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BAPTIST MEDICAL CENTER 111 DALLAS STREET SAN ANTONIO, TX 78205 Oct. 17, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on record review, interviews and policy review, the hospital failed to ensure patient rights were implemented in accordance with safe and appropriate restraint techniques determined by hospital policy for 1 of 1 patient (Patient #1) reviewed with a patient rights complaint allegation after the implementation of restraints.

Findings Include:

1. Review of a hospital document identified by S#2 as an incident report completed on 06/07/18 indicated that patient #1 had fallen at about 1940 on 06/07/18. Review of the medical record for patient #1 on 10/16/18 beginning at 12:00 p.m. in the conference room revealed the following in part:

2. Review of medical records on 10/16/18 beginning at 12:00 p.m. in the conference room revealed the following in part:

A restraint order form dated 06/07/18 and timed at 2320, indicated that the physician checked the criteria that make restraint necessary on the restraint order as "Interfering with medical interventional devices (e.g. tubes, drains, dressings, endotracheal tube, etc.)."

A non-violent restraint flowsheet dated 06/07/18, timed at 2300 and signed by S#7 indicated that the reason for the restraint was not checked off on the non-violent restraint flowsheet, it was left blank. The section regarding "patient/family education upon application of restraints and understands" was not completed.

The nursing notes on 06/07/18 at 23:27, by S#7 stated in part, "eICU has called back. Regading (sic) the wrist restraints. Dr ...has ordered them. Pt's wife will be staying overnight. Wrist restraints have been applied so that won't get out of the bed ...He is a high fall risk and has attempted before to get out of bed."

The restraint order form dated 06/08/18 and timed at 9:41, indicated that the physician checked the criteria that make restraint necessary on the restraint order as "Interfering with medical interventional devices (e.g. tubes, drains, dressings, endotracheal tube, etc.)."

A non-violent restraint flowsheet dated 06/08/18 and timed at 0800, indicated that the reason for the restraint was checked off as "Interfering with medical interventional devices (e.g. tubes, drains, dressings, endoctracheal tube, etc.)."

The nursing notes by S#7 on 06/08/18 at 07:18, stated in part, "Overnight summary: Pt's wife stayed overnight to watch over Pt. Wrist restraints are still in place as Pt still keeps trying to get out of the bed ..." There was no mention in the medical record of the patient interfering with medical devices.

The date and time that the restraint was discontinued or terminated was not documented. Therefore, the exact date and time that the restraints were removed could not be determined due to lack of nursing documentation.

A care plan for restraints was not found in the medical record and could not be provided by the hospital.

3. In an interview on 10/17/18 at 9:45 a.m. in the conference room, S#7 confirmed the above findings after his own review of the medical records.

In an interview on 10/17/18 at 1:20 p.m. in the conference room, S#1 confirmed the above findings after her own review of the medical records.

4. The hospital policy entitled, "Restraint and Seclusion" with a last review date of "09/16" was reviewed on 10/16/18 at 5:05 p.m. in the conference room and stated the following in part:

"B. Authorization and Ordering of Restraints
1. d. Restraint orders must be dated and timed when signed by physician, and include: 1) criteria for release; 2)type of restraint used; 3) reason for restraint; 4) duration of restraint orders; 5) instructions for monitoring: 6) any special considerations needed to ensure the patient's safety; and 7) who is responsible for implementing the restraint (non-violent restraint orders only)
"C. Documentation
1. a. Significant changes in the patient's condition that warranted restraint use
...
b. Relevant orders for use of restraints ...clinical justification, type of restraint to be used ...
d. Use of restraints must be addressed in the patient's modified plan of care.
e. Disconinuation of restraint at earliest time possible."
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interviews and policy review, the hospital failed to ensure vital signs and neurological assessments were documented in order to monitor the patient's condition.

Findings Include:

1. Review of a hospital document identified by S#2 as an incident report completed on 06/07/18 indicated that patient #1 had fallen at about 1940 on 06/07/18.

2. Review of the medical record on 10/16/18 beginning at 12:00 p.m. in the conference room revealed the following in part:

Vital signs were documented on 06/07/18 at 20:00, 21:00 and 22:00 after patient #1 fell on [DATE] at about 1940 but were not documented including a blood pressure as having been taken every 30 minutes x 1 hour which would have been at 21:30 on 06/07/18 according to hospital policy.

Neurological assessments for patient #1 indicated that neurological assessments were not documented after the patient's fall at about 1740 on 06/07/18 until 06/08/18 at 00:00 and 00:25 and should have been documented at about 20:00 when vital signs were taken. In addition, neurological assessments were not documented every 30 minutes x 2, and every 1 hour x 2 according to hospital policy.

3. In an interview on 10/17/18 at 9:45 a.m. in the conference room, S#7 confirmed the above findings after his own review of the medical records.

In an interview on 10/17/18 at 1:24 p.m. in the conference room, S#1 confirmed the above findings after her own review of the medical records.

4. The hospital policy entitled, "Falls Prevention and Resources," with a last review date of "06/18" was reviewed on 10/16/18 at 4:50 p.m. and stated the following in part:

I. Post-Fall Management
5. Obtain vital signs, a physical assessment and neuro checks after every fall according to the following sequence:
a. Every 15 minutes x 4; every 30 min x2, every 1 hour x2; every 2 hours x2 then every 4 hours x 48 hours.