HospitalInspections.org

Based on medical record review, policy review and staff interview, the facility failed to ensure a bedfast patient was repositioned to prevent the development of pressure ulcers and failed to ensure a bath was offered daily as per policy. (A0395)

Based on medical record review and staff interview, the facility failed to ensure restraint use was in accordance with the physician's order. This affected three of five patients reviewed for restraints (Patients #5, #7, and #10). The facility's census was 22.

Findings include:

1. Review of the medical record for Patient #5 revealed orders for secured mittens from 11/22/24 at 11:51 AM through 12/10/24 at 11:59 AM. The medical record contained documentation on 12/06/24 at 8:00 PM of unsecured mittens, on 12/07/24 at 9:11 AM of bilateral soft wrist restraints, on 12/07/24 at 9:24 AM of one secured and one unsecured mittens, and on 12/10/24 at 8:00 AM of unsecured mittens.

The medical record contained orders for unsecured mittens from 12/10/24 at 11:59 PM through 12/31/24 at 11:00 AM. The medical record contained documentation on 12/18/24 at 8:00 AM of bilateral soft wrist restraints, on 12/18/24 at 8:00 PM of one secured and one unsecured mittens, on 12/23 at 8:00 PM of one secured and one unsecured mittens, and on 12/30/24 at 7:29 AM of secured mittens.

The medical record lacked documentation of any restraint order changes for the above dates and times when the ordered restraint was not used.

Interview on 01/02/25 at 1:45 PM, Staff A verified the findings.

2. Review of the medical record for Patient #7 revealed orders for unsecured mittens from 10/22/24 at 8:56 AM through 11/01/24 at 6:08 PM. The medical record contained documentation on 10/29/24 at 9:02 AM and on 10/30/24 at 7:41 AM of bilateral soft wrist restraints.

The medical record contained orders for secured mittens from 11/01/24 at 6:08 PM through 11/09/24 at 7:00 PM. The medical record contained documentation on 11/02/24 at 8:00 AM of bilateral soft wrist restraints and on 11/05/24 at 11:35 AM of unsecured mittens.

The medical record contained documentation of bilateral soft wrist restraints in place from 11/12/24 at 9:58 PM through 11/15/24 at 6:00 AM. The medical record lacked an order for restraints on 11/13/24.

The medical record contained an order for bilateral wrist restraints on 11/16/24 at 9:24 PM and 11/18/24 at 3:43 AM. The medical record lacked an order for restraints on 11/17/24. The medical record contained documentation of bilateral soft wrist restraints in place on 11/17/24.

The medical record lacked documentation of any restraint order changes for the above dates and times.

Interview on 01/02/25 at 3:20 PM, Staff A verified the findings.

3. Review of the medical record for Patient #10 revealed orders for bilateral soft wrist restraints from 12/10/24 at 2:57 PM through 12/16/24 at 9:15 PM. The medical record contained documentation on 12/16/24 at 8:00 PM of secured mittens.

The medical record contained orders for unsecured mittens from 12/16/24 at 9:15 PM through 12/25/24 at 5:31 PM. The medical record contained documentation of secured mittens from 12/16/24 at 9:15 PM through 12/25/24 at 5:31 PM.

The medical record contained orders for secured mittens from 12/25/24 at 5:31 PM through 01/02/24. The medical record contained documentation of unsecured mittens on 12/29/24 at 8:00 PM through 12/30/24 at 8:00 PM.

The medical record lacked documentation of any restraint order changes for the above dates and times.

Interview on 01/02/25 at 4:30 PM, Staff A verified the findings.

Based on medical record review, policy review, and staff interview; the facility failed to ensure the condition of the patient who is restrained was monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy for three of five patients reviewed for restraints (Patients #5, #7, and #10). The facility's census was 22.

Findings include:

Review of the policy titled "Restraints and Seclusion," revised 01/01/24, revealed documentation every two hours of observations of safety, comfort, mobility, skin integrity, food/hydration, and toileting.

1. Review of the medical record for Patient #5 revealed orders for restraints from 11/22/24 through 12/31/24. The medical record lacked documentation every two hours of safety checks on 12/06/24 from 4:00 AM to 8:00 AM, on 12/07/24 from 5:33 AM to 9:11 AM, on 12/14/24 from 4:00 PM to 8:00 PM, on 12/23 from 4:00 AM to 10:00 AM, on 12/25/24 from 4:00 AM to 8:00 AM, and on 12/26/24 from 6:00 AM to 2:00 PM.

Interview on 01/02/25 at 1:45 PM, Staff A verified the findings.

2. Review of the medical record for Patient #7 revealed orders for restraints from 10/22/24 through 11/18/24. The medical record lacked documentation every two hours of safety checks on 10/10/24 from 6:00 AM to 9:36 AM, on 10/10/24 from 9:36 AM to 12:00 PM, on 10/20/24 from 6:00 AM to 10:00 AM, on 10/26/24 from 4:00 AM to 7:33 AM, on 10/28/24 from 6:00 AM to 12:00 PM, on 11/02/24 from 6:00 AM to 10:00 AM, on 11/08/24 from 6:00 AM to 10:00 AM, and on 11/17/24 from 10:00 AM to 8:00 PM.

Interview on 01/02/25 at 3:20 PM, Staff A verified the findings.

3. Review of the medical record for Patient #10 revealed orders for restraints from 12/10/24 through 01/02/25. The medical record lacked documentation every two hours of safety checks on 12/15/24 from 4:00 PM to 8:00 PM, on 12/22/24 from 2:00 PM to 8:00 PM, on 12/23/24 from 6:00 AM to 9:01 AM, on 12/23/24 from 9:01 AM to 12:00 PM, on 12/24/24 from 6:00 AM to 10:00 AM, on 12/25/24 from 4:00 PM to 8:00 PM, on 12/26/24 from 5:58 AM to 10:00 AM, on 12/31 from 2:00 AM to 8:00 AM, and on 12/31/24 from 12:00 PM to 4:00 PM.

Interview on 01/02/25 at 4:30 PM, Staff A verified the findings.

Based on medical record review, policy review and staff interview, the facility failed to ensure a bedfast patient was repositioned to prevent the development of pressure ulcers and failed to ensure a bath was offered daily as per policy. This affected one of five patients reviewed for pressure ulcers (Patient #1). The facility's census was 22.

Findings include:

Review Patient #1's medical record revealed an admission date of 08/28/24 with a diagnosis of acute respiratory failure with hypoxia and quadriplegia after falling and breaking his neck. The patient also had a history of chronic obstructive pulmonary disease and liver cirrhosis. Review of the patient's history and physical, written on 11/28/24 by the physician, Staff E, revealed the patient came to the hospital for complex medical treatment, to wean the patient from the ventilator, and wound therapy. The doctor noted the patient had several pressure ulcers present on admission and consulted wound care.

A skin assessment was completed on 08/28/24 and the patient had five wounds: one to the scrotum, one to the sacrum, one on both gluteal folds, and one to his right fifth toe. Review of Patient #1's medical record revealed the patient was to be repositioned every two hours and to keep the heels elevated or in pressure relief boots.

On 08/28/24 the sacral wound measured 1.5 centimeters (cm) by 0.1 cm by 0.15 cm. On 08/29/24 the sacral wound was reassessed and measured 3 cm by 2 cm by 0.1 cm.

Review of Patient #1's flow sheets revealed the patient was not repositioned and/or the feet were not elevated or in protective boots on 09/02/24 from 7:01 AM through 3:59 PM, on 09/04/24 from 6:01 AM through 6:59 PM, on 09/05/24 from 5:01 AM through 9:59 AM, on 09/06/24 from 6:01 AM through 6:59 PM, on 09/09/24 from 4:01 AM through 9:59 AM, on 09/11/24 from 8:01 AM through 6:59 PM, on 09/12/24 from 10:36 AM through 6:59 PM, on 09/13/24 from 8:01 AM through 09/14/24 at 5:59 PM, on 09/15/24 from 6:01 AM through 7:59 PM, on 09/18/24 from 10:01 AM through 5:59 PM, on 09/25/24 from 12:01 PM through 7:59 PM, on 09/26/24 from 1:01 PM through 09/27/24 at 4:59 PM, On 09/28/24 at 6:01 AM through 6:59 PM, on 10/01/24 at 6:01 AM through 10/02/24 at 6:59 PM, on 10/04/24 at 5:01 AM through 10/05/24 at 9:59 AM, on 10/05/24 from 6:01 PM through 10/06/24 at 8:29 AM, on 10/07/24 at 5:01 AM through 10/08/24 at 12:29 AM, on 10/08/24 at 5:01 PM through 10/09/24 at 11:59 PM, on 10/09/24 at 3:48 PM through 10/10/24 at 6:59 AM, on 10/12/24 at 7:01 AM through 7:59 PM, on 10/16/24 at 4:50 PM through 10/17/24 at 6:59 AM, on 10/20/24 at 6:01 PM through 10/23/24 at 7:00 AM, on 10/24/24 at 7:01 AM through 6:59 PM, on 10/25/24 at 5:01 AM through 6:59 PM, 10/26/24 at 6:01 AM through 7:59 PM, on 10/29/24 at 6:01 AM through 7:59 PM, on 10/31/24 at 6:01 PM through 11/01/24 at 6:59 AM.

On 09/05/24 and 09/12/24 the sacral wound measured 3 cm by 3 cm by 0.1 cm. On 09/19/24 the sacral wound measured 4 cm by 5 cm by 0.1 cm. On 09/26/24 the sacral wound measured 4 cm by 6 cm by 0.1 cm. On 10/17/24 and 10/24/24 the sacral wound measured 2 cm by 3 cm by 0.1 cm. On 10/31/24 the sacral wound measured 5 cm by 3 cm by 0.1 cm.

On 10/31/24 the patient developed one pressure ulcer to each heel. The right pressure ulcer measured 5 cm by 5 cm by 0.1 cm. The left heel pressure ulcer measured 6 cm by 6 cm by 0.1 cm.

Further review of the flow sheets revealed the patient did not receive a bath on 09/01/24, 09/04/24, 09/13/24, 10/01/24, 10/07/24 and 10/09/24.

Review of the facility policy titled "Clinical Guidelines and Protocols," revised on 10/01/24, revealed patients should be bathed daily and bedfast patients should be repositioned every two hours.

These findings were verified during interview on 01/02/24 at 1:20 PM with Staff D.