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Based on medical record review, staff interview, observation, and policy review; the facility failed to ensure orders were obtained for all restraints used and all restraints used as ordered. This affected two of five medical records reviewed with restraint usage (Patients 1 and 9). A total of ten medical records were reviewed.

Findings include:

The medical record for Patient 1 was reviewed on 09/04/12. The patient was admitted on 03/28/12 with diagnoses of stroke with left sided weakness, atrial fibrillation, coronary artery disease, diabetes, and morbid obesity. The medical record contained documentation on the nursing flowsheets that a grey belt (a seat belt used to prevent patients from getting out of wheelchairs) was used on 03/29/12 at 4:00 PM and at 12:00 PM, on 03/30/12 at 8:00 PM, on 03/31/12 at 8:00 AM and 3:49 PM, and on 04/01/12 at 8:00 AM. The medical record lacked documentation of an order for this restraint. On 09/05/12 at 9:41 AM, Staff B verified that orders for this restraint were not able to be located.

The Safety Device Criteria policy stated that any safety device must be ordered by a physician within 24 hours of implementing the device, must be re-ordered every 24 hours, and requires a physician's order to discontinue use of the device.


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A tour of Unit C was completed on 09/05/12 at 10:38 AM. Patient 9 was observed outside of the building alone wearing his/her helmet. Patient 9 had an order for a grey belt to be used when the patient was in the chair. The grey belt was hanging off of the wheelchair on the cement ground.
Staff H observed Patient 9 outside unattended without a grey belt applied on 09/05/12 at 10:38 AM. Staff H was interviewed on 09/05/12 at 10:38 AM and stated therapies will often leave patients outside on sunny days and notify the recreational therapist located immediately inside the door of the patient being left outside. Staff H stated the patient required a grey belt for the patient's safety and there was a current order for the grey belt in the patient's chart.
Staff I, recreational therapist, was interviewed on 09/05/12 at 10:42 AM. Staff I stated that he/she was not notified of the patient being left alone outside.
Staff J, physical therapist, was interviewed on 09/05/12 at 10:50 AM. Staff J stated that he/she left the patient outside alone and did not notify any staff of the patient being left outside alone. Staff J stated he/she is a float and did not see the patient's order for the grey belt.
On 09/05/12, the policy for Safety Device Criteria was reviewed. The policy stated whenever a safety device is removed, the patient shall be constantly observed during that period. The policy stated a physicians order is required to discontinue a device.

Based on observation and facility policy review, the facility failed to ensure the safety for one of 18 patients (Patient 17) by not having the call-light accessible to the patient, failed to notify the physician of orders not followed for two (Patients 10 and 18) of ten medical records reviewed and failed to ensure only authorized nursing staff obtained physician telephone orders for one (Patient 17) of ten medical records reviewed. The active census at the time of the complaint survey was 27.

Findings Include:

1.) A tour of Unit B was completed on 09/05/12 at 1:15 PM. Patient 17 had a green fall star located on the doorway of the room. Patient 17 was observed sitting in a wheelchair located on the right side of the patient's bed. The patient's call-light was located on the left side of the patient's bed and not accessible by the patient.
The facility's Fall Prevention Protocol was reviewed on 09/05/12. The policy stated there must be convenient access to call-light, patient belongings and telephone and the call bell must be in reach.
2.) The medical record review for Patient 10 was completed on 09/05/12. On 08/26/12 at 10:04 PM, the nurse documented the patient's ordered Adderall (a pharmaceutical psychostimulant) and Stelazine (an antipsychotic and antianxiety medication) as not given due to missing dose. The medical record did not have evidence the physician was notified of the missed medications. On 08/27/12, the nurse documented the patient refused the ordered Adderall (a pharmaceutical psychostimulant). There was no evidence of physician notification of the refusal in the patient's chart.
On 09/05/12, Staff D was interviewed and stated the physician should have been notified of the missed dose and the nurse should have received an order to hold the medication.
The medical record review for Patient 18 was completed on 09/05/12. Patient 18 was admitted on 09/02/12 with a diagnosis of stroke. On 09/03/12 at 10:00 PM, the nurse documented Atorvastatin (used to treat high cholesterol, and to lower the risk of stroke and heart attack) as not given to the patient due to the medication was missing. The Atorvastatin was not administered to the patient until 09/04/12 at 9:13 PM. There was no documentation in the patient's chart that the physician was notified of the missed dose.
On 09/05/12 at 2:26 PM, Staff H was interviewed and stated the physician should have been notified of the missed dose and the nurse should have received an order to hold the medication.
3.) The medical record review for Patient 17 was completed on 09/05/12. The medical record had a physician's telephone order for Ocean Spray Nasal Spray documented as received by a student practical nurse on 09/01/12 at 6:00 PM. The medical record had documentation of a telephone order received by a licensed practical nurse dated 08/31/12 at 2:30 PM for blood work.
The facility's policy for Receipt and Transcription of Practitioner Orders policy was reviewed on 09/05/12. The policy stated telephone orders may only be given to a registered nurse, physician assistant, respiratory therapist, pharmacist, or dietician.