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.

WEST VIRGINIA UNIVERSITY HOSPITALS 1 MEDICAL CENTER DRIVE MORGANTOWN, WV 26506 June 2, 2011
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff makes a written modification to the plan of care when applying restraints to patients in ten (10) of ten (10) medical records (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) reviewed. This has the potential to negatively impact all restrained patients' care by not modifying interventions and assessments to meet their needs. Findings include:

1. Review of the medical record for Patient #1 revealed the patient was placed in a Posey vest restraint in the morning of 5/1/11, then bilateral soft wrist restraints then progressed to four (4) point vinyl restraints by 1250 the same day, then the restraints were discontinued on 5/2/11, all without a written modification to the plan of care.

2. Review of the medical record for Patient #2 revealed the patient was placed in four (4) point vinyl restraints on 4/7/11 at 0405 and discontinued at 0500 without a written modification to the plan of care.

3. Review of the medical record for Patient #3 revealed the patient was placed bilateral soft wrist restraints on 4/4/11 and discontinued 4/7/11 without a written modification to the plan of care.

4. Review of the medical record for Patient #4 revealed the patient was placed in four (4) point vinyl restraints on 5/25/11 at 0133 and discontinued at 0738 without a written modification to the plan of care.

5. Review of the medical record for Patient #5 revealed the patient was placed in four (4) point vinyl restraints on 4/8/11 and discontinued on 4/9/11 without a written modification to the plan of care.

6. Review of the medical record for Patient #6 revealed the patient was placed in bilateral soft wrist restraints on 4/10/11 and discontinued on 4/16/11 without a written modification to the plan of care.

7. Review of the medical record for Patient #7 revealed the patient was placed in a Posey vest restraint and bilateral soft wrist restraints on 3/15/11 and discontinued on 3/19/11 without a written modification to the plan of care.

8. Review of the medical record for Patient #8 revealed the patient was placed in four (4) point soft restraints and also four (4) side rails up on 3/10/11 at 0000 and continued with various types of restraints until restraints were discontinued 3/16/11 at 0800, all without a written modification to the plan of care.

9. Review of the medical record for Patient #9 revealed the patient was placed in bilateral soft wrist restraints 3/24/11 at 0000, changed to a Posey vest restraint 3/25/11 at 2300, then placed in four (4) point soft restraints along with the Posey vest restraint 3/26/11 at 0145 and remained in various restraints until discontinued 3/30/11 at 0830, all without a written modification to the plan of care.

10. Review of the medical record for Patient #10 revealed the patient was placed in a soft right wrist restraint 4/7/11 at 2000 and discontinued 4/11/11 at 0830 without a written modification to the plan of care.

11. During an interview with the Nurse Manager (NM) of 7-East in the afternoon of 6/2/11, the medical records were reviewed and the NM agreed with the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff obtains physician orders for restraints for patients in nine (9) of ten (10) medical records (Patient #1, 3, 4, 5, 6, 7, 8, 9, 10) reviewed. This has the potential to negatively impact all patient care by patients not being appropriately assessed for restraints by physicians. Findings include:

1. West Virginia University Hospitals (WVUH) policy, Use of Medical-Surgical Restraints, last revised 10/31/08, states in part "...A time-limited order for restraint is initiated on the order of a LIP (licensed independent practitioner)...If the LIP is not available to issue such an order, restraint use may be initiated by an RN (registered nurse) based on an appropriate assessment of the patient. The LIP must be notified within 12 hours of the initiation of the restraint and a written/CHIP'ed order is entered into the patient's record...The order must identify the type of restraint...All restraint orders must be renewed every 24 hours if restraint continues to be warranted..."

2. WVUH policy, Use of Behavioral Health Restraints, last revised 12/30/10, states in part "...A time-limited order for seclusion or restraint is initiated on the order of a physician. If the physician is not available to issue an order, emergency seclusion or restraint may be initiated by a qualified RN based on an appropriate assessment of the patient. The physician must be notified as soon as possible following the initiation of the seclusion or restraint and a verbal or written order must be entered into the patient's record at that time, but not to exceed one hour from the initiation of the restraint or seclusion..."

3. Review of the medical record for Patient #1 revealed the patient was placed in a Posey vest restraint on 5/1/11 at 0442, however the order for the vest restraint was not obtained until two (2) hours later at 0640 with the physician not authenticating the order until 0754. The patient was then placed in four (4) point vinyl restraints at 1250 that same day with the order not being entered until 1947 that evening and the physician did not authenticate the order until 5/2/11 at 0647. There is documentation in the nursing notes of the physician changing the patient from four (4) point vinyl restraints to four (4) point soft restraints at 2130 on 5/1/11, however, the last order entered for restraints on 5/1/11 does not indicate what type of restraints or how many to be used. That order was also not authenticated by the physician until 5/2/11 at 0647.

4. Review of the medical record for Patient #3 revealed the patient was placed in bilateral soft wrist restraints on 4/4/11 at 0230 and removed for a "trial release" on 4/6/11 at 1800. The patient was placed back in the restraints on 4/7/11 at 0430 with no documented evidence of a physician's order.

5. Review of the medical record for Patient #4 revealed the patient was placed in four (4) point vinyl restraints on 5/25/11 at 0200 and the order was entered by the RN as a verbal order "Per Protocol" at 0656.

6. Review of the medical record for Patient #5 revealed the patient was placed in four (4) point vinyl restraints on 4/8/11 at 2335 with no re-order until 4/9/11 at 1005.

7. Review of the medical record for Patient #6 revealed the patient was placed in bilateral soft wrist restraints on 4/10/11 at 0000 with the most recent order for restraints entered 4/9/11 at 1137 "Per Protocol." The next order entered was a telephone order for restraints on 4/10/11 at 0401 but did not specify what type of restraint to be used and was not authenticated by the physician until 4/12/11 at 1122. The restraints were discontinued 4/10/11 at 0800 then re-started 4/11/11 at 0200 with no documented evidence of a physician's order until 4/12/11 at 1349. The patient remained in bilateral soft wrist restraints until 4/13/11 at 1600. The restraints were re-started 4/15/11 at 0000 and discontinued 4/16/11 at 1600. Restraint orders were entered for 4/13/11 at 1019 with the ordering mode as "Written" with no physician authentication. A restraint order was entered, by the physician, on 4/14/11 at 2322, however the patient was not in restraints. A restraint order was entered, by the physician, on 4/15/11 at 2342 but did not specify what type of restraint was to be used.

8. Review of the medical record for Patient #7 revealed the patient was placed in bilateral soft wrist restraints and a Posey vest restraint on 3/15/11 at 0000, however, the order was not obtained and entered until 0259 and did not specify what type of restraint was to be used. The restraint orders entered on 3/16/11, 3/17/11 and 3/19/11 did not specify what type of restraint was to be used.

9. Review of the medical record for Patient #8 revealed the patient was placed in four (4) point soft restraints and four (4) side rails on 3/10/11 at 0000 with no evidence of an order. The restraints were removed at 1600 for a "trial release" and re-started at 2000 with no documented evidence of a physician's order. An order for restraints was entered 3/11/11 at 0740 but does not specify what type of restraint was to be used. The restraints continued until 3/11/11 at 1600 and were removed again for a "trial release" then re-started at 1700. There is no evidence of an order for this restart. The restraints continued until 3/12/11 at 1400 when only the bilateral ankle restraints were removed; the four (4) side rails and bilateral wrist restraints remained intact. At 1800 the right ankle restraint was reapplied with still no evidence of an order. On 3/13/11 at 0000 both ankle restraints were documented as being discontinued. Then at 0400 the soft left ankle restraint was reapplied with no evidence of a physician's order. The patient remained in bilateral soft wrist restraints, soft left ankle restraint and four (4) side rails until 3/14/11 at 0900. Then at 1900 that evening the patient was placed in a Posey vest restraint. There is a physician's order for restraint entered at 2013, however it does not specify what type of restraint is to be used. The patient remained in the Posey vest restraint until it was discontinued 3/16/11 at 0800. There was no evidence of an order for restraints for 3/15/11. The physician's order for restraint entered 3/16/11 at 0441 did not specify what type of restraint was to be used.

10. Review of the medical record for Patient #9 revealed the patient was placed in bilateral soft wrist restraints 3/24/11 at 0000 and continued until 2000, however there is no evidence of a physician's order for restraints. The patient was placed in a Posey vest restraint 3/25/11 at 2300 with no evidence of a physician's order. On 3/26/11 at 0100, bilateral soft ankle restraints were added. The physician's order was obtained at 0008, however it did not specify what type of restraint was to be used. At 0145 the patient was placed in four (4) point soft restraints as well as the vest restraint. These continued until 3/27/11 at 0000 when the bilateral ankle restraints were removed. The next order for restraints was entered 3/27/11 at 0204 but did not specify what type of restraint was to be used. The patient remained in bilateral soft wrist restraints and the vest restraint until 1230 that afternoon when all three (3) were discontinued. On 3/29/11 at 0500, the bilateral soft wrist restraints were re-started and a physician's order was entered, however, the order did not specify what type of restraint was to be used. The patient remained in the bilateral soft wrist restraints until they were discontinued 3/30/11 at 0830.

11. Review of the medical record for Patient #10 revealed the patient was placed in a soft right wrist restraint 4/7/11 at 2000, however the physician's order was entered by the physician at 1306 for a personal restraint (physical hold). The patient remained in the right wrist restraint until 4/9/11 at 1600 when removed for a "trial release" then reapplied at 1950. There is no evidence of a physician's order for the reapplication of the restraint. The patient remained in the right wrist restraint until 4/10/11 at 0800 when it again was removed for a "trial release" and the restraint remained off and was reapplied at 2040. A physician's order for restraint was entered at 2145 by the RN as a telephone order for a personal restraint (physical hold). The restraint was documented as being discontinued 4/11/11 at 0830.

12. During an interview with the Nurse Manager (NM) of 7-East in the afternoon of 6/2/11, the medical records were reviewed and the NM agreed with the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on medical record review and staff interview, the hospital failed to ensure the nursing staff obtains appropriate restraint orders in five (5) of ten (10) medical records (Patient #3, 4, 6, 8, 10) reviewed. This has the potential to negatively impact all restrained patients' care by the physicians not having knowledge of restraint use. Findings include:

1. Review of the medical record for Patient #3 revealed the patient was placed in bilateral soft wrist restraints on 4/4/11 at 0230 and removed for a "trial release" on 4/6/11 at 1800. The patient was placed back in the restraints on 4/7/11 at 0430 with no documented evidence of a physician's order.

2. Review of the medical record for Patient #4 revealed the patient was placed in four (4) point vinyl restraints on 5/25/11 at 0200 and the order was entered by the RN as a verbal order "Per Protocol" at 0656.

3. Review of the medical record for Patient #6 revealed the patient was placed in bilateral soft wrist restraints on 4/10/11 at 0000 with the most recent order for restraints entered 4/9/11 at 1137 "Per Protocol."

4. Review of the medical record for Patient #8 revealed documented evidence the patient was placed in four (4) point soft restraints and four (4) side rails on 3/10/11 at 0000 with no evidence of an order. The restraints were removed at 1600 for a "trial release" and re-started at 2000 with no documented evidence of a physician's order. The restraints continued until 3/11/11 at 1600 and were removed again for a "trial release" then re-started at 1700. There is no evidence of an order for this restart.

5. Review of the medical record for Patient #10 revealed the patient was placed in a soft right wrist restraint 4/7/11 at 2000. The patient remained in the right wrist restraint until 4/9/11 at 1600 when removed for a "trial release" then reapplied at 1950. There is no evidence of a physician's order for the reapplication of the restraint.

6. During an interview with the Nurse Manager (NM) of 7-East in the afternoon of 6/2/11, the medical records were reviewed an the NM agreed with the above findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff develops a nursing care plan for patients during hospitalization in ten (10) of ten (10) medical records (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) reviewed. This has the potential to negatively impact all patient care by not identifying patient care needs and modifying nursing interventions to meet those needs. Findings include:

1. West Virginia University Hospitals (WVUH) policy, Plan of Care (Initiation), last revised 1, 2008, states in part "...Biophysical assessments and routine patient care are documented on the daily patient care record..."

2. Review of the medical record for Patient #1 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

3. Review of the medical record for Patient #2 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

4. Review of the medical record for Patient #3 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

5. Review of the medical record for Patient #4 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

6. Review of the medical record for Patient #5 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

7. Review of the medical record for Patient #6 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

8. Review of the medical record for Patient #7 revealed the patient was admitted [DATE]. There was no nursing care plan documented in the medical record.

9. Review of the medical record for Patient #8 revealed the patient was admitted on [DATE]. There was no nursing care plan documented in the medical record.

10. Review of the medical record for Patient #9 revealed the patient was admitted on [DATE]. There was no nursing care plan documented in the medical record.

11. Review of the medical record for Patient #10 revealed the patient was admitted on [DATE]. There was no nursing care plan documented in the medical record.

12. During an interview with the Nurse Manager (NM) of 7-East in the afternoon of 6/2/11 the above medical records were reviewed and the NM agreed with the above findings. The NM explained the nursing care plans are verbal and there are "dry erase boards" in each patient room. The nurse writes patient goals for the day or night shift on the "dry erase board" and it is changed daily.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review and staff interview, the hospital failed to ensure the nursing staff makes a written modification to the plan of care when applying restraints to patients. Cross refer to Tag A-0166.

The hospital failed to ensure the nursing staff obtains physician orders for restraints for patients. Cross refer to Tag A-0168.

The hospital failed to ensure the nursing staff obtains appropriate restraint orders. Cross refer to Tag A-0169.

The hospital failed to ensure the nursing staff follows hospital policy when assessing patients in various types of restraints. Cross refer to Tag A-0175.

The hospital failed to ensure all members of the Medical Staff have a working knowledge regarding restraints and hospital policies. Cross refer to Tag A-0176.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on document review, medical record review and staff interview, the hospital failed to ensure the nursing staff follows hospital policy when assessing patients in various types of restraints in seven (7) of ten (10) medical records (Patient #1, 2, 4, 5, 7, 8, 9) reviewed. This has the potential to negatively impact all restrained patients' care by not ensuring patient safety and also discontinuing restraint use at the earliest possible time. Findings include:

1. West Virginia University Hospitals (WVUH) policy, Use of Medical-Surgical Restraints, last revised 10/31/08, states in part "...Evaluation of whether restraints can be discontinued should be an ongoing process...Patients need to be released from their restraints every two (2) hours and documentation of this release must occur along with CMS checks. Assessment of the patient in restraints must include proper application of the restraints; attempts to eliminate restraints; and the alternatives that were tried to manage the behavior. The restrained patient's assessment must be documented at a minimum of every two (2) hours..."

2. WVUH policy, Use of Behavioral Health Restraints, last revised 12/30/10, states in part "...Documentation must include time of initiation, type of restraint device and location of restraint device. Assessment of the patient in seclusion or restraint must include: ...The patient's functional status must be reassessed every 15 minutes and the assessment will include (as appropriate to the type of restraint or seclusion)..."

3. Review of the medical record for Patient #1 revealed the patient was placed in four (4) point vinyl behavioral restraints 5/1/11 at 1250. The restraints were changed to four (4) point soft restraints at 1900, however the reasoning for the restraints remained the same as for the vinyl restraints. Documentation revealed nursing began documenting the restraint flowsheet every two (2) hours (Q2H) instead of continuing the every fifteen (15) minute (q15min) checks.

2. Review of the medical record for Patient #2 revealed the patient was placed in four (4) point vinyl behavioral restraints 4/7/11 at 0405 and the restraints were discontinued at 0500. Nursing documentation of the restraint flowsheet was only at 0400 and 0500.

3. Review of the medical record for Patient #4 revealed the patient was placed in four (4) point vinyl restraints due to aggressive behavior. Nursing documentation of the restraint flowsheet revealed Q2H documentation.

4. Review of the medical record for Patient #5 revealed the patient was placed in four (4) point vinyl behavioral restraints 4/8/11 at 2350. Nursing documentation of the restraint flowsheet revealed documentation once on night shift at 2335, then not again until 4/9/11 at 0755.

5. Review of the medical record for Patient #7 revealed the patient was placed in bilateral soft wrist restraints and a Posey vest restraint on 3/15/11 at 0000. Nursing documentation of the restraint flowsheet revealed no evidence of documentation on 3/15/11 from 0400 through 2000 and again from 3/18/11 at 0600 through 3/19/11 at 0000.

6. Review of the medical record for Patient #8 revealed documented evidence the patient was placed in four (4) point soft restraints and four (4) side rails on 3/10/11 at 0000. Nursing documentation of the restraint flowsheet revealed documenting Q2H instead of the required q15min throughout the day on 3/10/11.

7. Review of the medical record for Patient #9 revealed documented evidence the patient was placed in four (4) point soft restraints and a Posey vest restraint 3/26/11 at 0145 due to being agitated, restless, confused. Nursing documentation of the restraint flowsheet revealed documenting every 1.5 hours until 0800 then Q2H.

8. During an interview with the Nurse Manager (NM) of 7-East in the afternoon of 6/2/11, the medical records were reviewed an the NM agreed with the above findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on document review and staff interview the hospital failed to ensure all members of the Medical Staff have a working knowledge regarding restraints and hospital policies. This has the potential to negatively impact patient care by patients being placed in the wrong type of restraint, not being appropriately monitored and being injured. Findings include:

1. Review of the Medical Staff Bylaws, Rules & Regulations revealed nothing regarding the training of physicians or Licensed Independent Practitioners (LIPs) in the use or ordering of restraints.

2. Review of the Restraint Education Program revealed no participation by physicians or LIPs.

3. During an interview with the Risk Manager (RM) in the morning of 6/2/11, the RM stated (per the Manager of Medical Staff Affairs) there is no formal training program for physicians and LIPs regarding restraints.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review, it was determined the hospital's QA/PI Program failed to appropriately monitor the effectiveness and safety of restraint usage in one (1) of its units, 7 East (a thirty-four (34) bed unit). This has the potential to adversely affect the safety of those patients who are being restrained.
Findings include:

1. A review of the "Performance Improvement Minutes" for April 2011 revealed restraints are being discussed. Review of "Restraint Compliance Totals" for April and May 2011 revealed more specific restraint data is being collected for Unit 7 East.

2. However, as evidenced by deficiencies cited at A0166, A0168, A0169, A0175 and A0176, the hospital's QA/PI Program is not capturing areas of deficient practice relative to restraints via the monitoring process.