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Based on facility policy review and record review the facility failed to obtain restraint orders for one (Patient #3) of two patient restraint records reviewed. The facility census was 26.

Findings included:

1. Review of facility policy titled "Restraints" implemented September 2009 showed the following direction:
Section 3: Orders for restraint are timed limited and must include
a. Date and time
-The Physician must sign, date and complete the physician order after a face-to-face evaluation of the patient's physical and mental status within 24 hours of the initiation of the restraint.

2. Record review of Patient #3's current medical record showed Patient #3 was admitted on 1/17/11.

Review of Patient #3's "24 Hour Flowsheet" dated 1/20/11, showed at 7:30 PM, mittens remain in place. Review of the "Restraint Flowsheet" showed an assessment for restraints at 9:00 PM.

Review of Patient #3's Physician orders showed a Restraint Order dated 1/20/11 for right and left mittens for picking/pulling at/reaching for lines/tubes/dressings. The order had no time, was not written as a verbal/telephone order and had no physician signature.

Based on facility policy review, record review and interview the facility failed to ensure restraint orders are authenticated according to the facility policy for two (Patients #1 and #3) of two patient restraint records reviewed. The facility census was 26.

Findings included:

1. Review of facility policy titled "Restraints" implemented September 2009 showed the following direction:
-Section 3: Orders for restraint are timed limited. No prn (as needed) orders are acceptable. The policy documents the restraint orders must include:
a. Date and Time

-The physician must sign, date and complete the physician order after face-to-face evaluation of the patient's physical and mental status within 24 hours of the initiation of the restraint.

2. Current medical record review of Patient #1's physician orders showed:
-An order dated 1/11/11 for side rails up times four for Patient #1 picking/pulling at lines/tubes/dressings. The order had no physician signature.
-An order dated 1/2/11 for side rails up times four for Patient #1 picking/pulling at lines/tubes/dressings had been signed by the physician, but was not timed.
-An order dated 1/5/11 for a lap board and right and left wrist restraints for Patient #1 picking/pulling at lines/tubes/dressings had been signed by the physician, but was not timed.


3. Current medical record review of Patient #3's physician orders showed a telephone order for right and left mittens for Patient #3 picking/pulling at/reaching for lines/tubes/dressings. The physician's order was dated 1/18/11 at 2:00 PM, but had not been signed by the physician.

During an interview on 1/26/11 at 8:15 AM, Staff B Chief Clinical Officer stated that verbal orders are to be signed by the physician within 24 hours. Staff B stated that physician's orders need to be dated and timed.

Based on record review and interview the facility failed to ensure staff documented the date and time restraint related deaths were reported to CMS (Centers for Medicare & Medicaid) for one (Patient #9) of one restraint related death record reviewed and failed to report one (Patient #9) restraint related death to CMS by the end of the next business day following the death. The facility census was 26.

Findings included:

1. Review of the facility policy titled "Restraints" implemented September 2009, showed the following direction:
-Death Reporting Requirements
The hospital administration must report the following information to CMS:
-Each death that occurs while a patient is in restraint.
-Each death that occurs within 24 hours after the patient has been removed from a restraint.
Staff must document in the patient's medical record the date and time the death was reported to CMS.

2. Discharged medical record review on 1/26/11 showed Patient #9 was admitted on 12/14/10.

Review of nurses' notes dated 12/29/10 at 9:00 AM, showed Patient #9 with wrist restraints for pulling at tubes.

Review of the death summary showed Patient #9 expired on 12/29/10 at 2:53 PM.

Further review of the nurses' notes showed no date or time staff notified CMS of patient's death, which was within 24 hours of restraint removal.

During an interview on 1/26/11 at 2:00 PM, Staff J Chief Executive Officer stated that she was not aware the facility had a patient expire within 24 hours of being in restraints. Staff A stated that they had not reported the death to CMS and therefore it was not documented in the chart.

Based on record review and interview, the facility failed to ensure physician progress notes were authenticated (signed, dated, and timed) for two (Patients #1 and #5) of 12 records reviewed. The facility census was 26.

Findings included:

1. Review of the facility policy titled "Authentication of Medical Record" dated September 2009, showed the following direction:
- All entries in the medical record will include a signature.
- All entries in the medical record will be timed and dated.

2. Review of Patient #1's discharged medical record showed physician progress notes written on 12/30/10, 1/5/11 and 1/9/11 were signed and dated, but were not timed.

3. Review of Patient #5's current medical record showed physician progress notes written on 1/14/11, 1/15/11, 1/17/11, 1/21/11, 1/22/11, 1/23/11 and 1/24/11 were signed and dated but were not timed.

During an interview on 1/26/11 at 11:00 AM, Staff H Director of Health Information Management, stated that all entries in the medical record should be signed, dated and timed. Staff H stated that if a document is signed it should be dated and timed at the time the signature occurred.


16309

Based on record review and interview, the facility failed to ensure physician orders were authenticated (signed, dated, and timed) for two (Patients #1 and #10) of 12 records reviewed. The facility census was 26.

Findings included:

1. Review of the facility policy titled "Verbal and Written Orders" dated September 2009, showed the following direction:
-Written orders must be authenticated and dated by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished.

2. Review of Patient #1's discharged medical record showed the following physician's orders were not timed:
-On 12/29/10 complete blood count, complete metabolic panel, vitamin B12, folic acid lab test in am; discontinue Librium (anxiety medication) and start Ativan (anxiety medication) 4 milligrams (mg) every morning
-On 12/30/10 discontinue Ativan scheduled dose; Ibuprofen (pain medication) for back pain and give Ativan 1-2 mg intravenous every 12 hours as needed


3. Review of Patient #10's current medical record showed physician admitting orders were signed by the physician, but were not dated and timed.

During an interview on 1/26/11 at 8:15 AM, Staff B Chief Clinical Officer stated that physician orders should be dated and timed.

Based on record review and interview the facility failed to ensure verbal orders were signed by a physician with 48 hours for two (Patient's #1 and #3) of 12 records reviewed. The facility census was 26.

Findings included:

1. Review of the facility's policy titled "Verbal and Written Orders" dated September 2009 showed the following direction: 2. c. Verbal orders shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 48 hours of receipt.

2. Review of Patient #1's discharged medical record on 1/25/11 showed the following physician's orders:
-A verbal order dated 1/1/11 at 10:15 PM, for Dilaudid (pain medication) 2 milligrams(mg) intravenous(IV) every six hours as needed. The order was not signed, dated or timed.

The following physician's orders were signed, but had no date or time to indicate being completed within the 48 hours.

-A verbal order dated 12/31/10 at 4:00 PM, to discontinue Foley catheter; may use condom catheter if needed.
-A verbal order dated 1/4/11 for Haldol (antipsychotic medication) 5 mg IV times one now.
-A verbal order dated 1/6/11 at 1:10 PM, to discontinue tube feeding.

3. Review of Patient #3's current medical record on 1/25/11 showed a verbal order dated 1/18/11 at 2:15 AM, for chest x-ray in the morning. The order was not signed, dated or timed.

During an interview on 1/26/11 at 8:15 AM, Staff B Chief Clinical Officer stated that physician verbal orders are to be signed within 48 hours. Staff B stated that if the physician does not date or time the orders then you can not verify they are signed within the 48 hours.