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Based on policy review, review of the restraint monitoring record, record review and staff interview the hospital's nursing staff failed to monitor a restrained patient per policy for 1 of 3 sampled restrained patients (#7).

The findings include:

Review of the hospital's policy, "Restraint and Seclusion," revised 11/2009, revealed "...II. Medical Restraint - (Non-Violent Behavior)...C. Patient Monitoring: ...3. Other monitoring activities shall be completed as specified on the currently approved Medical Restraint Form...".

Review of the hospital's form, "Medical Restraint: Doctor's Order and Daily Record," revised 11/06/2009, revealed a table labeled "Nursing Restraint Documentation" with a section labeled, "Evaluation Complete Q (every) 1 hr (hour)" with a space for the nurse to initial the hourly evaluation.

Closed record review of Patient #7 revealed a 64 year-old admitted 03/01/2010 with sepsis secondary to a wound infection. Record review revealed the patient was subsequently intubated due to respiratory distress and was restrained with soft wrist restraints on 03/03/2010, 03/04/2010, 03/05/2010 and 03/06/2010. Record review revealed no documentation the staff evaluated the patient from 03/03/2010 at 0600 - 0730 (1 hour, 30 minutes); 0900 - 1030 (1 hour, 30 minutes); 1200 - 1325 (1 hour, 25 minutes); 1700 - 1825 (1 hour, 25 minutes) and 03/06/2010 at 1200 - 1325 (1 hour, 25 minutes).

Interview on 03/17/2010 at 1400 with administrative staff revealed the nursing staff should evaluate a patient in restraints for medical reasons every hour. Interview confirmed Patient #7 was not monitored by the hospital's restraint policy from 03/03/2010 at 0600 - 0730 (1 hour, 30 minutes); 0900 - 1030 (1 hour, 30 minutes); 1200 - 1325 (1 hour, 25 minutes); 1700 - 1825 (1 hour, 25 minutes) and 03/06/2010 at 1200 - 1325 (1 hour, 25 minutes).

Based on policy review, record review and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess pain per policy for 1 of 3 sampled patients receiving pain medication (#4).

The findings include:

Based on the hospital's policy, "Assessment/Reassessment," revised 04/2009, revealed "...Pain Assessment and Management" XXII. Pain is assessed ...within 30 to 60 minutes following administration of analgesic therapy...".

Closed record review of Patient #4 revealed an 89 year-old admitted 12/09/2009 with a hip fracture. Record review revealed the patient had an open reduction and internal fixation of the left hip 12/11/2009. Review of the patient's medication administration record (MAR) revealed the administration of Demerol (narcotic pain medication) 25 mg (milligrams) IV (intravenously) on 12/09/2009 at 0429 for a pain level of 5 (on a scale of 1 to 10 with 10 being the greatest). Record review revealed the patient's pain level was reassessed at 1427 (9 hours, 58 minutes later). Further review of the patient's MAR revealed the administration of Demerol 50 mg IV on 12/10/2009 at 0501 for a pain level of 8. Record review revealed the patient's pain level was reassessed at 1448 (9 hours, 47 minutes later).

The nurse who administered the pain medication to Patient #4 was not available for interview.

Interview on 03/17/2010 at 1245 with administrative nursing staff revealed "pain reassessment should be performed within 60 minutes of giving the medication." Interview confirmed the nursing staff failed to follow the hospital's policy for reassessment of Patient #4's pain after the administration of pain medication on 12/09/2009 at 0429 and 12/10/2009 at 0501.

Based on policy review, medical staff by-laws - rule and regulations review, medical record review and staff interview, the hospital's staff failed to ensure a physician's order for restraint was authenticated (signed, dated, and timed) for 2 of 3 restrained patients reviewed (#7, #8).

The findings include:

Review of hospital policy, "Restraint and Seclusion," revised 11/2009, revealed "...MD Order: 1. Due to regulatory changes, a physician orders the use of restraint or seclusion in accordance with hospital policy, the NC Administrative Code and the Centers for Medicare and Medicaid Services (CMS)...".

Review of the hospital's medical staff's rules and regulations, revised 09/2008, revealed "...II. Medical Records: ...O. A physician's orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, time, dated and signed by the physician...".

1. Closed record review of Patient #7 revealed a 64 year-old admitted 03/01/2010 with sepsis secondary to wound infection. Record review revealed the patient was subsequently intubated due to respiratory distress and was restrained on 03/03/2010, 03/04/2010, 03/05/2010 and 03/06/2010. Record review revealed a form "Medical Restraint: Doctors Order and Daily Record" dated 03/03/2010, 03/04/2010 and 03/06/2010 by a nurse revealed no documented evidence the physician authenticated (signed, dated and timed) the orders.

Interview on 03/17/2010 at 1400 with administrative staff revealed "all physician orders should be dated, timed and signed". Interview confirmed the restraint order for Patient #7 on 03/03/2010, 03/04/2010 and 03/06/2010 was not complete due to the physician not dating and timing the orders. Interview confirmed the physician failed to follow the hospital's policy and medical staff rules and regulations.

2. Closed record review of Patient #8 revealed a 47 year-old admitted to the emergency department 02/09/2010 with an overdose. Record review revealed Patient #8 was restrained with medication and hard wrist restraints from 1630 until 2015. Record review revealed a form (not dated), "Violent and Self Destructive Restraint and/or Seclusion" with a section for "Orders for Restraint and/or Seclusion" at the bottom of the form. Review of the form revealed a physician's signature, not dated or timed.

Interview on 03/17/2010 at 1400 with administrative staff revealed "all physician orders should be dated, timed and signed". Interview confirmed the restraint order for Patient #8 on 02/09/2010 was not complete due to the physician not dating and timing the order. Interview confirmed the physician failed to follow the hospital's policy and medical staff rules and regulations.


NC00062905