HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure that a registered nurse supervised the care for two(2) of four current sampled patients(Patient # 6, #7).

The facility failed to ensure:

Orders for restraint were completed for Patient # 6 and Patient # 7 per facility policy ; and

Vital signs were measured and recorded for Patient # 7 during a blood transfusion per facility policy.

Findings include:

Restraint Orders:

Patient # 6

Record review of the clinical record for Patient # 6 revealed he was admitted to the facility on 01-15-15 with a diagnosis of Septicemia and was ventilator-dependent.

Review of physician order, dated 02-09-15 , revealed a telephone order for bilateral "mitten, limb/soft restraints;" left and right hand and wrists. Further review of this order revealed the section titled "Nursing Assessment/Reason for Restraint (Patient Behaviors/Observations) was left completely blank. The section titled "Alternatives Considered/Attempted Prior to Interventions" was also completely blank.

Observation on 02-09-15 at 10:30 a.m. revealed Patient # 6 laying in bed ; bilateral soft mitten restraints in place.

Patient # 7

Record review of the clinical record for Patient # 7 revealed he was admitted to the facility on 01-31-15 ; he was ventilator-dependent.

Review of physician order, dated 02-09-15, revealed a written order for soft "left wrist" restraint. The Registered Nurse documented the restraint was applied at 8:00 ; the RN failed to document if it was "a.m. or p.m." Further review of this same order revealed the section titled "Nursing Assessment/Reason for Restraint (Patient Behaviors/Observations) was left completely blank.

The restraint order for Patient # 7 was signed by a physician but was not dated or timed.

Interview on 02-09-15 at 11 a.m. with RN Staff Educator # 5 she stated all sections of the "Restraint Initiation Order" should be completed prior to restraints being applied. All entries / signatures on this form should be dated and timed.

Review of facility policy titled" Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," dated 10/2014, read: "..."the following guidelines for restraint application are required for each episode for non-violent and violent /self destructive behavior: ...clinical justification...describing the unsafe situation and how it impacts the patient's safety...what less restrictive measures have been considered or attempted..."

Vital Signs/ Blood Transfusion:

Patient # 7:

Record review of the clinical record for Patient # 7 revealed he was admitted to the facility on 01-31-15 ; he was ventilator-dependent.

Record review of physician order, dated 02-04-15 ( time 2055) , read: " transfuse 2 units of packed red blood cells(PRBC). "

Record review of Patient # 7's clinical record revealed a form titled " Blood and Blood Components Flowsheet," dated 02-04-15. Further review revealed documentation that 2 units of PRBC were transfused on 02-04-15: one started at 2100 hours and the other started at 2345 hours.

Further review of this same form failed to reveal that Patient # 7's temperature was measured and recorded at the required time intervals of (2-04-15) : 2135, 2330 and (02-05-15): 0005, 0145, 0245, and 0300. These six (6) areas for recording of patient temperature were left blank.

Interview on 02-09-15 at 11 a.m. with RN Staff Educator # 5 she stated the 6 sections left blank on Patient # 7's Blood Component Flowsheet should have had documented temperature readings.

Review of facility policy titled " Transfusion Therapy," dated 08/2013, read: "...2.Vital signs will be observed and documented at a minimum at the following intervals/times: pre-transfusion... 15 minutes after start of transfusion...30 minutes after start of transfusion... 1 hour after start of transfusion...hourly until transfusion complete.....at the conclusion of the transfusion and 1 hour post transfusion..."