HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 Patient (Pt #3), the Hospital failed to ensure that Pt #3 was free of physical restraints.

Findings include:

1. On 12/30/19, the Hospital's policy titled "Restraints/Seclusion" (revision April 2016) was reviewed and required "...Restraints are to be used only in emergent situations where there is an imminent risk of a patient harming him/her self, or others..."

2. On 12/30/19, Pt #3's clinical record was reviewed. Pt #3 was admitted to the Hospital on 12/27/19 with blindness, permanent tracheostomy (opening in the neck to place a tube in the person's windpipe) and alleged aggressive behavior.

-Pt #3's "Daily Assessment Inquiry" dated 12/29/19 at 10:00 AM, 12:00 PM and 4:00 PM indicated "restraint status - apply left wrist, right wrist, left ankle, right ankle - restraint clinical justification - history of severe falling/high risk of falling, any condition causing patient to injure self, patient unable to interpret environment, agitation or threat of lack of control and unable to comply with requests..."

-Pt #3's Admission Assessment Report dated 12/28/19 indicated "History of falling - No"

- Pt #3's orders for restraints dated 12/29/19 at 4:36 AM and 12/30/19 at 8:50 AM indicated: "Apply soft restraints - order good for 24 hours." The orders lacked documentation for the reason or indication for the use of soft restraints.

3. On 12/30/19 at 11:10 AM, an interview was conducted with the 2 North Unit Manager (E #3). E #3 stated that Pt #3 was placed in restraints due to Pt #3 trying to get out of bed.

4. On 12/30/19 at 10:55 AM, an interview was conducted with the Registered Nurse (E #4). E #4 stated that he came to work at 7:00 AM on 12/30/19 and removed Pt #3's restraints because Pt #3 did not need restraints.

Based on document review and interview, it was determined that for 1 of 1 Patient (Pt #3) reviewed for restraints, the Hospital failed to ensure that the least restrictive method was utilized to protect the patient from harm.

Findings include:

1. On 12/30/19, the Hospital's policy titled "Restraint/Seclusion" (revision date April 2016) was reviewed and required "...Restraints/seclusion will be used to manage violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, staff members, or others. Restraints/seclusion will be used only after less restrictive measures have failed or have been evaluated to be ineffective..."

2. Pt #3 was admitted to the Hospital on 12/27/19 with blindness, permanent tracheostomy (opening in the neck to place a tube in the person's windpipe) and alleged aggressive behavior. Pt #3's clinical record dated 12/27/19 indicated that Pt #3 was placed in soft restraints. There was no documentation in Pt #3's clinical record that a less restrictive restraint intervention was attempted prior to application of soft restraints. Pt #3's clinical record dated 12/29/19 at 7:29 PM indicated "...After lunch, Pt #3 became confused and Pt #3 tried to leave his bed on several occasions. Pt #3 was redirected and soft restraints were put in place..."

3. On 12/30/19 at 11:15 AM, an interview was conducted with the 2 North Manager (E #3). E #3 stated that Pt #3 was placed in soft restraints when he became confused and tried to leave his bed. There was no documentation in Pt #3's clinical record that a less restrictive restraint intervention was implemented prior to application of soft restraints for all 4 limbs (left wrist, right wrist, left ankle and right ankle). E #3 stated that there was no less restrictive restraint method attempted prior to application of the soft restraints on all 4 limbs.

Based on document review and interview, it was determined that for 1 of 1 Patient (Pt #3) reviewed for restraints, the Hospital failed to ensure that the use of restraint was in accordance with a written modification to Pt #3's plan of care.

Findings include:

1. On 12/30/19, the Hospital's policy titled "Multi-Disciplinary Care Plan" (revision date November 2011) was reviewed and required "...The care plan should include goals/expected outcomes, interventions and patient/family education relevant to the patient's problems..."

2. On 12/30/19, Pt #3's clinical record was reviewed. Pt #3 was a 65 year old admitted to the Hospital on 12/27/19 with blindness, permanent tracheostomy (opening in the neck to place a tube in the person's windpipe) and alleged aggressive behavior. Pt #3's clinical record dated 12/27/19 indicated that Pt #3 was placed in soft restraints on 12/27/19. Pt #3's multidisicplinary care plan dated 12/28/19, did not address the use of restraints.

3. On 12/30/19 at 11:20 AM, an interview was conducted with the Manager of 2 North (E #3). E #3 stated that Pt #3's care plan should include restraints.

Based on document review and interview, it was determined that for 1 of 9 patients ( Pt #5) reviewed for care plans, the Hospital failed to ensure that the nursing staff developed and kept a current nursing care plan.

Findings include:

1. On 12/30/19, the Hospital's policy titled "Multi-Disciplinary Care Plan" (revision date November 2011) was reviewed and required "...The care plan should include goals/expected outcomes, interventions and patient/family education relevant to the patient's problems..."

2. On 12/30/19, Pt #5's clinical record was reviewed. Pt #5 was admitted to the Hospital on 12/18/19 with the diagnosis of altered mental status, schizoaffective disorder (a mental disorder characterized by abnormal thought processes), depressive disorder, leukocytosis (a high level of white blood cells) and hypertension (high blood pressure).

-Pt #5's clinical record dated 12/26/19 indicated that Pt #5 had a central intravenous line (an intravenous line placed in a vein that leads to the heart) inserted.

-Pt #5's care plan dated 12/19/19 does not include any goals or interventions for Pt #5's central intravenous line care.

3. On 12/30/19 at 11:20 AM, an interview was conducted with the Manager of 2 North (E #3). E #3 stated that Pt #5's care plan should include central intravenous line care goals and interventions.

Based on document review and interview, it was determined that the Hospital failed to ensure that there was an active program in place for the prevention, control and investigation of infections. This potentially placed all current and future patients at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.42 Infection Control, was not in compliance.

Findings include:

1. The Hospital failed to ensure a system was in place for identifying and controlling infections (See deficiency at 749 A).

2. The Hospital failed to develop a policy for central intravenous line care to control infections. (See deficiency at 749 B).

3. The Hospital failed to ensure infection control education was conducted regarding central intravenous line care (See deficiency at 749 C).

4. The Hospital failed to ensure that intravenous lines and feeding tube lines were not left disconnected, potentially allowing for the contamination of the open lines (See deficiency at 749 D).

A. Based on document review and interview, it was determined that for 1 of 1 Patient (Pt #4) reviewed for isolation, the Hospital failed to ensure a system was developed for identifying and controlling infections.

Findings include:

1. On 12/30/19, the Hospital's policy titled "Isolation Precautions" (undated) was reviewed and required "...Use Contact Precautions for specified patients known or suspected infected or colonized (no signs or symptoms) with epidemiologically (study of the causes and control of disease) important microorganisms (too small to be seen, example includes bacteria) that can be transmitted by direct contact with the patient..."

2. On 12/30/19, Pt #4's clinical record was reviewed. Pt #4 was admitted to the Hospital on 12/22/19 with the diagnoses of altered level of consciousness, renal (kidney) failure and sepsis (infection).

- Pt #4's lab report dated 12/26/19, indicated "MRSA (infection -Methicillin resistant staphylococcus aureus - nasal culture)."

- Pt #4's physician order dated 12/29/19 indicated "Contact Precautions." Pt #4's lab report indicated that MRSA was noted on 12/26/19 but Pt #4's contact isolation was not ordered until 12/29/19 (3 days later).

3. On 12/30/19 at 11:25 AM, an interview was conducted with the Manager of 2 North (E #3). E #3 stated that Pt #4's isolation should have been ordered on 12/26/19 when Pt #4's lab result came back positive for MRSA. E #3 stated that she is not sure what happened.

B. Based on document review and interview, it was determined that for 1 of 2 Patients (Pt #5) reviewed for central intravenous lines (an intravenous line placed in a vein that leads to the heart) the Hospital failed to develop a policy for central intravenous line care to control infections.

Findings include:

1. On 12/31/19, the CDC Guidelines for "Prevention of Intravascular Catheter related Infections," (2011) was reviewed and indicated "Replace dressing short term central venous catheter site every 2 days for gauze dressing.."

2. The Hospital did not have a policy/protocol for central intravenous line care.

3. On 12/30/19, Pt #5's clinical record was reviewed. Pt #5 was admitted to the Hospital on 12/26/19 with the diagnosis of altered mental status, schizoaffective disorder (a mental disorder characterized by abnormal thought processes), depressive disorder, leukocytosis (a high level of white blood cells in the blood) and hypertension (high blood pressure).

-Pt #5's clinical record indicated that on 12/26/19 Pt #5 had a central intravenous line inserted.

-Pt #5's clinical record dated 12/30/19 indicated that Pt #5's central intravenous line dressing change was done and "flush" was given. There is no documentation in Pt #5's clinical record regarding an assessment of the central intravenous line site or how often a flush was given.

4. On 12/30/19 at 11:30 AM, an interview was conducted with the Manager of 2 North (E #3). E #3 stated that Pt #5's central intravenous line dressing change should have been done on 12/29/19 (every 72 hours). E #3 stated that there should be documentation in Pt #5's clinical record regarding an assessment of central intravenous line site every shift.

C. Based on document review and interview, it was determined that for 3 of 3 Registered Nurses (E #7, E #8 and E #13) employee files reviewed, the Hospital failed to ensure infection control education was conducted regarding central intravenous line care.

Findings include:

1. On 1/2/20, the Hospital's annual competency list was reviewed. The competency list lacked documentation of infection control training for central intravenous line care.

2. On 1/2/20, the employee files for Registered Nurses (E #7, E #8 and E #13) were reviewed. The employee files lacked documentation on training for infection control regarding central intravenous lines.

3. On 1/2/20 at 10:15 AM, an interview was conducted with the Senior Vice President Patient Care (E #2). E #2 stated that there is no formal education regarding the infection control for central intravenous line care. E #2 stated that it needs to be added to the annual education for nurses.



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D. Based on document review and interview, it was determined that for 1 of 10 clinical records (Pt. #1) reviewed, the Hospital failed to ensure that intravenous lines and feeding tube lines were not left disconnected, potentially allowing for the contamination of the open lines.

1. On 1/2/20, the Hospital's policy titled, IV [intravenous] Catheter Insertion, Maintenance and Termination," (revised October 2018), was reviewed. The policy required, "III. Procedures... A. Insertion... Attach IV tubing to the IV fluid bag... Do not contaminate the connecting ports..."

2. On 1/2/20, the Hospital's policy titled, "Enteral [food passing directly into the stomach or small intestine] Tube Feeding Therapy," (revised July 2006), was reviewed. The policy required, "II. Policy... E. Enteral tube feedings are provided by pharmacy in a closed system... III. Procedures... B. Steps... 2. RN... h. Attach tubing to the enteral feeding pump, begin the feeding as prescribed by the physician's order..."

3. On 12/30/19, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 11/7/19 with the primary diagnoses of "fever from infectious & parasitic [an organism that lives on or in a host] diseases, systemic [affecting the entire body] or unspecified sites [and] Methicillin Resistant Staphylococcus Aureus infection ..."

4. A Physician's order dated 11/8/19 at 1:00 PM, included, "Osmolyte [a nutritional formula for tube-fed patients] 1,500 ml [milliliters] ng [nasogastric] tube ... 30 ml/hr. [milliliters per hour] once a day ... advance 10 cc/hour [cubic centimeters per hour] until 55 cc/hr."

5. Pt. #1's Medication Administration Record (MAR) indicated that Heparin (blood thinning medication) was administered by pump beginning on 11/8/19, with 25,000 units in 250 ml solution, at 4.6 ml/hr. A Heparin pump was maintained throughout Pt. #1's admission.

6. On 12/31/19, a memo regarding "Family Complaint Regarding Care of [Pt. #1], written by the Relief Shift Supervisor (E #14), dated 11/10/19, was reviewed. The memo included, "... On 11/10/19, she [Pt. #1's mother] brought me a video that she says she took on the day shift [date not provided] showing the patient's IV disconnected [Heparin pump] and dripping on the floor. The feeding tube was disconnected and looks like it was clogged..."

7. On 12/30/19 at 10:20 AM, an interview was conducted with the 2 North Unit Manager (E #3). E #3 stated that she met with Pt #1's mother each day. E #3 stated that she remembers that one time Pt #1's feeding tube became dislodged while turning Pt #1. E #3 stated that Pt #1's mother saw the feeding tube disconnected but the feeding tube was reconnected immediately.

8. On 1/2/20 at 11:45 AM, an interview was conducted with E #14. E #14 stated that the IV wasn't out that long and could have been dislodged by Pt. #1's mother. E #14 stated that feeding tube was disconnected at the port and she did not know how long it was disconnected.