All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).
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Observations:
Based on a review of facility documents, medical records (MR), video observation, and employee interviews (EMP), it was determined the facility failed to follow their policy in monitoring a patient's condition in one of ten medical records reviewed (MR1).
Findings include:
Review of facility policy "Restraints and Seclusion" with a review date of July 10. 2023, revealed "... III. DOCUMENTATION A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented ... IX. Use of restraints or Seclusion for Violent of Self-Destructive Behavior (Previously identified as "Behavioral Management") ... E. ONGOING PATIENT ASSESSMENT AND CARE INTERVENTIONS ... 4. Patients in restraint or seclusion for Violent or Self-Destructive behavior will be continuously observed and reassessed. The continued need for the use of restraints/seclusion will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. For Violent or Self-Destructive behavior - every 15 minutes ... F. DISCONTINUATION OF RESTRAINT/SECLUSION 1. The RN or physician, CRNP or PA may discontinue restraint/seclusion if the criteria for discontinuation have been met. 2. The time and criteria for release will be documented when the restraint is removed and/or seclusion discontinued ... "
Review of facility policy "UPMC Pinnacle Hospitals Nursing Standards of Care "revealed "I. Title: Unit Standard of Care for Emergency Dept Actions. II Goals/Expected Outcomes and Nursing Actions ... c. Ongoing assessment for medical patient: ... 6) Vital signs to be documented following the standards below for medical patients. During the course of treatment and evaluation in the ED ...b. ESI Severity Index] 2 - at least q 1 hr [every hour] ..."
Review of MR1 on August 12, 2024, revealed patient was brought in by police to the Emergency Department on July 28, 2024, at 12:40 AM with an admitting diagnosis of alcohol intoxication. At 1:11 AM the physician gave an order for one-to-one supervision and physical restraints. At 1:26 AM the physician ordered labs including ETOH (Ethanol - alcohol level). At 2:00 AM the patient's Blood Alcohol Content (BAC) resulted in 379 mg/dl (over 400 is at risk for serious complications including coma and death). Partial restraints were released at 2:43 AM, and the last extremity was released at 3:30 AM from restraints. Restraint ordered discharged but one to one supervision order remained. At 4:38 AM the Physician wrote "... ETOH elevated at 379; will be sober around 1500 [3:00 PM] this afternoon but will monitor." MR1 showed the patient was classified as an ESI 2 (emergency service index) which would result in vitals being monitored at least every hour. At 3:50 AM Registered Nurse documented that Oxygen saturation was at 87% on 2 liters of oxygen and patient was increased to 4 liters. At 4:10 AM Oxygen saturation decreased to 80% and patient oxygen was again increased to 6 liters of oxygen. At 7:07 AM the Registered Nurse entered the room and found the patient unresponsive. Emergency Medical code was started at 7:15 AM. Patient was pronounced dead at 7:31 AM.
Further review of MR1 revealed that restraint monitoring was documented as completed at 1:45 AM, 2:00 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:00 AM, 3:15 AM, and 3:30 AM.
On August 13, 2024, observation of video recording of the hallway directly outside the patient's room on July 28, 2024, showed nursing exiting the patient room at 3:32 AM. During the time period that was documented in MR1 as the patient being observed and oxygen increased, no one was seen entering MR1's room. Further review of the video revealed no nursing staff entering or exiting the room between 3:33 AM and 7:07 AM.
Interview conducted on August 13, 2024, with EMP9 (physician) revealed that they were not made aware of the low oxygen saturation change in condition.
Interview conducted on August 13, 2024, with EMP8 confirmed that no one entered the patient room to assess the patient or take vital signs according to policy. In addition, EMP8 confirmed that no one was assigned to the patient to provide the one-to-one observation per order and the video observation did not match what was documented in the medical record.
| | Plan of Correction - To be completed: 09/20/2024
Upon notification of the findings following the PA DOH investigation, the UPMC West Shore leadership team met to review the report findings, the Standard of Nursing Care for Emergency Department and relevant policies. An educational plan was developed to augment activities already in process to address the areas of concern.
Education regarding the requirements for restraint monitoring and documentation was presented to nursing leaders of all three UPMC Pinnacle Hospitals on August 16, 2024.
Staff education was provided to the emergency department staff in the form of a Practice Alert deployed on August 12, 2027. After review of the document, each staff member signed an attestation confirming that he/she reviewed the information and understood the expectations. Further, this information was discussed and reinforced during the department shift huddles. Content included in the document is as follows:
- The ED Unit Standard of Care, included within the Nursing Plan for Provision of Care, that includes direction for the frequency of vital sign reassessment per assigned ESI level.
- The standard of care for the patient in restraints, as defined in the policy HS-HS-NA0416 Restraint and Seclusion, that includes the mandate for 1:1 continuous observation for the patient in seclusion or violent restraints. In addition, staff were reminded to collaborate with the provider to determine if the order for 1:1 observation needs to continue after the episode of restraints ends. The expectation is that the order is discontinued if a 1:1 is no longer necessary.
- The expectation at UPMC Pinnacle Hospitals is that documentation in the legal medical record must accurately reflect the care the patient receives while under our care. Staff were cautioned to never document care we did not give, as it will be considered falsification of the medical record. To support the direction, staff were provided with excerpts from the PA Department of Health and State Board of Nursing regulations. In addition, staff were provided with the contact information for UPMC legal resources to answer any questions.
A staff meeting was held on August 28, 2024. The information included in the Practice Alert was discussed and reinforced during the meeting. In addition, the following pertinent information was reviewed:
- Expectations regarding provider notification were reviewed: UPMC Pinnacle expects that clinicians will communicate changes in patient condition promptly to the provider(s) responsible for the patient to determine if intervention is required. All communications regarding a change in patient condition are expected to be documented accurately and timely in the permanent medical record.
- The process to ensure 1:1 assignment for patients requiring violent restraints was reviewed. When a patient is placed in violent restraints/seclusion, a 1:1 is promptly assigned. The charge nurse will then notify the Administrator on Duty (AOD) who will go to the emergency department to validate the assignment. A log will be maintained at the main desk to document the time the restraints are applied, the time the AOD is notified, and the time the restraint is discontinued. If the episode of restraints continues past the change of shift, the charge nurse and AOD on the oncoming shift will validate that a 1:1 continues to be assigned. Last, the form provides a reminder to confirm if the 1:1 needs to continue after the restraint is discontinued.
After the staff meeting, the minutes were sent via email with a 'read' receipt for review by those staff members that were not present for the meeting.
Monitoring/Auditing:
Provider Notification Audits: The emergency department unit director or designee will audit 30 randomly selected charts per month to determine compliance with provider notification of a change in patient condition. Compliance will be calculated by dividing the number of documented provider notifications by the total number of observations that required notification.
Vital Sign Assessment Audits: The emergency department unit director or designee will audit 30 randomly selected charts per month to determine compliance with vital sign assessments per the unit standard for patients assigned as ESI 2.
The provider notification and vital sign assessment audits will continue until 100% compliance is achieved for three (3) consecutive months. Staff members that are noncompliant will received additional education and coaching.
Results of the provider notification and vital sign reassessment audits will be reported to the UPMC West Shore Chief Nurse Officer, Director of Nursing, and the Critical Care Director monthly for the duration of the action plan. The accuracy of the medical record will be evaluated during the audits. Any inaccuracies identified will be addressed using the Just Culture framework.
Violent Restraints 1:1 Log
A log will be maintained that documents the time the emergency department charge nurse notifies the Administrator on Duty (AOD) that a patient was placed in Violent Restraints/Seclusion. The AOD will go to the emergency department and verify that a staff member is assigned to provide 1:1 continuous observation. Both the CN and AOD will sign the log. The emergency department unit director or designee will review the log to ensure every violent restraint episode was reported to the AOD and will evaluate the timeliness of the notification.
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