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Based on medical record review, staff interview, and facility policy review, it was determined the facility failed to ensure patients' right to a safe environment related to the use of restraints. The facility failed to ensure staff performed the restraint assessment as required by facility policy and failed to ensure staff did not use an order for restraints as a prn or as needed order for restraints. (A115) The cumulative effect of this systemic practice resulted in the facility's inability to ensure patients' right to a safe environment.

Based on medical record review, policy review, and staff interview, the facility failed to ensure nursing staff followed facility policy for enteral tube feedings related to failure to document tube feeding intakes every 8 hours, failure to administer a j-tube water bolus ordered by a physician and failure to ensure staff first attempted to forcefully flush the j-tube when noted to be occluded. (A395) The cumulative effect of this systemic practice resulted in the facility's inability to ensure the patients' nursing needs were met.

Based on medical record review, policy review, and staff interview, the facility failed to ensure staff followed the current facility policy related to the use of restraints. This affected one patient of 10 records reviewed. (Patient #2)


Findings include:

The medical record of Patient #2 was reviewed on 03/15/16. Review of a Nursing Note on 01/16/16 revealed the patient was picking and pulling at medical equipment. The patient's trach collar was found lying in the bed next to the patient. The collar was reapplied. The patient was also noted to be pulling at the telemetry wires. Bilateral mitts were placed on the patient to protect the patient. The facility policy for restraints revealed the mitts were not considered a restraint and did not require a physician's order.
Nursing Notes on 01/18/16 revealed the patient was again found to be picking at medical devices, having bitten a hole through the bilateral mitts. Restraints non-violent or non-self destructive were placed on the patient's left upper wrist, right ankle, and waist in the form of a lockbelt. A physician's order was noted on 01/18/16 at 08:43 PM as required by facility policy. Daily orders for restraints were also noted on 01/19/16, 01/20/16, 01/21/16, 01/24/16, and 01/26/16.
The facility policy for restraints was reviewed on 03/17/16 at 2:15 PM. If restraints are discontinued prior to the expiration of the original order, a new order must be obtained with the re-application of restraints. The policy also revealed that a nursing focus note should be written every shift. At a minimum the patient should be observed and assessed every 2 hours and results should be documented.
The Restraint Flowsheet noted no restraint assessment on 01/20/16 at 12:00 PM or at 2:00 PM. The restraint assessment resumed at 4:00 PM and 6:00 PM on 01/20/16 however, there were no assessments at 8:00 PM, 10:00 PM, 12:00 AM, or 2:00 AM. The medical record noted the restraint assessment at 4:00 AM and 6:00 AM. There were no restraint assessments again on 01/21/16, 01/22/16, or 01/23/16. The assessment documented at 6:00 AM on 01/21/16 revealed the criteria for the discontinuation of the restraints had not been met. There was no order to discontinue the restraints and there was no focus note to reveal the status of the restraints. Staff C confirmed that it was not clear as to whether the restraints were on or not. The restraint assessments resumed on 01/24/16 at 03:30 AM. The medical record revealed there was a "trial off" period at 12:00 PM on 01/24/16. This trial off period continued every 2 hours on 01/24/16. It was confirmed with Staff C that a "trial off" period is similar to "as needed" restraints which is not permitted according to facility policy.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the current policy regarding documenting tube feeding intake was followed and failed to ensure staff followed the policy related to trouble shooting enteral tube feedings. This affected one patient of 10 patient records reviewed. (Patient #2)

Findings include:

The medical record of Patient #2 was reviewed on 03/15/16. The patient was admitted to the facility on 01/14/16 at 3:10 PM. The patient was noted to weigh 140 pounds. The patient was noted to weigh 189 pounds prior to his/her surgery. The physician ordered a continuous tube feeding via the patient's jejunostomy tube (j-tube) to infuse at 62 mL per hour and 50 mL water boluses every 2 hours. The start time of this order was 01/14/16 at 6:35 PM.

The facility policy titled Standards of Care (#102011-001) was reviewed on 03/17/18 at 4:00 PM. According to the policy nursing staff are instructed to total and document intake and output every 8 hours. Staff C, facility educator, was interviewed on 03/17/16 at 4:15 PM. According to Staff C nurses are instructed to document intake and output at 6:00 AM, 02:00 PM, and 10:00 PM. Staff C explained that it is not a requirement to document at those times but nurses are encouraged to document at those times.

The facility policy titled Enteral Nutrition (#20071116800250) was also reviewed on 03/17/16 at 05:00 PM. According to the policy initial weight should be obtained on admission. Subsequent weights and their intervals are determined by an order. The policy also instructs staff to administer feeding at the ordered rate. Program pump to deliver formula and water at prescribed rates. Under the heading, Troubleshooting enteral tube feedings, staff are instructed to first try flushing an occluded tube with water forcefully.

On 01/14/16 at 10:00 PM the tube feeding pump was cleared of 195 mL. A water bolus of 75 mL was also noted. There was no intake and output noted 8 hours later, at 6:00 AM on 01/15/16 but more than 16 hours later, at 2:40 PM, it was noted the continuous tube feeding was infusing at 62 mL per hour. There was no tube feed intake documented at this time. On 01/15/16 at 10:17 PM the pump was cleared of 728 mL. There was also a water bolus of 376 mL documented. In almost 24 hours, only 728 mL was cleared from the pump. The record lacked evidence if the 376 mL water bolus was given at one time or as an accumulation of 50 mL water boluses every 2 hours for the last 24 hours. It was confirmed with Staff B that the 728 mL should have been approximately 1488 mL (62 x 24). The next intake was documented on 01/16/16 at 02:00 AM. The pump was cleared of 154 mL and there was a 75 mL water bolus. The intake and output documentation at 9:21 AM revealed only that the tube feeding was infusing at 62 mL per hour and that there was a 50 mL water bolus given. It was confirmed with Staff C that the 50 mL water bolus was not given as ordered. The tube feeding pump was cleared of 681 mL at 6:00 PM. The tube feed intake was not documented every 8 hours as ordered.

Further review revealed after 15 hours of the continuous tube feed infusing at 62 mL per hour, only 681 mL was cleared as 62 x 15 equals 930 ml. The 50 mL water bolus was also noted at 6:00 PM on 01/16/16 but the water bolus, ordered every 2 hours, was not documented again until 9:00 AM on 01/17/16. The continuous tube feeding wasn't documented again until 1:15 PM on 01/17/16, more than 17 hours after the last time the tube feeding intake was documented. And after 17 hours, 620 mL was cleared from the pump. It was confirmed with Staff C that if the pump was infusing at 62 mL per hour for 17 hours, approximately 1054 mL should have been cleared from the pump. The pump infusing the patient's tube feeding was cleared again on 01/18/16 at 12:26 AM, approximately 9 hours from the last time it was cleared but only 137 mL (9 x 62 = 558)was documented as intake. The 50 mL water bolus was documented at 4:00 PM on 01/17/16 but not documented as given at 6:00 PM, 8:00 PM, or 10:00 PM. The water bolus was given at 12:26 AM on 01/18/16. It was confirmed with Staff C that neither the water bolus nor the tube feeding were given as ordered. On 01/18/16 at 12:26 AM, 5:34 AM, and 6:44 AM, the tube feeding was noted to be infusing at 60 mL per hour instead of the ordered 62 mL per hour. The tube feeding intake was documented next at 5:34 AM on 01/18/16. The pump was cleared of 326 mL. There was a 50 mL water bolus given at this time as well. The medical record lacked documentation the 2:00 AM water bolus was given. The tube feeding was documented approximately 1 hour later, at 6:44 AM. The intake indicated 63 mL was cleared from the pump. The water bolus, ordered every 2 hours, was given at this time. The intake from the tube feeding wasn't documented again until 1:20 AM on 01/19/16. It was confirmed with Staff C that more than 18 hours elapsed before nurses documented the tube feeding. It was further confirmed that when the tube feeding intake was documented at 1:20 AM, the pump was cleared of 683 mL. The water bolus of 50 mL every two hours was not documented as given at 8:44 AM, 10:44 AM, 12:44 PM, 2:44 PM, 4:44 PM, 6:44 PM, 8:44 PM, 10:44 PM, or 12:44 AM. It was confirmed with Staff C that 9 water boluses were missed, amounting to 450 mL.

Review of a physician's progress note on 01/19/16 revealed the patient complained of thirst. The tube feeding intake was documented as 1094 mL for the entire day on 01/22/16. This amount was cleared from the pump at 4:00 PM. A nursing note at 6:11 PM on 01/22/16 revealed the patient's j-tube was occluded. The medical record lacked documentation an attempt was first made to "forcefully" flush the tube with water. The physician was notified and Viokase with bicarbonate was ordered and given "to no effect." A registered dietician's assessment revealed the patient's nutritional needs were 1770-2065 fluid mL per day. A nursing note at 5:23 PM on 01/23/16 revealed the patient's j-tube "flushed easily." The tube feeding was noted to be infusing at 32 mL per hour on 01/23/16 at 07:29 PM and 40 mL per hour at 09:00 PM. At 6:00 AM on 01/24/16 the tube feeding continued to infuse at 40 mL per hour. The medical record lacked documentation the water bolus was given at all on 01/22/16 or 01/23/16. At 8:28 AM on 01/24/16 the tube feeding continued to infuse at 40 mL per hour. The tube feeding was noted to be infusing at 50 mL per hour at 12:30 PM on 01/24/16. The tube feeding was changed to the ordered rate of 62 mL per hour at 7:00 AM on 01/25/16. The pump was cleared of 373 mL at this time. There was no documentation of the tube feeding or water bolus at all on 01/26/16 or 01/27/16. A nursing note on 01/26/16 at 2:51 AM revealed that he/she was unable to give the patient's 9:00 PM medications as the j-tube was again clogged. A physician was notified and he/she ordered the patient to be given dextrose 5% with 45% NaCl continuously at 50 mL per hour. A physician's progress note at 2:45 PM on 01/27/16 revealed the patient's j-tube was now unclogged and the tube feeding should return to the previous orders. The tube feeding was noted to be infusing at 40 mL per hour at 12:57 AM on 01/28/16. It was confirmed with Staff C that 40 mL per hour was not the ordered rate for the patient's tube feeding. The tube feeding pump was cleared of 380 mL at 5:55 AM on 01/28/16. The pump was now noted to be infusing at 62 mL per hour. The tube feeding was noted to be on hold again at 12:00 PM on 01/28/16 as the j-tube was dislodged. The j-tube was re-inserted with an x-ray confirming placement on 01/29/16. The tube feeding was noted to be infusing at 62 mL per hour at 10:37 AM. A physician's progress note on 01/29/16 at 5:15 PM revealed the decision was made to transfer the patient to another hospital because of complexity and sepsis with hypotension. The patient was transferred at 8:46 PM on 01/29/16. The patient was noted to weigh 128 pounds on 01/27/16, 12 pounds less than the 140 pounds on 01/14/16, the day the patient was admitted.

Staff C was interviewed on 03/18/16 at 09:00 AM. Staff C confirmed the tube feeding intake was not documented every 8 hours, that there were periods where the tube feeding was not infusing at the ordered rate, and that when the j-tube was occluded, the medical record lacked documentation of attempting to forcefully flush the tube with water.