HospitalInspections.org

Based on Life Safety Code Recertification survey, the Condition for Physical Environment is not met based on the results of Department of Safety Inspection survey completed on April 20, 2011. See Life Safety Code 2567 for deficiencies.

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that the use of restraint was in accordance with a written modification to the patient's plan of care for four of four medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

A review on March 17, 2011, of facility policy "Restraints" effective date December 16, 2010, revealed "Restraining a patient is an exception and documentation must be thorough and concise. Documentation in the patient's medical record will include: ... d. Incorporation of restraint utilization within the patient's plan of care, ... ."

A review on March 17, 2011, of MR1, MR2 and MR3 revealed physician orders dated January 15, 2011, and February 8, 2011, for the use of mitts. Nursing documentation indicated that hand mitts were applied on those dates. Further review of the patients' plan of care revealed no documentation for the use of hand mitts.

A review on March 17, 2011, of MR4 revealed a physician order dated December 1, 2010, for the use of bilateral soft wrist restraints. Nursing documentation indicated that soft wrist restraints were applied on that date. Further review of the patient's plan of care revealed no documentation for the use of bilateral soft wrist restraints.

An interview conducted on March 17, 2011, at 3:00 PM with EMP1 confirmed that the patients' plan of care in MR1, MR2, MR3 and MR4 was not updated to include the use of restraints.

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that the condition of the patient in restraints was monitored according to the established facility policy for four of four restraint medical records reviewed (MR1, MR2, MR3 and MR4).

Findings include:

A review on March 17, 2011, of facility policy "Restraints" last revised December 16, 2010, revealed, "Monitoring/Assessment via the health care provider as listed under the "scope" of the policy, must be conducted every two (2) hours--one limb at a time - including removal of restraints. ... "

A review on March 17, 2011, of MR1, MR2 and MR3 revealed physician orders for hand mitts. The record did not contain documentation that the patient was assessed every two hours while in restraints.

A review on March 17, 2011, of MR4 revealed physician orders for bilateral soft wrist restraints. The record did not contain documentation that the patient was assessed every two hours while in restraints.

An interview conducted on March 17, 2010, at 3:00 PM with EMP1 confirmed that there was no documentation that nursing staff directly observed the patient every two hours as per the facility policy.

Based on review of facility policy and interview with staff (EMP), it was determined the facility failed to follow their policy, which required that two members of the medical staff be included on the Utilization Review Committee.

Findings include:

A review on March 17, 2011, of facility policy "Utilization Review" effective date December 2009 revealed, "Membership of the Utilization Review Committee shall consist of at least: Two appointed members of the Medical Staff ... "

An interview conducted on March 17, 2011, at 1:00 PM with EMP4 revealed that the Utilization Review Committee, which met twice monthly, included only one member of the medical staff. Further interview revealed that no meeting minutes were recorded or available or review.