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Based on interview and record review, the hospital failed to ensure the type and location of the restraint was documented accurately for one of six sampled patients (Patient 1). This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed the physical restraint devices include hand mittens or mitts; and soft limb restraints (wrist and ankle).

On 11/13/24, Patient 1's closed medical record was reviewed with the Director of Quality Management.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 3/1/24, and discharged on 5/31/24.

Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed on 3/2/24 at 2100 hours, a soft limb restraint was placed on Patient 1's left hand.

Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed on 3/6/24 at 0800 hours, a soft limb restraint was placed on Patient 1's left wrist.

Patient 1's closed medical record showed Patient 1 was on restraint on 3/7/24, for 24 hours.

On 11/13/24 at 1438 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the Assistant Administrator. When asked, the Assistant Administrator stated if a restraint was applied to the patient's hand, the type of restraint should have been a mitten, not a soft limb restraint.

On 11/13/24 at 1501 hours, an interview was conducted with the Director of Quality Management. When asked, the Director of Quality Management stated if the soft limb was used for restraint, the location of the restraint should have been the wrist.

On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the monitoring and assessment were consistently performed as per the hospital's P&P for two of six sampled patients (Patients 1 and 3). This failure posed the risk of substandard outcomes to the patients.

Findings:

Review of the hospital's P&P titled Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed to perform ongoing safety checks and monitoring (at least every two hours or as noted on the designated forms) by the patient's clinical team of the patient's response to the restraint, including any condition changes for non-violent behavior restraints.

1. On 11/13/24, Patient 1's closed medical record was reviewed with the Director of Quality Management.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 3/1/24, and discharged on 5/31/24.

Review of Patient 1's closed medical record showed Patient 1 was on restraint on 3/7/24, for 24 hours.

Review of the safety checks and monitoring (Q2 hours) form dated 3/7/24, showed the following safety checks and monitoring were performed every two hours except at 1400 hours:

* Range of motion offered/provided
* Food/fluids offered/provided
* Toileting offered/provided
* Dignity/comfort/hygiene maintained
* Managed safety/no injury
* Mental status unchanged
* Skin integrity unchanged
* Temporary release during care (direct observation maintained)
* Circulatory status of restrained extremities unchanged
* Pain managed per policy

2. On 11/13/24 at 1000 hour, a tour of the Intensive Care Unit was conducted. Patient 3 was observed to be restrained with the soft two-points restraints on both wrists.

On 11/13/24, Patient 3's medical record was reviewed with the Director of Quality Management.

Patient 3's medical record showed Patient 3 was admitted to the hospital on 10/21/24.

Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed the soft limb restraints were applied to the patient's left and right wrist on 11/11/24 at 0001 hours.

Review of the safety checks and monitoring (Q2 hours) form dated 11/12/24, showed the safety checks and monitoring were performed during the restraints. However, the following was missing:

* On 11/12/24 at 2000 hours, the section of Pain Managed per Policy was left blank.

* On 11/12/24 at 2200 hours, the sections of Circulatory Status of Restrained Extremities Unchanged and Pain Managed per Policy were left blank.

On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.

Based on interview and record review, the hospital failed to ensure RN 3 had been validated for competency for the restraint use as per the hospital's P&P. This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Core: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed upon hire and periodically as determined by the hospital's hospital care and safety quality council, all staff having direct patient care responsibilities shall be trained on the restraint freedom program along with the proper and safe use of restraints and seclusion used in the hospital. This should include how to recognize and respond to signs of physiological or psychological distress.

On 11/13/24, Patient 1's closed medical record was reviewed with the Director of Quality Management.

Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 3/1/24, and discharged on 5/31/24.

Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) showed RN 3 applied soft limb restraints to Patient 1's left hand on 3/2/24 at 2100 hours.

Review of RN 3's Self-Assessment for Restraints, showed RN 3 rated RN3's proficiency as 4 (expert-serve as a resource) and Frequency as 4 (daily or weekly). When requested for RN 3's validated competency for restraints other than the self-assessment, the hospital was not able to provide the requested document.

On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff clarified with the physician about the use of BiPAP and metoprolol (a medication used to treat high blood pressure) PRN and failed to ensure the legibility of medical record for one of six sampled patients (Patient 6). These failures posed the risk of poor health outcomes for the patient.


Findings:

Review of the hospital's P&P titled Physician's Orders dated October 2022 showed if the medication or treatment is an "as-needed" or PRN, specify the condition for which the medication or treatment is to be used.

Review of the hospital's P&P titled Core: Corrections to the Medical Record dated June 2022 showed the purpose is to ensure a consistent and legal mechanism for maintaining the integrity of the medical record when corrections are necessary. The Procedure section showed making corrections to a Paper Medical Record as follows:

* In black ink, draw a single line through the incorrect data.
* Writes "error" above the incorrect data.
* Write the correct data below the lined-out material.
* Sign and date the correction.

On 11/13/24 at 1239 hours, Patient 6's closed medical record review was conducted with the Director of Quality Management.

Patient 6's closed medical record showed the patient was admitted to the hospital on 10/24/24.

a. Review of the Physician Order form showed RN 3 wrote a telephone order for BiPAP, PRN for SOB only, RT was aware. The form showed the Telephone Order Read Back to the physician's name and dated 11/8/24. The time section was blank.

On 11/13/24 at 1239 hours, during an interview with RN 2, RN 2 was asked to review the order for when the patient would need this PRN treatment. RN 2 stated the SOB would be presented differently from patient to patient. It would depend on each patient's medical history and/or clinical condition. It would include the oxygen level, the patient's respiratory rate, and the patient's clinical presentation. RN 2 stated based on this written order, the RN would need to clarify with the physician for the parameter or criteria to implement this PRN order for the patient.

The Director of Quality Management stated there was no a documented evidence RN 3 clarified with the physician about the SOB.

b. Review of the Physician Order form dated 11/9/24 at 0730 hours, showed the telephone order read back was hand-written as follows:

* Hydralazine (a medication used to treat high blood pressure) which was lined-out. There was no the word of error or signature was written as per the hospital's P&P.

* Metoprolol 25 mg IVP, BID, PRN every six hours for HR greater than 120 bpm, SBP 150 mmHg. The number "5" of the 150 mmHg was overwritten by the number "1."

Review of the physician's order dated 11/9/24 at 1519 hours, showed metoprolol, 25 mg IVP every six hours, prn, hold for HR below 60 bpm and for SBP less than 110 mmHg.

On 11/13/24 at 1239 hours, an interview and concurrent record review was conducted with RN 2. RN 2 reviewed the physician's order and stated there were two written orders which should be available for review in the EHR. RN 2 reviewed the EHR and stated there was no another order for metoprolol BID written in EHR.

During a follow-up interview with the Director of Quality Management, the Director of Quality Management confirmed the parameter for the use of metoprolol PRN written in EHR was not consistently with the parameter for the use of metoprolol PRN hand-written on the Physician Order form. The Director of Quality Management could not locate document to show the physician was clarified about the discrepancy.

Based on interview and record review, the hospital failed to ensure Patient 5 or the patient's family member received the Patient Guide to Blood Transfusion pamphlet before a blood transfusion. This failure could lead to violate the patient's rights.

Findings:

On 11/13/24, Patient 5's medical record was reviewed with the Director of Quality Management.

Patient 5's medical record showed Patient 5 was admitted to the hospital on 10/18/24.

Review of the Blood/Blood Component Transfusion Record dated 11/10/24, showed Patient 5 received blood transfusion started at 1000 hours and ended at 1315 hours.

Review of the Informed Consent for Transfusion form showed a telephone consent was obtained from Patient 5's family member on 11/10/24 at 0800 hours, for the blood transfusion. The form showed the physician signed on 11/10/24 at 1000 hours. However, the box of "I hereby certify that the patient has received a copy of the California Department of Health Care Services information pamphlet, A Patient's Guide to Blood Transfusion. (CA only)" was unchecked.

On 11/13/24 at 1530 hours, the Director of Quality Management verified the above findings.