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Based on record review and interview, the facility failed to have a physician order for restraint for 2 (P-1, P-7) of 2 patients reviewed for restraint resulting in the potential for injury and loss of patient rights. Findings include:

See Specific Tag:

A-168 Failure to have a physician order for restraint.

Based on record review and interview, the facility failed to assess and provide wound care according to standards of practice and hospital policy for 1 (P-1) of 1 patients reviewed for wound care resulting in an increase in the size of the wound and the potential for poor patient outcomes. Findings include:

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A-395 Failure to assess and evaluate the care of the patient according to standards of practice and hospital policy.

Based on record review and interview, the facility failed to have a physician order for medical restraints for 2 (P-2, P-7) of 2 patients reviewed for restraint usage resulting in the violation of patients' rights and the potential for adverse patient outcomes. Findings include:

On 7/25/2023 a 1515, review of the medical record for P-1 revealed he was admitted to the facility 12/1/2022-3/11/2023 with acute bronchitis, acute kidney injury with acute tubular necrosis, acute on chronic respiratory failure with hypoxia. P-1 was in and out of bilateral mitt restraints and bilateral soft wrist restraints to prevent interference with medical equipment.

Review of physician orders revealed restraint orders for P-1 on the following dates in 2023: 1/16, 1/30, 1/31, 2/1, 2/3, 2/5, 2/6, 2/21, 2/27, 3/1, 3/2, 3/3, 3/6, 3/8, 3/9, and 3/10.

Review of the nursing flow sheet for documentation of patient assessments every two hours during restraint revealed the patient had remained in restraints on the following days in 2023: 2/2, 2/4, 2/22, 2/23, 2/24, 2/28, 3/4, 3/5, and 3/7.

On 7/25/2023 at 1545, Staff B confirmed restraint orders should be present for each day the patient was in restraint.

On 7/26/2023, Physician Staff K confirmed restraint orders should be written every day restraint usage needs to be continued. He further stated, "I'm not good with that. I need to work on that."

On 7/26/2023 at 1020 review of the medical record for P-7 revealed he was admitted to the facility 5/13/2023-7/22/2023 with acute on chronic respiratory failure and encephalopathy. P-7 was placed in bilateral mitt restraints to prevent interference with medical equipment.

Review of physician orders revealed restraint orders for P-7 on the following dates in 2023: 5/16, 5/20, 5/21, 5/23, 5/24, 5/25, 5/26, 5/29, 5/30, 5/31, 6/1, 6/2, 6/3, 6/4, and 6/5.

Review of the nursing flow sheet for documentation of patient assessments every two hours during restraint revealed the patient had remained in restraints on the following days in 2023: 5/17, 5/18, 5/22, 5/27, and 5/28.

On 7/26/2023 at 1100, Staff B was queried as to who the Medical Director of the facility was to which she replied it was Physician Staff K.

Facility policy #8961868 titled "Restraint and Seclusion Policy" effective 7/28/2021 states, "Restraints/seclusion can only be ordered by Licensed Independent Practitioners (LIPs), residents, Physician Assistants (PAs), and Advanced Practice Registered Nurses (APRNs)... NON-VIOLENT/NON-SELF-DESTRUCTIVE-RESTRAINTS 1. The order is good for the episode of care. If restraints/seclusion are discontinued and are needed again, a new order must be obtained..."

On 7/26/2023 at 0840, Quality Performance Improvement Coordinator Staff B was queried as to the meaning of "episode of care" in the policy. Staff be stated it was the time the patient was in restraint to the time they were taken out of restraint prior to the renewal of the order. Staff B confirmed no time frame was given in the policy for how often a non-violent restraint order needed to be renewed.

Based on record review and interview, the facility failed to assess and provide wound care according to acceptable standards of practice and hospital policy for 1 (P-1) of 1 patients reviewed for wound care resulting in an increase in the size of the wound and the potential for poor patient outcomes. Findings include:

Medical record review of P-1's admission from 12/1/2023-3/11/2023 revealed on 12/1/2023 Staff L documented a Stage II pressure ulcer of the coccyx. Physician orders were reviewed and reflect orders for care of the coccyx pressure ulcer on 12/6/2022 for twice daily dressing changes with collagenase to damp saline into creased and folded fluff. Review of nursing interventions reveals no documentation of dressing changes on 12/7/2022, 12/9/2022, 12/10/2022, 12/15/2022, 12/18/2022, 12/19/2022, 12/23/2022 and only (1) dressing change on 12/11/2022, 12/12/2022, 12/13/2022, 12/14/2022, 12/20/2022, 12/21/2022, 12/22/2022, 12/24/2022, 12/25/2022. Documentation of dressing changes demonstrated various care of the wound and did not consistently adhere to physician orders.

Review of the medical record demonstrated P-1 was transferred to a nearby acute care facility on 12/26/2022 for chest pain and returned 8 hours later and upon readmission the skin assessment of the coccyx pressure wound is documented as "unstageable". The wound care nurse evaluated P-1 on 12/26/2022 and recommended collagenase and dressing changes every 12 hours. Medical record review showed multiple gaps in documentation of dressing changes with no dressing changes on 12/27/2022, 12/30/2022, 1/4/2023, 1/5/2023, 1/7/2023, 1/10/2023, 1/13/2023 and 1/24/2023. Documentation reveals no dressing change documentation from 1/24/2023-1/30/2023, 2/3/2023-2/6/2023, 2/11/2023-2/15/2023, 2/24/2023-3/1/2023, 3/1/2023-3/6/2023 and 3/6/2023-3/9/2023. Documentation of dressing changes did not consistently follow orders.

During an interview on 7/26/2023 at 1300 Staff L was asked whether there were times when there was a delay in obtaining orders for wound care and she responded "yes". When asked whether enough support is provided for patient wound care, Staff L responded "no, not as of late" and "in my heart I feel we need a full-time wound nurse".

Review of Policy #1095934, Physician's Orders and Guidelines on 7/26/2023 at 1530 revealed on page 3 "PROCEDURE: 1. Review all electronic orders entered by the physician or their designee. Once reviewed RN must initiate all orders to activate the orders in the EMR."