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Based on interview and record review, the hospital failed to ensure physician orders were not written on an as needed basis [prn] for the application of wrist restraints for 1 of 6 patients reviewed [Patient #6].

Findings Included:

Patient #6's physician discharge summary dated 04/10/10 reflected, "[Patient #6] a 59 year old male admitted to [hospital] 03/01/10. [Patient #6] was treated for obstructive sleep apnea, respiratory failure, resolution of pneumonia, dysphagia, aspiration, depression, obesity, and anxiety ...he was able to be free of the mechanical ventilator, although at times he required minimal support he was, however able to remain off the ventilator for a period of time ...he had his tracheotomy downsized, at one point it appeared he was too weak and deconditioned to breathe long enough through that, retaining CO2 [Carbon Dioxide], and requiring support. Therefore in order to free him from the requirements of BiPAP [Bilevel Positive Airway Pressure] or mechanical ventilation, which he refused to participate with in both cases, the tracheotomy was upsized rapidly ...he did have an episode of fever and probable bacteremia after that, but that was a one day event and subsequently did well with resolution of his fever in 24 hours and no recurrence. He was treated with antibiotics, but no cultures were positive ...he remained somewhat passive/aggressive and would not participate with all therapies including the previously mentioned BiPAP. He was manipulating the bed in a fashion to put his head flat, which he was told not to do ...he demanded capping of this tracheotomy at night which he was asked not to do, and in the end we were able to maintain his saturations without either of those appliances attached to his tracheotomy ...he was discharged 04/09/10 to...Rehabilitation.

The general notes dated 03/27/10 reflected the following;

The note dated 03/27/10 timed at 22:00 reflected, "Patient complained of being cold, heart rate elevated, shivering blankets applied, Temp [Temperature] 98.2...at 22:30 patient now disoriented, heart rate 150 ' s, Temp now 105.1 axillary. Dr...notified with orders received ...pan cultures sent stat, ice packs applied, Tylenol additional 650 mg [milligrams] per peg given ...at 23:00 patient placed on BiPAP per order of Dr...patient non-compliant continues to remove BiPAP, restrained bilateral wrist per order Dr...solumedrol 100 mg IVPB [Intravenous piggy back] given, Temp now 103.7 axillary..."

The physician's orders dated 03/27/10 timed at 23:00 reflected, "Restrain pt [patient] if needed ..." a second order entitled, "physician order for restraint" dated 03/27/10 timed at 23:00 reflected, "attempts to pull out vital device/line/tube...alternatives attempted to prevent use ...limiting access to lines, tubes, diversional activities, noise reduction, reality re orientation, medication review, unrestrained mittens...inability to comprehend risk to self or others...type of restraint order soft wrist left and right..."

On 11/04/10 at 11:30 AM MD #6 was interviewed. The surveyor asked MD #6 if he was trained on the hospital restraint policy. MD #6 stated he was. MD #6 was asked why he ordered a prn [as needed] restraint order. MD #6 offered no response.

On 11/05/10 at 9:45 AM RN #20 was interviewed. The surveyor asked RN #20 why she wrote a prn restraint order for wrist restraints to be applied to Patient #6. RN #20 stated she did not realize it was a prn order. RN #20 acknowledged restraints were not to be written as prn.

The policy entitled, "Restraint Management and Seclusion Management" with a revision date of 04/01/10 reflected, "Order for Restraint/Seclusion: The use of restraint or seclusion must be in accordance with the order of a physician...who is responsible for the care of the patient and authorized to order restraint and seclusion by hospital policy...must never be written as a standing order or a prn order..."

Based on interview and record review, the hospital failed to ensure agency personnel [RN #20] was provided training and demonstrated competency in the application of wrist restraints for 1 of 6 patients reviewed [Patient #6].

Findings Included:

Patient #6's physician discharge summary dated 04/10/10 reflected, "[Patient #6] a 59 year old male admitted to [hospital] 03/01/10. [Patient #6] was treated for obstructive sleep apnea, respiratory failure, resolution of pneumonia, dysphagia, aspiration, depression, obesity, and anxiety...he was able to be free of the mechanical ventilator, although at times he required minimal support he was, however able to remain off the ventilator for a period of time...he had his tracheotomy downsized, at one point it appeared he was too weak and deconditioned to breathe long enough through that, retaining CO2 [Carbon Dioxide], and requiring support. Therefore in order to free him from the requirements of BiPAP [Bilevel Positive Airway Pressure] or mechanical ventilation, which he refused to participate with in both cases, the tracheotomy was upsized rapidly...he did have an episode of fever and probable bacteremia after that, but that was a one day event and subsequently did well with resolution of his fever in 24 hours and no recurrence. He was treated with antibiotics, but no cultures were positive...he remained somewhat passive/aggressive and would not participate with all therapies including the previously mentioned BiPAP. He was manipulating the bed in a fashion to put his head flat, which he was told not to do...he demanded capping of this tracheotomy at night which he was asked not to do, and in the end we were able to maintain his saturations without either of those appliances attached to his tracheotomy...he was discharged 04/09/10 to...Rehabilitation.

The general notes dated 03/27/10 reflected the following;

The note dated 03/27/10 timed at 22:00 reflected, "Patient complained of being cold, heart rate elevated, shivering blankets applied, Temp [Temperature] 98.2...at 22:30 patient now disoriented, heart rate 150 's, Temp now 105.1 axillary. Dr...notified with orders received...pan cultures sent stat, ice packs applied, Tylenol additional 650 mg [milligrams] per peg given...at 23:00 patient placed on BiPAP per order of Dr..., patient non-compliant continues to remove BiPAP, restrained bilateral wrist per order Dr...solumedrol 100 mg IVPB [Intravenous piggy back] given, Temp now 103.7 axillary..."

The physician's orders dated 03/27/10 timed at 23:00 reflected, "Restrain pt [patient] if needed ..." A second order entitled, "physician order for restraint" dated 03/27/10 timed at 23:00 reflected, "attempts to pull out vital device/line/tube...alternatives attempted to prevent use ...limiting access to lines, tubes, diversional activities, noise reduction, reality re orientation, medication review, unrestrained mittens...inability to comprehend risk to self or others...type of restraint order soft wrist left and right..."

On 11/05/10 at 9:45 AM RN #20 was interviewed. RN #20 was asked if she had attended hospital restraint training for agency personnel. RN #20 stated she was aware of the restraint rules but not the actual hospital policy on restraints.

On 11/05/10 at 2:45 PM Personnel #1 was interviewed. Personnel #1 was asked by the surveyor to provide evidence that non-employee agency nursing staff have had restraint training and demonstrated competency in the application of restraints. Personnel #1 stated, "no she could not."

The policy entitled, "Restraint Management and Seclusion Management" with a revision date of 04/01/10 reflected, "Order for Restraint/Seclusion: The use of restraint or seclusion must be in accordance with the order of a physician...who is responsible for the care of the patient and authorized to order restraint and seclusion by hospital policy...all direct patient care staff, including contract or agency personnel, must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion...training will be provided in orientation and also annually during the annual update/skills lab..."

Based on interview and record review, the hospital failed to enforce their policy and procedure for hospital contract staff orientation, skills competency and evaluations for 8 of 8 non-employee licensed nurses [contract/agency shared employees] [Personnel #13, #14, #15, #16, #17, #18, #19, and #20] who provided direct patient care on 03/27/10 and from 05/05/10 to 11/03/10.

Findings Included:

A list of the above agency personnel files was provided by Personnel #9 on 11/04/10 at approximately 1:00 PM. Personnel #9 provided the surveyor a list of the following dates non-employee contract nursing staff provided care in the hospital;

Personnel #13 worked; 05/05/10, 05/07/10, 05/11/10, 05/13/10, 05/27/10, 05/28/10, 05/29/10, 06/04/10, 06/06/10, 06/07/10, 06/09/10, 06/10/10, 06/11/10, 06/14/10, 06/16/10, 06/17/10, 06/19/10, 06/25/10, 07/02/10, 07/03/10, 07/09/10, 07/28/10, 07/29/10, 07/30/10, 08/01/10, 08/03/10, 08/04/10, 08/09/10, 08/12/10, 08/19/10, 08/21/10, 08/23/10, 08/27/10, 08/28/10, 09/03/10, 09/08/10, 09/09/10, 09/11/10, 09/13/10, 09/14/10, 09/16/10, 09/17/10, 09/21/10, 09/22/10, 09/24/10, 09/25/10, 09/28/10, 09/29/10, 10/01/10, 10/02/10, 10/04/10, 10/05/10, 10/06/10, 10/08/10, 10/11/10, 10/13/10, 10/15/10, 10/18/10, 10/20/10, 10/23/10, 10/26/10, 10/28/10, 10/29/10, 11/02/10 11/03/10.

Personnel #14 worked; 08/18/10, 08/19/10, 08/27/10, 08/31/10, 09/14/10, 09/16/10, 09/17/10, 09/18/10, 0920/10, 09/21/10, 09/24/10, 09/27/10, 09/28/10, 09/30/10, 10/09/10, and 10/25/10.

Personnel #15 worked; 05/04/10, 05/05/10, 05/21/10, 05/26/10, 06/01/10, 06/02/10, 06/09/10, 06/15/10, 06/25/10, 06/29/10, 06/30/10, 07/13/10, 07/21/10, 07/30/10, 08/02/10, 08/18/10, 09/07/10, 09/14/10, 09/15/10, 09/28/10 09/29/10, 10/05/10, 10/12/10, 10/19/10, 10/26/10, 11/02/10.

Personnel #16 worked; 05/27/10, 06/06/10, 07/08/10, 07/14/10, 07/15/10, 07/16/10, 07/27/10, 07/29/10, 07/30/10, 07/31/10, 08/07/10, 08/08/10, 08/09/10, 08/10/10, 08/15/10, 08/16/10, 08/27/10, 08/28/10, 08/31/10, 09/08/10, 09/10/10, 09/11/10, 09/14/10, 09/15/10, 09/16/10, 09/17/10, 09/18/10, 09/22/10, 09/23/10, 09/24/10, 09/30/10, 10/01/10, 10/02/10, 10/04/10, 10/08/10, 10/09/10,10/13/10, 10/14/10, 10/22/10, 10/24/10, 10/30/10 and 10/31/10.

Personnel #17 worked; 05/05/10, 05/06/10, 05/09/10, 05/10/10, 05/12/10, 05/13/10, 05/14/10, 05/15/10, 05/16/10, 05/20/10, 05/21/10, 05/24/10, 05/27/10, 06/03/10, 06/04/10, 06/05/10, 06/09/10, 06/11/10, 06/12/10, 06/14/10, 06/15/10, 06/16/10, 06/19/10, 06/23/10, 06/24/10, 06/25/10, 06/26/10, 06/27/10, 07/02/10, 07/03/10, 07/04/10, 07/09/10, 07/10/10, 07/15/10, 07/16/10, 07/21/10, 07/22/10, 07/23/10, 07/28/10, 07/29/10, 07/30/10, 07/31/10, 08/01/10, 08/02/10, 08/03/10, 08/09/10, 08/11/10, 08/13/10, 08/14/10, 08/16/10, 08/17/10, 08/18/10, 08/19/10, 08/20/10, 08/23/10, 08/29/10, 08/31/10, 09/01/10, 09/03/10, 09/04/10, 09/14/10, 09/16/10, 09/17/10, 09/18/10, 09/19/10, 09/20/10, 09/22/10, 09/24/10, 09/25/10, 09/26/10, 09/28/10, 09/30/10, 10/01/10, 10/05/10, 10/08/10, 10/09/10, 10/10/10, 10/12/10, 10/15/10, 10/19/10, 10/22/10, 10/23/10, 10/26/10, 10/28/10, 10/30/10, 10/31/10, 11/01/10 and 11/02/10.

Personnel #18 worked; 07/31/10, 08/01/10, 08/14/10, 08/20/10, 08/21/10, 08/24/10 and 09/02/10.

Personnel #19 worked; 08/19/10, 08/20/10, 08/27/10, 08/28/10, 09/01/10, 09/02/10, 09/03/10, 09/06/10, 09/14/10 and 09/17/10.

Personnel #20 worked; 03/27/10, 95/09/10, 05/26/10, 05/27/10, 05/29/10, 05/30/10, 07/03/10, 07/04/10, 07/27/10, 07/31/10, 08/14/10, 08/15/10, 08/19/10, 08/23/10, 09/01/10, 09/03/10, 09/06/10, 09/08/10, 09/10/10, 09/16/10, 09/18/10, 09/19/10, 09/20/10, 09/29/10, 09/30/10, 10/01/10, 10/02/10, 10/07/10, 10/14/10, 10/16/10, 10/19/10, 10/22/10, 10/23/10, 10/28/10, 10/29/10 and 10/30/10.

On 11/4/10 at approximately 3:00 PM Personnel #1 was interviewed and was asked to provide the surveyor with non-employee nursing training/competency evaluations. Personnel #1 stated she could not provide evidence of training/competency of non-employee nursing staff.

The policy entitled, "Competency Assessment and Professional Scope of Practice" with a revision date of 08/01/10 reflected, "Orientation....all staff whether clinical or supportive, including contract staff, shall receive an orientation to specific job duties and responsibilities and their work environment, as required by Federal and State law/regulation and organizational need...other issues required by law the hospital, Texas law and federal regulations such as restraints...supervisors will ensure new employees complete a competency assessment tool for their position...the supervisor will review and validate the competency assessment and follow-up on any training needs..."