HospitalInspections.org

Based on review of medical records (MR), observation, and staff interview (EMP), it was determined the facility failed to obtain orders for the use of buddy cushions as restraints for four of four patients (MR1, MR2, MR3, and MR8).

Findings include:

Review of facility policy "Restraints" revised February 2009, revealed" ... Restraints are: ... 2. Used to prevent risk of injury to the patient or others when less restrictive interventions are not sufficient. ...B. ... 2. Define the ordering requirements for restraint by licensed individual practitioner. ... C. Definitions ... 1. A physical restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body.

Review of policy "Patient Rights and Responsibilities" dated "March 2010" revealed "Z. Patients have the right to be free from restraint of any formed imposed as a means of coercion, discipline, convenience, or retaliation by staff. Patients have the right to safe implementation of restraints by trained staff."

Review of facility policy "Daily Nursing Assessment Flowsheet" dated "March 2009" revealed "F. The Restraint documentation section has been included to facilitate complete and timely documentation of the need for and continued use of restraints. Staff should initial each timed box reflecting monitoring of the patient."

Review of facility policy "Documentation: Nursing Assistant-MHA(Mental Health Assistant)/PCT(Patient Care Tech)" dated "January 2009" revealed "The MHA/PCT will document observable behavior of patients in structured group activity, care of patents in restraints, and in activities of daily living in the patient's medical record."

1) Observation on May 20, 2010 at 9:15 AM on Unit 2E revealed two of four patients (PT1 and PT3) sitting in wheelchairs with buddy cushions. When asked of if they could remove the buddy cushions, PT1 would not respond, and PT3 started pulling at the buddy pillow stating "I want it out." PT3 was unable to remove the buddy cushion.

Further observation of PT1 revealed no attempts to get out of the wheelchair.

Review of MR8 (PT1) at the time of the observation revealed no physician order for the buddy cushion. Further review of MR8 revealed no documentation to support the use of a buddy cushion.

Review of MR3 (PT3) at the time of the observation revealed no physician order for the buddy cushion. Further review of MR3 revealed no documentation to support the use of a buddy cushion. Additional review of MR3 revealed, "Behavioral Health Physician Progress Notes ... sits quietly in w.c.{wheelchair}] with a buddy cushion."

2) Observation on May 20, 2010 at 2:25 PM on Unit 2E revealed PT2 sitting in a wheelchair with a buddy cushion. Observation of PT2 revealed no attempts to get out of the wheelchair.
When asked if they could remove the buddy cushion, PT2 stated "Take out the four screws ..." PT2 was unable to remove the buddy cushion.

Review of MR2 (PT2) at the time of the observation revealed no physician order for the buddy cushion. Further review of MR2 revealed no documentation to support the use of a buddy cushion.

3) Interview on May 20, 2010 at approximately 10:00 AM with EMP2 confirmed the above findings and revealed "I can tell you it's not there. It's [buddy cushion] something we typically do not write. ..."

4) Interview with EMP2 on May 10, 2010, at approximately 12:30 PM confirmed the above findings and revealed "I know it's [physician order for the buddy cushion] is not there."

5) Review of MR1 on May 20, 2010, revealed "April 10, 2010, ... Pt.(patient) seen in dining room. [Patient] is in a W.C.(wheelchair) with a buddy cushion. Tries constantly to pry off the buddy cushion." Further review revealed no physician order or any nursing documentation to support the use of the buddy cushion.

Based on review of medical records (MR), facility policy,staff interview (EMP), and observation, it was determined the facility failed to develop a plan of care for the use of buddy cushions for four of four patients (MR1, MR2, MR3, and MR8).

Findings include:

Review of facility policy "Transdisciplinary Care Planning" revised "July 2005" revealed " ... Policy Patient care needs are identified and prioritized and a plan of care which appropriately addresses priority needs, is initiated within 24 hours of admission. ... Procedure ... 1. Based on prioritization of patient care needs identified, an appropriate care plan will be initiated by the RN."

1) Observation on May 20, 2010, at 9:15 AM on Unit 2E revealed PT1(MR8) and PT3(MR3) sitting in wheelchairs with buddy cushions. Further observation on May 20, 2010, at 2:25 PM on Unit 2E revealed PT2 (MR2) sitting in a wheelchair with a buddy cushion.

2) Review on May 20, 2010, of MR2, MR3, and MR8 revealed no documented evidence of the use of a buddy cushion in the plan of care.

Interview on May 20, 2010 at approximately 10:00 AM with EMP2 confirmed the above findings and revealed "I can tell you it's not there. It's [buddy cushion] something we typically do not write. ..."

3) Review of MR1 on May 20, 2010, revealed "April 10, 2010, ... Pt.(patient) seen in dining room. [Patient] is in a W.C.(wheelchair) with a buddy cushion. Tries constantly to pry off the buddy cushion." Further review of MR1 on May 26, 2010 revealed no documented evidence of the use of a buddy cushion in the plan of care.

Interview with EMP2 on May 26, 2010 confirmed that MR1 had no documented evidence of the use of a buddy cushion in the plan of care.