HospitalInspections.org

Based on a review of the medical records of 17 patients, review of hospital policies and procedures, interviews with administrative staff, review of staff credentials, tours of three patient care units, and review of related documentation, it was determined that the hospital failed to protect and promote the rights of each patient:

Findings include:

1. The facility failed to ensure that patients had the right to receive care in a safe setting (Refer to Tag A 144).

2. The facility failed to ensure that the use of restraints was in accordance with the order of a physician or other licensed independent practitioner authorized to order restraint by hospital policy (Refer to Tag A 168).

A. Based on review of a treatment administration record (TAR) and interview with administrative staff, it was determined that physician/licensed independent practitioner orders are not carried out by nursing staff.

Findings include:

1. Review of the TAR during a tour of the Red Zone Unit in the afternoon on 8/3/2021, the following was observed:

a. Patient #15:

(i) There was no documentation that the "Crest Pro Health Swabs" ordered to be administered on 8/2/2021 were administered, or documentation as to why they were not administered.

(ii) There was no documentation that the "Zeasorb 2% Powder Antifungal Powder" ordered to be administered at 1700 (5:00pm) on 8/2/2021 was administered, or documentation as to why it was not administered.

a. Patient #16: There was no documentation that the "RINSE GASTROSTOMY STOMA WITH NORMAL SALINE SOLUTION" order was carried out at 0600 (6:00am) on 8/3/2021, or documentation as to why it was not.

2. Administrator #6 agreed with the findings.

B. Based on tours of three (3) patient care units and interview with administrative staff, it was determined that not all drugs are kept in locked storage areas.

Findings include:

1. During a tour of the Red Zone Unit on 8/3/2021, a medication cart containing medications in fourteen (14) drawers was unlocked.

2. Administrator #1 agreed with the findings.

C. Based on a tour and interview with administrative staff, it was determined that laboratory specimens are not kept in a secure location.

Findings include:

1. During a tour of the Red Zone Unit on 8/3/2021, a small unlocked refrigerator in the hallway was found to contain a tube containing urine.

2. Administrator #15 stated that although there was no written policy or protocol for handling and storage of laboratory specimens, the specimen should have been in a locked refrigerator.

D. Based on a review of policy and procedure, a tour of three (3) patient care units, review of patient documentation, and interview with administrative staff, it was determined that a policy for supervision of patients was not implemented.

Findings include:

Reference: Policy and procedure titled "1:1 PCA (Personal Care Assistant) Coverage" states:
"Policy Statement:
It is the policy of Matheny Medical & Educational Center to provide patients, visitors, and staff with a safe and protected environment. Patient level of supervision is the observation that shall be utilized to prevent self-injury or injury to others, in those patients whose behavior is impulsive and unpredictable as to require presence of a staff member. Enhanced supervision might also be utilized related to certain medical conditions (i.e: post hospitalization IV therapy, or Lesch-Nyhan disease) that elicit a closer supervision scenario for that patient.
DEFINITIONS:
Patient level of supervision - is defined as any patient requiring additional surveillance beyond routine nursing/PCA observation for the safety of the patient that does not limit the activities of the patient. There are 3 types of patient levels of supervision, they are as follows:
1. One to One Observation: requires that a patient be visually observed by a staff member who remains with the patient at all times.
a) Strict 1:1 - assigned care for one patient [sic] cannot help with mealtime or ADLs (Activities of Daily Living) of other patients. ..."

1. Patient #4:

a. A physician order dated 7/28/21 stated: "STRICT 1:1 [one-to-one observation] PCA SUPERVISION AT ALL TIMES; DURING PROGRAM TIME ONLY MON-FRI (Monday-Friday) W (With))/APPROVAL OF INSTRUCTOR MAY BE ON CONSTANT SUPERVISION FOR SHORT PERIODS (30 MIN MAX) [Minutes Maximum]" was in the medical record.

b. During a tour of the Green Zone Unit at 1:11pm on 8/3/2021, a review of the flow sheet used by the staff member to document the 1:1 Observation stated: ".....
Strict 1:1 supervision at all times:
..... Sign for 1:1 coverage every 2 hours
...."
The reverse side of the flow sheet had staff initials already entered in the 2:00PM and 3:00PM grid boxes for 8/3/2021.

2. Patient #6:

a. A physician order dated 7/28/21 stated: "STRICT 1:1 PCA SUPERVISION FROM 7A - 11P ....."

b. During a tour of the Green Zone Unit at 1:15pm on 8/3/2021, a review of the flow sheet used by the staff member to document the 1:1 Observation stated: ".....
Strict 1:1 supervision at all times:
..... Sign for 1:1 coverage every 2 hours
...."
The reverse side of the flow sheet had staff initials already entered in the 3:00PM grid box for 8/3/2021 and the 7:00AM, 9:00AM, and 11:00AM grid boxes for the next day - 8/4/2021.

3. Patient #14:

a. A physician order dated 7/28/21 stated: "STRICT 1:1 PCA SUPERVISION FROM 7A - 11P WHILE AWAKE ....."

b. During a tour of the Green Zone Unit at 1:18pm on 8/3/21, a review of the flow sheet used by the staff member to document the 1:1 Observation stated: ".....
Strict 1:1 supervision at all times:
..... Sign for 1:1 coverage every 2 hours
...."
The reverse side of the flow sheet had staff initials already entered in the 7:00AM, 9:00AM, and 11:00AM grid boxes for the next day - 8/4/21.

4. Patient #7:

a. A physician order dated 7/23/21 in the medical record stated: "BASIC 1:1 PCA SUPERVISION FROM 0700-2300

b. A "Safety Monitoring Sheet" in the medical record stated: ".....
Miscellaneous at all times
Basic 1:1 supervision 7a -11p
....."

c. A "Safeguarding Monitoring Sheet" reviewed during a tour of the Yellow Zone Unit on the morning of 8/3/2021 revealed that there was no documentation that the patient was monitored between 2:00pm and 10:00pm on 8/2/2021.

5. Patient #17:

a. A physician order dated 6/23/21 in the medical record stated: "***SUPERVISION
*** WHEN IN BED EVERY 15 MIN (Minutes) CHECKS."

b. A physician order dated 7/23/21 in the medical record stated: "***SUPERVISION *** WHEN IN BED EVERY 15 MIN (Minutes) CHECKS."

c. "MONITORING SIGN OF SHEETs EVERY 15 MINUTE CHECKS WHEN NOT IN BED OVERNIGHT" sheets reviewed during a tour of the Yellow Zone Unit on the morning of 8/3/2021 revealed that there was no documentation that the patient was monitored every 15 minutes at any time during the nights of 7/20/2021 or 7/27/2021 per physician orders.

6. Administrator #1 agreed with the findings.

Based on a review of the medical records of 2 of 2 patients who were physically restrained (Patients #2 and #3), review of policy and procedure, review of the Instructors Manual for Safety Interventions utilized by the facility, interview with administrative staff, and review of the security log, it was determined that the use of restraints is not in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient.

Findings include:

Reference #1: Policy and procedure titled "Restraints and Seclusions" states: ".....
Policy Statement:
It is the policy of Matheny Medical and Educational Center to discourage the use of restraints and seclusion when caring for our patients. In accordance with Federal requirements and New Jersey regulations (NJAC 8:43G-18.4 and 10:42-1.1 et seq.) the following procedures have been adopted in the rare likelihood that restraints may be necessary. .....
The use of restraints is distinct from the use of safety and protective devices, which is outlined in the 'Safeguarding Equipment/Protective Devices and Protective Devices' policy.
PROCEDURES:
Definition: Physical restraints are defined as: A) any manual method, device, material, or equipment, which upon application interferes with the mobility of a patient, and limits his/her ability to engage in free body movement to a position of choice .....
.....
3. If a patient needs to be restrained for any reason, a doctor's order will be written to document the reasons and conditions for use. ..... A physician's order must be written to document the use of the restraint and there will be no PRN or standing orders for restraints. .....
....."

Reference #2: The "SCM (Safe Crisis Management) Instructor's Manual" states:
"Emergency Safety Interventions
.....
Least Restrictive Alternative
The use of emergency safety physical intervention refers to the application of force that restricts mobility or movement or that disengages from harmful physical contact. The level of force that can be used in these circumstances is governed by the principle of the "Least Restrictive Alternative". [sic] The SCM program provides emergency safety physical interventions that are constructed on a continuum which moves from lower to higher levels of restriction. .....
.....
Types of Emergency Safety Interventions
.....
5. Emergency Safety Physical Interventions (ESPI)
'Physical restraint is an application of physical force by one or more individuals that reduces or restricts the ability to move his or her arms, legs or head freely' (CWLA, Best Practice Guidelines Behavior Support and Intervention, 2004).
.....
c. Types of emergency safety physical interventions
* Standing assists - single or multiple-person
Restriction with an individual in an upright position. Single or multiple-person.
.....
* Seated/kneeling assists - single or multiple-person
Restriction with an individual in a seated position. Single or multiple-person.
.....
Cradle Assist
.....
1. From an extended arm assist, interrupt the individual's balance by nudging them forward with your lead arm.
2. Step you lead foot so your toes are positioned between the individual's heels.
3. Lead hand reaches to the individual's opposite hip, extends past the front of the torso and secures the individual's forearm (held near the wrist, but not on the wrist joint).
4. Trailing arm secures the individual's other arm in the same manner.
5. Hold the individual's arms securely to their hips (they should not be able to clasp their hands together).
6. When possible, thumbs should be with your fingers and the openings held against the individual's body.
....."

1. Review of documentation regarding Patient #3:

a. Medical record:

(i) A "Green Team Report" sheet dated 7/2/21 at 2100 (9:00pm) stated:
"Behavior Displayed By Patient/Resident/Client/Student
Screaming/Verbal Threats (tick mark entered in corresponding tick box)
.....
Other (Describe Behavior) attempting to Grab [sic] cart (illegible word) Biting (tick mark entered in corresponding tick box)
Attempting to hit staff (tick mark entered in corresponding tick box)
.....
Hitting staff (tick mark entered in corresponding tick box)
.....
Personal Control Techniques (PCT) Used
.....
1 Person Cradle Assist (tick mark entered in corresponding tick box)
....."

(ii) A "Green Team Nursing Report" sheet dated 7/2/21 at 2133 (9:33pm) stated:
"Behavior Displayed By Patient
Screaming/Verbal Threats (tick mark entered in corresponding tick box)
.....
Other (Describe Behavior) Attempting to Grab Cart (tick mark entered in corresponding tick box)
Attempted to bite Staff (tick mark entered in corresponding tick box)
Attempting to hit staff (tick mark entered in corresponding tick box)
.....
Hitting staff (tick mark entered in corresponding tick box)
.....
Personal Control Technique (PCT) Authorization
I hereby authorize the use of personal control techniques as specified for this individual
Nurse's Printed Name: (first and surname of RN entered)
Condition of patient while technique was applied (document every 15 minutes):
Patient was combative, agitated, spitting during PCT attempts. During PCT patient head butting, attempting to bite and spit. PCT maintained for five min. (minutes) until calm and safe to self.
Observations of Distress:
No signs or symptoms of distress observed. No difficulty breathing or overt injuries noted during PCT.
Personal Control Techniques (PCT) Used And Duration
.....
1 Person Cradle Assist (tick mark entered in corresponding tick box)
Time Applied: 2105 (9:05pm)
Duration: 5min. (5 minutes)
....."
The form was signed by the RN who authorized the use of the PCT.

(iii) There was no evidence in the medical record of a physician/licensed independent practitioner order that the patient be physically restrained.

b. Documentation dated 7/2/21, provided by Administrator #1, stated: "Writer stopped _________ (first name of Patient #3) from pushing nursing cart, _________ (first name of Patient #3) became physically aggressive, pulling (his/her) clothing and hitting (him/her). .....
A one person cradle assist was used for 5 minutes, until _________ (first name of Patient #3) was calm enough to get back to (his/her) room. ....."

2. Review of documentation regarding Patient #2:

a. Medical record:

(i) A "Green Team Report" sheet dated 7/26/21 at 1528 (3:28pm) stated:
"Behavior Displayed By Patient/Resident/Client/Student
Screaming/Verbal Threats (tick mark entered in corresponding tick box)
.....
Other (Describe Behavior) Dangerous location in road
Attempting to hit staff (tick mark entered in corresponding tick box)
.....
Hitting staff (tick mark entered in corresponding tick box)
.....
Personal Control Techniques (PCT) Used
.....
2 Person Modified Cradle Assist (tick mark entered in corresponding tick box)
....."

(ii) A "Green Team Nursing Report" sheet dated 7/26/21 at 1530 (3:30pm) stated:
"Behavior Displayed By Patient
Screaming/Verbal Threats (tick mark entered in corresponding tick box)
.....
Other (Describe Behavior) Dangerous location in road (tick mark entered in corresponding tick box)
Attempting to hit staff (tick mark entered in corresponding tick box)
.....
Hitting staff (tick mark entered in corresponding tick box)
.....
Personal Control Technique (PCT) Authorization
I hereby authorize the use of personal control techniques as specified for this individual
Nurse's Printed Name: (first and surname of RN entered)
Condition of patient while technique was applied (document every 15 minutes):
No distress noted, patient was screaming and hitting staff
Observations of Distress:
None
Personal Control Techniques (PCT) Used And Duration
.....
2 Person Modified Cradle Assist (tick mark entered in corresponding tick box)
Time Applied: 1458 (2:58pm)
Duration: 30 seconds
....."
The form was signed by the RN who authorized the use of the PCT.

(iii) There was no evidence in the medical record of a physician/licensed independent practitioner order that the patient be physically restrained.

b. Documentation dated 7/26/21, provided by Administrator #1, stated: ".....
A Green Team was called overhead for ______ ________ (first and surname of Patient #2) at approximately 14:50 (2:50pm) regarding escalated behavior and unsafe location. I put myself between _____ (first name of Patient #2) and the road and instructed (him/her) to move away from the road as (his/her) current location was not safe. ______ (first name of Patient #2) became physically aggressive as I became more firm with my directives for the need to leave the street. At this time a one person wheelchair assist was necessary, followed by a brief 2 person modified cradle assist with _______ (first name of Staff #10) (Behavior Technician) in response to further physically aggressive behavior, lasting approximately 30 seconds. .....
....."

3. Administrator #14 agreed during interview at 9:51am on 8/4/2021 that the use of either a cradle assist or a modified cradle assist restricts a patient's freedom of movement.