HospitalInspections.org

Based on review of three or three (#7, #8 and #11) medical record of patients in restraints, it was determined a physician order was not obtained and/or dated and/or signed prior to the initiation of restraints. This failed practice did not assure the patient was assessed for the least restrictive device. This failed practice had the potential to affect all patients in restraints in the facility. The findings follow:

A. Patient #7 was admitted 07-07-11 with the following noted:
1) On 09-16-11, an order was written for restraints but the order was not timed or dated when signed by the physician.
2) On 09-20-11, an order was written for restraints but the order was not timed or dated when signed by the physician.
3) On 09-21-11, an order was written for restraints but the order was not timed or dated when signed by the physician.
4) On 09-22-11, an order was written for restraints but the order was not signed by the physician.

B. Patient #8 was admitted 09-21-11 with the following noted:
1) Documentation on the Nursing Progress Note dated 09-25-11-1600 " ....placed in vail bed.. " . There was no documentation of an order for a vail bed on 09-25-11.
2) Physician Order dated 09-26-11 (no time) reflected "Place pt (patient) in vail bed for pt safety TO (telephone order) Dr (Named). The order was not signed, timed or dated by the physician.
3) Physician Order for Restraints was dated by the Registered Nurse 09-28-11 but was not signed, timed or dated by the physician.
4) Physician Order for Restraints was dated by the Registered Nurse (seperate order) 09-28-11 but was not signed, timed or dated by the physician.
5) Physician Order for Restraints was dated by the Registered Nurse 09-30-11 but was not signed, timed or dated by the physician.
6) Physician Order for Restraints was dated by the Registered Nurse (seperate order) 09-30-11 but was not signed, timed or dated by the physician.

C. Patient #11 was admitted 07-29-11, but with the following noted:
There were 49 orders written for restraints. Fifteen of the 49 orders for restraints were not signed, timed or dated by the physician.

Based on observation at 1000 on 09-30-11 it was determined there were not an adequate number of licensed nurses to provide nursing care to all patients as needed. This failed practice had the potential to affect all 25 patients on census. The findings follow:

Patient # 8- in room 223 was observed at 1000 sitting up in the bed asleep. The patient had a meal tray on the over bed table. The Surveyor asked what was on the tray because it did not look like the tray had been opened. Observation of the contents on the tray revealed an unopened carton of milk, an unopened carton of yogurt, an egg, sausage and a can of unopened Ensure. Nurse #1 was asked if the patient had been fed. Nurse #1 stated the patient fell asleep after her respiratory treatment and the breakfast tray was left. The findings were verified by the Administrator at the time of the observation.


Based on medical record review it was determined there were not an adequate number of licensed nurses to provide nursing care to all patients as needed. Record review of 10 patients with wounds revealed 2 of 10 patients did not receive wound care as ordered by the physician. This failed practice had the potential to affect all patients with wounds.. The findings follow:

A. Patient #6-Review of the wound care orders revealed an order for Dakins ? strength -apply to L (left) LE wound and R (right) hip wound BID(twice a day) apply wet to dry dressing using gauze dressing and secure with tape. Xenderm to peri-rectal area BID. There was no documentation in the medical record that the dressing changes were done on 09-24-11.

B. Patient #2-Review of the wound care orders revealed the following:
1) 07-22-11 an order dated for WTD (wet to dry) dressing changes daily to all wounds.
2) There was no WTD dressing change documented to the sacrum on 08-25-11 and 08-27-11.
3) 07-24-11 an order to apply large deoderm to pernineal wound after cleaning the wound with NS (Normal Saline)- to be changed every three days and prn. Xenoderm to remainder buttocks everday
There was no documentation of dressing change to perineal dressing on 08-11-11 and 08-12-11
4) 08-19-11 an order for wound care to foot/toe wounds-paint with betadine daily and leave open to air. There was no documentation of wound care to foot/toe on 08-22-11, 08-23-11, 08-25-11, 08-29-11 and 09-01-11.

Based on review of 11 of 11 medical records, it was determined verbal/ telephone orders were used as a common practice to relate the orders of the physician. The practice had the increased potential for miscommunication that could contribute to a medication or other error which could affect all 25 patients on census. The findings follow:

A. Patient #1 was admitted 02-17-11. Twenty five physician orders were written. Nine of 25 physician orders were verbal/telephone orders. Eight of 9 verbal/telephone orders had no date or time documented when signed by the physician.

B. Patient #2 was admitted 07-21-11. Fifty-three physician orders were written. Forty of the 53 physician orders were verbal/telephone orders. Twenty- four of the 40 verbal/telephone orders had no physician signature; 16 of 16 verbal/telephone orders signed by the physician had no date or time recorded when signed by the physician.

C. Patient #3 was admitted 09-13-11. Fifteen physician orders were written. Eleven of the 15 physician orders were verbal/telephone orders. Three of the 11 verbal/telephone orders had no physician signature; 7 of 8 signed physician orders had no date or time when signed by the physician.

D. Patient #4 was admitted 08-24-11. Twenty-nine physician orders were written. Seventeen of the 29 physician orders were verbal/telephone orders. Two of 17 verbal/telephone orders did not have a physician signature; 15 of 17 physician orders did not have a time or date when signed by the physician.

E. Patient #5 was admitted 09-27-11. Seven physician orders were written. Six of the 7 physician orders were verbal/telephone orders. Three of 6 verbal/telephone orders had no physician signature; 2 of 3 signed verbal/telephone orders had no date or time when signed by the physician.

F. Patient #6 was admitted 09-23-11. Twenty nine physician orders were written. Eleven of the 29 physician orders were verbal/telephone orders. Nine of 11 verbal/telephone orders had not been signed by a physician. Two of 2 signed verbal/telephone orders had no date or time when signed by the physician.

G. Patient #7 was admitted 07-07-11. One hundred and eleven physician orders were written. Fifty nine of 111 physician orders were verbal/telephone orders. Forty five of 59 verbal/telephone orders were not signed by the physician.

H. Patient #8 was admitted 09-23-11. Fourteen physician orders were written. Eight of 14 physician orders were verbal/telephone orders. Seven of 8 verbal/telephone orders were not signed by the physician. One of 1 signed verbal/telephone order was timed and dated when signed by the physician.

I. Patient #9 was admitted 09-21-11. Eleven physician orders were written. Six of 11 physician orders were verbal/telephone orders. Two of 6 verbal/telephone orders were not signed by the physician. Four of 6 verbal/telephone signed orders were not timed or dated when signed by the physician.

J. Patient #10 was admitted 08-24-11. Nineteen physician orders were written. Ten of the 19 physician orders were verbal/telephone orders. Eight of 10 verbal/telephone orders were not signed by the physician. Two of 2 verbal/telephone orders signed were not dated or timed when signed by the physician.

K. Patient #11 was admitted 07-29-11. One hundred and eleven physician orders were written. Seventy-one or 111 were verbal/telephone orders. Thirty-one of 71 verbal/telephone orders were not signed by the physician. Thirty- three signed verbal/telephone orders were not dated or timed when signed by the physician.