HospitalInspections.org

Based on interview and record review, the hospital failed to ensure alternatives and/or least restrictive interventions were documented for 1 of 4 patients reviewed with wrist restraints [Patient #1].

Findings included:

The history and physical dated 01/28/11 reflected, "[Patient #1] was a 75 year old female who was in the physician's office...she is known to have advanced Alzheimer's Dementia with Psychotic Delusions ...the patient has been managed and cared for by her sister, who is her primary caregiver...she also was taken to the medical hospital wound care center, where she followed up with the wound care physician...the patient however, was noted to have worsening of her psychotic symptoms and was noted to be picking on her wounds...as a result, had an advancement of her noted ulcers...her sacral wound is noted as a stage 4 and was noted to become infected with purulent discharge...for this reason the need for aggressive management the patient was referred for a direct admission to....[current hospital]..."

The restraint order/assessment sheet dated 02/23/11 reflected under the section entitled, "Please check less restrictive intervention attempted, yet not successful,observed, or reported, by patient-care service staff..." No documentation was found which indicated least restrictive interventions were attempted..."

On 03/18/11 at approximately 1:00 PM [Staff #1] was shown Patient #1's restraint orders. [Staff #1] verified the 02/23/11 restraint/assessment document under the section least restrictive interventions was left blank and not completed for Patient #1 while in wrist restraints.

The policy entitled, "Restraints and Seclusion" with a revision date of 06/10 reflected, "To keep the patient safe, minimize the use of restraints, explore practical alternatives, and use as a last resort...restraint must be the least restrictive intervention that protects the patient's safety and alternatives have failed. Restraint use must end as soon as possible. This must be demonstrated by patient care staff through their documentation..."

Based on interview and record review, the hospital failed to ensure the patient's condition which warranted the need for wrist restraints were documented for 1 of 4 patients reviewed with wrist restraints [Patient #1].

Findings Included:

1) The history and physical dated 01/28/11 reflected, "[Patient #1] was a 75 year old female who was in the physician's office...she is known to have advanced Alzheimer's Dementia with Psychotic Delusions...the patient has been managed and cared for by her sister, who is her primary caregiver...she also was taken to the medical hospital wound care center, where she followed up with the wound care physician...the patient however, was noted to have worsening of her psychotic symptoms and was noted to be picking on her wounds...as a result, had an advancement of her noted ulcers...her sacral wound is noted as a stage 4 and was noted to become infected with purulent discharge...for this reason the need for aggressive management the patient was referred for a direct admission to....[current hospital]..."

The restraint order/assessment sheet dated 02/23/11 reflected under the section entitled, "Clinical Justification for Restraint Use..." No documentation was found which indicated the clinical justification for Patient #1's wrist restraints.

On 03/18/11 at approximately 1:00 PM [Staff #1] was shown Patient #1's restraint/assessment orders. [Staff #1] verified the 02/23/11 restraint/assessment document under the section entitled, "clinical justification" was left blank and not completed for Patient #1 while in wrist restraints.

The policy entitled, "Restraints and Seclusion" with a revision date of 06/10 reflected, "Restraint use must end as soon as possible. This must be demonstrated by patient care staff through their documentation...every use of restraint is to be documented in the patient's record. At a minimum documentation must include...the justification for restraint [Restraint Assessment and Physician Order..."

Based on interview and record review the hospital failed to ensure the Registered Nurse evaluated/assessed 1 of 4 Patient's reviewed [Patient #1] while in wrist restraints. The Registered Nurse further failed to evaluate and document a skin tear [Patient #1] possibly sustained while in wrist restraints.

Findings included:

1) The history and physical dated 01/28/11 reflected, "[Patient #1] was a 75 year old female who was in the physician's office...she is known to have advanced Alzheimer's Dementia with Psychotic Delusions...the patient has been managed and cared for by her sister, who is her primary caregiver...she also was taken to the medical hospital wound care center, where she followed up with the wound care physician...the patient however, was noted to have worsening of her psychotic symptoms and was noted to be picking on her wounds...as a result, had an advancement of her noted ulcers...her sacral wound is noted as a stage 4 and was noted to become infected with purulent discharge...for this reason the need for aggressive management the patient was referred for a direct admission to....[current hospital]..."

The restraint order/assessment sheet under the section entitled, "Daily Comprehensive Assessment completed by RN" reflected no RN signature which indicated the assessment was completed for Patient #1 while in wrist restraints for 02/02/11, 02/10/11, 02/11/11, 02/12/11, 02/13/11, 02/14/11, 02/15/11, 02/16/11, 02/17/11.

On 03/18/11 at approximately 1:00 PM [Staff #1] was shown Patient #1's restraint order/assessment sheet. [Staff #1] verified the above restraint/assessment document under the section entitled, "Daily Comprehensive Assessment" was not signed by the RN as completed for Patient #1 while in wrist restraints for the above dates.

The physician's orders dated 02/28/11 timed at 2:50 PM reflected, "Iodosorb gel to Right posterior hand wound, covered by foam three times a week, no sting to peri wound..."

The 02/28/11 wound progress note reflected, "Right hand skin tear...1.5 x 0.5 x 0.4...100 % [percent] no slough, no odor..."

The 02/28/11 24-hour patient record and plan of care reflected under the skin section of the document no documentation indicating Patient #1 had a skin tear to the right hand. The narrative notes timed at 08:00 AM reflected, "Wrist restraints checked, blood circulation checked on both hands ...no change in patient's condition..." No documentation was found which addressed the skin tear to the right hand.

On 03/31/11 at 11:30 AM [Staff #1] was interviewed. [Staff #1] was asked to review Patient #1's medical record. [Staff #1] stated Patient #1's skin tear was not documented in the nurse's notes nor did the facility have an incident report indicating the patient sustained a skin tear. The surveyor asked whether the patient sustained the skin tear while in restraints. [Staff #1] stated she did not know.

On 03/31/11 at 12:45 PM, [Staff #5] was interviewed. [Staff #5] was asked what happened to Patient #1's right hand. [Staff #5] stated she did not know. She stated she remembered someone asking her to look at the skin tear on her hand. She stated she did and provided treatment. [Staff #5] was asked how the patient obtained the skin tear since both wrists were restrained. She stated she did not know she just provided treatment to her hand.

On 03/31/11 at 5:00 PM [Staff #13] was interviewed. [Staff #13] was asked by the surveyor what happened to Patient #1's hand. He stated he found a skin tear and the wound nurse saw the patient. [Staff #13] was asked if he completed an incident report and documented the skin tear. [Staff #13] stated no he did not he did not think it was a big deal as it was so small. [Staff #13] was asked whether the patient sustained the skin tear while in restraints. He stated he did not know.

The policy entitled, "Restraints and Seclusion" with a revision date of 06/10 reflected, "Perform a comprehensive assessment, if restraint is a consideration. Use concrete, objective observations to describe the patient's behavior..."

The skin tear policy with a revision date of 12/08 reflected, "Document category and type of skin tear, assessment of findings, interventions and patient responses, notifications and consultations and evaluation of effectiveness of care..."