HospitalInspections.org

Based on review of medical records and interview, the facility failed to provide a safe setting when a patient who needed assistance with bathing was not offered or given a bath in spans of 5 to 11 days.

Findings included:

Review of the medical record for patient #1 revealed patient #1 was admitted on 4/28/17 at 3:30 pm. Patient #1 did not receive a bed bath or shower until 5/6/17, which is eight days in between. The gaps in time for documented showers or bed baths were as follows:
May 13 to 20, eight days in between
May 23 to June 3, 11 days in between
June 3 to June 8, five days in between
June 17 to June 22 (patient refused), five days in between
June 24 to July 1, seven days in between
July 1 to July 6 (patient refused), five days in between
July 8 to July 13, five days in between
July 13 to July 24, 11 days in between
July 28 to August 2, five days in between

The above was confirmed in an interview with staff #1 on the afternoon of 9/19/17.

Based on review of medical records and interview, the facility failed to ensure restraints were in accordance with the order of a physician.

Findings included:

Facility policy titled "Nursing services policy on non-violent, non-self-destructive behavior restraint" stated in part,
" ...9. When clinically indicated, the nurse who is trained in safety devices and upon a physician's/LIP's [licensed independent practitioner] order implements the medical safety device."

Review of patient #1's medical record revealed patient #1 was in and out of "Rear Fastening Seat Belt" and "Side Rails X 4 [times four]" restraints. There was documentation patient #1 was in restraints on the following days without physician orders:
*4/29/17
*7/22/17
*7/29/17
*8/27/17
*8/28/17

The above was confirmed in an interview with staff #1 on the afternoon of 9/19/17.

Based on review of documents, review of medical records and interview, the facility failed to ensure the condition of the patient who is restrained was monitored at intervals determined by hospital policy.

Findings included:

Facility policy titled "Nursing services policy on non-violent, non-self-destructive behavior restraint" stated in part,
" ...17. For each patient, documentation of all assessments will be reflected in the appropriate format in the patient record. The purpose of the entry is to provide clinical justification for use and to document clinical oversight. Such documentation includes:
A. Relevant orders for use (Restrain & Restraint Alternatives Documentation Record).
B. The patient's behavior necessitating use.
C. Results of patient monitoring.
D. Assessment, reassessment, and modification of the plan of care.
E. Significant changes in the patient's condition.
18. Complete documentation of required assessment will be done every 2 hours."

Facility document titled "Restraint and restraint alternative documentation record" stated in part, "Reassessment/monitoring time
1. Perform visual checks q 30 min to 1 hr and prn (initial) [every 30 minutes to 1 hours and as needed]
2. Type of restraint is least restrictive and appropriate. Check q 2 hr & prn
3. Distal pulses, skin temp, color sensation, edema. Check q2 hr & prn
4. Restraints applied correctly, no signs of bruise or abrasion. Check q2 hr and prn
5. Assist/perform ROM [range of motion] and reposition. Check q2hr and prn
6. Fluids/nutrition needs met. Check q2hr and prn
7. Hygiene/elimination needs met (oral care, foley, BR [bathroom]). Check q2 hr & prn
8. Physical, psychological comfort status. Check q2hr & prn"


Review of patient #1's medical record revealed patient #1 was in and out of "Rear Fastening Seat Belt" and "Side Rails X 4 [times four]" restraints. There were physician orders for the restraint but no documentation of monitoring on the following days:
*5/1/17
*5/2/17
*7/23/17
*7/24/17
*8/11/17
The above was verified in an interview with staff #1 on the afternoon of 9/19/17.