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Based on record review and interview, the facility failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care. This affected one (Patient #7) of six patients reviewed for restraints. The census at the time of the survey was 30.

Findings include:

Record review for Patient #7 revealed restraint by the use of mittens on 11/01/18, 11/02/18 and 11/19/18. Review of Patient #7's plan of care and team conference meeting minutes lacked evidence the use of restraints was addressed.

During interview on 11/21/18 at 11:39 A.M., Staff B confirmed the above findings.

Review of the facility policy titled "Restraints and Seclusion (R02-N)", revealed "modification of the patient's treatment plan related to restraint use, patient's response to restraint, and plan for reduction/elimination is included in the patient's medical record."

Based on record review and interview, the faciliy failed to ensure the use of restraints was in accordance with the physician order. This affected two (Patients #4 and #5) of six patients reviewed for restraint use. The census at the time of the survey was 30.

Findings include:

1. Record review revealed Patient #4 had a physician's order on 11/14/18 at 7:04 A.M. for soft wrist restraints. At 7:05 A.M., an RN documented on the restraint flowsheet a right mitten was in place. At 7:24 A.M., the same RN reviewed and confirmed the physician's order for soft wrist restraints. There was no documented evidence Patient #4 was placed in soft wrist restraints or that the order was questioned.

During interview on 11/20/18 at 11:00 A.M., Staff B confirmed the above findings.

2. Record review for Patient #5 revealed the use of bilateral soft wrist restraints between 11/11/18 and 11/13/18 inclusive. There was no physician order for the use of restraints on 11/12/18.

During interview on 11/21/18 at 11:39 A.M., Staff B confirmed the above findings.

Based on record review and interview, the facility failed to ensure nursing staff documented the condition of the patient while restraints were in use. This affected three (Patients #4, #5 and #6)of six patients reviewed for the use of restraints. The census at the time of the survey was 30.

Findings include:
1. Review of Patient #4's electronic medical record for the period of time 11/13/18 to 11/20/18 revealed the restraint documentation required every shift was not completed.

During interview on 11/21/18 at 11:39 A.M., Staff B confirmed the above findings.

2. Review of Patient #5's electronic medical record revealed for the period of time 11/08/18 to 11/19/18 revealed the the restraint documentation required every shift was not completed.

During interview on 11/21/18 at 11:39 A.M., Staff B confirmed the above findings.


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3. Record review for Patient #6 revealed a physician's order for mitten hand restraints for use on 10/24/18, 10/25/18 and 10/26/18. On 10/25/18 and 10/26/18 for the period of time of 7:00 P.M. to 7:00 A.M., the every shift restraint documentation was not completed as required.

During interview on 11/21/18 at 11:39 A.M., Staff B confirmed the above findings.

The facility policy titled "Restraints and Seclusion (R02-N)" documented the following items were to be documented on each restrained patient every shift and as needed:

Behavior/condition necessitating use of protective restraints

Type of device applied and patient response

Alternatives to restraint and patient response

Based on record review and interview, the facility failed to document the patient's responsible party was educated prior to the blood transfusions and failed to document vital signs were monitored during and after the transfusion. This affected two (Patients #4 and #6) of three sampled patients who received a blood transfusion. The census at the time of the survey was 30.

Findings include:

1. Record review revealed Patient #6 was admitted on 08/20/18 with diagnoses including acute kidney injury, sepsis, urinary tract infection, protein calorie malnutrition, acute respiratory failure with hypoxia and anemia secondary to chronic renal failure. The patient had a sacral pressure sore and multiple skin ulcers. The patient also had tracheostomy, received ventilator breathing support, had a feeding tube, was on dialysis and was in contact precautions for Vancomycin resistant Enterococci (antibiotic resistant infection).

The physician ordered two units of red blood cells transfused on 08/23/18 at 10:57 A.M., one unit on 10/15/18 starting at 11:53 A.M., and one unit on 10/23/18 starting at 1:36 A.M.

The consent for the blood transfusions was obtained on 08/21/18 at 12:58 P.M., prior to the physician orders and signed by the patient's spouse. The consent form had an area for the physician or licensed practitioner to sign, date and time as follows: that this person explained the matter indicated above (consent/refusal of blood or blood products) related to the procedure and the risk, consequences and alternative, and the patient and/or legally responsible person indicated appeared to understand and consented to the procedures described above. This portion of the form was not signed.

Documentation review of the blood transfusion on 10/23/18 revealed pre-transfusion vital signs were obtained at 6:14 A.M. The patient's vital signs obtained at 6:30 A.M. revealed a blood pressure of 148/79, maxillary temperature of 98.4 degrees Fahrenheit (F), pulse rate of 60 and respiratory rate of 16 per minute. The starting time of the transfusion was 6:46 A.M. At 8:00 AM the patient's blood pressure increased to 160/81, respiratory rate increased to 33 per minute, and temperature to 97.4 degrees F. There was no documentation identifying whether the entire unit of blood was transfused, the ending time of the transfusion and an assessment of the patient at the conclusion of the transfusion.

During interview on 11/21/18 at 1:34 PM, Staff C confirmed the consent for Patient #6 was completed before the physician's order was obtained, which was not in accordance with facility policy. Staff C also confirmed the physician did not complete the section of the consent where the risks, consequences and alternatives were explained to the patient and/or representative. Staff C stated vital sign assessment should be done immediately prior to the blood transfusion, fifteen minutes after initiation, and at the conclusion of the transfusion, and the transfusion should be within a four hour maximum time frame.



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2. Review of Patient #4's medical record revealed a physician order for two units of packed red blood cells on 11/19/18. The consent form was signed by the patient's representative and a registered nurse on 11/14/18 at 10:00 A.M., five days prior to the physician's order.

The same consent also lacked documented evidence a physician explained the risk, consequences and alternatives of the procedure and verified the patient and/or his representative understood and consented to the blood transfusion.

Review of Patient #4's Transfusion Record revealed no documentation whether or not Patient #4 was medicated prior to the transfusion; whether or not informed consent for the transfusion was obtained; whether or not Patient #4 had a previous transfusion; and whether or not the blood was released for use.

During interview on 11/20/18 at 1:33 P.M., Staff A verified the above findings.

Review of the facility policy titled "Blood/Blood Components Administration (B04-N)" documented the following:

-"informed consent must be obtained after a physician order's transfusion of blood and/or blood components and before the type and cross-match are obtained."

-"RN must remain with patient for the first 15 minutes. If any adverse conditions arise,the blood transfusion should be stopped immediately"

-"For each separate infusion, vital signs (including temp) should be recorded prior to starting, at 15 minutes and immediately post-transfusion or as indicated on the Blood Banking Blood Administration Record."

-"Record immediate post transfusion vital signs, including temperature."