HospitalInspections.org

Based on interview and record review the facility failed to ensure that 1 of 1 (Patient#3) patients had a written order for the use of restraint for non violent behavior.

Findings included:

on 09/01/19 at 0915 Patient #3 had restraint placed on the left wrist. The order was documented as a telephone order on 09/01/19 at 0915. The written order is required to be signed by the physician within 1 calendar day of initiation. as of 09/05/19 the order remained unsigned.

During an interview on 09/05/18 at 1120 with Personnel #2 in the Conference Room. Personnel #2 agreed with the above findings.

The restraint Initiation/order (Non-violent Non-self destructive Behavior) order reflected..." Physician/LIP/AHP Assessment/Restraint Order Confirmation (to be completed within 1 calendar day from initiation of the restraint... I have completed a comprehensive assessment of the patient including potential medical problems that may be contributing to the patient's present behavior. I have determined that the restraint(s) are medically necessary for a limited period of time (not to exceed 8 calendar days) to protect patient due to: Restraint reason(s) identified above: other: Physician/LIP/AHP Signature...Time...Date..."

Based on interview and record review the hospital does not have a well-organized nursing service, in that, the nurses failed to follow physician orders to turn every 2 hours for 1 of 1 (Patient#3) of 10 patients sampled.

Findings included:

Patient #3 was admitted to the hospital on 08/21/19 . the chart contained an order to reposition the patient every 2 hours starting on 08/22/19 at 0000. Patient #3's The Electronic Medical Record evidenced the patient was repositioned almost every 2 hours with the following exceptions. On 08/22/16 from 1800 until 0200 on 08/23/19 the patient remained on her right side. On 08/23/19 from 1600 until 2345 the patient remained on her right side. On 08/24/19 from 0128 until 0543 the patient remained on her right side, from 0543 until 1200 the patient remained supine, and from 1200 until 0000 on 08/25/19 the patient remained on her left side. On 08/25/19 from 1620 until 2000 the patient remained on her left side. On 08/26/19 at 1235 until 1721 the patient remained on her right side and from 1721 until 0007 on 08/27/19 the patient remained on her left side. On 08/28/19 from 1615 until 2200 the patient remained on her left side. On 08/29/19 from 1200 until 1732 the patient remained supine. On 08/30/19 from 1200 until 1745 the patient remained supine. On 08/31/19 from 1600 until 0000 on 09/01/19 the patient remained on her left side. On 09/01/19 from 0000 until 0443 the patient remained supine and from 0602 until 1005 the patient remained supine.

During an interview on 09/05/19 ending at 1615 Personnel #1 acknowledged the above findings.