HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that staff failed to obtain an order for the use of restraints for 2 of 3 restrained patients (Patient #'s 1 and 4) in the sample. Findings included:

The hospital policy entitled "Restraints and Seclusion" stated, "...Restraint must be ordered by a physician...A written order, based on an examination of the patient by the MD (medical doctor)/DO (doctor of osteopathic medicine) or LIP (licensed independent practitioner) is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate...Orders for restraints must be renewed on a daily basis..."

Medical record and document review revealed:

A. Patient #1

1. Review of the hospital "Incidents" log revealed:
- 4/28/17 at 2:45 AM: Patient #1 incident described as "Tube/Line Dislodgement...PT (patient) got out of mitt restraints and pulled out NGT (nasogastric tube)"

2. 4/30/17 and 5/2/17: Physician ordered "soft wrist restraints"

3. "Flowsheets...Nsg (Nursing) Restraints Non Violent" documented the patient was in restraints, with restraint monitoring every 2 hours, on the following dates:

5/1/17 (1:41 AM - 10:00 PM)
5/3/17 (12:00 AM - 10:00 PM)
5/4/17 (12:00 AM - 10:00 PM)
5/5/17 (12:00 AM - 8:00 PM)

4. No evidence of a physician's order for restraints for 4/28, 5/1, 5/3, 5/4 and 5/5/17.

These findings were confirmed by Director of Quality Management A on 6/7/17 between 2:45 PM and 3:05 PM.

B. Patient #4
1. Medical record and "Flowsheets...Nsg (Nursing) Restraints Non Violent" documentation revealed the patient was in restraints, with restraint monitoring every 2 hours, on the following dates:

5/22/17 (12:00 AM - 10:00 PM)
5/27/17 (12:00 AM - 10:55 PM)
5/29/17 (12:00 AM - 10:00 PM)
6/2/17 (12:00 AM - 10:00 PM)
6/4/17 (12:00 AM - 10:00 PM)
6/6/17 (12:00 AM - 5:33 PM)

2. No evidence of a physician's order for restraints for 5/22, 5/27, 5/29, 6/2, 6/4 and 6/6/17.

These findings were confirmed by Director of Quality Management A on 6/9/17 at 8:35 AM.

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 2 of 6 patients (Patient #'s 1 and 4) in the sample. Findings included:

The hospital RN "Job Description" stated, "...RN assures implementation of assessment plan, evaluation, and follow up of the plan of care...assessment...through...observation, and physical examination...Assures that medical orders are...processed and integrates the medical care plan into the provision of nursing care...Assures that documentation in the medical records are complete...Provides nursing care to meet patient's needs...Adheres to established policies and procedures..."

The hospital policy entitled "Assessment and Reassessment of Patients" stated, "...All patients receiving care or treatment...are assessed by qualified professionals...to identify patient care needs, identify additional information required and to base care decisions on the information developed about each patient's needs...Assessment by Nursing...Biophysical, including pain assessment...Critical components...such as physiological status...will be obtained..."

The hospital policy entitled "Guidelines and Protocols Clinical" stated, "...To ensure quality patient care, certain standards of care must be upheld...The following...outlines...designates the minimum frequency...tasks must be performed to maintain quality care...Vital signs...Every 12 hours...Assessment...recorded on ...flowsheet...Every 12 hours and as condition changes..."

On 6/6/17 at 1:48 PM, Director of Quality Management A stated that the hospital provided nursing care 24 hours each day, via two 12 hour nursing shifts (day shift and night shift).

Medical record review revealed:

A. Patient #1

1. 5/9/17 1:13 PM "Hospitalist Progress Note": "...complaining of neck pain...Poor respiratory effort...Decreased power all ext (extremities) mostly left upper ext...Will consult neurology and consider getting MRI (magnetic resonance imaging) cervical spine after neurology evaluation..."

2. 5/9/17 6:10 PM: Physician documented an order for neurological checks "Frequency q (every) 1 hour...Duration Until specified"

3. 5/10/17 "Discharge Summary": documented that the patient was transferred from Select Specialty Hospital to another hospital for "...further neurosurgical evaluation...critically ill..."

4. No documented evidence that neurological checks were performed between 5/9/17 at 6:10 PM through time of patient transfer to another hospital on 5/10/17 at 12:09 PM.

This finding was confirmed by Director of Quality Management A on 6/7/17 at 4:08 PM.

5. No documented evidence that the nurse performed an assessment during the following nursing shifts:

5/5/17: day shift
5/10/17: day shift prior to transfer to another hospital at 12:09 PM

On 6/7/17 at 3:28 PM, Director of Quality Management A confirmed these findings.

B. Patient #4

1. 5/19/17 12:00 AM: "H & P (History and Physical)": "Assessment...anoxic encephalopathy, status post cardiac arrest...acute respiratory failure...ventilator dependent...acute kidney injury...coronary artery disease...PLAN...ask cardiology...neurology...nephrology to see the patient...help with management of multiple active issues..."

3. On 5/19/17 at 9:54 PM, the physician ordered neurological checks to be performed "Every shift...Duration Until Specified"

4. No documented evidence that neurological checks were performed on the following day shifts:
5/21, 5/26, 5/27, 6/1, 6/2, 6/4 and 6/5/17

On 6/9/17 at 8:35 AM, Director of Quality Management A:
- confirmed these findings
- reported that the order for neurological checks was still an active order