HospitalInspections.org

Based on review of clinical records, review of facility documents and interview, the facility failed to ensure the patient had the right to participate in the development and implementation of his or her plan of care in two out of ten patients.

Findings included:

Facility document titled, "Patient Rights" stated in part, "4. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication ... and to participate in the development and implementation of your plan of care."

Review of clinical records for patients #2 and 5 revealed no documentation of patient and/or family participation in the development and implementation of his or her plan of care.

The above was verified in an interview with the Chief Nursing Officer on the afternoon of 8/30/16.

Based on review of clinical records, review of facility documents and interview, the facility failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner.

Findings included:

Facility policy titled, "Restraint Reduction Plan" stated in part, "Rights of Patients: All patient have the right to be free from physical or mental abuse, and corporal punishment. All patient have a right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time ...
Requirements for ordering of restraint for any reason: This policy requires that a physician or other licensed independent practitioner (LIP) responsible for the care of the patient order restraint prior to the application of restraint ...
Use of Restraint Protocols: A protocol cannot serve as a substitute for obtaining a physician's or other LIP's order prior to initiating each episode of restraint or seclusion use ...
PRN ordering of restraint: Orders for the use of restraint must never be written as a standing order or on an as needed basis (PRN).
Staff cannot discontinue a restraint intervention, and then re-start it under the same order. This would constitute a PRN order. A 'trial release' constitutes a PRN use of restraint, and, therefore, is not permitted."

Review of patient #7's clinical record revealed a non-behavioral restraint order dated 2/25/16 at 7:00 AM. On the restraint flow sheet, at 9:00 am the nurse charted, "NP [nurse practitioner] okay to release from restraints, continue close monitoring with frequent visual checks." Restraints were reapplied at 8:00 pm without a new order. The next non-behavioral restraint order was dated 2/26/16 at 7:00 pm. Patient #7 was in restraints for approximately 24 hours without an order by a physician or LIP.

The above was verified on the afternoon of 8/30/16 in an interview with the Chief Nursing Officer.