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CORNERSTONE SPECIALTY HOSPITALS ROUND ROCK
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on review of the record of patient #1 and staff interview, this patient developed a sacral decubitus during his stay at this hospital.
Findings were:
Nursing skin documentation on admission revealed that Patient #1 had skin tears on his arms and multiple bruises on all extremities. " His sacral area was red, it was mostly healed. " On 6/16 the sacral area was open and orders were written for care of the area to be provided every 4 hours. There was no documented evidence of the every four hours care to the patients sacral area from 6/16 through the patients discharge on 7/3.
The above was confirmed in interview on 7/5 with facility staff.
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0167
Based on review of the medical record for patient #1 and staff interview, the facility failed to ensure that all hospital policies related to restraints were followed.
Findings were:
Cornerstone hospital policy K20:04:08 "Restraints used in the provision of non-emergent medical and surgical care" #6 requires that "a daily restraint order is required if continued use of restraints is necessary for the patient beyond 24 hours." For patient #1 the physician had not signed the restraint order for both 7/16 and 7/17 although the use of restraints was documented for these days.
The above was confirmed in interview on 7/5 with facility staff.
CONTENT OF RECORD: STANDING ORDERS
Tag No.: A0457
Based on review of the clinical record for patient #1 and staff interview there were 7 orders for physical restraints that were signed beyond 48 hours from the telephone and/or verbal order. An additional 2 restraint orders (6/16 and 6/17) were not signed by any physician as of 7/5 .
Findings were:
The clinical record for patient #1 revealed that he was restrained daily from 6/5 through 6/25. On 7 occasions the telephone/verbal restraint orders were not signed within 48 hours as required. These orders were signed 3 to 5 days after the restraint order. There were two orders that had not been signed as of 7/5 these were restraint orders 6/16 and 6/17.
The above was confirmed in interview on 7/5 with facility staff.