HospitalInspections.org

Based on review of medical records (MR), and policy and procedure, and interviews with staff (EMP) it was determined the facility failed to follow established policies for completion of restraint orders in four of eight restraint medical records reviewed. (MR26, MR27, MR28, and MR29)

Findings include:

Review of policy and procedure titled "Restraint Policy" dated July 2010, stated "Orders: ... 2. The order for restraints for medical/surgical reasons will include: Date and time, Duration of restraint use (may not exceed 24 hours), Type of restraint to be used; reason for restraint use. 3. Restraint orders for behavioral health reasons will include: Date and time, Type of restraint, Time limited: Adult: 4 hours, Age 9-17: 2 hours, Age under 9: 1 hour. ..."

1) Review of MR26, MR27, MR28, and MR29 revealed incomplete physician orders for restraints which failed to include type of restraint to be used, duration of restraint use, and/or reason for restraint use.

2) An interview was conducted August 6, 2010, at approximately 12:30 PM, with EMP2 and EMP5, who concurred that the physician orders for restraints in MR26, MR27, MR28, and MR29 were not complete orders as required by facility policy.

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that written orders were timed in 18 of 34 medical records reviewed. (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR10, MR11, MR13, MR14, MR23, MR25, MR27, MR31, MR33, and MR34)

Findings include:

Review of "Medical Staff Rules & Regulations of Clearfield Hospital ... Annual Approval Signatures: ... Date 1/25/10 Article II Medical Orders Section 3: Oral Orders ... Oral orders shall be taken only by qualified personnel who shall transcribe the orders in the proper place in the medical record of the patient. The order shall include the date, time, and full signature of the person taking the order and shall be countersigned by the prescribing or covering practitioner within 24-hours. .... Article IX Medical Records ... Section 2: Authentication All entries in the record shall be dated and authenticated by the person making the entry. ... "

1) During a review of medical records, it was revealed that 18 of 34 records failed to have dates and/or times for verbal orders when the practitioner countersigned the orders.

2) An interview was conducted with EMP on August 6, 2010, it was revealed "this is not a surprise, we have been trying to have the physicians date and time entries in the patient medical records".