HospitalInspections.org

The hospital reported an average daily census of 16 patients with a current census of 21 patients. Based on observation, record review, patient and staff interview the hospital failed to identify the use of a Geri chair (chair with a tray that attaches across the patients lap used to confine a patient) as a restraint for one of three restrained patients (patient #12). The hospital's failure to correctly define restraints put the patient's safety at risk due to improper supervision and physician awareness.
Findings include:
- Patient #12 observed on 5/14/14 at 10:05am in room 500 and in the Geri chair revealed patient #12 unable to remove the tray from Geri chair to free her.
- The hospital policy for restraints reviewed on 5/12/14 at 2:00pm directed "...A restraint is: A. Any manual method, physical or mechanical device, material, or equipment that mobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely..."
- Observation on 5/12/14 at 3:30pm of patient #12 in room 500 revealed the patient sitting in Geri chair with tray latched.
- Nursing Staff D interviewed on 5/12/14 at 3:30pm at the nurses station stated staff placed patient #12 in the Geri chair to prevent her from wandering.
- Administrative staff A interviewed on 5/12/14 at 4:30pm in the conference room acknowledged use of a Geri chair to prevent patient from wandering is a restraint.
- Patient #12's medical record reviewed on 5/13/14 revealed a diagnosis of wound care. The medical record lacked acknowledgement of restraint use and lacked documentation of physician order for restraint, care planning for restraint or safety checks. The medical record documented use of Geri chair starting 5/7/14.
- Administrative nursing staff B interviewed on 5/13/14 at 3:00pm verified the medical record lacked physician order for restraint and care plan for restraint use.

Based on record review, policy review and staff interview the hospital failed to modify the patient's plan of care to include the use of a restraint for one of three restrained patients (patient #12). The hospital's failure to modify the patient's plan of care with restraint use put the patient's safety at risk.
Findings include:
- Patient #12 observed on 5/14/14 at 10:05am in room 500 and in the Geri chair revealed patient #12 unable to remove the tray from Geri chair to free her.
- Hospital policy for restraints reviewed on 5/12/14 at 2:00pm directed "...Care Plan: The patient's care plan will be modified to reflect the need for a restraint..."
- Nursing Staff D interviewed on 5/12/14 at 3:30pm at the nurses station stated staff place patient #12 in the Geri chair to prevent her from wandering.
- Patient #12's medical record reviewed on 5/13/14 revealed a diagnosis of wound care. The medical record lacked modification of the care plan for restraint use.
- Administrative nursing staff B interviewed on 5/13/14 at 3:00pm verified patient #12's medical record lacked modification of the care plan for restraint use.

Based on observation, policy review, medical record review and interview the hospital failed to obtain a physician order for use of restraint for one of three patients restrained (patient #12). The hospital's failure to obtain a physician order for restraint use put the patient's safety at risk.
Findings include:
- Patient #12 observed on 5/14/14 at 10:05am in room 500 and in the Geri chair revealed patient #12 unable to remove the tray from Geri chair to free her.
- Nursing Staff D interviewed on 5/12/14 at 3:30pm at the nurses station stated staff place patient #12 the Geri chair to prevent her from wandering.
- The hospital policy for restraints reviewed on 5/12/14 at 2:00pm directs "...Orders: Restraint use will be initiated upon the order of a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraints..."
- Patient #12's medical record reviewed on 5/13/14 revealed a diagnosis of wound care. The medical record lacked a physician order for use of restraints.
- Administrative nursing staff B interviewed on 5/13/14 at 3:00pm verified patient #12's medical record lacked physician order for use of restraints.

The hospital reported an average daily census of 16 patients with a current census of 21 patients. Based on medical record review and staff interview the hospital failed to ensure multiple practitioners dated and/or timed all entries into the medical record for fourteen of twenty sampled patients (#'s 1, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 18, and 19). This deficient practice resulted in an incomplete medical record.

Findings included:

- The hospital's Medical Staff Bylaw and Rules and Regulations reviewed on 5/15/14 at 10:20am directed,"...All medical record entries must be legible, complete, dated, timed and authenticated (signed)..."

- Patient #1's medical record reviewed on 5/12/14 revealed an admission on 5/4/14 with a diagnosis of decubitus ulcer (an open wound in the skin and underlying tissue). The medical record revealed the history and physical lacked a date and time when the physician authenticated the document. The medical record revealed seven Speech Therapy (ST) and one respiratory therapy (RT) note lacked a time when authenticated.

- Patient #5's medical record reviewed on 5/13/14 revealed an admission on 4/21/14 with a diagnosis of decubitus ulcer. The medical record revealed the history and physical lacked a date and time when the physician authenticated the document.

- Patient #6's closed medical record reviewed on 5/14/14 revealed an admission on 5/7/14 with a diagnosis of bacteremia (a bacterial infection). The medical record revealed the history and physical and discharge summary lacked a date and time when the physician authenticated the documents.

- Patient #7's medical record reviewed on 5/14/14 revealed an admission on 4/21/14 with a diagnosis of respiratory failure. The medical record revealed the history and physical, discharge summary and a pulmonary consult lacked a date and time when the physician authenticated the documents.

- Patient #8's medical record reviewed on 5/14/14 revealed an admission on 4/8/14 with a diagnosis of post left hip fracture. The medical record revealed the history and physical and discharge summary lacked a date and time when the physician authenticated the documents.

- Patient #9's medical record reviewed on 5/14/14 revealed an admission on 4/3/14 with a diagnosis of sepsis (an infection throughout the body). The medical record revealed the history and physical, a pulmonary consult, and an infectious disease consult lacked a date and time when the physician authenticated the documents.

- Patient #10's medical record reviewed on 5/14/14 revealed an admission on 1/31/14 with a diagnosis of respiratory failure. The medical record revealed the history and physical and a discharge summary lacked a date and time when the physician authenticated the documents.

Patient #12's medical record reviewed on 5/12/14 revealed an admission on 5/5/14 with a diagnosis of decubitus ulcer to the right shoulder and sacrum. The medical record revealed the occupational therapy assessment lacked a time when the therapist authenticated the document.

- Patient #13's medical record reviewed on 5/12/14 revealed an admission on 4/24/14 with a diagnosis of laryngeal cancer (throat cancer). The medical record revealed seven Speech Therapy (ST) notes lacked a time when authenticated.

- Patient #14's medical record reviewed on 5/13/14 revealed an admission on 4/25/14 with a diagnosis of bacteremia (infection in the blood stream). The medical record revealed two consults lacked a date or time when the physician authenticated the document.

- Patient #15's medical record reviewed on 5/14/14 revealed an admission on 5/1/14 with a diagnosis of decubitus ulcer right heel and foot (an open wound in the skin and underlying tissue). The medical record revealed the history and physical lacked a date or time when the physician authenticated the document.

- Patient #16's medical record reviewed on 5/14/14 revealed an admission on 5/8/14 with a diagnosis of chronic renal (kidney) failure and wound care. The medical record revealed a consult lacked a date or time when the physician authenticated the document.

- Patient #18's medical record reviewed on 5/15/14 revealed an admission on 5/3/14 with a diagnosis of respiratory failure. The medical record revealed the history and physical lacked a date or time when the physician authenticated the document.

- Patient #19's medical record reviewed on 5/15/14 revealed an admission on 4/30/14 with a diagnosis of osteomyelitis (a bone infection). The medical record revealed a consult lacked a date or time when the physician authenticated the document.

- Administrative nursing staff C interviewed on 5/14/14 at 4:00pm acknowledged medical records lacked dates and times with signatures.

The hospital reported an average daily census of 16 patients with a current census of 21 patients. Based on observation and staff interview the hospital failed to ensure an acceptable level of safety and quality for emergency supplies in one of one crash cart. The hospitals failure to ensure safety and quality of emergency supplies had the potential to risk patient safety.
Findings include:

- The hospital policy for the crash cart reviewed on 5/15/14 at 10:15am directs "...crash cart checks to ensure all medications and supplies are stocked, rotated as needed and not expired..."

- Observation of the crash cart at the nurse's station on 5/12/2004 at 12:10am revealed the following outdated supplies;
1. One-red top tube for blood draw with expiration date of 12/2013.
2. One-red top tube for blood draw with expiration date of 5/2011.
3. Two-red top tubes for blood draw with expiration dates of 2/2014.
4. One-22 gauge Introcan Safety needle with expiration date of 3/2013.
5. One-22 gauge Introcan Safety needle with expiration date of 12/2011.
6. Two-Ultrasyte valve with expiration dates of 10/2012.
7. One-small bore intravenous tubing extension set with expiration date of 7/2011.
8. Four-small bore intravenous tubing extension sets with expiration dates of 4/2012.
9. One-size 8.0 trach tube (tube inserted in airway to assist with breathing) with expiration date of 12/2013.
10. One-size 7.0 trach tube with expiration date of 12/2012.
11. One-size 6.0 trach tube with expiration date of 4/2013.
- Nursing staff E interviewed on 5/12/2014 at 12:10pm verified outdated supplies in crash cart.