HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 3 of 3 (#2, #4, #5) patients reviewed for restraints out of a total sample of 5.
Findings:

Review of the hospital's policy, Care Plans (last revision 09/2016) revealed, in part,"... The team leader/designee shall develop an maintain the care plans throughout the patient's entire length of stay assuring continuity and accountability for the nursing care of the patient...Procedure: Complete the care plan...as follows:...ii. Individualize the care plan by completing all sections of the care plan with the patient specific data...iii. All care plans must have safety addressed and must be continued throughout hospitalization...v. ...If new issues arise, must initiate new intervention and monitor...vi. All interventions must be dated and initialed when initiated. All interventions that are discontinued must e documented with date of d/c on the care plan update form. b. Evaluate progress towards goal and document progress and modifications on care plan updates form at a minimum of bi-weekly by the Team Leader."


Patient #2
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 03/11/18 for continued physical and speech therapy, severe protein calorie malnutrition management, and postoperative care for his recent cranioplasty. Patient #2 had a recent history of a large right-sided with resulting hemiparesis and hemicraniectomy, then a cranioplasty with replacement of skull along with VP Shunt placement for hydrocephalus management. Review of the physician's orders revealed an order for a right upper extremity restraints from 3/11/18 to 3/13/18 due to the patient attempting to pull at his tracheostomy. Review of Restraint Monitoring forms revealed the patient had restraints implemented during this time period. Review of Patient #3's care plan revealed no problem, goals or interventions for the use of restraints.

Patient #4
Review of the medical record for patient #4 revealed she was admitted to the hospital 02/17/17 for extended care for her severe COPD, endstage and chronic respiratory failure which eventually required ventilatory support. Further review revealed soft wrist restraints were implemented 02/24/17 through 02/28/18 morning when she was transferred to a short term acute care hospital related to a cardiorespiratory arrest. Further review of Patient #4's care plan revealed no problem, goals, or interventions documented for the use of restraints.

Patient #5
Review of the medical record for patient #5 revealed he was admitted to the hospital 02/19/18 for continued physical therapy. His diagnoses included Intracranial hemorrhage (with some lasting effects of lethargy and Trach/PEG dependence),Acute hypoxic respiratory failure, Seizure disorder, Critical Illness Myopathy, Hypertension, and Diabetes. Further review revealed a left soft wrist restraint was implemented 02/22/18, after Patient #5 extubated himself. Review of the care plans for Patient #5 revealed a nursing diagnosis of "Alteration in safety/safety awareness" was initiated with no date or time, and no goals or interventions related to restraints had been documented.


In an interview 03/13/18 at 3:45 p.m. S1CNO and S2MSC reviewed Patient #5' record and verified no care plan was initiated for his restraints. Both agreed the care plan should have been updated with goals and interventions when the restraint was implemented.

Based on record review and interview the hospital failed to ensure each order for restraint(s) used to ensure the physical safety of the non-violent or non-self-destructive patient was instituted and renewed as per hospital policy and procedure. This deficient practice was evidenced by:
1) failure to ensure each order for restraints was complete, dated, and timed for 3 of 3 (#2, #4, #5) patient records reviewed for restraints; and
2) failure to ensure evidence of a reassessment by a physician before each continuation of the use of restraints order was documented for 2 (#4, #5) of 3 (#2, #4, #5) patient records reviewed for restraints from a total sample of 5.
Findings:

Review of hospital policy #1.576, titled "Safety Protocols: Use of Restraints" (review date 09/2016), provided by S2MSC as current, revealed the following, in part: "...B. Orders: A physician's order will be obtained for the restraints for a maximum of 24 hours. After the original order expires, the patient receives a "face-to face" reassessment by a physician who writes a new order if restraints are going to be continued. Each subsequent order shall be for a maximum of 24 hours and shall then require reassessment by the physician. The physicians order must include the type, reason and duration under which the restraint can be used. Each order must be dated, timed, and signed. A verbal physician order must be countersigned by the physician."

1) failure to ensure each order for restraints was complete, dated, and timed .

Review of a hospital memo dated 12/07/17 from S1CNO, addressed to physicians and clinical staff, read, " Please be reminded that all entries made in the client's medical record must be signed. Each entry that you sign must have the date and time. REMEMBER: DATE AND TIME WHEN YOU SIGN" Attached was hospital policy #1.160.001, titled Documentation (12/17), provided by S2MSC as current, revealed, in part that all entries in the medial record shall be dated, timed, and signed by the author.

In an interview 03/13/18 at 11:14 a.m. S2MSC reported the omission of dating and timing of medical record entries had been identified recently, discussed in QA, and was being monitored. He reported that 10 medical records were being reviewed by QA for the last two months, and last month there was 90 % compliance. He agreed there seemed to be a higher number of entries not signed, dated, and/or timed than the monitoring would suggest.

Patient # 2
Review of the medical record for Patient #2 revealed an Restraint Assessment and Physician order form that documented an assessment by an RN stating the reason for restraints was to protect medical devices: danger to himself, "pulling Trach out". The assessment was signed and dated by the RN, with no time of assessment or start time of the restraints noted on the order. No documentation of a verbal order was noted. Further review revealed the order was signed by the physician with a date of 03/11/18. No time of the signature of the physician was noted. Review of an order sheet titled "Continue Restraint Order" revealed a preprinted order sheet that stated, "Face to Face reassessment by the physician indicates clinical justification for continued use of restraints for the following reason/action: (circle) protective medical device(s), other. 'Protect medical devices' was circled. Below that documentation were blanks next to the words, "Start date:, Start time:, End Date:, and End Time: " These were filled in with '3/12/18, 7A' (for start date and time) and ' 3/13/18, 7A' (for end date and time.) Directly below that was the Type of restraint to be used, with instructions to circle all that apply (Soft Wrist: Left, Right, Soft Ankle: Left, Right, and Mitten device: Left/Right). Soft Wrist, Right were circled. At the bottom of the order sheet was a Physician Signature line. The signature line contained the physician's signature, with no date or time. Further review of the restraint orders revealed no documented times the orders were received or signed, with no evidence documented as to what time the restraint initiation orders were received/given or whether the restraint continuation orders were signed within 24 hours of renewal or continuation.

Patient #4
Review of the medical record for patient #4 revealed she was admitted to the hospital 02/17/17 for extended care of her severe COPD, endstage and chronic respiratory failure which eventually required ventilatory support. Further review revealed soft wrist restraints were implemented 02/24/17 through 02/28/18 her transferred to a short term acute care hospital. Further review revealed an initial restraint order for right and left upper extremity restraints. The assessment section of the order sheet, completed by the RN documented the time limit as "24 hours. 0930 (9:30 a.m.). Further review revealed a physician's signature with no date or time of that signature. Further review of restraint continuation orders revealed orders with start date and times/end dates and times as follows: 1) start 2/25/17 at 7:01 a.m., end 2/26/17 at 7:00 a.m., 2) Start: 2/26/17 at 7:01 a.m., end 2/27/17 at 7:00 a.m., 3) start 2/27/17 at 7:01 a.m., end 2/28/17 at 7:00 a.m. Each continuation order was signed by a physician with no documentation of the time the order was provided or a date and time of the signature. Further review of physician orders and progress notes revealed no assessment or mention of the patient's need and use of restraints.

Patient #5
Review of the medical record for patient #5 revealed he was admitted to the hospital 02/19/18 for continued physical therapy. His diagnoses included Intracranial hemorrhage (with some lasting effects of lethargy and Trach/PEG dependence),Acute hypoxic respiratory failure, Seizure disorder, Critical Illness Myopathy, Hypertension, and Diabetes. Further review revealed a left soft wrist restraint was implemented 02/22/18, after Patient #5 extubated himself. Review of restraint orders for Patient #5 revealed an initial order that had an assessment signed by an RN on 2/22/18. Under 'Acute medical/surgical reason ' a time limit was documented as "01:45" (1:45 a.m.). Further review revealed the physician signed the orders with a date of 2/22/18, but with no time of the signature documented. No documentation of the initial order having been received as a verbal order by the nurse. Review of continuation or renewal orders for Patient #5's left soft wrist restraint revealed a daily order from 2/23/18 through 3/14/18, each starting at 7:00 a.m. or 7:01 a.m. and ending at 7:00 a.m. Restraint continuation/renewal orders for Patient #5 from 2/23/18 through 3/3/13/18 were signed by a physician with no date or time documented (other than the start and end dates filled in by the night nurse). The continuation/renewal order for the time period of 3/13/18 through 3/14/18 at 7:00 a.m. was not signed by any physician. Review of physician progress notes revealed no assessment by the physician or notation regarding the patient's continued need for restraints before the order to continue.

2) failure to ensure evidence of a reassessment by a physician before each continuation of the use of restraints order was documented .


Patient #4
Review of the medical record for patient #4 revealed she was admitted to the hospital 02/17/17. Further review revealed soft wrist restraints were implemented 02/24/17 through 02/28/18. Further review revealed an initial restraint order for right and left upper extremity restraints. The assessment section of the order sheet, completed by the RN documented the time limit as "24 hours. 0930" (9:30 a.m.). Further review revealed a physician's signature with no date or time of that signature. Review of restraint continuation orders revealed orders with start date and times/end dates and times as follows: 1) start 2/25/17 at 7:01 a.m., end 2/26/17 at 7:00 a.m., 2) Start: 2/26/17 at 7:01 a.m., end 2/27/17 at 7:00 a.m., 3) start 2/27/17 at 7:01 a.m., end 2/28/17 at 7:00 a.m. Review of physician progress notes revealed no documentation of an assessment or mention of the patient's need for and use of restraints.


Patient #5
Review of the medical record for patient #5 revealed he was admitted to the hospital 02/19/18. Further review revealed a left soft wrist restraint was implemented 02/22/18, after Patient #5 extubated himself. Review of restraint orders for Patient #5 revealed an initial order had an assessment signed by an RN on 2/22/18. Restraint continuation/renewal orders for 2/23/18 through 3/3/13/18 were signed by a physician with no date or time documented. The continuation/renewal order for the time period of 3/13/18 through 3/14/18 at 7:00 a.m. was not signed . Review of physician progress notes revealed no assessment or notation regarding the patient's continued need for restraints before the order to continue . Review of Restraint monitoring sheets revealed the patient had restraints in place each day from 02/22/18 through 3/13/18.


In an interview 03/13/18 at 1:04 p.m. S9RN reported the physician would be called for restraint orders (by the nurse), if not onsite, but only after the patient had been assessed and other interventions did not resolve the problem. She indicated that the hospital used soft extremity restraints to protect patients from harming themselves, like attempting to pull their lines out, ET tubes or Trachs. When asked to review restraint orders on the medical records for Patients #4 and #5, S9RN verified the orders did not have a time the order was received or that the physician signed them. She agreed that the restraint orders did not document a time (and sometimes date) to provide evidence of when the order was started, or if an order for continuation was received within 24 hours, as required by hospital policy and procedure. She indicated that on the continuation orders, the night nurse of a patient would write the date and time to begin the order and the time and date that the order expired, and place these on the chart for the physician to sign when he (or she) made rounds the next day. She reported that not all the doctors made rounds by 7:01 a.m., the documented time the restraint renewal orders started. S9RN indicated she didn't realize there was not a time on the order and "could guarantee" she had never put a date and time of the order on the order sheet, only the date and time the restraints were to start and when it would expire.


In an interview 03/13/18 at 1:46 p.m. S10LPN reported she had provided are to Pt #2 who had previously had a soft wrist restraint to prevent him from pulling his Trach out. She reported the patient was no longer in restraints. S10LPN indicated the current procedure was the night shift nurse puts a restraint renewal order on the chart with the reason restraints are needed circled (Protect medical device, or other), fills in the boxes for start date and time, end date and time, and the type of restraint to be used (Soft Wrist- right/left, Soft-Ankle- right/left, or Mitten device-right/left). She indicated the physician would sign the preprinted order, filled out by the night nurse and placed on the patient's medical record, when they (the physicians) made rounds the next day. The LPN reported that Patient #2's physician did not usually make rounds until lunch time, and verified that he did not signed the continuation order until after it was to be and had been renewed.


In an interview 03/13/18 at 3:45 p.m. S1CNO and S2MSC reviewed the medical records for Patients #2, #4, and #5, they both verified the restraint orders were not dated and signed. The CNO indicated that it was hospital policy that all entries, signatures, and orders should be dated and timed. Both the CNO and MSC agreed that the orders did not provide documentation to evidence that patients with restraints were assessed before each new renewal order was provided and initiated, or that the orders were renewed at a minimum of every 24 hours as hospital policy required.