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A. Based on clinical record review, Facility's Policy review, and staff interview, it was determined that for 2 of 3 (Pt. #11 & 12) patients on restraints the Facility failed to ensure use of restraints were ordered according to Hospital policy.

Finding include:

1. On 8/18/2011 the Facility's Policy titled "Utilization of Restraints & Seclusion" was reviewed. The policy includes, "...the use of restraints or seclusion requires an order by a physician or other licensed independent practitioner...Procedure: A. Licensed Independent Practitioner (LIP) Physician...3. Write an order with the date and time, for restraint within one (1) hour of the restraint initiation. B. Registered Nurse: ....restraints may be initiated by a trained registered nurse..contact (LIP) to request a in-person evaluation and a written order within 1 hour of initiation of restraint...."

2. On 8/18/2011 at approximately 9:30 AM, the clinical record of Pt. #11 was reviewed. Pt. #11 was a 40 year old male admitted in the Emergency Department (ED) on 8/15/11 with diagnoses of Wrist Laceration and Alcohol Intoxication . The Behavioral Restraint Flowsheet indicated that Pt. #1 was placed in restraints from 6:40 AM to 7:30 AM on 8/15/11. The clinical record lacked a physician order for the restraint.

3. On 8/18/2011 at approximately 10:00 AM, the clinical record of Pt#12 was reviewed. Pt. #12 was a 50 year old male who presented in the ED on 7/5/11, with a diagnosis of Alcohol Withdrawal. The Behavioral Restraint Flowsheet indicated that Pt. #12 was placed in restraints on 7/5/11 at 9:50 AM. The Behavioral Restraint order was written at 11:40 AM, 1 hour and 50 minutes after Pt. #12 was placed in restraints (50 minutes past the one hour timeframe that orders are to be written after initiation of the restraint).

4. On 8/18/2011 at approximately 1:00 PM, these finding were confirmed with the Nursing Director of ED and Director of Quality and Case Management.

A. Based on clinical record review, Facility's Policy review, and interview, it was determined that for 2 of 3 patients (Pt. #11 &12) on restraints, the Facility failed to ensure the reassessment of restrained patients according to Hospital policy.

Finding include:

1. On 8/18/2011 the Facility's Policy titled "Utilization of Restraints & Seclusion" was reviewed. The policy required, "...All patients in seclusion or restraints, due to violent or self destructive behavior, will be monitored continuously with circulation checks, respiratory assessment, skin assessment, level of consciousness/mental status, comfort, range of motion/positioning (including release of restraints on a rotating basis), nutrition/hydration, and hygiene /elimination... Safety/environment/dignity assessments provided and document every 15 minutes...."
2. On 8/18/2011 at approximately 9:30 AM, the clinical record of Pt#11 was reviewed. Pt. #11 was a 40 year old male admitted in the Emergency Department (ED) on 8/15/11 with diagnoses of Wrist Laceration and Alcohol Intoxication . The Behavioral Restraint Flowsheet indicated that Pt. #1 was placed in restraints on 8/15/11 at 6:40 AM. The flowsheet documentation included an assessment at 6:40 AM, and 7:00 AM. However, the flowsheet lacked subsequent assessment at 7:15 AM and at 7:30 AM. Restraints were discontinued at 7:30 AM on 8/15/11.

3. On 8/18/2011 at approximately 10:00 AM, the clinical record of Pt#12 was reviewed. Pt. #12 was a 50 year old male who presented in the ED on 7/5/11, with a diagnosis of Alcohol Withdrawal. The patient was placed in restraints on 7/5/11 at 9:50AM. The Behavioral Restraint Flowsheet lacked documentation of elimination and hygiene assessments every 15 minutes .

4. On 8/18/2011 at approximately 1:00 PM, these finding were confirmed with the Nursing Director of ED and Director of Quality and Case Management.

A. Based on clinical record, Hospital policy reviews, and staff interview, it was determined that for 1 of 11 clinical records reviewed (Pt#1), the Hospital failed to ensure that the physician's order for urinalysis (UA) and Urine Drug Screen (UDS) were implemented.

Findings include:

1. On 8/17/11 at approximately 10:30 A.M., the clinical record of Pt. #1 was reviewed. Pt. #1 was a 27 year-old male who presented in the Emergency Department (ED) on 1/8/11 at 1:45 PM with diagnoses of Alcohol Intoxication and Drug Abuse. The ED record included a physician's order dated 1/8/11 at 2:31 PM, for Depakote level, ETOH (alcohol) level, UA and UDS. The clinical record contained laboratory results for Depakote and ETOH, however there were no results found in the clinical records for the UA and the UDS

2. Hospital policy titled: "Scope of Care" was reviewed on 8/18/11 at 11:00 AM. The policy required: "... Emergency Nursing Competencies...Dimensions... Characteristics of emergency nursing practice include: Assessment... planning... implementation of interventions...."

3. On 8/17/11 at approximately 2:10 PM, the Emergency Department Nursing Director and the ED Nurse (E #1) caring for Pt. #1 were interviewed. The Director stated and confirmed that the UA and UDS were not done and E#1 confirmed that he did not perform the order for the UA and UDS.


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B. Based on review of Facility policy, clinical records and staff interview, it was determined that for 2 of 10 (Pt. #1 & 2) records reviewed, the Hospital failed to ensure reassessment were conducted hourly as required by policy.

Findings include:

1. The Hospital policy titled, " Patient Assessment/Intervention guidelines" reviewed on 8/17/11 at approximately 2:00 PM required, "Reassessment: 2. Reassess the patient as frequently as his/her condition indicates. A reassessment shall be taken at least every hour. 4. Serial vital signs should be assessed at least hourly for any patient being evaluated pending admission to the hospital."

2. The clinical record of Pt. #1 was reviewed on 8/17/11 at approximately 11:00 AM. Pt. #1 was a 27 year old male who presented in the Emergency Department on 1/8/11 at time 1:45 PM. The triage documentation on 1/8/11 at 1:52 PM included the chief complaint as " detox " with a level of severity at 3 out of 5. The triage vital signs taken at 1:54 PM and 1:58 PM were: Temperature 98.3, Pulse 95, Respiration 16, and BP 125/107. The vital signs was not reassessed until 6:00 PM, 4 hours after the initial vital set was taken

3. The clinical record of Pt. #2 was reviewed on 8/17/11. Pt. #2 was a 45 year female, who presented in the ED with complaints of Suicidal Ideation. The triage vitals signs at 9:36 AM included the following: Temperature 98.0, Pulse 111, Respiration 16, and BP of 154/99. Pt. #2's vital signs was not reassessed until 1:04 PM, 4 hours after the initial set was taken.

4. The above findings were confirmed with the Nursing Director of the Emergency Department during interviews on 8/17/11 at approximately 2:00 PM and 8/18/11 at approximately 11:00 AM

A. Based on clinical record review, Facility's Policy review, and staff interview, it was determined that for 2 of 3 (Pt. #11 & 12) patients on restraints the Facility failed to ensure use of restraints were ordered according to Hospital policy.

Finding include:

1. On 8/18/2011 the Facility's Policy titled "Utilization of Restraints & Seclusion" was reviewed. The policy includes, "...the use of restraints or seclusion requires an order by a physician or other licensed independent practitioner...Procedure: A. Licensed Independent Practitioner (LIP) Physician...3. Write an order with the date and time, for restraint within one (1) hour of the restraint initiation. B. Registered Nurse: ....restraints may be initiated by a trained registered nurse..contact (LIP) to request a in-person evaluation and a written order within 1 hour of initiation of restraint...."

2. On 8/18/2011 at approximately 9:30 AM, the clinical record of Pt. #11 was reviewed. Pt. #11 was a 40 year old male admitted in the Emergency Department (ED) on 8/15/11 with diagnoses of Wrist Laceration and Alcohol Intoxication . The Behavioral Restraint Flowsheet indicated that Pt. #1 was placed in restraints from 6:40 AM to 7:30 AM on 8/15/11. The clinical record lacked a physician order for the restraint.

3. On 8/18/2011 at approximately 10:00 AM, the clinical record of Pt#12 was reviewed. Pt. #12 was a 50 year old male who presented in the ED on 7/5/11, with a diagnosis of Alcohol Withdrawal. The Behavioral Restraint Flowsheet indicated that Pt. #12 was placed in restraints on 7/5/11 at 9:50 AM. The Behavioral Restraint order was written at 11:40 AM, 1 hour and 50 minutes after Pt. #12 was placed in restraints (50 minutes past the one hour timeframe that orders are to be written after initiation of the restraint).

4. On 8/18/2011 at approximately 1:00 PM, these finding were confirmed with the Nursing Director of ED and Director of Quality and Case Management.

A. Based on clinical record review, Facility's Policy review, and interview, it was determined that for 2 of 3 patients (Pt. #11 &12) on restraints, the Facility failed to ensure the reassessment of restrained patients according to Hospital policy.

Finding include:

1. On 8/18/2011 the Facility's Policy titled "Utilization of Restraints & Seclusion" was reviewed. The policy required, "...All patients in seclusion or restraints, due to violent or self destructive behavior, will be monitored continuously with circulation checks, respiratory assessment, skin assessment, level of consciousness/mental status, comfort, range of motion/positioning (including release of restraints on a rotating basis), nutrition/hydration, and hygiene /elimination... Safety/environment/dignity assessments provided and document every 15 minutes...."
2. On 8/18/2011 at approximately 9:30 AM, the clinical record of Pt#11 was reviewed. Pt. #11 was a 40 year old male admitted in the Emergency Department (ED) on 8/15/11 with diagnoses of Wrist Laceration and Alcohol Intoxication . The Behavioral Restraint Flowsheet indicated that Pt. #1 was placed in restraints on 8/15/11 at 6:40 AM. The flowsheet documentation included an assessment at 6:40 AM, and 7:00 AM. However, the flowsheet lacked subsequent assessment at 7:15 AM and at 7:30 AM. Restraints were discontinued at 7:30 AM on 8/15/11.

3. On 8/18/2011 at approximately 10:00 AM, the clinical record of Pt#12 was reviewed. Pt. #12 was a 50 year old male who presented in the ED on 7/5/11, with a diagnosis of Alcohol Withdrawal. The patient was placed in restraints on 7/5/11 at 9:50AM. The Behavioral Restraint Flowsheet lacked documentation of elimination and hygiene assessments every 15 minutes .

4. On 8/18/2011 at approximately 1:00 PM, these finding were confirmed with the Nursing Director of ED and Director of Quality and Case Management.

A. Based on clinical record, Hospital policy reviews, and staff interview, it was determined that for 1 of 11 clinical records reviewed (Pt#1), the Hospital failed to ensure that the physician's order for urinalysis (UA) and Urine Drug Screen (UDS) were implemented.

Findings include:

1. On 8/17/11 at approximately 10:30 A.M., the clinical record of Pt. #1 was reviewed. Pt. #1 was a 27 year-old male who presented in the Emergency Department (ED) on 1/8/11 at 1:45 PM with diagnoses of Alcohol Intoxication and Drug Abuse. The ED record included a physician's order dated 1/8/11 at 2:31 PM, for Depakote level, ETOH (alcohol) level, UA and UDS. The clinical record contained laboratory results for Depakote and ETOH, however there were no results found in the clinical records for the UA and the UDS

2. Hospital policy titled: "Scope of Care" was reviewed on 8/18/11 at 11:00 AM. The policy required: "... Emergency Nursing Competencies...Dimensions... Characteristics of emergency nursing practice include: Assessment... planning... implementation of interventions...."

3. On 8/17/11 at approximately 2:10 PM, the Emergency Department Nursing Director and the ED Nurse (E #1) caring for Pt. #1 were interviewed. The Director stated and confirmed that the UA and UDS were not done and E#1 confirmed that he did not perform the order for the UA and UDS.


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B. Based on review of Facility policy, clinical records and staff interview, it was determined that for 2 of 10 (Pt. #1 & 2) records reviewed, the Hospital failed to ensure reassessment were conducted hourly as required by policy.

Findings include:

1. The Hospital policy titled, " Patient Assessment/Intervention guidelines" reviewed on 8/17/11 at approximately 2:00 PM required, "Reassessment: 2. Reassess the patient as frequently as his/her condition indicates. A reassessment shall be taken at least every hour. 4. Serial vital signs should be assessed at least hourly for any patient being evaluated pending admission to the hospital."

2. The clinical record of Pt. #1 was reviewed on 8/17/11 at approximately 11:00 AM. Pt. #1 was a 27 year old male who presented in the Emergency Department on 1/8/11 at time 1:45 PM. The triage documentation on 1/8/11 at 1:52 PM included the chief complaint as " detox " with a level of severity at 3 out of 5. The triage vital signs taken at 1:54 PM and 1:58 PM were: Temperature 98.3, Pulse 95, Respiration 16, and BP 125/107. The vital signs was not reassessed until 6:00 PM, 4 hours after the initial vital set was taken

3. The clinical record of Pt. #2 was reviewed on 8/17/11. Pt. #2 was a 45 year female, who presented in the ED with complaints of Suicidal Ideation. The triage vitals signs at 9:36 AM included the following: Temperature 98.0, Pulse 111, Respiration 16, and BP of 154/99. Pt. #2's vital signs was not reassessed until 1:04 PM, 4 hours after the initial set was taken.

4. The above findings were confirmed with the Nursing Director of the Emergency Department during interviews on 8/17/11 at approximately 2:00 PM and 8/18/11 at approximately 11:00 AM