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Based on interviews and the review of clinical records, it was determined facility staff failed to ensure restraints used for the management of violent and/or self-destructive behaviors had orders renewed every four (4) hours for one (1) of three (3) patients sampled for restraint use (Patient #2).

The findings include:

Patient #2's clinical documentation was reviewed with a registered nurse (RN) (Staff Member (SM) #4) on 2/22/19 and 2/26/19.

Patient #2's clinical documentation included a restraint order, dated 11/22/18 at 5:35 p.m., for "non-violent" restraints. This restraint order was for "Limb Restraints" for all four extremities. The "Condition that Warrants Restraint" was documented in this order as: "Confusion ... Lack of Awareness of Potential Harm to Self ... Cognitive Impairment ... Delirium". The "Description of Behavior" was documented in this order as: "Cognitive impairment exists that poses an imminent threat that the patient will remove invasive device(s) necessary for medical management" and "Repeated non-compliance with ordered activity restrictions." The "Duration" of this order was documented as "1 day".

The following information was found in a note documented by a nurse on 11/22/18 at 5:55 p.m.: " ... (patient) starting to climb out of bed and would not listen to (spouse), unable to reason with (patient). (Physician's name omitted) made aware ordered one time ativan and diluadid knowing gets scheduled dilaudid and ativan [sic]. 40 minutes later (patient) hitting, kicking and spitting at (spouse), hit (him/her) across the face ..." Documentation in this note also detailed behaviors including, but not limited to, visual hallucinations, removing pulse oximetry probe, and patient not following instructions.

The following information was found in a physician note dated 11/23/18 at 12:25 p.m.: "Subjective/interval history: Had agitation and impulsiveness with danger to (himself/herself) and required restraints overnight. Now out."

During an interview on 2/26/19 at 1:30 p.m., SM #4 reported that he/she felt documentation in the summary note indicated the aggressive behavior had concluded and the restraints were applied due to the patient removing tubes and not due to violent behaviors.

The following information was found in a facility policy with a subject of "Restraint and Seclusion of Patient" (with an effective date of 10/1/2018):
- "Restraint of the Violent and/or Self-Destructive Patient is indicated when: Excessive and unanticipated Violent or Self-Destructive behavior, with the intent to harm, that jeopardizes the immediate physical safety of the patient, a staff member or others."
- "The order shall remain in effect until the patient's behavior or situation is determined to no longer require the use of the restraint, but no longer than 4 hours for adults (18 years of age or older)."

Documentation indicated Patient #2 had restraints in use from 11/22/18 at 5:35 p.m. through 11/23/18 at 8:00 a.m. The aforementioned order was entered as "non-violent" restraints although documentation indicated Patient #2 was "kicking, hitting, and spitting at (spouse)" The restraint order to address violent behaviors was not renewed every four (4) hours as required.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure the required one (1) hour face-to-face assessment was documented by the LIP (Licensed Independent Practitioner) for one (1) of three (3) patients selected for restraint review (Patient #2).

The findings include:

Patient #2 did not have a one (1) hour face-to-face assessment documented after the application of restraints for the management of violent behaviors.

The following information was found in a note documented by a nurse on 11/22/18 at 5:55 p.m.: " ... (patient) starting to climb out of bed and would not listen to (spouse), unable to reason with (patient). (Physician's name omitted) made aware ordered one time ativan and diluadid knowing gets scheduled dilaudid and ativan [sic]. 40 minutes later (patient) hitting, kicking and spitting at (spouse), hit (him/her) across the face ..."

Patient #2's clinical documentation included a restraint order, dated 11/22/18 at 5:35 p.m., for "non-violent" restraints. This restraint order was for "Limb Restraints" for all four extremities. The "Condition that Warrants Restraint" was documented in this order as: "Confusion ... Lack of Awareness of Potential Harm to Self ... Cognitive Impairment ... Delirium". The "Description of Behavior" was documented in this order as: "Cognitive impairment exists that poses an imminent threat that the patient will remove invasive device(s) necessary for medical management" and "Repeated non-compliance with ordered activity restrictions." The "Duration" of this order was documented as "1 day".

The absence of documentation of the one (1) hour face-to-face assessment by the Licensed Independent Practitioner (LIP) due to the application of the aforementioned restraints was discussed with Staff Member (SM) #4 on the afternoon of 2/26/19. SM #4 reported he/she did not believe the restraints were implemented due to violent behaviors (please see Tag 171 for more information).

The following information was found in a facility policy with a subject of "Restraint and Seclusion of Patient" (with an effective date of 10/1/2018):
- "For the purpose of this policy (LIP) Licensed Independent Practitioner [sic] includes physicians, nurse practitioners and physicians' assistants."
- "Violent and/or Self-Destructive restraint orders shall require a face-to-face evaluation of the patient by the LIP responsible for the care of the patient. The LIP shall perform and document a face-to-face evaluation of the patient's physical and psychological status within one hour of the initiation of the restraint."

On the morning of 2/27/19, SM #2 was asked for copies of the LIP assessment documentation prior to and after the implementation of the aforementioned restraints on 11/23/18 at 5:35 p.m. The survey team was provided with physician notes documented on 11/22/18 at 9:52 a.m. and 11/23/18 at 12:25 p.m. Although nursing documentation indicated a LIP had seen the patient at the time the restraints were implemented and the restraint order indicted the restraint order included the response of "Yes" to "I have examined the patient and determined the need for use of restraints continues", no LIP documentation detailing the patient's condition and behaviors within one (1) hour of the initiation of the restraints was found by or provided to the surveyor.

Based on observation, interviews and document review, it was determined hospital staff failed to implement performance improvement activities after identifying a problem area.

The findings include:

A surveyor review of the hospital's "Patient Safety and Quality Plan", quality meeting minutes and data related to plan indicators was conducted on 2/26/19. A review of medical record audits (nursing chart review for documentation of nursing care ) for fiscal years 2018 and 2019 revealed the following:
The FY 19 (fiscal year (July 1 to June 30)), nursing chart review has 20 indicators related to nursing care, 14 (fourteen) of the 20 (twenty) indicators were also included in the FY 18 reviews.
For the FY 19 nursing chart review the following indicators failed to show sustained improvement:
1. "UTA"/"Comment" explained
2. Hygiene (CHG/Bath)
3. SCD (per order)
4. Wound Assessment
5. Line & Drains Assessment
6. MD order compliance-Oral Care
7. MD order compliance-IV Access Flushes
8. MD order compliance-other
9. Intake/Output per order

Indicators 2, 3, 4, 5, and 9 were included in the FY 18 nursing chart reviews and also failed to show sustained improvement in FY 18. The indicators for MD order compliance (6, 7, and 8) were reviewed as one indicator in FY 18 and failed to show improvement for the year.

A review of "Patient Safety and Quality Committee Minutes" for the time period of July 2018 until the present found the following related to the "Medical Record Subcommittee Report"; discussion of oral care audit results present for 6 (six) of 7 (seven) committee meetings. The following documentation was found under the heading "Plan"; "Quality department continues to email each individual staff member and nursing leadership with documentation failures. Ongoing. Continued presentation of audit results and education of restraint documentation, pain reassessment, and critical value procedures at orientation, shared governance meeting and nursing team meetings" "EPIC 2018 update is coming soon, which should help with capturing more accurate data collection." The aforementioned documentation was found in each of the "Patient Safety and Quality Committee Minutes" with no variations noted.

The above findings were shared with Staff Member (SM) #2, Director of Quality and SM #4 the afternoon of 2/26/19. Discussion included how the collected data was evaluated, if an action plan was developed and what changes were made to the action plan when no improvement was noted.

SM #2 stated that after the audits were completed staff members who had failed to document care were sent an email and that the issues were discussed during the "huddle" with staff each day. SM #2 was asked if other changes were implemented, SM #2 answered there had not been. SM #2 stated there had been a serious adverse event that occurred October 2018 and that the focus had been on that event. While the surveyor agreed that it was appropriate that a serious event would take priority, it was brought to SM #2's attention that the data surrounding the documentation of nursing care was collected over a period of 19 (nineteen) months with no evidence of sustained improvement and no evidence of changes implemented to correct the problem. Failing to document nursing care meant there was no evidence the care had been provided and nursing care affects all patients in all areas of the hospital.

A review of hospital document "Patient Safety & Quality Plan FY 2017-2019" revealed the following in part under the heading "Scope and Prioritization of Improvement Efforts" "Priorities are also based on high risk, high volume, and/or problem-prone areas considering the incidence, prevalence, and severity of problems in those areas and their effect on health outcomes, patient safety and quality of care."

The above findings were shared with the management team for a final time prior to exit on 2/27/19. No further information was provided to the survey team.

Based on observation, interviews and document review, it was determined hospital nursing staff failed to a) follow hospital protocol related to the displacement of a PEG (percutaneous endoscopic gastrostomy) tube and b) follow hospital protocol related to daily weights for 1 of 8 patients included in the survey sample. (Patient #4)

The findings include:

Patient #4 was admitted on 9/6/18 from an OSH (outside hospital) after a complicated post CABG recovery. (Coronary artery bypass graft surgery (CABG) is a procedure used to treat coronary artery disease). Patient #4 was found to have suffered a CVA (CVA is the clinical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel.) Secondary to the CVA, a tracheostomy and a PEG (Percutaneous endoscopic gastrostomy) tube were placed on 8/29/18. (PEG is an endoscopic clinical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphasia or sedation). Patient #4 remained at the hospital until 9/24/18 when he/she was transferred to an OSH for evaluation of a PEG tube.

On 9/23/18, Staff Member (SM) #17, a registered nurse documented the following end of shift note: "Mid morning PCT reported to have found patient with PEG pulled out; right hand mitt was in place and temporary foley cath was inserted by charge nurse with tube securement in place; MD subsequently inserted a 23F feeding tube; correct placement was confirmed with abdominal x-ray."

Staff Member #7, the nurse manager, was asked if the nurses received any specialized training in replacing PEG tubes with a foley catheter, he/she stated they did not. SM #7 was asked how it was determined the nurse knew how to perform the aforementioned procedure, he/she stated the hospital policy instructed the registered nurse to use "Lippencott Procedure Manual" for practice guidance. The surveyor asked for and was provided copies of the policy that contained the above directive and the "Lippencott" protocol for the procedure. Review of "Lippencott's" enteral feedings special considerations revealed the following: "If the PEG tube is inadvertently removed and the tube is more than 6 weeks old, insert a foley catheter. Contact the primary team. DO NOT instill water, feeding or medications until the position is verified by the LIP. If the PEG tube is inadvertently removed and the tube is less than 6 weeks old, DO NOT insert anything. Contact the primary team." Patient #4's PEG tube had been placed 26 days prior to the inadvertent removal and as such the nurse should not have replaced the PEG tube with a foley catheter. SM #7 was asked what his/her expectation would have been for the nurse's actions in the aforementioned circumstances. He/she stated that the nurse would have been expected to follow the policy and not insert anything to replace the PEG tube.

A weight on admission and daily at 5 a.m. was ordered for Patient #4 on 9/6/18. The clinical record contained weight documented daily at various times of the day. Concerning were the weights recorded on 9/18/18 to 9/21/18 as follows:
9/18/18 at 5:38 p.m. 163 lb 11 oz
9/19/18 at 7:14 a.m. 158 lb 11 oz
9/20/18 at 3:39 p.m. 166 lb 10.7 oz
9/21/18 at 9:18 p.m. 150 lb 9.2 oz
This shows a weight gain of approximately 12 lbs from the 19th to the 20th, and a loss of approximately 16 lbs from the 20th to the 21st. "Lippencott" guidelines to weight measurement provided to the surveyor by management staff, contains the following guidance under "special considerations" "Report any weight gain greater than 1 kg (2.2 lb) per day."
A review of the clinical record failed to provide evidence the weight gain was reported and/or evidence the recorded weight was checked for accuracy. A review of the clinical record failed to provide evidence of a reason for the wide variation in weights.

The above findings were reviewed with SM #7 on 2/26/18 at 3:30 p.m.. When asked what action would have been expected of the nurse or PCT (patient care technician) when noting the variation in weight, he/she stated "At a minimum, I would expect the weight to have been checked for accuracy, and if the weight is correct for the physician to be notified of the change."

The findings were reviewed with the management team for a final time on 2/27/18 prior to exit. No further information was provided to the survey team.