HospitalInspections.org

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Based on record review and staff interviews the facility failed to ensure that the medical staff documented the attempt to secure autopsies in two (2) out of five (5) medical records reviewed as required by hospital policy (Patients #5 and #6).

Findings:

Review of the medical records for Patients #5 and #6 revealed the physician section for requesting an autopsy on the form entitled "Notification of Expiration" was blank. There was no checklist attached to death certificates and there was no documented evidence that the physician attempted to obtain an autopsy.

Review of the facility's Administrative Policy entitled "Autopsies" dated 10/27/11, revealed that the physician who pronounces the death must make every attempt to obtain consent for an autopsy and must document the effort made, then complete the checklist sheet attached to the death certificate form in non Medical Examiner (ME) cases.

Review of the facility's By-Laws: Rules and Regulations, dated February 2011, revealed under Regulatory Requirements that permission for an autopsy should be sought after it is determined that the death is not reportable to the ME.

This finding was confirmed with Staff #2 during the onsit visit.
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Based on record review and interviews the facility failed to ensure that the staff implemented the hospital policy for restraint use in three (3) out of six (6) medical records reviewed (Patients #15, #27 and #28).

Findings:

Review of the medical record for Patient #15 revealed on 10/01/11 at 11:30PM the ED nurse documented on the restraint flow sheet "patient is combative" and applied bilateral wrist restraints. The nurse continued to document every thirty (30) minutes from 11:30PM to 6:30AM that bilateral wrist restraints were in place. There was no documented evidence that a physician's order was obtained as required by policy.

Medical record review for Patient #27 revealed the patient arrived to the ED on 12/26/11 at 8:00AM and was diagnosed with seizures. On 12/26/11 at 5:30PM the physician ordered bilateral wrist restraints for medical management of agitation. However, the nursing flow sheet was undated making it differcult to determine when when the restraints were intiated.

The restraint flow sheet documented every thirty (30) minutes by the nurse from 12/27/11 at 8:30AM until monitoring stopped on 12/29/11 at 6:30AM. There is no further documention of the patient's behavior to indicate if the restraint was continued or removed as required by policy.

Medical record review for Patient #28 revealed on 12/10/11 at midnight that the nurse documented application of the bilateral wrist restraints occurred. The nurse continued to document the need for restraint every thirty (30) minutes until 12/11/11 at 6:30AM. The monitoring then abruptly stopped. The nurse did not document if the patient was still in restraints or the re-assessment/evaluation of the patient's behavior to indicate why the restraints were removed as required by hospital policy.

Review of the facility's policy entitled "Restraint" dated 1/2011 states "Restraints require written authorization of the physician. The RN will document from the time the patient restraint was initiated and every thirty (30) minutes thereafter. The RN must then document information regarding behavioral criteria for discontinuation of restraints."

These findings were confirmed with Staff #2 on 01/19/12 at 10:30AM.