HospitalInspections.org

On the days of the Recertification Survey based on medical record review and hospital policy review, the hospital failed to ensure that physician restraint orders were completed according to hospital policy for 1 of 10 closed records reviewed (Patient #5).


The findings include:


Record review conducted on 4/20/11 at 1145 revealed Patient #5 was admitted to the hospital on 2/9/11 and discharged on 4/9/11 with the diagnosis of Acute & Chronic Respiratory Failure. The hospital form, #1106-180-RC, titled, "PHYSICIAN'S ORDER FORM Medical Restraint - Physician Assessment and Order", revealed the following sections: "restraint justification", "rationale for restraint", "type of device", and "requirement for discontinuation of restraint". On 2/24/11, 3/2/11, 3/4/11, 3/5/11, 3/22/11, 3/29/11, 3/30/11, 4/2/11, and 4/3/11, the "rationale for restraint" section was not completed. On 3/13/11, the physician order form was completed but not signed by the physician until 3/14/11, and on 4/2/11, the physician order was completed but not signed by the physician until 4/3/11 which was outside the hospital policy addressing order renewal every calendar day. The findings were verified by the Chief Nursing Officer on 4/21/11 at 1030.

Hospital Policy #RC300.137, titled, "Restraints", revised 3/11, states, ".... 2. Physician Order A physician order is required for each episode of restraint prior to the application of the restraint. * Each order includes rationale for restraint, type of device, and criteria for discontinuation. *Renewal Order: Continued use of restraint beyond the first 24 hours is authorized by the physician. The physician shall perform an assessment of the patient at least once every calendar day, at which time restraints shall be either re-ordered or discontinued as clinically justified...".

On the days of the Recertification Survey based on record review and hospital policy review, the hospital failed to ensure the documentation that alternative/least restrictive methods were utilized prior to restraint for 1 of 10 closed patient records (Patient #5).


The findings include:


Record review conducted on 4/20/11 at 1145 revealed Patient #5 was admitted to the hospital on 2/9/11 and discharged on 4/9/11 with the diagnosis of Acute & Chronic Respiratory Failure. On 2/28/11, 3/1/11, 3/2/11, 3/3/11, 3/4/11, 3/7/11, 3/8/11, 3/9/11, 3/10/11, 3/11/11, 3/12/11, 3/13/11, 3/14/11, 3/15/11, 3/16/11, 3/18/11, 3/24/11, 3/25/11, 3/26/11, 3/27/11, 3/28/11, 3/29/11, 4/1/11, 4/2/11, 4/3/11, 4/4/11, 4/5/11, and 4/5/11, the hospital form #1496-RC, titled, "RESTRAINT FLOW SHEET", revised 3/11, showed staff did not document the alternative methods utilized prior to restraints. The findings were verified by the Chief Nursing Officer on 4/21/11 at 1030.

Hospital Policy #RC300.137, titled, "Restraints", revised 3/11, states, "...5. Documentation of Restraint Use and Patient Care The registered nurse assigned to the patient will be responsible for ensuring that the documentation on the Restraint Flow sheet is completed. When a restraint is used, there must be documentation in the patient's medical record of the following: *A description of the patient's behavior and the intervention used; *Alternatives or other less restrictive interventions attempted...".

On the days of the Recertification Survey based on record review and hospital policy review, the hospital failed to ensure that all telephone orders (TO) and/or verbal orders (VO) were authenticated within 48 hours according to hospital policy for 7 of 10 closed patient records reviewed. (Patient #2, 3, 5, 6, 7, 8, and 10)


The findings include:


Record review conducted on 4/20/11 at 1045 revealed Patient #2 was admitted to the hospital on 1/25/11 and discharged on 2/7/11 with the diagnosis of Peritonitis. On 1/26/11, 2/2/11, and 2/4/11, physician telephone orders were received and documented by staff but there was no documentation of a date and time when the telephone order was authenticated by the physician. On 1/26/11, a physician telephone order was received and documented by staff but the order was not authenticated until 1/31/11. On 2/4/11, a physician telephone order was received and documented by staff but was not authenticated by the physician until 2/15/11. On 2/7/11, physician telephone orders were received and documented by staff but the telephone orders were not authenticated until 2/22/11. All of the physician telephone orders were greater than the 48 hour timeframe.

Record review conducted on 4/20/11 at 1100 revealed Patient #3 was admitted to the hospital on 1/14/11 and discharged on 2/3/11 with the diagnosis of Intervertebral Disc Disorders. On 1/21/11, 1/22/11, 2/1/11, physician telephone orders were taken and documented by staff but there was no date and time to indicate when the telephone orders were authenticated by the physician. On 1/21/11, a physician telephone order was received and documented by staff but not authenticated by the physician until 1/28/11. On 2/2/11, a physician telephone order was received and documented by staff but not authenticated by the physician until 2/10/11. On 2/3/11, physician telephone orders were received and documented by staff but not authenticated until 2/10/11. All of the physician telephone orders were authenticated greater than the 48 hour timeframe.

Record review conducted on 4/20/11 at 1145 revealed Patient #5 was admitted to the hospital on 2/9/11 and discharged on 4/9/11 with the diagnosis of Acute & Chronic Respiratory Failure. On 2/10/11, a physician telephone order was received and documented by staff but not authenticated until 2/15/11. On 3/11/11, a physician telephone order was received and documented by staff but not authenticated until 3/14/11. A physician telephone order was received and documented on 3/16/11 but not authenticated until 4/18/11. All the telephone orders were authenticated greater than the 48 hour timeframe.

Record review conducted on 4/20/11 at 1355 revealed Patient #6 was admitted to the hospital on 2/2/11 and discharged on 2/11/11, with the diagnosis of Acute & Chronic Respiratory Failure. On 2/2/11, 2/3/11, 2/4/11, 2/5/11, 2/6/11, 2/7/11, 2/8/11, and 2/9/11, telephone orders were taken but none of the telephone orders showed the date and time to indicate when the order was authenticated by the physician.

Record review conducted on 4/20/11 at 1410 revealed Patient #7 was admitted to the hospital 2/1/11 and discharged on 2/11/11 with the diagnosis of Acute & Chronic Respiratory Failure. On 2/2/11, a telephone order was taken and authenticated on 3/2/11. On 2/10/11, a telephone order was taken and authenticated on 3/7/11. On 2/11/11, a telephone order was taken and authenticated on 2/28/11. On 2/11/11, a telephone order was taken and authenticated on 3/7/11.

Record review conducted on 4/20/11 at 1430 revealed Patient #8 admitted to the hospital on 2/17/11 and discharged on 3/10/11, with the diagnosis of Acute & Chronic Respiratory Failure. On 2/16/11, 2/17/11, and 3/9/11, telephone orders were taken but there was no documentation of a date and time to indicate when the order was authenticated by the physician. On 3/3/11 a TO was taken and authenticated on 3/18/11.

Record review conducted on 4/20/11 at 1500 revealed Patient #10 was admitted to the hospital on 1/20/11 and discharged on 2/18/11 with the diagnosis of Bacteremia. On 1/20/11, 1/21/11, 2/7/11, and 2/17/11, physician telephone orders were received but there was no documentation of the date and time when the order was authenticated by the physician. On 1/22/11, physician telephone orders were authenticated on 1/28/11. On 1/24/11, a physician telephone order was authenticated on 1/28/11. On 1/27/11, a physician telephone order was authenticated on 2/3/11. The telephone orders were authenticated greater than the 48 hour timeframe. The findings were verified by the Chief Nursing Officer on 4/21/11 at 1030.

Hospital Policy #RC300.150, titled, "Verbal Orders and Telephone Orders", revised 2/10, states, ".... PROCEDURE... * Verbal or telephone orders must be authenticated by the ordering physician or another practitioner who has hospital privileges and is responsible for the care of the patient within 48 hours. Charts are flagged indicating the need for physician signature date and time...".