HospitalInspections.org

Based on interview, record and policy review, the facility failed to ensure nursing staff assessed for appropriately dated, timed and signed physician's orders for continued use of restraints for two (#21, #30) of two current patients and one (#6) of one discharged patient reviewed for non-violent restraint use. The facility also failed to ensure staff documented every two hour assessments on two (#20 and #36) of two current patients and one (#6) of one discharged patient reviewed for non-violent restraint use. The facility census at the Lindell Campus was 29 and the facility census at the St. Anthony's Campus was 28.

Findings included:

1. Record review of the facility's policy titled, "Use of Physical Restraint For Medical Non-Violent, Non-Self Destructive Behavior" revised 04/13, showed the following information:
- Restraint use requires an order by a physician or licensed independent practitioner (LIP) responsible for the patient's care and authorized to order restraint use.
- The health and mental status for any patient in restraints will be monitored and addressed to preserve the patient's dignity, including response to restraint use.
- Document observations and care provided in the electronic or paper medical record.
- Every two (2) hours:
? Restraint Status (released for comfort/safety, and then reapplied).
? Ensure proper placement (Readjust: placement, call light, bed position).
? ROM (range of motion)/ambulation.
? Position;
? Fluid/nourishment;
? Toileting;
? Personal hygiene;
? Patient's response to restraint;
? Behavior observation;
? Level of consciousness/orientation/emotion;
? Continue/discontinue decision.

2. Record review of current Patient #21's restraint orders from 09/01/13 through 09/19/13 showed nursing staff failed to assess for a complete physician's order to restrain the patient. Further review showed the physician failed to time his dated signature for eight restraint orders; failed to date and time his signature on three restraint orders and failed to date, time and sign restraint orders on 09/17/13 and 09/18/13 as of 09/19/13.

3. During an interview on 09/18/13 at approximately 11:30 AM Staff C, Director of Quality Management (DQM) reviewed the patient's restraint orders and confirmed the physician failed to date, time and sign those orders.

4. Record review of Patient #30's 24 hour restraint orders showed there were no signed physician restraint orders for 09/17/13, 7:00 AM through 09/18/13, 7:00 AM and 09/18/13, 7:00 AM through 09/19/13, 7:00 AM.

5. Record review of Patient #6's Patient Restraint Order dated 07/22/13 showed the physician as of 09/18/13 at 2:00 PM had not signed, dated or timed the order.

6. During an interview on 09/18/13 at approximately 12:00 PM, Staff C, confirmed that the physician had not signed, dated or timed the order for Patient #6 to be restrained.

7. Record review of Patient #20's Restraint Flow Sheet-24-Hour Record showed that staff did not document on 09/15/13 every two hour assessments of the patient from 8:00 AM until 6:00 PM and did not document on 09/16/13 every two hour assessments of the patient from 9:00 PM until 11:00 PM while in restraints.

8. Record review Patient #36's Restraint Flow Sheet-24-Hour Record showed staff did not document on 09/15/13 every two hour assessments of the patient from 7:00 AM until 6:00 PM while in restraints.

9. Record review Patient #6's Restraint Flow Sheet-24-Hour Record showed that staff did not document on 07/20/13 every two hour assessments of the patient from 7:00 PM until 7:00 AM and
did not document on 08/05/13 every two hour assessments of the patient from 7:00 PM until 7:00 AM while in restraints.








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Based on observation, record review and policy review, the facility failed to ensure nursing staff followed policy and acceptable standards of practice for medication administration by failing to ensure timely administration of "time critical medications" (time-critical scheduled medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect) and failing to ensure nursing staff use two patient identifiers prior to administration of medications for one patient (#13) of 18 medication administrations observed. This failed practice placed all patients admitted to the facility at risk for harm. The facility census at the Lindell Campus was 29 and the facility census at the St. Anthony's Campus was 28.

Findings included:

1. Record review of the facility's policy titled, "Administration of Medications", dated 02/13 showed:
- Prior to medication administration, a patient must be positively identified by two forms of identification on the wristband issued at admission: never a room number.
- The 7 "R's" of administering medications will be followed with each medication administration:
-"Right" patient;
-"Right" medication;
-"Right" dose;
-"Right" time;
-"Right" route;
-"Right" reason; and
-"Right" documentation.
- Time-critical scheduled medications should be administered at the time prescribed or within 30 minutes before or after the scheduled dose.

2. Record review of the facility's "Timely Administration of Medications" list of time-critical medications, dated 10/12 showed TIME CRITICAL MEDICATION: GIVE WITHIN 30 MINUTES OF THE SCHEDULED TIME. Vancomycin IVPB (is the infusion of liquid substances directly into a vein/piggyback is an infusion connected on to an existing IV line) was listed as a time sensitive medication.

3. Observation on 09/17/13 at 10:10 AM showed Staff K, Registered Nurse (RN) entered the room of Patient #13 during a dressing change. Staff K, prepared the antibiotic (Vancomycin) for administration, connected the IV antibiotic to the IV pump to infuse, and then proceeded to assist with linen change. Staff K did not confirm patient identification prior to administration of medication and the time sensitive medication infusion was started 70 minutes after scheduled time at 9:00 AM.

4. Record review of Patient #13's medical record showed Vancomycin Hydrochloride 1.8 GM was ordered on 09/11/13, to be infused IVPB every 12 hours (9:00 AM and 9:00 PM) starting at 9:00 PM on 09/11/13.
- On 09/12/13 the 9:00 AM dose was administered at 10:27 AM;
- On 09/15/13 the 9:00 PM dose was administered at 9:40 PM;
- On 09/16/13 the 9:00 AM dose was administered at 10:24 AM;
- On 09/17/13 the 9:00 AM dose was administered at 10:11 AM.

5. During an interview on 09/17/13 at 1:23 PM, Staff N, Pharmacist, stated that Vancomycin had a half hour lead way to be administered due to it being a time critical medication.




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