed to include documented evidence of the 2 hour nursing assessments to evaluate the need for continued restraint use from August 19 at 10:00 PM to August 20 at 2:00 PM. It was noted that the Nursing Flow Sheets for August 18 - 21, 2017, indicate that the patient is calm, cooperative and sedated.


2. An interview was conducted with EMP2 on August 22, 2017 at approximately 1:00 PM. "There is no documentation of the 2 hour nursing assessments for 14 hours on this medical record (MR15)."


3. MR14 failed to include documented evidence of the 2 hour nursing assessments to evaluate the need for continued restraint use from August 17 at 2:00 AM to August 20 at 2:00 AM, & 2:00 PM, and again on August 19, 2017 at 10:00 PM until August 20, 2017 at 12:00 PM.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on a review of facility documents and staff interviews (EMP) it was determined that UPMC Altoona failed to follow their established policies and procedures for the administration of Propofol in 3 of 3 medical records reviewed (MR1, MR13 & MR15).

Findings include:


UPMC Altoona Standard of Practice, S 19. Subject: Sedation in the Adult ICU Patients on Mechanical Ventilation. Purpose: To outline the management of sedation and analgesia in adult patients cared for in critical care units. To standardize assessments of need and appropriate utilization of agents in sedation and analgesia ... Follow the qualified physician's orders ... Titrate in increments of 5 mcg/kg/min every 15 minutes, most patients can be maintained at 5 mcg/kg/min to 50 mcg/kg/min ... A standardized assessment tool (Riker SAS Scale) should be used to state the goal of sedation and used for routine assessment and documentation of sedation. Assess for over-sedation prior to administration of any scheduled dose of sedative. Reassess need for continuous sedation and/or analgesia daily. Nursing Assessment During Infusion: 1. Neuro assessment q 1 hour. 2. Vital signs q 30 minutes X 3 hours, then q 1 hour, if stable ... 4. Monitor SAO2 continuously with documentation q 1 hour ... Documentation of Riker SAS Scale on Cerner Critical Care Flow Sheet q 2 hours. 8. Use Riker SAS Scale to determine sedation level: 7- Dangerous Agitation = Behaviors that could harm self/others. 6- Very Paginated = Agitated despite verbal reminder/biting ETT. 5-Agitated = Anxious/mildly agitated/calms to verbal reminder. 4- Calm/cooperative = Calm/easily arousable/follows commands. 3-Sedated = Difficult to arouse but awakens to verbal stimuli. 2- Very Sedated = Arouses/moves but does not follow commands. 1- Unarousable = Minimal/no response to noxious stimuli ... ."



1. MR1 revealed a physician order dated July 17, 2016 at 1:17 PM, for Propofol 1000 mg/100 ml Premix ... Titrate to Riker 3-4. Sedation was discontinued on July 25, 2017, at 9:28 AM. It was noted that the Riker SAS score was documented as being outside of the physician ordered titration range 36 times.

2. MR13 revealed a physician order dated August 18, 2017, at 8:38 AM, for Propofol 1000 mg/100 ml ... titrate to Riker 4. Sedation ws discontinued on August 21, 2017 at 8:00 AM. It was noted that the Riker SAS score was documented as being outside of the physician ordered titration range 30 times, additionally there were 9 times that there was no documentation of a Riker SAS Score.

3. MR15 revealed a physician order dated August 18, 2017 at 12:33 AM, for Propofol to maintain a Riker SAS Score of 3. Sedation continued as of August 22, 2017. It was noted that the Riker SAS score was documented as being outside of the physician ordered titration range 36 times.

4. An interview conducted with EMP2 & EMP3 on August 22, 2017, at approximately 10:30 AM, confirmed the above findings.