HospitalInspections.org

Based on policy review and interview, the facility's policies do not identify the type of mitt used by the facility for purposes of restraint.
Findings Include:
Review on 11/22/13 of policy " Restraints- Acute Medical Surgical " last revised 10/10 revealed Section II: Definitions lists criteria of practices/equipment which are not considered " restraints " . This area does not include soft hand protectors. Section IV: Equipment lists " mitts " as restraints. This policy does not delineate between " mitts " and " soft mitts or soft hand protectors " .
Review on 11/22/13 of policy " Soft Mitts " effective 10/13/11 revealed soft hand protectors are not restraints, may be initiated by a nurse and not used in behavioral health.
Interview on 11/22/13 at 11:18am with Staff # 29, Manager of Medical Rehabilitation revealed soft mitts do not need a physician order and it is a nursing judgment call to use them.
Interview on 11/22/13 at 11:30am with Staff #2, Senior VP of Nursing Services revealed " soft mitts " are not classified as restraints, just as interventions which need to be documented every 8 hours.

Based on medical record review, policy review and interview, nursing staff did not conduct an assessment of skin integrity in accordance with facility policy for 1 of 1 patients with soft hand protectors.(Patient # 25)
Findings Include:
Review on 11/22/13 of policy " Soft Mitts " effective 10/13/11 indicates nursing documentation for the use of soft hand protectors should include a pre-application skin integrity assessment of the hand/wrist areas to which the hand protector(s) are being applied and the reason for use. Effectiveness and patient ' s tolerance, as well as the removal of the soft hand protector(s) and skin integrity are to be documented every eight hours and as needed.
Review on 11/22/13 of a Nursing Progress note for Patient # 25 dated 11/17/13 at 1:46am indicated soft mitts were initiated to prevent the patient from pulling at IV lines, external catheter and tracheostomy collar. No evidence was found in the medical record to indicate if mitts were applied bilaterally, if a pre-application skin assessment was performed, effectiveness/patient tolerance of soft mitts, when mitts were removed and skin integrity assessment every 8 hours per facility policy.
During interview on 11/22/13 at 11:18am with Staff # 29, Manager of Medical Rehabilitation Patient # 25' s medical record was reviewed. No additional documentation was found to indicate if the mitts were applied bilaterally, if a pre-application skin assessment was performed, the effectiveness/patient tolerance of soft mitts, when mitts were removed and skin integrity assessment every 8 hours. There is a specific section in the electronic medical record (EMR) in which the nurse can document the soft mitt assessment. This area was not activated to populate in the EMR.
Interview on 11/22/13 at 11:30am with Staff #2, Senior VP of Nursing Services revealed " soft mitts " are not classified as restraints, just as interventions which need to be documented every 8 hours.

Based on observation and interview the facility does not maintain all aspects of the physical plant.

Findings include:

During a tour of the Emergency Department on 11/18/13 it was observed that the hand washing sink outside of room #36 did not drain.

Interview with Staff # 5 on 11/18/13 confirmed the above finding.

During a tour of patient floors on 11/18/13 the following was observed:
-4th floor, janitor's closet 4-3. The ventilation exhaust was not functioning. Water was pooling on the floor due to a steady drip from the water hose that connected to the chemical solution mixer.

-8th floor, janitor's closet 833B.There was an opening in the ceiling approximately 8 feet by 4 feet. The grate for the floor drain was missing. The cove molding was missing.

-12th floor, soiled hold 1233A, hopper area. The sheet vinyl flooring is in disrepair with pieces missing and pulling away from the subfloor. The floor drain was coated with filth. The cove molding was pulling away from the wall.

-12th floor, janitor's closet. The room was malodorous with a dirty floor and sewer flies in the room.

Interview with Staff #7 on 11/18/13 confirmed the above findings.

During a tour of the post anesthesia care unit (PACU) and the operating suite on 11/19/13 the following was observed:

-In bay #11 (PACU), the ceiling tile was water stained, approximately six inches in diameter.

-In bay #23 and #24 (PACU) both sidewalls had heavy damage to the drywall. Interview with Staff #5 revealed this was secondary to bed movement.

-In the operating suite, in the sterile core, in alcove 173 1B & 2B, and 5B & 6B the cove molding was loose and pulling away from the wall.

-In operating room #12, both floor level exhausts were heavily dust loaded behind the grate.

-Interview with Staff #7 on 11/19/13 confirmed the above findings.

During a tour of the Patient Services Kitchen on 11/20/13 two wood pallets were observed in the main freezer with boxes, containing food items, stored on them. The pallets were made of raw wood and were not positioned six-inches off the ground.

Interview with Staff #7 on 11/20/13 confirmed the above finding.

During a tour of the Retail Kitchen on 11/20/13 the flooring underneath the ice machine was observed to be in disrepair with cracked floor tiles that were lifting away from the subfloor.

Interview with Staff #7 on 11/20/13 confirmed the above finding.

During a tour of the Central Sterilization and Processing Department on 11/19/13 a water leak in the sterilizer equipment space was observed. On the floor in the area of the leak there were approximately ten cloth towels that were damp. In addition, the two exhaust vents in this space were heavily dust loaded.

Interview with Staff #7 on 11/23/13 confirmed the above finding.

Based on observation and interview, 1 out of 12 operating rooms (Room #10) did not have emergency lighting.

During a tour of the operating suite on 11/19/13 it was observed that operating room #10 was not equipped with emergency lighting.

Interview with Staff #1 on 11/20/13 confirmed the above noted finding.