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Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure the physician assessment was completed for the use of restraints that were greater than 24 hours for three of three restraint records reviewed (MR16, MR27, and MR28).

Findings include:

Review on December 15, 2011, of the facility policy "Restraints," last reviewed and revised November 2011, revealed "... III Procedure C ... Continued use of restraints greater than 24 hours requires a physician assessment and a written order for renewal. ... "

1) Review of MR16 on December 16, 2011, revealed daily physician orders for a pelvic waist restraint dated October 7, 2011 through October 15, 2011. There was no documentation the physician reassessed the patient on the following dates: October 8 and 9, 2011.

2) Review of MR27 on December 16, 2011, revealed daily physician orders for a pelvic restraint dated September 22, 2011 through October 9, 2011. There was no documentation the physician reassessed the patient on the following dates: September 22 and 25, 2011, and October 1, 2011.

3) Review of MR28 on December 16, 2011, revealed daily physician orders for a bed enclosure dated October 28, 2011 through November 14, 2011. There was no documentation the physician reassessed the patient on the following dates: October 28, 29, and 30, 2011, and November 1, 2, 3, 4, 5, 10, 11, and 12, 2011.

4) An interview with EMP4, conducted on December 16, 2011, at 10:30 AM confirmed that MR16, MR27, and MR28 did not contain the physician assessment for restraint use for the dates indicated above.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the physician order for restraints included the clinical justification for the application of the restraint for four of four restraint records reviewed (MR16, MR27, MR28, and MR30).

Findings include:

Review on December 15, 2011, of the facility policy "Restraints," last reviewed and revised November 2011, revealed "... III Procedure C Physician Orders ... Continued use of restraints greater than 24 hours requires a physician assessment and a written order for renewal. This must occur each calendar day that the restraint remains in use. The order is to contain clinical justification for application of the restraint, the type, and time limit. ... "

1) Review of MR16 on December 16, 2011, revealed the physician order for the pelvic restraint did not include the clinical justification for the application of the pelvic restraint on the following dates: October 12, 14, and 15, 2011.

2) Review of MR27 on December 16, 2011, revealed the physician order for the pelvic restraint did not include the clinical justification for the pelvic restraint on the following dates: October 5, 7, 8, and 9, 2011.

3) Review of MR28 on December 16, 2011, revealed the physician order for the bed enclosure restraint did not include the clinical justification for the bed enclosure restraint on the following dates: October 29 and 30, 2011, and November 9, 2011.

4) Review of MR30 on December 16, 2011, revealed nursing documentation that the patient had a four siderails restraint applied on October 13, 2011, and October 26, 2011. There was no documentation of a physician order in MR30 on October 13, 2011, and October 26, 2011, for the four siderails restraint.

An interview conducted on December 16, 2011, at 10:45 AM with EMP4 confirmed that MR16, MR27, and MR28, did not contain the clinical justification for the type of restraints applied.

An interview with EMP5 conducted on December 16, 2011, at approximately 11:15 AM confirmed there was no documentation of a physician order for the four siderails in MR30 and that four siderails was considered a restraint.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure physician orders for pelvic restraints and/or bed enclosure restraints were not PRN orders for four of four restraint records reviewed (MR16, MR27, MR28, and MR32).

Findings include:

Review on December 15, 2011, of the facility policy "Restraints," last reviewed and revised November 2011, revealed "... III Procedure C. A physician order (either telephone or written) is required as soon as possible following the initiation of the restraint. The order is to be date and time specific. Continued use of restraints greater than 24 hours requires a physician assessment and a written order for renewal. ... The maximum period a restraint can be ordered is 24 hours. PRN orders are not acceptable. ... "

1) Review of MR16 on December 16, 2011, revealed daily physician orders for a pelvic restraint. These orders were dated October 7, 2011, through October 15, 2011, with a time limit of 24 hours for each order. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of the bed, the pelvic restraint was reapplied. A new physician order for the pelvic restraint was not obtained for each episode when the patient was placed in a pelvic restraint. This occurred on October 7, 8, 10, 11, and 14, 2011.

2) A review of MR27 on December 16, 2011, revealed daily physician orders for a pelvic restraint. These orders were dated September 22, 2011, through October 9, 2011 with a time limit of 24 hours for each order. The patient was removed from the pelvic restraint and placed in bed. When the patient was taken out of bed, the pelvic restraint was reapplied. A new physician order for the pelvic restraint was not obtained for episode when the patient was placed in a pelvic restraint.

3) Review of MR28 on December 16, 2011, revealed daily physician orders for a bed enclosure. These orders were dated October 28, 2011 through November 14, 2011, with a time limit of 24 hours for each Bed Enclosure order. The patient was periodically removed from the Bed Enclosure each day. When the patient became agitated, MR28 was placed back into the Enclosed Bed. A new physician order for the Enclosed Bed was not obtained for each restraint episode.

4) Review of MR32 on December 16, 2011, revealed daily physician orders for a Bed Enclosure for "HS" [bedtime]. These orders were dated September 20, 2011, through September 29, 2011, with a time limit of 24 hours for each bed enclosure order. Continued review of MR32 on December 16, 2011, revealed each of these orders was obtained between 8:30 AM and 12:30 PM. The bed enclosure restraint was to be used at bedtime only. The nursing staff obtained these orders prior to the patient's need for the restraint. There was documentation that the patient was taken out of the bed at intervals during the 24 hour period and returned to the bed enclosure without obtaining a new physician order for the restraint.

5) An interview conducted with EMP3 on December 16, 2011, at 2:00 PM, confirmed that MR28 did not contain a new physician order for the bed enclosure restraint for each time the patient was placed in the restraint. EMP3 also confirmed that MR16 and MR27 did not contain a new physician order for the pelvic restraint for each time the patient was placed in the restraint. EMP3 stated that the restraints were not used for behavioral purposes. The restraints were used in order to prevent the patient from causing harm to self or others due to their diagnosis.

6) An interview with EMP5 on December 16, 2011, at approximately 11:30 AM confirmed the physician orders in MR32 were written in the morning for the bed enclosure restraint to be applied at bedtime.

Based on review of facility policy and procedure, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that nursing reassessments were conducted following the administration of pain medications for 21 occurrences in five of 12 medical records reviewed for the administration of pain medication (MR28, MR29, MR30, MR31, MR32).

Findings include:

Review of the facility policy and procedure "Pain Management," August 4, 2010, revealed "Effective pain management is provided by a cooperative effort of all caregivers to improve the patient's quality of life and function. Inpatients are assessed for pain at a minimum of every 24 hours. Nursing is responsible for giving analgesics ordered by the CRNP/physician and assessing the effectiveness of any interventions used to meet the pain level designated by the patient as tolerable ... VII. References: Clinical Nursing Skills & Techniques, Perry & Potter, 6th Edition, Mosby, Inc., 2006 ... Chapter 15 Pain Assessment and Basic Comfort Measures, page 378 ... Evaluation 1. Within 1 hour of an intervention (e.g., when the drug used is at its peak effect) ask patient to verbalized how well the pain has been relieved. Have patient rate pain intensity now on a scale of 0 to 10."

1) Review of the medication administration record (MAR) for MR28 revealed the patient received Tylenol No. 3 with Codeine for pain on November 2, 2011, at 10:30 AM, on November 7, 2011, at 10:05 AM, on November 16, 2011, at 8:20 PM, on November 19, 2011 at 8:40 PM, and on November 20, 2011, at 9:00 PM. Further review of MR28 revealed that Tylenol No. 3 with Codeine, one tab every four hours for pain as needed was given as ordered by the physician on October 25, 2011. There was no documentation in MR28 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

Interview with EMP3 on December 16, 2011, at approximately 11:30 AM confirmed there was no documentation of a nursing reassessment of the effectiveness of the pain medications given in MR28.

2) Review of the MAR for MR29 revealed the patient received two tablets of "Oxycodone APAP/5/325" for severe pain as ordered by the physician on October 20, 2011, at 12:55 AM. Further review of the MAR for MR29 revealed Percocet 5/325 was given as ordered by the physician on October 20, 2011 at 9:45 PM, and on October 21, 2011, at 8:00 AM. There was no documentation in MR29 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

3) Review of the MAR for MR30 revealed the patient received Tramadol 50 mg for pain on October 20, 2011, at 8:30 AM and 2:00 PM, on October 22, 2011, at 12:40 PM and 10:15 PM, on October 23, 2011, at 8:00 PM and on October 25, 2011 at 9:00 AM. Further review of MR30 revealed that acetaminophen 325 mg, two tabs for pain, headache or temperature, was given as ordered by the physician on October 19, 2011, at 10:30 AM. There was no documentation in MR30 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

4) Review of the MAR for MR31 revealed the patient received APAP 650 mg/20.3 ml cup [acetaminophen] as ordered by the physician for headache or pain on July 15, 2011, at 11:20 AM, on July 16, 2011, at 6:00 AM and on July 17, 2011, at 9:00 PM. Continued review of the MAR for MR31 revealed that the patient received acetaminophen 325 mg tablets, two tablets by mouth as needed for headache or pain as ordered by the physician on August 4, 2011, at 4:00 PM and on August 6, 2011, at 11:00 AM. There was no documentation in MR31 of a nursing reassessment of the effectiveness of the pain medications given for the above dates and times.

5) Review of the MAR for MR32 revealed that the patient received acetaminophen 325 mg tablets, two tables as needed for headache or pain as ordered by the physician on September 15, 2011, at 2:10 PM. There was no documentation in MR32 of a nursing reassessment of the effectiveness of the pain medication given.

Interview with EMP4 on December 16, 2011, at approximately 11:00 AM confirmed there was no documentation of a nursing reassessment of the effectiveness of the pain medications given in MR29, MR30, MR31, MR32. EMP4 also confirmed that pain reassessments should be documented within one hour of giving a pain medication.

Based on a review of Medical Staff Bylaws, facility documentation of delinquent medical records, and interview with staff (EMP), it was determined the facility failed to ensure that medical records were completed within 30 days following discharge.

Findings include:

A review on December 16, 2011, of the Medical Staff Bylaws, last revised May 24, 2011, revealed " ... VII. Documentation ... F. The need for timely completion of medical records within thirty days, per requirements is necessary for good patient care and appropriate reimbursement of the institution. ...."

A review on December 16, 2011, of facility medical records monthly statistics revealed there were 38-74 medical records per month that did not have completed Discharge Summaries within 30 days of the patient's discharge from January 2011 through November 30, 2011.

An interview conducted with EMP6, on December 16, 2011 at 2:15 PM, confirmed that 38-74 medical records were delinquent beyond 30 days per month from January 2011 through November 30, 2011. EMP6 also confirmed that the Medical Records Department defers to the Medical Staff Bylaws for the time frames for Medical Records completion guidelines.