HospitalInspections.org

Based on documentation review the hospital failed to provide a written notice of the final decision for one of six grievances reviewed. Findings include:

The hospital's grievance policy and procedure last revised on April 28, 2008, indicates that a verbal complaint which is not resolved by the staff person at the time of the complaint and is referred to other staff for resolution is a grievance.

A grievance dated July 19, 2010 indicates that a patient's family member was concerned about a patient who had a puddle of urine on the floor. In addition, the concern was that no staff were present in the room from 8:00 a.m. until 11:30 a.m. The grievance report form further indicated that video tape was reviewed and multiple staff were in the patient's room.

The grievance form indicates that the complaint was resolved by the employee taking the grievance. However, documentation indicates that the patient's family member was still "upset" that the patient was wet with urine and concerned that none of the staff checked to see if the patient was wet with urine. The documentation indicates that management staff would follow up with the patient's family member.

The grievance form indicates that no written notice was completed because the complaint was resolved immediately. However, the documentation also indicates that follow up was completed with the patient's family member on July 20, 2010.

Employee (E) was interviewed about the grievance while onsite on October 8, 2010 and stated that although follow up was completed, it was determined that no written notice was completed because the individual who initially took the grievance determined that the concern was resolved immediately.

Based on documentation review and interviews the hospital failed to ensure that the use of restraints did not occur on an as needed basis for three of eleven patients (#2, 3, and 4) records reviewed. Findings include:

Review of the hospital's restraint policy and procedure last updated on January 9, 2007, indicated that re-starting of a restraint can not be done under the same order. This constitutes an as needed order (PRN) and restraints can not be ordered on an as needed basis.

Patient #4's medical record indicates that the patient was admitted on September 16, 2010 and discharged on October 8, 2010. The patient had a history of recurrent intracranial hemorrhages resulting in left sided weakness. A physician's restraint order dated October 7, 2010, indicates the patient requires bilateral soft wrist and ankle restraints for wandering and unsafe ambulation related to impaired memory, inability to follow directions, confusion and disorientation.

A nurses note dated October 7, 2010 at 9:00 a.m., indicates that a right hand mitt and right wrist and ankle restraints are in use when no one is in the patient's room.

On October 7, 2010 patient #4 was observed in her room in a geri chair without restraints on at 10:45 a.m. Later in the day the patient was observed in the hall in a geri chair by the nurses station with her right hand and wrist restrained in a mesh mitt that was secured to the arm of the geri chair. A review of her record did not contain physician orders reflecting this change.

Patient #2's medical record indicates that the patient was admitted on February 15, 2010 and discharged on March 10, 2010. The patient was admitted with respiratory failure. A review of the patients restraint documentation indicates that the on March 17, 2010 the physician had ordered a renewal of soft wrist and ankle restraints and a lap tray. The nursing restraint documentation indicates that the patients leg restraints were off at 12:00 p.m. and leg restraints were replaced at 10:00 p.m. The physician renewal was the only order received that day.

Patient #3's medical record indicates that the patient was admitted on May 24, 2010 and discharged on September 13, 2010. A review of the patient's restraint documentation indicates an as needed use of restraints. According to the documentation bilateral wrist and ankle restraints were initiated on June 23, 2010. A physician's order indicates that in addition to the renewal of the bilateral wrist and ankle restraints a lap tray was also ordered. The order for bilateral wrist and ankle restraints and the lap tray were renewed until his discharge on September 13, 2010. According to the nurses documentation the lap tray was used when the patient was up in the chair and the bilateral soft wrist and ankle restraints were utilized when the patient was in bed. However, the physician's order did not reflect this, but reflected an as needed use when the order for both the lap tray and the bilateral ankle and wrist restraints were renewed every 24-hours. In addition, on August 19, 2010 a nursing notes at 3:30 p.m. indicates that the patient was restrained with bilateral wrist restraints then bilateral ankle restraints were added because he was trying to get out of bed. A new order was not received to reflect the addition of the ankle restraints.

Employee (B)/administrative nurse and (C)/administrative nurse, interviewed together on October 8, 2010 at 11:50 a.m. stated that a new physicians order would be required for the reapplication of restraints.

Based on documentation review and interviews the hospital failed to ensure that restraints were removed at the earliest possible time for one of eleven patient (#3) records reviewed. Findings include:

The hospital's restraint policy and procedure last updated on January 9, 2007, indicates that restraints must be discontinued at the earliest possible time and restraints may only be employed while the unsafe situation continues. Once the specific situation ends, the restraint must end.

Patient #3's medical record indicates that he was admitted on May 24, 2010 and discharged on September 13, 2010. The patient had a diagnoses of a right sided temporal contusion with subarachnoid hemorrhage and respiratory failure. The patient was admitted to the hospital for ventilator weaning and rehab. The patient had a history of hallucinating and once the patient was weaned off the ventilator the patient frequently attempted to get out of bed and was resistive with cares. The hospital initiated bilateral wrist and ankle restraints for the patients safety. However, according to the documentation in the nurses notes and nursing restraint documentation the patient remained in bilateral soft ankle and wrist restraints while he was sleeping on the following days:
*June 23, 2010 at 6:30 p.m.
*June 25, 2010 on the night shift when it was documented that the patient slept well but awoke at 5:00 a.m.
*June 26, 2010 at 12:00 a.m.
*June 28, 2010 at 8:15 a.m., when the documentation indicates the patient is too drowsy to eat
*July 11 into July 12, 2010 when it indicates the patient slept throughout the night.
*July 14 into July 15, 2010, at 12:00 a.m.
*July 15, 2010 at 8:00 p.m.
*July 23, 2010 at 4:00 a.m.
*July 23, 2010, documentation indicates that the patient slept well.
*July 24, 2010 at 12:00 a.m.
*July 26, 2010 at 12:00 a.m.
*July 27, 2010, at 5:00 a.m.
*July 27, 2010, documentation indicates that the patient slept most of the night, the night of July 27 into July 28, 2010.
*July 28 into July 29, 2010 when documentation indicates patient slept well all night and restraints released hourly.
*July 30, 2010 at 2:00 a.m.
*July 31, 2010 at 5:15 a.m.
*August 1, 2010 at 5:30 a.m.
*August 3, 2010 at 4:00 p.m.
*August 7, 2010 at 10:00 p.m.-12:00 a.m. documentation indicates the patient is resting quietly.
*August 11, 2010 at 12:09 a.m.
*August 12, 2010 at 3:00 a.m. after medicated with haldol and percocet and the patient is documented to be sleeping.
*August 15, 2010 at 3:15 a.m.
*August 16, 2010 at 3:40 a.m.
*August 16, 2010 into August 17, 2010 when documentation indicates patient slept well (that night).
*August 20, 2010 into August 21, 2010 when documentation (time not given) indicates that the patient slept throughout the night.
*August 24, 2010 at 8:00 p.m. when documentation indicates the patient is pleasant and cooperative and remains in four point restraints.
*August 25-26, 2010 at 6:00 a.m.
*August 26, 2010 documentation indicates the patient slept well after taking Seroquel 300 mg.
*September 5, 2010 at 12:01 a.m.

Employee (B)/administrative nurse and (C)/administrative nurse, interviewed together on October 8, 2010 at 11:50 a.m. stated that although they could not comment directly on this patient's use of restraints, they questioned the need for a restraint when a patient is sleeping.