HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt.#1) clinical records reviewed regarding use of restraints, the hospital failed to ensure that the staff documented the required assessments/reassessments while patient wwas in non-violent restraints.

Findings include:

1. On 01/30/24, the hospital's policy titled, "Restraints" (revised 09/03/20) was reviewed and required, "Observation/Monitoring: Acute Medical and Surgical Care (non-violent or non-self-destructive behavior) ... At a minimum of every two Hours: Monitor circulation, movement, and sensation (CMS) - Skin integrity, Condition or symptoms that warranted use of restraint ... Documentation of the above observation and monitoring will be reflected on the appropriate flowsheet ..."

2. On 01/30/24, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 10/23/23 with diagnosis of acute UTI (urinary tract infection). On 10/24/23 through 11/06/23, Pt.#1 was placed on soft restraints to bilateral wrists due to interference with medical treatment. The Non-violent Restraint Q2H (every 2 hour) Observation flow sheets dated 10/23/23 through 11/06/23 were reviewed and indicated that for the following dates the clinical record lacked documentation that assessments for circulation, movement, sensation, and skin integrity were completed every 2 hours as required:

-10/26/23 from 6:00 PM to 10/27/23 at 2:00 AM (8 hours)
-10/27/23 from 10:00 AM to 12:00 PM (2 hours)
-10/29/23 from 10:00 AM to 10/30/23 at 2:00 AM (16 hours).
-10/30/23 from 10:00 PM to 10/31/23 a 8:00 AM (10 hours).

3. On 01/30/24 at approximately 11:30 AM, an interview was conducted with the Nursing Director (E #8). E #8 confirmed that for the above dates, the clinical record lacked documentation of every 2-hour assessments for (Pt.#1). E #8 stated that staff are required to complete and document an assessment for circulation, movement, and sensation while patients are on non-violent restraints.

Based on document review and interview, it was determined that for 1 of 5 (Pt.#1) clinical records reviewed for post fall assessment, the hospital failed to ensure that a registered nurse completed vital signs and neurological checks, as required.

Findings include:

1. On 01/30/24, the hospital's policy titled, "Fall Prevention/Post Fall Assessment" (effective date 02/07/23) was reviewed and required, " ... V. C. In case of a fall, the following post-fall management should be followed ... 4. RN to take full set of vitals, as well as neurological checks every 2 hours x 3 occurrences..."

2. On 01/30/24, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 10/23/23 with diagnosis of acute UTI (urinary tract infection).

-The Physician Hospitalist note dated 11/08/23 at 9:35 PM, included, "I was called to evaluate (Pt.#1) status post unwitnessed fall. Reportedly (Pt.#1) fell off his bed ... is noted to have small laceration above (Pt. #1) left eyebrow. CT brain, cervical spine were negative for acute finding. Skin laceration was managed with Dermabond ... Sitter at the bedside."

-The Vital Signs flow sheets dated 10/23/23 through 11/20/23 were reviewed. The flow sheets indicated that on 11/08/23 after (Pt.#1's) fall (at 7:15 PM), the first set of vital signs were done at 10:51 PM (3 hours and 31 minutes post fall). The neuro checks every 2 hours x 3 post-fall were not completed as required.

3. On 01/31/24 at 11:40 AM, an interview was conducted with the Nursing director (E#8). E#8 confirmed that after an unwitnessed fall, the nurse is required to complete a set of vital signs and neurological assessments every 2 hours three times. E#8 confirmed that staff failed to complete the required post fall assessments.