HospitalInspections.org

Based on review and interview the governing body failed to:



A. ensure nursing documentation of attempted any other comfort measures before medicating the patient and call the Rapid Response Team to a significant patient change in 1(1) of 2(1 and 2) patients reviewed,

ensure nursing initiated CPR immediately when called as a code blue and complete the code blue documentation in 2 (1 and 2) out of 2 charts reviewed,

ensure nursing documented the dosage of cardiac drugs administered during a Code Blue event in 1(2) of 2(1 and 2) charts reviewed.

Refer to Tag A0144




B. ensure nursing documented patient restraint assessments every two hours to ensure comfort and safety. RN failed to sign, date, and time nursing assessments in 2(1 and 5) of 2(1 and 5) charts reviewed,

ensure nursing followed physician orders for restraints application and failed to have written orders for the application of restraints in in 1(1) of 2 (1 and 5) charts reviewed,

ensure education of the clinical staff on proper use and documentation of restraints in 4(4,5,6,and 7) out of 4(4,5,6,and 7) charts reviewed,

ensure Performance Improvements through Quality to decrease the excess number of restraints for 13 out of 17 months reviewed.


Refer to Tag A0154




C. ensure physicians conducted face to face re-evaluation, before writing a new order, for the continued use of restraints within 24 hours on 2(#1-2) of 2(#1-2) patients reviewed,

ensure physician dated and timed physician orders on 2(#1-2) of 2(#1-2) patients reviewed,

ensure physicians completed the restraint order sheet on reason for restraint use, alternatives documented attempted before restraint use, invasive interventions that apply to the patient, and procedures performed before restraint application on 1(#1) of 2(#1-2) charts reviewed.


Refer to Tag A0172




D. take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 17 out of 17 months (January 2016-May of 2017).


Refer to Tag A0283




D. ensure performance improvements to identify problem-prone areas from the data that had been collected for 17 months (January 2016-May of 2017).

refer to tag A0297




E. ensure nursing was well-organized with a plan of administrative authority and delineation of responsibilities for patient care to a qualified Chief Nursing Officer (CNO).

Refer to TAG A0386




F. ensure nursing documented ongoing assessments of the patient's needs, updating or revising the patient's nursing care plan, in response to a Code Blue status change and patient restraints in 1(1) of 2(1 and 2) patient charts reviewed.

Refer to TAG A0396

Based upon record review and interview, the facility failed to:




A. ensure that attempted interventions before medicating the patient and calling the Rapid Response Team to a significant patient change in 1(1) of 2(1 and 2) patients reviewed were documented,

ensure nursing initiated CPR immediately when called as a code blue and complete the code blue documentation in 2 (1 and 2) out of 2 charts reviewed,

ensure nursing documented the dosage of cardiac drugs administered during a Code Blue event in 1 (2) of 2 (1 and 2) charts reviewed.


Refer to Tag A0144




B. ensure that patient restraint assessments every two hours to ensure comfort and safety were documented. RN failed to sign, date, and time nursing assessments in 2 (1 and 5) of 2 (1 and 5) charts reviewed,

ensure nursing followed physician orders for restraints application and failed to have written orders for the application of restraints in in 1 (1) of 2 (1 and 5) charts reviewed,

ensure education of the clinical staff on proper use and documentation of restraints in 4 (4,5,6,and 7) out of 4 (4,5,6,and 7) charts reviewed,

ensure Performance Improvements through Quality to decrease the excess number of restraints for 13 out of 17 months reviewed.


Refer to Tag A0154




C. ensure physicians conducted face to face re-evaluation, before writing a new order, for the continued use of restraints within 24 hours on 2 (#1-2) of 2 (#1-2) patients reviewed,

ensure physician dated and timed physician orders on 2 (#1-2) of 2 (#1-2) patients reviewed,

ensure physicians completed the restraint order sheet on reason for restraint use, alternatives documented attempted before restraint use, invasive interventions that apply to the patient, and procedures performed before restraint application on 1 (#1) of 2 (#1-2) charts reviewed.


Refer to Tag A0172

Based on review and interview, the facility failed to:


1.) take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 17 out of 17 months (January 2016-May of 2017).


Refer to Tag A0283




2.) have performance improvements to identify problem-prone areas from the data that had been collected for 17 months (January 2016-May of 2017).

refer to tag A0297

Based on review and interview, nursing failed to:

A. Be well-organized with a plan of administrative authority and delineation of responsibilities for patient care to a qualified Chief Nursing Officer (CNO).

Refer to TAG A0386


B. document ongoing assessments of the patient's needs, updating or revising the patient's nursing care plan, in response to a Code Blue status change and patient restraints in 1 (1) of 2 (1 and 2) patient charts reviewed.

Refer to TAG A0396

Based on review and interviews the facility failed to;

A.) There was no documentation that the nurse attempted any interventions before medicating the patient and failed to notify the Rapid Response Team to a significant patient change in 1 (#1) of 2 (#1 and #2) patients reviewed.

B.) Initiate cardiopulmonary resuscitation (CPR) for 2 minutes after a Code Blue was initiated and complete the cardiopulmonary resuscitation documentation in 2 (#1 and #2) out of 2 charts reviewed.

C.) document the dosage of cardiac drugs administered during a Code Blue event in 1 (#2) of 2 (#1 and #2) charts reviewed.


Review of patient #1's chart revealed, the patient was admitted to the facility on 11/18/16 with a diagnosis of Cardiac Arrest, Anoxic Encephalopathy, and Chronic Systolic Congestive Heart Failure with EF of 14%. Review of the patient #1's history and physical (H&P) revealed it was dated as dictated on 11/18/16 but not signed until 3/1/17, 4 months later. The H&P revealed, Patient #1 was a 40 year old Hispanic male who had a history of pulmonary disease, DVT, and paraplegia who went to the ED with chest pain. The patient coded and went into PEA for 26 minutes. The patient ended up with a tracheostomy and peg tube for feedings. The patients echo revealed EF 10% to 14% with large apical thrombus. The patient needed continued mechanical ventilation, anticoagulation and nutritional support and he was admitted to the facility.


Review of patient #1's Nursing Daily Flowsheet on 1/23/17 at 8:50AM revealed the patient was assessed by the nurse and family was in the room. At 1325 (1:25PM) the nurse documented, "Family calls out said he was moaning/grimacing. Found patient to be anxious with facial grimacing and was moving about."


Review of the "Pain Assessment and Intervention" section revealed the nurse documented the following:

Time- 1325
Location of pain- grimacing/moving
Pain rating- ? Unable to assess
Quality-1/aching
Intervention Medication/Nonpharmacological- med
Medication route-PO (by mouth)."


Review of the medication MAR revealed the nurse administered Hydrocodone -Acetaminophen 1 tablet by mouth and Lorazepam 1 mg IV at 1325 (1:25PM).There was no documentation that the nurse attempted any other interventions before medicating the patient. There was no documentation that patient #1's vital signs were taken before giving pain medications. There was no further nursing documentation noted until 1422 (2:22PM) 57 minutes later.

1422 (2:22PM) the nurse documented, "Pts heart rate dropped to 60 pacing. RN charge went to check on pt. family present.

1425 (2:25PM) Entered room, pt is on vent per resp. spt central 16, tidal vol 500 100% O2 Peep of 5 1433. Pt went into V-tach and then stopped breathing. Pt remains on vent.

1436 (2:36PM) Code stated. See flowsheet.

1454 (2:54PM) Dr.___ (staff #8) here at this time further orders written being carried out. Pt has 21 ½ g rt ac (three words are illegible) Dopamine 10mg/kg been started see times per flo sheet." (DIC).

Review of the "Code Blue Record" revealed on 1/23/17 patient #1 was found by staff #8. Under "found by" on the sheet is a comment that asked, "witnessed yes or no." This section of the code sheet was left blank.

The time marked on the code sheet of "time code called' was 1433 (2:33PM). It stated the patient was pulseless and in V-tach (Ventricular Tachycardia- is a type of regular and fast heart rate that arises from improper electrical activity in the ventricles of the heart.)

The time documented that the code started was "1435" (2:35PM) 2 minutes after the code was called. There was no documentation that revealed why the patient had a two minute delay before CPR was started.

"1438 (2:38) the defibrillator was applied to the patient 5 minutes after the code was called. There was no shock advised.

1439 (2:39PM) the CPR continued Staff #8(MD) notified and in route." The box under "EPI" (Epinephrine, also known as adrenalin/cardiac drug) was marked as given 1 amp but was scratched out.

"1440 (2:40PM) the drug EPI 1 amp was given.
1441 (2:41PM) CPR when not analyzing with defibrillator. Pt was analyzed.
1442 (2:41PM) 1 amp of Atropine (anticholinergic) was administered.
1443 (2:43PM) has a pulse, B/P 160/58, CPR stopped.
1444 (2:44PM) Dr. Perez here orders noted.
1445 (2:45PM) Dopamine @ 10mcg/kg/min.
1448 (2:48PM) B/P 92/46
1451 (2:51PM) HR, 128, B/P 73/41, RR 16, 500 ml NS bolus and lab drawn.
1500 (3:00PM) HR 131, 73/48, RR 16 ABG drawn by Dr.____ (staff #8.)"

At the bottom of the code sheet the time stopped for the code was marked at 1443 (2:43PM). There was signature line for the physician and the RN to sign the code sheet. There were no signatures found. Under the signature lines were the questions, "Variance Completed yes or no and Code Evaluation completed yes or no." Both the questions were left blank.

Review of the chart revealed there was no documentation that the Rapid Response Team was called to assess the patient. Review of the policy and procedure "Rapid Response Team" stated,

"The Rapid Response Team (RRT) is a group of clinicians who bring critical Expertise to the bedside whenever needed. The RRT has several roles. The team assists the staff member in assessing and stabilizing the patient's condition and organizing information to be communicated to the patient's physician.

2. Mechanisms for activating team:
Staff members contact the RRT via overhead pager. Team members will be expected to respond in a timely manner. At this time, the floor nurse should gather the patients chart, current medications list and recent vital signs to provide to team upon approval."


Review of the patients "Interdisciplinary Plan of Care" from 11/18/16-1/24/17 revealed no mention of code or in the Team Conference held on 1/24/17.


Review of patient #1's intake and output record revealed the patient was on a continuous tube feeding of 60cc/hr. The nurse documented 60cc from 0700-1400. At 1500 the nurse received an order to hold the feedings but had pre-charted 60cc from 1500-1800 and had marked over the 60cc with a "0" and a line through it very heavily with a pen.


An interview with staff #2 and #3 was conducted on 5/24/17. Staff #2 was a participant in patient #1's code blue on 1/23/17. Staff #2 stated he was not aware the Code Blue Record was incomplete and could not answer why the code was called at 1433 (2:33PM) and not initiated until 1435 (2:35PM).Staff #2 stated when the rapid response team is called they fill out a RRT form. Staff #2 or #3 were able to provide a RRT form for patient #1 on 1/23/17. Staff #3 confirmed the above findings but had no QAPI to support the oversight of codes called in the facility. Staff #3 saw the pre-charting done by the nurse on the intake and output form for 1/23/17. Staff #3 confirmed the findings but had no explanation.



Review of patient #2's chart revealed he was admitted to the facility on 12/13/16 with a diagnosis of Acute Respiratory failure requiring a tracheostomy attached to mechanical ventilation, Dysphagia requiring percutaneous endoscopic gastrostomy tube and a post CVA on 11/8/16.


Review of patient #2's nursing notes revealed patient #2 was having leakage around his trach cuff area and Respiratory Technician (RT) along with physician was called on 12/15/16 at 2100 (9:00PM). "2300 RT in room to change out trach. Pt began to desat and RT had difficulty replacing trach due to patients anatomy. RT began to bag pt while Dr.____ staff #8 was notified and states "I'm on my way. "RT and nurse continue to ventilate pt.


2321 (11:21PM) Dr.___ staff #8 here to attempt to replace trach. Orders received to get Bronch cart. Bronchoscopy performed by Dr.___ staff #8. Trach replaced by Dr.___ staff #8 then obtain second xray, then inserted rt chest tubes without difficulty.

0100 (1:00AM) CXR obtained MD stated pt has pneumothorax on l side and need to insert L chest tube, Left chest tube inserted using sterile technique. CXR obtained to verify placement approx. 0300.

0400 (4:00AM) Moderate amount of edema noted to face, upper extremities and scrotum. Body cool and dry. FMS out, incont of BM. FMS replaced. No response from patient.

0600 (6:00AM) Modelling noted to l arm and rt leg. Unable to obtain B/P, HR weak and difficult to count. Dr. ___ staff #8 notified and family member___ notified of pts declining condition.

0612 (6:12AM) Code Blue called. CPR and ACLS used per protocol on pt. see meds per code sheet.

0625 (6:25AM) pts sister ___ called back and states stop CPR and life sustaining measures. Code called by Dr.___staff #8." (DIC)


Review of patient #2's chart revealed a Rapid response record dated 12/16/16. The time the documented as called was at 0600 (6:00AM). The arrival time of the team was 0610 (6:10AM) at 10 minute delay. The event ended at 0625 (6:25AM).


Review of the Code Blue record for patient #2 revealed the code was called at 0610 (6:10AM) but CPR was not started until 0612(6:12AM) a 2 minute delay. The patient went two minutes without resuscitation efforts. Review of the code sheet revealed the patient was given the following cardiac medications:

0612 (6:12AM) - EPI no dosage documented.
0615 (6:15AM) - EPI no dosage documented.
0618 (6:18AM) - EPI no dosage documented.
0620 (6:20AM) - Atropine no dosage documented.
0621 (6:21AM) - EPI no dosage documented.
0622 (6:22AM) - Atropine no dosage documented.
0623 (6:23AM) - EPI no dosage documented.
0625 (6:25AM) - Code Called.

There was no information if patient was ever shocked with defibrillator. At the bottom of the code sheet the time stopped for the code was marked at 0625 (6:25AM). There was signature line for the physician and the RN to sign the code sheet. There were no signature for the physician found. Under the signature lines were the questions, "Variance Completed yes or no and Code Evaluation completed yes or no." Both the questions were left blank.

Based on review and interview the facility failed to;

A.) Document patient restraint assessments every two hours to ensure comfort and safety. RN failed to sign, date, and time nursing assessments in 2 (#1 and #5) of 2 (#1 and #5) charts reviewed.

B.) Follow physician orders for restraints application and failed to have written orders for the application of restraints in 1 (#1) of 2 (#1 and #5) charts reviewed.

C.) Educate the clinical staff on proper use and documentation of restraints in 4 (4,5,6,and 7) out of 4 (4,5,6,and 7) charts reviewed.

D.) Initiate Improvements through Quality to decrease the excess number of restraints for 13 out of 17 months reviewed.



1.) Review of the policy and procedure "Restraints" stated, "Documentation: 2. Document observations and care provided in the medical record. Include, at a minimum, the following;


A. Daily
Initial restraint assessment
Reason for restraint
Physician notification
Least restrictive measures attempted
Teaching


B. 60 Minute Post Initial Restraint Application:
RN restraint check


C. Observe patient and document the following every two hours:
Restraint Status (released for comfort/safety, then reapplied)
Ensure proper placement
ROM/Ambulation
Position
Fluid/Nourishment
Toileting
Personal Hygiene
Behavior Observation
Level of consciousness/orientation


D. Every Shift
Assessment
Vital Signs."


Review of patient #1's physician orders revealed the patient was ordered soft limb restraints from 11/18/16-1/13/17.


Review of the nursing documentation for restraints revealed a "Restraint Management Flowsheet." The flowsheet had check boxes to show what type of restraint was utilized and an assessment that should be done every two hours. There was a section for the day shift from 7:00AM-6:00PM and 6:00PM-7:00AM. In the assessment box there was a signature line with date and time to be completed on each shift. The assessment included:

"Plan of Care Reviewed/Updated
Patient/Family Educated (as needed)
Restraint Device on
Restraint Release/Reposition
Mental Status
Behavior exhibited
Offer Fluids/Nutrition
Offer Toileting
Skin/Circulation Check
Turn/Position Change
Personal Hygiene."


Review of the Nursing Management Flowsheet revealed the following;

11/19/2016- The RN failed to sign, date, or time the flowsheet for the 7:00AM-7:00PM (day) shift.

11/20/2016- There was no documented type of restraint utilized. No date or time after RN signature for 7:00AM-7:00PM.

11/21/2016- There was no documented type of restraint utilized for the day shift but the nurse documented the assessment for restraints. The restraints were documented as removed at 7:00PM for non-movement.

11/22/16- An order to place the patient back on the soft limb restraints was written by the nurse at 6:00AM. There was no documentation that the patient was placed back on soft limb restraints until 9:00PM.

11/23/16- Patient #1's restraints were removed and discontinued at 8:00AM and put back on at 7:00PM. There was no documentation on why the restraints were removed and no order to reapply the restraints.

11/24/16-There was no documentation on type of restraint for the day shift but the assessment for restraints was completed. There was no documentation on any restraint care given from 1:00PM- 6:00PM. The day shift nurse failed to date and time the assessment.

11/25/16- No nurse signature, date, or time found for the day shift. There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

11/26/16- No nurse signature, date, or time found for the day shift. There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

11/27/16- No nurse signature, date, or time found for the day shift.

11/28/16- No nurse signature, date, or time found for the day shift.

11/30/16- No nurse signature, date, or time found for the day shift.

12/1/16- No nurse signature, date, or time found for the day shift. There was no documented assessment at 5:00PM two hour assessment time.

12/5/16- There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

12/6/16- Patient #1 was documented assessed in restraint every three hours instead of every two on the day shift. No type of restraint documented for night shift.

12/7/16- No type of restraint documented for the day or night shift.

12/8/16- Patient skin check, position change, personal hygiene was not documented from 7:00AM-6:00PM. Patient personal hygiene or type of restraint used was not documented from 6:00PM- 7:00AM.

12/11/16- No restraint documentation from 7:00AM-6:00PM. Patient had an order for soft limb restraints.

12/13/16- No date or time documented for 7:00AM-6:00PM shift.

12/14/16- Patient personal hygiene was not documented for the day or night shift.

12/17/16- No nurse date or time found for the day shift.

12/18/16- No nurse date or time found for the day shift.

12/19/16- No assessment flowsheet found for patient #1.

12/22/16- There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

12/23/16- There was no documented type of restraint for the day or night shift.

12/24/16- No nurse date or time found for the day shift.

12/25/16- No nurse date, time, or hygiene documentation found for the day shift. No hygiene documentation found for the night shift.

12/26/16- There was no documented type of restraint for the night shift.

12/27/16- There was no documented type of restraint for the day shift. No documented time on the day shift and no date for the night shift.

12/28/16- There was no documented type of restraint for the night shift.

12/29/16- No documented time on the day shift. There was no documented type of restraint for the night shift.

12/30/16- Patient personal hygiene was not documented for the day shift. There was no documented type of restraint or type of restraint for the night shift.

1/1/17- There was no documented type of restraint or time for the day shift. There was no documented type of restraint for the night shift.

1/2/17- There was no documented type of restraint for the night shift.

1/3/17- No nurse signature, date, or time found for the day shift. There was no documented type of restraint for the night shift.

1/4/17- There was no documented type of restraint for the night shift.

1/5/17- No nurse time found for the day shift. There was no documented type of restraint for the night shift.

1/7/17- Patient personal hygiene was not documented for the day shift. There was no documented type of restraint for the night shift.

1/8/17- There was no documented type of restraint for the night shift.

1/9/17- No nurse date or time found for the day shift. There was no documented type of restraint for the night shift.

1/10/17- There was no documented type of restraint for the night shift.

1/11/17- No nurse date or time found for the day shift.

1/12/17- No nurse signature, date, or time found for the day shift.

1/14/17- There was no documented type of restraint for the night shift.

1/15/17- There was no documented type of restraint or time for the night shift.

1/16/17- No documented nurse signature, date or time found for the day shift.

1/18/17- No documented nurse time found for the day shift. There was no documented type of restraint or time for the night shift.

1/19/17- No documented nurse time found for the day shift. There was no documented type of restraint or time for the night shift.

1/21/17- There was no documented type of restraint or time for the night shift.

1/23/17- No documented nurse date or time found for the day shift.


Review of patient #1's nursing care plan revealed there was no documentation for restraints from 11/18/16-1/13/17.


Review of patient #5 revealed the Nursing Management Flowsheet for restraints on 1/31/17 had no nursing signature, date, or time for days. There was no documentation on type of restraint or personal hygiene offered for the night shift.



An interview with staff #2 and #3 on 5/24/17 confirmed the findings on restraint assessments. Staff #2 reported there had been a period where the nurses had missed training and they have tried to improve on that. Staff #2 stated that he had just recently been placed in the Director of Nursing (DON) position. Review of the DON employment record revealed he had signed his job description as DON on 4/28/17.


Review of staff #4's (LVN) employment record on 5/24/17 revealed the nurse had no nursing education in his chart.


Review of staff #5's (RN) employment record on 5/24/17 revealed staff #5 had no current restraint training.


Review of staff #6 and #7 employment record on 5/24/17 revealed the employees skills were not dated or signed off for restraint training or any other skills required to perform their jobs in the clinical setting.


An interview was conducted with staff #2 and #3 on 5/24/17 concerning the lack of restraint training documented for the employees. Staff #2 and #3 confirmed the above findings. Staff #3 reported the last CNO had not kept up with the staff training.



2.) Review of the Quality Assessment Performance Improvement documentation revealed in 2016 there was only data for restraints and restraint use. Review of the Quality scorecard revealed data was gathered for the following;

"Restraint Days
# Patients on Restraints
Restraint days rate (#restraint days/#patient days) x100
Restraint Rate Target."


Review of the Quality indicator Restraint Rate Target for year to date revealed the target was 3.50. The Restraint days rate (#restraint days/#patient days) x100 year to date was 9.10. The restraint day's rate was out of range January 2016-December 2016 and March of 2017. There was no performance improvement (PI) projects or any documentation to support that Quality was following restraints.


An Interview with staff #3 on 5/24/17 confirmed that there was no PI documentation for restraints. Staff #3 reported that she had just recently went to training to start utilizing the PI process two weeks ago. Staff #3 stated she had been in this position about three years.

Based on review and interview the facility failed to;

A.) Conduct a physician face to face re-evaluation, before writing a new order, for the continued use of restraints within 24 hours on 2(#1-2) of 2(#1-2) patients reviewed.

B.) Sign date and time physician orders on 2(#1-2) of 2(#1-2) patients reviewed.

C.) Complete the restraint order sheet on reason for restraint use, alternatives documented attempted before restraint use, invasive interventions that apply to the patient, and procedures performed before restraint application on 1(#1) of 2(#1-2) charts reviewed.


Review of the facility's policy and procedure "Restraints" stated, "Medical Staff and Qualified (LIP):
1. The attending physician/LIP must examine the patient as soon as possible when notified that restraint use is indicated, but no later than 24 hours after the initiation of non-violent, non self destructive restraint use.
2. Telephone orders may only be used for the first episode of restraint based on nursing assessments."


Review of patient #1's physician restraint orders revealed at the bottom of the form above the physician's signature was the following statement, "I have completed a comprehensive assessment of the patient and have determined that Restraints are the least alternative for this patient and are needed to address the patient's medical condition. I agree with the above assessment and order the type of restraint recommended above *** May obtain a telephone order for initial restraint order only."


Review of patient's #1's chart revealed the restraint orders were filled out by the RN and the physician would come in sign, date and time the order. Review of physician restraint order for 1/2/2017 revealed the physician did not sign the order until 1/4/2017 at 1912 (7:12PM) the face to face was not done by the physician within 24 hours.


Review of patient #1's chart revealed the patient was documented to be in soft limb restraints without a physician order on the following dates:
11/22/16
12/28/16
1/6/17
1/11/17
1/12/17



Review of the nurses notes and restraint flowsheet revealed patient #1's restraints were discontinued on 11/21/16 at 1900 (7:00PM) and reapplied by the nurse on 11/22/16 at 2100 (9:00PM). There was no physician order found to reapply the restraints.


Review of patient #1's physician orders revealed the restraint orders were missing physician signatures, date and times on the following dates:
12/10/2016
1/5/2017


Review of patient #1's physician orders revealed the restraint orders were missing date and time when signed by physician on the following dates:
1/8/17
1/9/17
1/10/17


Review of patient #1's physician restraint order form dated 12/2/2016 revealed a section with check boxes titled, "Alternatives To Restraints Tried" was left blank. The alternatives listed are as followed:

"Patient/Family education
RE-orientation to environment
Family S.O. / sitter at bedside
Increased observation
Diversional Activities
Other environmental modifications
Re-taping/changing location of line/devices
Concealing device/line
Repositioning patient
Bed Alarm
Modification as ordered by physician
Other"


Review of patient #1's physician restraint order form dated 12/16/2016 revealed a section with check boxes titled, "Invasive Interventions That Apply To Patient" was left blank. The interventions are as followed:
"Endotracheal tube
Tracheostomy
Oxygen
IV-Peripheral or central
Foley Catheters
Feeding Tubes
Other" Patient #1's chart revealed he had a Foley catheter, Feeding tube, Tracheostomy, and an IV on 12/16/17.


Under the Invasive intervention section of the order was a section on procedures that was also left blank. The procedures were as follows:
"1. Explain the procedure and the rational to the patient and family.
2. Obtain appropriate type/size restraint from the designated area.
3. Perform the environmental search (remove cigarettes, matches, lighters, sharp objects. etc.)
4. Apply the device per the manufactures recommendations and policy.
5. RN restraint check 30 minutes post initial restraint application.
6. Assess and monitor patient and document according to policy.
7. Address the use of restraints in patient's PLAN OF CARE.
8. Educate patient/family on use of restraints in patient's EDUCATION RECORD
9. Assess for appropriateness of trial release at a minimum of every two hours."



Review of patient #1's physician restraint order form revealed the following dates were left blank, on a reason for restraint use:
11/18/16
11/24/16
11/25/16


Review of patient #2's physician orders revealed the restraint orders were missing physician signatures, date and times on the following dates:
5/16/17
5/23/17

An interview was conducted with #3 on 5/24/17. Staff #3 confirmed physician restraint orders were not completed and missing from the charts.

Based on review and interview, the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are sustained for 17 out of 17 months (January 2016-May of 2017).


Review of the Quality Assessment Performance Improvement (QAPI) for 2016 and 2017 from January -May revealed the only Performance Improvements (PI) found, addressed hand hygiene and falls for September of 2016.


Review of the Quality Assessment Performance Improvement documentation revealed in 2016 there was only data for restraints and restraint use. Review of the Quality scorecard revealed data was gathered for the following;

"Restraint Days
# Patients in Restraints
Restraint days rate (#restraint days/#patient days) x100
Restraint Rate Target."


Review of the Quality indicator Restraint Rate Target for year to date revealed the target was 3.50. The Restraint days rate (#restraint days/#patient days) x100 year to date was 9.10. The restraint day's rate was out of range January 2016-December 2016 and January-March of 2017. There was no performance improvement (PI) projects or any documentation to support that Quality was following restraints for 2016 or 2017.


Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues.


An Interview with staff #3 on 5/24/17 confirmed that there was no PI documentation for restraints. Staff #3 reported that she had just recently went to training to start utilizing the PI process two weeks ago. Staff #3 stated she had been in this position about three years.

Based on review and interview, the facility failed to have performance improvements to identify problem-prone areas from the data that had been collected for 17 months (January 2016-May of 2017).


Review of the Quality Assessment Performance Improvement (QAPI) for 2016 and 2017 from January -May revealed the only Performance Improvements (PI) found, addressed hand hygiene and falls for September of 2016.


Review of the Quality Assessment Performance Improvement documentation revealed in 2016 there was only data for restraints and restraint use. Review of the Quality scorecard revealed data was gathered for the following:

"Restraint Days
# Patients on Restraints
Restraint days rate (#restraint days/#patient days) x100
Restraint Rate Target."


Review of the Quality indicator Restraint Rate Target for year to date revealed the target was 3.50. The Restraint days rate (#restraint days/#patient days) x100 year to date was 9.10. The restraint day's rate was out of range January 2016-December 2016 and January-March of 2017. There was no performance improvement (PI) projects or any documentation to support that Quality was following restraints for 2016 or 2017.


Review of the QAPI scorecard for January- April 2017 revealed the data was out of range on restraints, ventilator wean rates, overall satisfaction, and delinquency rates on completions of Discharge Summary. There was no PI projects found to address these ongoing issues.


An Interview with staff #3 on 5/24/17 confirmed that there was no PI documentation for restraints. Staff #3 reported that she had just recently went to training to start utilizing the PI process two weeks ago. Staff #3 stated she had been in this position about three years.

Based on review and interview, nursing failed to be well-organized with a plan of administrative authority and delineation of responsibilities for patient care to a qualified Chief Nursing Officer (CNO).


Review of the facility's CNO job description stated, "Education and Training: Must possess RN licensure in good standing in the state where the hospital resides. Master's Degree, or active progression toward a Master's Degree is required with completion of degree within 2 years of hire date."



Review of staff #2's employee file revealed he signed the job description on 4/28/17. There was a note in the file that stated, "I am planning to attain my Masters Degree in Nursing (MSN) by 2021. My plan is to enroll in the master program at Texas A&M University-Texarkana." The letter indicates a four year plan. The job description stated, "a Master's Degree is required with completion of degree within 2 years of hire date."



Review of staff #2's education credentials revealed the CNO possessed an Associate Degree of Nursing. Staff #2 has not competed a Bachelors Degree in Nursing and was not enrolled in a masters prepared program with a plan of completion within two years.

Based on review and interview, nursing failed to document ongoing assessments of the patient's needs, updating or revising the patient's nursing care plan, in response to a Code Blue status change and patient restraints in 1 (1) of 2 (1 and 2) patient charts reviewed.


Review of patient #1's chart revealed the patient was admitted to the facility on 11/18/16 with a diagnosis of Cardiac Arrest, Anoxic Encephalopathy, and Chronic Systolic Congestive Heart Failure with EF of 14%. Review of the patient #1's history and physical(H&P)revealed it was dated as dictated on 11/18/16 but not signed until 3/1/17, 4 month later. The H&P revealed Patient #1 was a 40 year old Hispanic male who had a history of pulmonary disease, DVT, and paraplegia who went to the ED with chest pain. The patient coded and went into PEA for 26 minutes. The patient ended up with a tracheostomy and peg tube for feedings. The patients echo revealed EF 10% to 14% with large apical thrombus. The patient needed continued mechanical ventilation, anticoagulation and nutritional support and he was admitted to the facility.


Review of patient #1's Nursing Daily Flowsheet on 1/23/17 at 8:50AM revealed the patient was assessed by the nurse and family was in the room. At 1325 (1:25PM) the nurse documented, "Family calls out said he was moaning/grimacing. Found patient to be anxious with facial grimacing and was moving about."


Review of the "Pain Assessment and Intervention" section revealed the nurse documented the following:

"Time- 1325
Location of pain- grimacing/moving
Pain rating- ? Unable to assess
Quality-1/aching
Intervention Medication/Nonpharmacological- med
Medication route-PO (by mouth)."


Review of the medication MAR revealed the nurse administered Hydrocodone -Acetaminophen 1 tablet by mouth and Lorazepam 1 mg IV at 1325 (1:25PM).There was no documentation that the nurse attempted any other comfort measures before medicating the patient. There was no documentation that patient #1's vital signs were taken before giving pain medications. There was no further nursing documentation noted until 1422 (2:22PM) 57 minutes later.

1422 (2:22PM) the nurse documented, "Pts heart rate dropped to 60 pacing. RN charge went to check on pt. family present."

1425 (2:25PM)" Entered room pt is on vent per resp. spt central 16, tidal vol 500 100% O2 Peep of 5 1433. Pt went into V-tach and then stopped breathing. Pt remains on vent."

1436 (2:36PM) "Code started. See flowsheet."

1454 (2:54PM) "Dr.___ (staff #8) here at this time further orders written being carried out. Pt has 21 ½ g rt ac (three words are illegible) Dopamine 10mg/kg been started see times per flo sheet." (SIC).


Review of the "Code Blue Record" revealed on 1/23/17 patient #1 was found by staff #8. Under "found by" on the sheet is a comment that asked, "witnessed yes or no." This section of the code sheet was left blank.


The time marked on the code sheet of "time code called" was 1433 (2:33PM). It stated the patient was pulseless and in V-tach (Ventricular Tachycardia- is a type of regular and fast heart rate that arises from improper electrical activity in the ventricles of the heart.)


The time documented that the code was started was "1435" (2:35PM) 2 minutes after the code was called. There was no documentation that revealed why the patient had a two minute delay before CPR was started.


"1438 (2:38) The defibrillator was applied to the patient 5 minutes after the code was called. There was no shock advised."


1439(2:39PM) "the CPR continued MD notified and in route." The box under "EPI" (Epinephrine, also known as adrenalin/cardiac drug) was marked as given 1 amp but was scratched out.


"1440 (2:40PM) the drug EPI 1 amp was given.
1441 (2:41PM) CPR when not analyzing with defibrillator. Pt was analyzed.
1442 (2:41PM) 1 amp of Atropine (anticholinergic) was administered.
1443 (2:43PM) has a pulse, B/P 160/58, CPR stopped.
1444 (2:44PM) Dr. Perez here orders noted.
1445 (2:45PM) Dopamine @ 10mcg/kg/min.
1448 (2:48PM) B/P 92/46
1451 (2:51PM) HR, 128, B/P 73/41, RR 16, 500 ml NS bolus and lab drawn.
1500 (3:00PM) HR 131, 73/48, RR 16 ABG drawn by Dr.____ (staff #8.)"


At the bottom of the code sheet the time stopped for the code was marked at 1443 (2:43PM). There was signature line for the physician and the RN to sign the code sheet. There were no signatures found. Under the signature lines were the questions, "Variance Completed yes or no and Code Evaluation completed yes or no." Both the questions were left blank.

Review of the chart revealed there was no documentation that the Rapid Response Team was called to assess the patient. Review of the policy and procedure "Rapid Response Team" stated, "The Rapid Response Team (RRT) is a group of clinicians who bring critical Expertise to the bedside whenever needed. The RRT has several roles. The team assists the staff member in assessing and stabilizing the patient's condition and organizing information to be communicated to the patient's physician.

2. Mechanisms for activating team:
Staff members contact the RRT via overhead pager. Team members will be expected to respond in a timely manner. At this time, the floor nurse should gather the patients chart, current medications list and recent vital signs to provide to team upon approval."


Review of the patients "Interdisciplinary Plan of Care" from 11/18/16-1/24/17 revealed no mention of code or in the Team Conference held on 1/24/17.


Review of patient #1's intake and output record revealed the patient was on a continuous tube feeding of 60cc/hr. The nurse documented 60cc from 0700-1400. At 1500 the nurse received an order to hold the feedings but had pre-charted 60cc from 1500-1800 and had marked over the 60cc with a "0" and a line through it very heavily with a pen.


An interview with staff #2 and #3 was conducted on 5/24/17. Staff #2 was a participant in patient #1's code blue on 1/23/17. Staff #2 stated he was not aware the Code Blue Record was incomplete and could not answer why the code was called at 1433 (2:33PM) and not initiated until 1435 (2:35PM).Staff #2 stated when the rapid response team is called, they fill out a RRT form. Staff #2 or #3 were able to provide a RRT form for patient #1 on 1/23/17. Staff #3 confirmed the above findings but had no QAPI to support the oversight of codes called in the facility. Staff #3 saw the pre-charting done by the nurse on the intake and output form for 1/23/17. Staff #3 confirmed the findings but had no explanation.



1.) Review of the policy and procedure "Restraints" stated, "Documentation: 2. Document observations and care provided in the medical record. Include, at a minimum, the following:

A. Daily
Initial restraint assessment
Reason for restraint
Physician notification
Least restrictive measures attempted
Teaching


B. 60 Minute Post Initial Restraint Application:
RN restraint check


C. Observe patient and document the following every two hours:
Restraint Status (released for comfort/safety, then reapplied)

Ensure proper placement
ROM/Ambulation
Position
Fluid/Nourishment
Toileting
Personal Hygiene
Behavior Observation
Level of consciousness/orientation


D. Every Shift
Assessment
Vital Signs."


Review of patient #1's physician orders revealed the patient was ordered soft limb restraints from 11/18/16-1/13/17.


Review of the nursing documentation for restraints revealed a "Restraint Management Flowsheet." The flowsheet had check boxes to show what type of restraint was utilized and an assessment that should be done every two hours. There is a section for the day shift from 7:00AM-6:00PM and 6:00PM-7:00AM. In the assessment box there was a signature line with date and time to be completed on each shift. The assessment included:

"Plan of Care Reviewed/Updated
Patient/Family Educated (as needed)
Restraint Device on
Restraint Release/Reposition
Mental Status
Behavior exhibited
Offer Fluids/Nutrition
Offer Toileting
Skin/Circulation Check
Turn/Position Change
Personal Hygiene."


Review of the Nursing Management Flowsheet revealed the following:

11/19/2016- The RN failed to sign, date, or time the flowsheet for the 7:00AM-7:00PM (day) shift.

11/20/2016- There was no documented type of restraint utilized. No date or time after RN signature for 7:00AM-7:00PM.

11/21/2016- There was no documented type of restraint utilized for the day shift but the nurse documented the assessment for restraints. The restraints were documented as removed at 7:00PM for non-movement.

11/22/16- An order to place the patient back on the soft limb restraints was written by the nurse at 6:00AM. There was no documentation that the patient was placed back on soft limb restraints until 9:00PM.

11/23/16- Patient #1's restraints were removed and discontinued at 8:00AM and put back on at 7:00PM. There was no documentation on why the restraints were removed and no order to reapply the restraints.

11/24/16-There was no documentation on type of restraint for the day shift but the assessment for restraints was completed. There was no documentation on any restraint care given from 1:00PM- 6:00PM. The day shift nurse failed to date and time the assessment.

11/25/16- No nurse signature, date, or time found for the day shift. There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

11/26/16- No nurse signature, date, or time found for the day shift. There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

11/27/16- No nurse signature, date, or time found for the day shift.

11/28/16- No nurse signature, date, or time found for the day shift.

11/30/16- No nurse signature, date, or time found for the day shift.

12/1/16- No nurse signature, date, or time found for the day shift. There was no documented assessment at 5:00PM two hour assessment time.

12/5/16- There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

12/6/16- Patient #1 was documented assessed in restraint every three hours instead of every two on the day shift. No type of restraint documented for night shift.

12/7/16- No type of restraint documented for the day or night shift.

12/8/16- Patient skin check, position change, personal hygiene was not documented from 7:00AM-6:00PM. Patient personal hygiene or type of restraint used was not documented from 6:00PM- 7:00AM.

12/11/16- No restraint documentation from 7:00AM-6:00PM. Patient had an order for soft limb restraints.

12/13/16- No date or time documented for 7:00AM-6:00PM shift.

12/14/16- Patient personal hygiene was not documented for the day or night shift.

12/17/16- No nurse date or time found for the day shift.

12/18/16- No nurse date or time found for the day shift.

12/19/16- No assessment flowsheet found for patient #1.

12/22/16- There was no documented type of restraint for the 6:00PM- 7:00AM (night) shift.

12/23/16- There was no documented type of restraint for the day or night shift.

12/24/16- No nurse date or time found for the day shift.

12/25/16- No nurse date, time, or hygiene documentation found for the day shift. No hygiene documentation found for the night shift.

12/26/16- There was no documented type of restraint for the night shift.

12/27/16- There was no documented type of restraint for the day shift. No documented time on the day shift and no date for the night shift.

12/28/16- There was no documented type of restraint for the night shift.

12/29/16- No documented time on the day shift. There was no documented type of restraint for the night shift.

12/30/16- Patient personal hygiene was not documented for the day shift. There was no documented type of restraint or type of restraint for the night shift.

1/1/17- There was no documented type of restraint or time for the day shift. There was no documented type of restraint for the night shift.

1/2/17- There was no documented type of restraint for the night shift.

1/3/17- No nurse signature, date, or time found for the day shift. There was no documented type of restraint for the night shift.

1/4/17- There was no documented type of restraint for the night shift.

1/5/17- No nurse time found for the day shift. There was no documented type of restraint for the night shift.

1/7/17- Patient personal hygiene was not documented for the day shift. There was no documented type of restraint for the night shift.

1/8/17- There was no documented type of restraint for the night shift.

1/9/17- No nurse date or time found for the day shift. There was no documented type of restraint for the night shift.

1/10/17- There was no documented type of restraint for the night shift.

1/11/17- No nurse date or time found for the day shift.

1/12/17- No nurse signature, date, or time found for the day shift.

1/14/17- There was no documented type of restraint for the night shift.

1/15/17- There was no documented type of restraint or time for the night shift.

1/16/17- No documented nurse signature, date or time found for the day shift.

1/18/17- No documented nurse time found for the day shift. There was no documented type of restraint or time for the night shift.

1/19/17- No documented nurse time found for the day shift. There was no documented type of restraint or time for the night shift.

1/21/17- There was no documented type of restraint or time for the night shift.

1/23/17- No documented nurse date or time found for the day shift.



Review of patient #1's nursing care plan revealed there was no documentation for restraints from 11/18/16-1/13/17.


Review of patient #5 revealed the Nursing Management Flowsheet for restraints on 1/31/17, had no nursing signature, date, or time for days. There was no documentation on type of restraint or personal hygiene offered for the night shift.


An interview with staff #2 and #3 on 5/24/17 confirmed the findings on restraint assessments. Staff #2 reported there had been a period where the nurses had missed training and they have tried to improve on that. Staff #2 stated that he had just recently been placed in the Director of Nursing (DON) position. Review of the DON employment record revealed he had signed his job description as DON on 4/28/17.


Review of staff #4's (LVN) employment record on 5/24/17 revealed the nurse had no nursing education in his chart.

Review of staff #5's (RN) employment record on 5/24/17 revealed staff #5 had no current restraint training.

Review of staff #6 and #7 employment record on 5/24/17 revealed the employees skills were not dated or signed off for restraint training or any other skills required to perform their jobs in the clinical setting.


An interview was conducted with staff #2 and #3 on 5/24/17 concerning the lack of restraint training documented for the employees. Staff #2 and #3 confirmed the above findings. Staff #3 reported the last CNO had not kept up with the staff training.