HospitalInspections.org

Based on staff interview, clinical record review, and policy and procedure review, it was determined that the facility staff failed to inform and obtain consent from the authorized representative for 2 of 20 patients, Patients #1 and #19, regarding the use of restraints/protective devices.

The findings include:

1. Patient #1 was hospitalized from 6/5/10 through 6/10/10. According to the physician's discharge summary, the patient's diagnoses included fever of unknown origin, sepsis (ruled out), hypercholesterolemia, bipolar disorder, anxiety disorder, low vitamin D level, hypertension, hypothyroidism, profound mental retardation.

On 6/6/10, staff obtained verbal consent from the authorized representative for 1:1 supervision. The benefit of the supervision was documented as to observe closely, especially for any changes in the patient's medical condition. Staff documented the alternative to 1:1 supervision would be the use of wrist/ankle restraints.

Everyday from 6/5/10 through 6/10/10, physicians documented the order and assessment for side rails, mitten and/or wrist restraints. On 6/5/10 through 6/10/10, certified nursing assistant (C.N.A.) staff documented the use of bilateral wrist restraints and full side rails. There was no indication that staff attempted to inform or obtain consent from the authorized representative for the use of the wrist restraints and side rails.

On 9/16/10 at 9:05 a.m., the surveyor reviewed the lack of informed consent for the use of Patient #1's wrist restraints, with the Director of Clinical Services and the Director of Nursing. At 11:02 a.m., both managers verified that such consent had not been obtained for Patient #1.

The surveyor reviewed the policy and procedure titled, Protective Restraints/Mechanical Supports. According to the policy, "The individual and/or his/her authorized representative (AR) must give informed consent for the use of protective restraint."


2. Patient # 19's guardian did not provide informed consent for the use of protective restraints.

Patient # 19's closed clinical record was reviewed on 9/15/2010 and 9/16/2010. The patient was admitted to this acute care hospital on 11/30/2009 through 12/22/2009 for treatment of aspiration pneumonia, fever and hypoxia (decreased oxygen in the blood). The patient underwent cervical laminectomy of C-5, C-6 and C-7 at a different acute care hospital prior to this episode. A protective cervical collar was being utilized status post this surgical procedure and is not considered a restraint related to this citation. This 46 year old patient's diagnoses also included profound mental retardation, chronic obstructive pulmonary disease, right upper lobe lung nodule and TORCH syndrome (1). The clinical record revealed the patient was non-verbal and required complete assistance from others for her daily living skills due to her diagnoses of mental retardation and self care deficits. The restraint record revealed that the patient was restrained when in bed or not engaged in active treatment, physical therapy or during activities of daily living. The restraints were inconsistently documented as being released during hours the patient was asleep.

The clinical record revealed that multiple protective restraints (not including the cervical collar) were utilized during this hospitalization to prevent Patient # 19 from injuring herself due to self injurious behaviors and "neurological impairments". The clinical record did not include evidence that her mother/guardian was provided information regarding the use or potential negative consequences of the use of physical restraints prior to the implementation or throughout the entire hospitalization.

On 9/16/2010 at 12:50 p.m. the Director of Nursing (DON) and the Clinical Manager were interviewed regarding informed consent related to Patient # 19's protective restraints. The DON stated that the clinical record did not evidence the patient's guardian was informed of the risk/consequences of the use of restraints. The Clinical Manager stated that the patient's guardian/mother was present at the hospital numerous times, and observed the restraints. No further documentation was presented to evidence the guardian/mother provided informed consent for the use of restraints.

(1) TORCH syndrome or infection is an acronym used to describe a group of infectious agents to which fetal exposure en utero may cause severe congenital effects including mental retardation, hearing impairment, blindness, and death. These infectious agents include Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex/HIV and Syphilis. (Accessed at http://www.reference.com/browse/TORCH+infection on September 20, 2010 at 9:30 a.m.)

(2) (Best Practice-Evidence Based Practice Information Sheets for Health Professionals, Vol 6, Issue 3, 2002 accessed electronically on September 20, 2010 at 1:50 p.m.).

Based on clinical record review, staff interview and a review of hospital policies, the hospital employees failed to ensure less restrictive interventions were determined to be ineffective to protect the patient and others from harm, prior to the use of physical restraint implementation and continued use of physical restraints.

Findings include:

Patient # 19's closed clinical record was reviewed on 9/15/2010 and 9/16/2010. The patient was admitted to this acute care hospital on 11/30/2009 through 12/22/2009 for treatment of aspiration pneumonia, fever and hypoxia (decreased oxygen in the blood). The patient underwent cervical laminectomy of C-5, C-6 and C-7 at a different acute care hospital prior to this episode and a protective cervical collar was being utilized status post this surgical procedure and is not considered a restraint related to this citation. This 46 year old patient's diagnoses also included profound mental retardation, chronic obstructive pulmonary disease, right upper lobe lung nodule and TORCH syndrome (1). The clinical record revealed the patient was non-verbal and required complete assistance from others for her daily living skills due to her diagnoses of mental retardation and self care deficits.

The clinical record revealed that multiple protective restraints (not including the cervical collar) were utilized during this hospitalization to prevent Patient # 19 from injuring herself due to self injurious behaviors and "neurological impairments." The clinical record did not evidence an attempt to use less restrictive interventions prior to the implementation of the restraints. The clinical record did not include evidence of an attempt to decrease the use the protective restraints throughout her hospitalization or evidence that her mother/guardian was provided information regarding the use or potential negative consequences of the use of physical restraints prior to the implementation or throughout the entire hospitalization.

The clinical record did not evidence a review or evaluation of Patient # 19 by a Psychologist or Psychiatrist during this hospitalization episode.

On 9/16/2010 at 12:50 p.m. the Director of Nursing and the Clinical Manager were interviewed regarding Patient # 19's protective restraints. The Clinical Manager stated the patient was not physically restrained when on her usual residential unit (a separate unit of this facility, not included in this inspection.). The behavioral support plan (BSP) information included in the acute care clinical record revealed that a 2:1 staffing ratio was utilized prior to this hospital episode, to protect the individual from self injurious behaviors, physical restraints were not utilized. The Clinical Manager also stated that after the patient's discharge from the acute care hospital, physical restraints were not utilized. The DON and Clinical Manager did not provide information or documentation to evidence that less restrictive methods were attempted prior to restraining or during the course of Patient # 19's hospitalization. The Clinical Manager stated the patient's restraints were not reviewed by a psychologist or psychiatrist.

The policy regarding the use of protective or medical restraints ("Medical Restraints") was presented by the Clinical Manager on 9/14/2010. This policy did not include procedures to ensure informed consent was obtained from the patient, or guardian/parent. On 9/16/2010, the Facility Director presented the policy "Protective Restraints/Mechanical Supports." This policy stated: "The individual and/or his/her authorized representative (AR) must give informed consent for the use of protective restraints." The Facility Director was interviewed on 9/16/2010 at 1:45 p.m. and stated that informed consent should have been obtained from the patient's guardian.

(1) TORCH syndrome or infection is an acronym used to describe a group of infectious agents to which fetal exposure en utero may cause severe congenital effects including mental retardation, hearing impairment, blindness, and death. These infectious agents include Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex/HIV and Syphilis. (Accessed at http://www.reference.com/browse/TORCH+infection on September 20, 2010 at 9:30 a.m.)

Based on staff interviews, review of personnel files, and training policy, the facility staff had failed to consistently complete annual core training requirement for four out of six nursing staff employees.

The findings include:

On Wednesday September 15, 2001, this Medical Facility Inspector (MFI) was reviewing personnel files with a human resource employee. Of six Direct Contact nursing staff files reviewed, four were found to have not taken some part of the facility's required annual core training classes. A Licensed Practical Nurse did not have a current CPR certificate. One Registered Nurse (RN) had not completed the required annual update class (TOVA) Therapeutic Options of Va . This class is designed to help employees better manage patients acting out or presenting behavior as potentially harmful to self and or others. Two RN managers had not completed multiple required Core training classes.

On Wednesday September 15, 2010 while reviewing personnel files with a Human Resource employee, the Staff Development and Training Manager (SDTM) was also present to discuss staff training needs. SDTM was unable to produce documentation showing that four out of six Direct Contact nursing staff had completed their annual Core training requirements.

On Thursday September 16, 2010 this MFI asked to see the policy on the facility's Staff Development and Training . This policy was provided and goes on to refer to "annual refresher (Core) training classes in accordance with requirements for the position." This policy listed seventeen classes of which sixteen were required for Direct Contact staff to take every year. When the MFI asked the Director of Specialty Projects and Policy and Procedure about annual Core training she acknowledged they hadn't been completed.

Based on staff interviews and a tour of the hospital, the facility staff failed to maintain the environment in a manner to ensure the safety and well being of patients.

The findings include:

On Tuesday September 14, 2010 at approximately 1100AM, three Medical Facilities Inspectors (MFIs) conducted a tour of the Building 46 Medical Clinic area. The facility Medical Director (Med Dir) and the Director of Nursing (DON) were present for the tour. The acute care hospital unit was located on the 4th floor of building 46. Upon entering the unit the MFIs noted multiple ceiling tiles missing and several were stained or showing signs of water damage. In three out of five patient rooms there was water stains on some ceiling tiles and what appeared to be rust on metal frames around ceiling light fixtures. Through out the unit there was several areas were paint was chipping off the walls and dry wall was in need of repair. The Med Dir and DON acknowledged the unit was in need of repair.