HospitalInspections.org

Based on restraint policy review, medical record review and staff interviews the facility failed to ensure a physician's order was obtained for the use of restraints for 1 of 2 restrained patients reviewed (#2).

The findings include:

Review of the facility's policy, "Restraints and Seclusion", revised 07/2009, revealed "...Restraint must be ordered by a physician. ...Orders for restraints must be renewed on a daily basis. ...".

Closed medical record review of Patient #2 revealed an 85 year-old admitted on 01/29/2009 with respiratory failure and severe debility. Record review revealed the patient was restrained on 02/08/2009, 02/10/2009, 02/16/2009, 02/19/2009 and 03/16/2009 to prevent pulling out tubes/lines. Further review of the record revealed no physician's order for the use of restraints on 02/08/2009, 02/10/2009, 02/16/2009, 02/19/2009 and 03/16/2009.

Interview on 01/21/2009 at 1100 with administrative nursing staff revealed the hospital's restraint policy requires a physician's order for the use of restraints. Interview confirmed the patient was restrained on 02/08/2009, 02/10/2009, 02/16/2009, 02/19/2009 and 03/16/2009 and there was no evidence of a physician's order for the restraints. The interview confirmed the nursing staff failed to obtain an order for the use of restraints.

Based on hospital document review, medical records review and staff interviews the hospital's nursing staff failed to supervise and evaluate patient care by failing to: assess/reassess patients before and/or after pain interventions for 3 of 4 open records reviewed (#4, #5, #6) and turn a patient every two hours for 1 of 3 closed records reviewed (Patient #2).

The findings include:

Review of the hospital's document entitled "Nursing Flow-Sheet" revealed the following instructions in the "Pain" section: "Each patient should be assessed 30-60 minutes after an intervention."

1. Open medical record of Patient #4, a 75 year-old with a diagnosis of facial cellulitis (infection of the skin caused by bacteria), revealed evaluation of pain using the VAS (verbal/visual analogue scale) and FLACC (Face, Legs, Activity, Cry, Consolability) scoring systems. Review of the medical record revealed entries of 0 VAS and 0 FLACC scores on 1/18/2010 at 0700, 1000, 1300, 1500 1800, 2000, and 2200. Review revealed no scores were entered for the hours from 2300 (1/18/10) through 0600 (1/19/10). Review of the Medication Administration Record (MAR) dated 1/18/2010 beginning at 0700 and ending on 1/19/2010 at 0659 revealed an order for Oxycodone-Acetaminophen (Percocet - narcotic pain medication) 1 Tab po/pt (by mouth or feeding tube) every six hours as needed for pain scale 9-10. Review of the MAR revealed nursing documentation that Percocet 1 tablet was given on 1/18/2010 at 2100 and on 1/19/2010 at 0400. Record review revealed no documentation that the patient complained of pain (indication for pain medication) before the nurse gave the patient pain medication on 1/18/2010 at 2100 and on 1/19/2010 at 0400. Further record review revealed no documentation that Patient #4's pain was reassessed after the administration of the pain medication at 0400 on 1/19/2010.

Interview on 01/21/2010 at 1030 with administrative nursing staff revealed the nursing flow-sheet instructs the nurse to reassess 30-60 minutes after intervention. Further interview revealed, "Reassessing for pain after giving pain medication is standard of practice for nursing....No matter how much we educate, we are still having trouble getting consistency with this." Interview confirmed there was no evidence in the record of a pain score sufficient to indicate administration of pain medication prior to its administration at 2200 on 1/18/2010. Interview confirmed the nursing staff failed to reassess Patient #4 for pain after the administration of pain medication on 01/19/2010 at 0400.


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2. Open record review of Patient #5 revealed a 68 year-old admitted on 12/28/2009 with ventilator-dependent respiratory failure. Record review revealed a physician's order dated 12/28/2009 at 1600 for "Oxycodone/APAP 5/325 (narcotic pain medication) mg (milligrams) one tablet by PO (by mouth) every 6 hours PRN...." Review of the patient's MAR revealed the nurse administered Oxycodone one tablet by mouth on 01/18/2010 at 2210. Record review revealed no documentation that Patient #5's pain was reassessed after the administration of the pain medication. Further record review revealed a physician's order dated 01/05/2010 at 2000 for Morphine (narcotic pain medication) 1 to 2 mg IV (intravenously) every 2 hours PRN for pain. Review of the patient's MAR revealed the nurse administered Morphine 1 mg IV 01/19/2010 at 1830. Record review revealed no documentation that Patient #5's pain was reassessed after the administration of the pain medication.

Interview on 01/21/2010 at 1030 with administrative nursing staff revealed the pain management policy did not specify clearly when reassessment of pain after intervention should be performed. The interview revealed the nursing flow-sheet instructs the nurse to reassess 30-60 minutes after intervention. Further interview revealed, "Reassessing for pain after giving pain medication is standard of practice for nursing....No matter how much we educate, we are still having trouble getting consistency with this." Interview confirmed that the nursing staff failed to reassess Patient #5 for pain after the administration of pain medication on 01/18/2010 at 2210 and 01/19/2010 at 1830.

3. Open record review of Patient #6 revealed a 59 year-old admitted on 01/11/2010 with respiratory failure. Record review revealed a physician's order dated 01/12/2010 at 1200 for Hydrocodone (narcotic pain medication) one tablet by mouth every 6 hours as needed for pain. Review of the patient's MAR revealed the nurse administered one Hydrocodone tablet for pain on 01/16/2010 at 2130. Record review revealed no documentation that Patient #6's pain was reassessed after the administration of the pain medication.

Interview on 01/21/2010 at 1030 with administrative nursing staff revealed the pain management policy did not specify clearly when reassessment of pain after intervention should be performed. The interview revealed the nursing flow-sheet does instruct the nurse to reassess 30-60 minutes after intervention. Further interview revealed, "Reassessing for pain after giving pain medication is standard of practice for nursing....No matter how much we educate, we are still having trouble getting consistency with this." Interview confirmed that the nursing staff failed to reassess Patient #6 for pain after the administration of pain medication on 01/16/2010 at 2130.

4. Closed record review of Patient #2 revealed an 85 year-old admitted on 01/29/2009 with respiratory failure and severe debility. Record review revealed nurse's documentation of a Braden score (risk of skin breakdown assessment) on admission of 12 (high risk of skin breakdown). Record review revealed the patient was bed-ridden and unable to turn himself. Record review revealed no documentation that the patient was turned every 2 hours on the following days: 02/01/2009, 02/02/2009, 02/05/2009, 02/09/2009, 02/10/2009, 02/11/2009, 02/18/2009, 02/21/2009, 02/22/2009, 02/23/2009, 02/25/2009, 02/26/2009, 02/27/2009, 03/02/2009, 03/06/2009, 03/08/2009, 03/10/2009, 03/11/2009, 03/13/2009, 03/14/2009, 03/20/2009, 03/24/2009 and 04/01/2009 ( 23 of 70 days in the facility).

Interview on 01/21/2010 at 1015 with administrative nursing staff revealed, "Patients with a Braden score less than 16 should be turned every 2 hours." Interview confirmed that Patient #2's Braden Score was 12 on admission and never got higher than 12 during his hospitalization. Interview confirmed that Patient #2 was not turned every 2 hours on the following days: 02/01/2009, 02/02/2009, 02/05/2009, 02/09/2009, 02/10/2009, 02/11/2009, 02/18/2009, 02/21/2009, 02/22/2009, 02/23/2009, 02/25/2009, 02/26/2009, 02/27/2009, 03/02/2009, 03/06/2009, 03/08/2009, 03/10/2009, 03/11/2009, 03/13/2009, 03/14/2009, 03/20/2009, 03/24/2009 and 04/01/2009 ( 23 of 70 days in the facility). Interview revealed the nursing staff did not follow the facility's policy for skin care.


NC00061075