HospitalInspections.org

Based on review of facility documents, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure verbal orders for restraints were authenticated by the ordering psychiatrist within 24 hours for two of four restraint medical records reviewed (MR8 and MR9).

Findings include:

Review on September 14, 2017, of the facility document "Physician Orders" last reviewed April 2012, revealed "I. Policy: Gnaden Huetten Memorial Hospital Nursing Service policy for physician orders is in accordance with the Pennsylvania Department of Health Rules and Regulations as well as the Pennsylvania State Board of Nursing Rules and Regulations for nursing practice for RN's and LPN's. ... 4. Verbal orders are only acceptable in emergency situations. Telephone orders and verbal orders are to be immediately transcribed onto the patient's medical record and signed, dated, and timed by the physician within 24 hours. The orders must contain date, time, and full signature of person taking the order. ..."

Review of MR8 on September 15, 2017, revealed a verbal order from this patient's psychiatrist dated July 30, 2017, at 14:15 PM instructing nursing staff to apply restraints to the left wrist, right wrist, left ankle and right ankle due to this patient's high risk of harm to self and others. Further review revealed MR8's psychiatrist signed this order for restraint. There was no date and time authenticating when the psychiatrist signed the order.

Review of MR8 on September 15, 2017, revealed a verbal order from this patient's psychiatrist dated July 30, 2017, at 20:15 PM instructing nursing staff to apply restraints to the left wrist, right wrist, left ankle and right ankle due to this patient's high risk of harm to self and others. Further review revealed MR8's psychiatrist signed this order for restraint. There was no date and time authenticating when the psychiatrist signed the order.

Interview with EMP1, EMP2 and EMP3 on September 15, 2017, at approximately 11:30 AM confirmed MR8's verbal order from this patient's psychiatrist dated July 30, 2017, at 14:15 PM and on July 30, 2017, at 20:15 PM instructing nursing staff to apply restraints to the left wrist, right wrist, left ankle and right ankle due to this patient's high risk of harm to self and others. EMP1, EMP2 and EMP3 confirmed MR8's psychiatrist signed these orders for restraints and there was no date and time authenticating when the psychiatrist signed these orders.

Review of MR9 on September 15, 2017, revealed a verbal order from this patient's psychiatrist dated August 2, 2017, at 13:40 PM instructing nursing staff to apply restraints to the left wrist, right wrist, left ankle and right ankle due to this patient's high risk of harm to self and others. Further review revealed MR9's psychiatrist signed this order for restraints. There was no date and time authenticating when the psychiatrist signed the order.

Interview with EMP1, EMP2 and EMP3 on September 15, 2017, at approximately 11:45 AM confirmed MR9's verbal order from this patient's psychiatrist dated August 2, 2017, at 13:40 PM instructing nursing staff to apply restraints or the left wrist, right wrist, left ankle and right ankle due to this patient's high risk of harm to self and others. EMP1, EMP2 and EMP3 confirmed MR9's psychiatrist signed these orders for restraints and there was no date and time authenticating when the psychiatrist signed this order.