HospitalInspections.org

Based on interview and document review the hospital failed to provide written notice to patients on admission informing them there was no doctor of medicine or doctor of osteopathy present in the hospital at all times or how their medical needs would be met at a time when no physician was present.

This failure increased the potential for patients not being fully informed to make decisions regarding their care.

Findings:

During a concurrent interview and record review on 1/29/25 at 1:40 p.m. with the Chief Operating Officer (COO), the "[hospital name] Rounding Schedule (RS)," dated December 2024 was reviewed. The RS indicated, "noc [night]: 7 p.m.-7 a.m. Telemed [Telemedicine is the use of technology to provide medical care remotely. It can include video conferencing, phone calls, and messaging] On Call" for each day in December. The COO confirmed the hospital had a physician present from 7 a.m. to 7p.m every day and a physician was on call for telemedicine coverage of the hospital from 7 p.m. to 7 a.m. and were not present in the facility.

During a concurrent interview and record review on 1/29/25 at 1:40 p.m. with the COO, an undated "CONSENT TO ADMISSION AND TREATMENT, AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF INSURANCE BENEFITS" form was reviewed. The COO confirmed there was nothing included on the form to indicate there was not twenty-four-hour physician presence at the hospital.

Based on observation, interview and record review the facility failed to obtain a physician order for one out of three sampled patients (Patient 20) for soft mitten (mitts) restraints. Patient 20 was observed on 1/27/25, 1/28/25 and 1/29/25 by surveyor with bulky soft mitten restraints on both hands without a physician's order.

This failure resulted in a lack of appropriate safety monitoring evidenced by missing documentation of nursing assessments; thereby missing potentially important changes in condition to circulation, sensation and motion by not assessing the hands, fingers and any devices inserted into the patient's skin underneath the bulky soft mittens not observable with the naked eye as frequently as a restraint device would be monitored per the facility's policy.

Findings:

During a review of Patient 20's "History and Physical", dated 1/8/24, Patient 20 was admitted to the facility on 1/8/25 with a history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to head), tracheostomy (a surgical procedure which creates an opening in the trachea (windpipe) allowing air to enter the lungs), gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach to allow medication or liquid food to be administered) and chronic encephalopathy ( a condition characterized by persistent changes in brain function that can lead to cognitive, behavioral and neurological problems).

During a review of Patient 20's "Non-Violent Restraint Physician Orders", dated 1/8/25 and 1/9/25 the orders indicated Patient 20 had a signed physician order requiring the use of soft wrist restraints on the left side to ensure safety and support medical healing.
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During a review of Patient 20's "Non-Violent Restraint Physician Orders", dated 1/10/25, the order indicated Patient 20 had a signed physician order requiring the use of restraints, but the order did not indicate which type of restraint was used on Patient 20.

During a review of Patient 20's "Non-Violent Restraint Physician Orders", dated 1/11/25, the order indicated, Patient 20 had a signed physician order requiring the use of soft wrists restraints on the left side to ensure safety and support medical healing.

During a review of Patient 20's "Non-Violent Restraint Physician Orders", dated 1/12/25, the order indicated Patient 20 had a signed physician order requiring the use of soft wrist restraint for the left wrist to ensure safety and support medical healing. The restraint order was expired or discontinued on 1/13/25 at 10:00 a.m. A review of the medical record indicated no further physician order for a restraints.

During a review of Patient 20's "Nursing Daily Assessment", dated 1/23/25 at 9:45 p.m., the assessment indicated restraints were not in use; however, in the nursing assessment notes section, "soft mittens maintained for safety" was documented.

During a review of Patient 20's "Nursing Daily Assessment", dated 1/24/25 at 10:00 p.m., the assessment indicated restraints were not in use; however, in the nursing assessment notes section, "soft mittens on for safety" was documented.

During a concurrent observation and interview on 1/27/25 at 1:39 p.m., with Unlicensed Staff A at the bedside of Patient 20, Patient 20 was observed with mittens on both hands, which had bulky padding on the palm area and netting on the top of the hand. Unlicensed Staff A stated they were called mittens and Patient 20 had them on because she kept scratching and trying to pull out her feeding tube and getting out of bed. Unlicensed Staff A stated the mittens had just been changed because they were dirty and smelly and Patient 20 had also been given a bath in her bed. Unlicensed Staff A stated she would be responsible to document in Patient 20's medical record every time she removed the mittens. Patient 20 was observed wearing the mittens on both hands, able to move her arms freely but unable to pick anything up or use her fingers since the fingers were under netting and the palm area was under a large, padded area. Patient 20 was observed lifting her head off the bed and moving her legs freely with Unlicensed Staff A gently reminding Patient 20 to remain in bed. Patient 20 was in a large room with four other patients and Unlicensed Staff A stated she was assigned to stay there continually with the nurse who was also assigned to provide supervision and care to all of the four patients assigned to beds located in that room.

During an interview on 1/27/25 at 1:58 p.m. with Licensed Staff B, Licensed Staff B stated, she was Patient 20's nurse that day and stated Patient 20 was not wearing restraints on her hands, since mittens were not considered restraints. Licensed Staff B stated, if Patient 20's hands were tied down to the bed, then that would be considered a restraint but since Patient 20 would be able to move her arms it is not considered a restraint and therefore a doctor's order was not needed. Licensed Staff B stated the reason why Patient 20 would have the mittens on both of her hands would be to prevent her from pulling out her gastric tube or the tube with formula providing nourishment or her IV (intravenous catheter inserted into a vein to provide access to the bloodstream). Licensed Staff B stated, if Patient 20 had restraints, then she would be checked for circulation, sensation and blood flow to her hands every two hours. Surveyor asked Licensed Staff B where the IV was located since there was no visible tubing and Licensed Staff B stated the IV was capped (remained in the vein but no fluid was being infused) and located on the top of the hand under the netting part of the mittens. Licensed Staff B stated she would assess the IV every shift and would assess the hand as well, since Patient 20 would tend to keep her hands crinkled like a fist rather than straight and outstretched. Licensed Staff B stated Patient 20 had a history of traumatic brain injury which made her non-compliant with trying to pull out her lines (feeding tube and IV) and staying in bed.

During an interview on 1/27/25 at 2:25 p.m. with Licensed Staff C, Licensed Staff C stated mittens were not considered restraints unless the wrists were tied down then that would be considered a restraint and a physician order would be required. Licensed Staff C stated if mittens were being used alone by themselves then no, that would not be considered a restraint and physician order would not be required.

During an interview on 1/27/25 at 2:34 p.m., with Licensed Staff D, Licensed Staff D stated mittens were not considered restraints unless the wrist part of the hand was tied to the bed.

During a concurrent interview and record review on 1/28/25 at 10:24 am. with Chief Nursing Officer (CNO), Patient 20's "Non-Violent Restraint Physician Orders" dated 1/8/25 was reviewed. The paper order sheet indicated the reason for the restraints (Patient 20 was attempting to remove her tracheostomy or other medical devices), the signature of the physician, date and time of the order, the signature of the nurse, the type of restraint (wrists, mittens or side rail or combination) and when the order expired. CNO stated, per the facility policy the restraint orders were reviewed every day at around 10 a.m. and either renewed or not renewed and if not renewed the order would expire and the restraint would be removed. There was an order dated 1/9/25, 1/10/25, 1/11/25 and 1/12/25. The medical record was reviewed and there was no further restraint orders observed with CNO navigating the electronic medical record and the surveyor observing. CNO stated the use of mittens alone does not constitute the use of a restraint. CNO stated if mitten(s) were used in combination with a wrist restraint tied down then that would constitute a restraint and would require a physician's order. CNO stated the use of mitten(s) would not require a physician order. The progress notes were reviewed with CNO from 1/12/25 and no indication Patient 20 had mittens applied by nursing staff. During a review of "nursing daily assessments" dated 1/23/25 and 1/24/25, under the notes section of the nursing documentation indicated Patient 20 had mittens applied for safety. CNO was asked since mittens were applied as per the documentation but there was no assessment as to Patient 20's circulation of her fingers and hands as would if there was a restraint order, CNO could not answer the frequency of assessment for Patient 20's hands. CNO could not explain further the safety mechanism in place for assessing Patient 20's hands other than every hour the nurses look in at their patients, but they would not take off the mittens and assess the skin underneath the mittens. CNO stated the hourly rounding or looking in at patients would not capture if there was an injury or dislodgement of the IV for instance on Patient 20's hand which would be obscured under the netting from view.

During a concurrent observation and interview on 1/28/25 at 11:38 a.m., with CNO in Patient 20's room, Patient 20 was observed laying in bed with her mitts applied to both of her hands. Licensed Nurse E, who was taking care Patient 20, reviewed the electronic medical record and confirmed there were no current restraint orders, stating there would not be a restraint order for mittens since mittens were not considered a restraint.

During an observation on 1/29/25 at 1:00 p.m. Patient 20 was observed in her bed with mittens on both of hands.

During a concurrent observation and interview on 1/29/25 at 4:30 pm with CNO and Chief Operating Officer (COO), the unopened packaged of mitts was observed in an office, CNO stated it did seem like the mitts were bulky and would follow the definition of restraints. COO nodded in agreement.

During a review of the facility's policy and procedure titled, "Restraints Protocol," dated 11/14/24, indicated, "A. Restraints: Any method (physical restraint or medication) of applying involuntary restriction on a patient's bodily movement or access to his or her body areas ... any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to ones' own body ...Mitts unless tied down or pinned down or unless so bulky or applied so tightly patient cannot use or bend their hand.".

Review of the manufacturer's description of Patient 20's mittens titled "Posey Finger Control Mitt," undated, indicated, "Description of Product: Full padded, mesh mitt with finger separators. INTENDED USE: To protect patients assessed to be at risk of disrupting life-saving treatments (e.g. chronic tube pulling) or in danger of injury to themselves or to others by limiting hand movement. Follow your hospital's restraint policies and procedures that are compliant with USA CMS guidelines and state laws, or other governing agencies outside the USA."