HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to inform the Patient's representative of a change in condition and did not include the Patient's representiative in making informed decisions in patient care in 1 of 10 medical records reviewed. (Patient #2)

Refer to TAG: A-0131.

The Hospital failed to document the Patient's response to the use of restraints in 2 of 10 medical records reviewed. (Patient #2 and Patient #7)

Refer to TAG: A-0188

Based on record reviews and interviews, the Hospital failed to provide Patient #2 or his/her representative with the right to make informed decisions regarding his/her care when a restraint was initiated in 1 of 10 medical records reviewed.

Findings include:

Patient #2 was admitted to the Hospital in 3/2021 in the Intermediate Care Unit (IMC) after being brought to the Emergency Department for lethargy, short of breath, and wheezy.

Review of the nursing progress notes (DARP note) indicated that on 3/6/21 at 2:30 A.M. Patient #2 was restless and continued to attempt to get out of bed, vital signs were stable and Patient #2 was alert and oriented X 2 (Person and Place). An order for a SOMA enclosure bed was provided for patient safety.

Review of the nursing progress notes (DARP note) indicated that on 3/6/21 at 2:39 P.M., Patient #2's daughter called at around 11:00 A.M. and was notified by Nurse #1 that Patient #2 became restless overnight and required an enclosed bed restraint to keep him/her safe. Patient #2's daughter became verbally aggressive and shouted "why wasn't I made aware of this change? No one has updated me in two days. I need a call from the doctor now. RN#1 ensured Patient #2's daughter that she would pass off in report that the daughter was to be called with any changes to the patient's status regardless of the time of day or night.

During an interview on 12/1/21 at 12:45 P.M., Physician #1 said that if he gives a verbal order for a restraint, he tells the nurse to notify the family.

During an interview on 12/1/21 at 1:30 P.M., Nurse #1 said that the protocol for placing a patient in a restraint is to call family first.

During an interview on 12/2/21 at 9:00 A.M., the Vice President of Quality and Regulatory Compliance said that it would be the Hospital's typical practice to notify family if a patient is placed in restraints.

During an interview on 12/2/21 at 9:30 A.M. with the Clinical Manager and Clinical Leader of IMC/ Riley 3, they said the policy is that the family should be asked about being called in the middle of the night to notify of changes in patient care. The Clinical Manager said that they need to tighten up their communication on the unit.

During an interview on 12/2/21 at 10:45 A.M., Physician #2 said that when a restraint is ordered, usually family would be called to be notified. She was unsure if this happened in this case.

During an interview on 12/2/21 at 11:30 A.M., Physician #3 said that it is best practice to notify family with a change in condition.

During an interview on 12/2/21 at 12:00 P.M., Nurse #2 said that she would notify family when the use of a restraint is going to take place.

The Hospital failed to notify Patient #2's representative when there was a significant change in his/her condition which required Patient #2 to be placed in an enclosed bed as a restraint in the middle of the night.

Based on record review and interviews, the Hospital failed to document for 2 of 10 Patient's reviewed (Patient #2 and Patient #7), their response to the restraints used while admitted to the Hospital.

Findings include:

Review of the Hospital's policy titled Restraints and/or Seclusion, reviewed 4/2021, indicated that once a patient is placed in a restraint, the documentation included in the assessment must identify the patient's response to the use of the restraint.

Patient #2 was admitted to the Hospital in 3/2020 on the Intermidiate Care Unit (IMC) of the Saint's Campus. On 3/6/21 at 2:05 A.M., Patient #2 was placed in an enclosed bed restraint when he/she became restless and attempted to get out of bed.

Review of the every 2 hour assessments of the restraint indicated that the nursing documentation of the restraint assessment did not identify Patient #2's response to the restraint. The documentation identified skin assessment, range of motion assessment, nutrition/hydration offered and hygiene and elimination. The assessment identified alternatives provided to the patient at the time of the assessment, but never documented the Patient's response to the restraint used in 12 hours of use.

Record review indicated that on 3/6/21 at 2:00 P.M., Nurse #1 documented that Patient #2 was able to be moved out of enclosed bed and to a regular patient bed as his/her confusion lessened.

Patient #7 was admitted to the Hospital in 11/2021 on the Intermediate Care Unit (IMC) of the Saint's Campus. On 11/16/21 at 1:57 P.M., Patient #7 was placed in an enclosed bed restraint when he/she became increasingly agitated, attempting to get out of bed multiple times and was not easily redirectable.

Review of the every 2 hour assessments of the restraint indicated that the nursing documentation of the restraint assessment did not identify Patient #2's response to the restraint. The documentation identified skin assessment, range of motion assessment, nutrition/hydration offered and hygiene and elimination. The assessment identified alternatives provided to the patient at the time of the assessment, but never documented the Patient's response to the restraint used in 7 days of use.

Record review indicated that on 11/23/21 at 1:25 P.M. (7 days after the restraint was initiated) Patient #7 was taken out of the enclosed bed restraint and transferred to a chair with the assist of 2 staff members. Incontinence care was provided. Patient #7 was disoriented to person, place and time, but that is his/her baseline mental status. Pt. was alert and talkative, feeding him/herself ginger ale and applesauce. Patient was discharged later that day home, with family.

During an interview on 12/2/21 at 9:30 A.M., the Clinical Manager and the Clinical Leader of the Intermediate Care Unit (IMC) said that they ideally would want all decrease attempts to remove restraints documented. They said that they have told the nursing staff that if they didn't document it, it didn't happen.

The Hospital failed to identify Patient #2 and Patient #7's response to the enclosed bed restraint during any and all assessments that were documented in the Patient's medical record.