HospitalInspections.org

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §485.635 PROVISION OF SERVICES was out of compliance.

C-0271-The CAH's health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. The facility failed to follow its policies on restraints with regard to physician orders, time limitations for behavioral restraints and timing of the face-to-face assessment performed within 1 hour of restraint initiation. The failure created the potential for unsafe restraint use and potential injury to restrained patients.

C-0278 - A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain appropriate infection control processes in the area of hand hygiene. Specifically, the facility failed to ensure credentialed medical staff adhered to facility policies on appropriate hand hygiene indications and opportunities. The failure created the risk for patient exposure to healthcare associated infections.

Based on interviews and record review the facility failed to ensure all clinical staff adhered to its restraint policy. Specifically, the facility failed to ensure the placement of orders, time restrictions and face-to-face consultations were met in 3 of 3 restraint records reviewed (Patients #12, #13 and #18). Further, the facility failed to ensure staff demonstrated initial and ongoing competency.

The failure created the potential for unsafe restraint use and potential injury to restrained patients.

FINDINGS

POLICY

According to the policy Restraint, every opportunity to reduce the risks associated with restraint use will be taken. Behavior Management restraints are applied for behavioral health reasons to control an acutely disturbed patient exhibiting an unanticipated outburst of severely aggressive and destructive behavior that poses an imminent danger to self and others. Restraints are initiated with the provider's verbal or written order in accordance with a written modification to the patient's plan of care. With behavioral management situations, the written order for a physical restraint is limited to 4 hours for adults. The provider will see and evaluate the need for restraint or seclusion within one hour after initiation of the restraint.

The restraint order needs to specify the behavior requiring restraint, type of restraint to be used, extremity or body part being restrained, duration or timeframe for restraint, frequency of monitoring and assessment if different from facility policy and the specific timeframe the order is for.

Staff that have direct patient contact will have ongoing education and training in the proper and safe use of restraints and will have successfully demonstrated restraint application prior to restraining a patient. Restraint application competency will be measured annually. Competency will demonstrate knowledge in application, least restrictive alternatives, use of provider orders, documentation, patient positioning, slip knot tying and strategies for reducing risks.

REFERENCES

According to the Medical Staff Bylaws, each Medical Staff member and each practitioner exercising privileges shall continuously meet all responsibilities including: Abide by the Medical Staff Bylaws and Rules and all other lawful standards, policies and Rules of the Medical Staff and the facility.

The Lippincott Manual of Nursing Practice (9th ed., p. 195) states the specific facility will have to develop policies and procedures for the appropriate use of restraints and psychoactive drugs. Primary health care providers will have to write appropriate orders for restraints and psychoactive drugs.

According to the manufacturer instructions for use of limb restrictive products, all staff should receive proper inservice training so products are applied in accordance with the manufacturer's instructions, state and federal regulations and the facility's policies and procedures.

1. The facility failed to ensure its restraint policy was followed.

a) Review of the medical records of Patient #12 revealed a 29-year-old intoxicated individual arrived at the Emergency Department (ED) on 9/03/17 at 11:48 p.m. The ED provider began documentation on the patient at 12:11 a.m. There was no acknowledgement of the patient being placed in restraints during the initial assessment of the patient. Further review of the ED provider progress note showed a Reassessment/Reevaluation note that stated the patient had been brought in by ambulance and received psychoactive drugs prior to arrival and subsequent doses upon arrival to the ED. The ED provider also documented the patient "remains in 4-point restraints" but anticipate removal when s/he is more cooperative.

A 24-Hour Restraint Record-Downtime form was found within the medical record that showed Patient #12 was restrained in 4-point soft restraints from midnight until 5:00 a.m. on 9/04/17. The duration of restraint was 1 hour longer than the facility stated maximum timeframe for behavioral management restraints.

The Orders Patient Care section of the medical record showed no written orders for the physical restraint of Patient #12.

b) Patient #13 arrived at the ED by ambulance on 7/24/17 at 7:27 p.m. The ED physician progress note showed a service date/time of 7/24/17, 11:13 p.m. Patient #13 was assessed to be 30-years old in an altered mental state with an odor of alcohol on his/her breathe. There was no documentation within the ED physician progress note to acknowledge Patient #13 required restraint.

The Patient Rounds section of the medical record showed documentation completed by the assigned nurse on 7/24/17 at 7:40 p.m., which stated, "Restraints to hands placed, per MD VO, pt pulling at lines". A 24-Hour Restraint Record revealed Patient #13 was placed in soft wrist restraints from 7:45 p.m. until 8:15 p.m.

The Orders Patient Care section of the medical record did not show any written orders for the physical restraint of Patient #13.

c) The medical record of Patient #18 revealed s/he arrived at the ED on 9/27/17 at 1:33 p.m. for medical clearance under the control of law enforcement. Documentation in the ED provider progress note showed Patient #18 was intoxicated, combative, agitated, confused and had briefly been unconscious due to a seatbelt around the neck. There was no documentation within the progress note to show the ED provider assessed Patient #18 required restraint.

The Orders Patient Care section of the medical record revealed orders for soft restraints to the upper extremity written on 9/27/17 at 1:35 p.m. A second order was written to remove the restraints at 2:40 p.m. The order failed to specify the behavior requiring restraint, duration or timeframe for restraint.

An ED Assistance Summary form showed, dated 9/27/17 at 3:51 p.m., showed the application of restraints. At 2:15 p.m. a nurse documented Patient #18 was sedated. A progress note entered by the assigned nurse at 2:55 p.m. showed the restraints were removed because the patient was sleeping and handcuffed.

d) An interview was conducted with Registered Nurse (RN) #2 on 10/11/17 at 10:28 a.m. RN #2 stated there was a restraint protocol within the facility which clinical staff was required to follow. The protocol required the nurse and physician to document why the patient required restraint. A written order must be put in the order entry system for all restraints to give the reason and duration of restraints. According to RN #2, there would be a risk to the patient if the physician was not aware the patient was in restraints.

e) During an interview with Chief Nursing Officer (CNO) #1, on 10/11/17 at 1:28 p.m., the records of Patients #12, #13 and #18 were reviewed. CNO #1 confirmed all patients placed in restraints required a written order in the medical record and a face-to-face consultation documented by the provider within 1 hour of behavioral restraint initiation. The order and documentation should specify why the restraint was needed, the type of restraint and the duration of restraint. In the case of Patient #12, there should have been an order for the original restraint and a new order for 4-point restraints if the situation escalated. Patient #12's restraint duration should have been limited to 4 hours but the patient was in restraints longer than 4 hours. According to CNO #1, after the 4 hour period there should have been a new order written for Patient #12.

Patient #13 showed a verbal order was received. CNO #1 stated the nurse should have put the verbal order in the computer because s/he charted the receipt of a verbal order. The verbal order would be routed to the provider's inbox for signature. "I do not see the time [s/he] actually examined the patient because this date is not right". CNO #1 confirmed there was no order or face-to-face assessment documented within 1 hour of restraint initiation.

CNO #1 confirmed there was no 1-hour face-to face assessment documented on Patient #18. S/he stated there was no place for the provider to document the face-to-face. The provider would need to physically type the assessment in their progress note.

2. The facility failed to perform restraint competencies of clinical staff.

a) An interview was conducted with RN #2 on 10/11/17 at 10:28 a.m. RN #2 confirmed s/he had not received any specific training on the use and application of restraints other than reading the policy. RN #2 stated s/he had placed a patient in restraints approximately 2-3 weeks prior to this interview. RN #2 stated a lack of training could place the patient in danger if the restraints were applied incorrectly.

b) The CNO #1 was interviewed on 10/11/17 at 1:28 p.m. S/he stated all nursing staff received restraint use and application training upon hire and annually. According to CNO #1, this information should be documented on each staff member's Orientation Checklist in their employee record.

c) Three employee records (RNs #7, #8 and #9) were reviewed for documentation of restraint training. There was no restraint training listed on the General Orientation Checklist of the nursing staff records reviewed.

d) A second interview was conducted with CNO #1 on 10/11/17 at 3:35 p.m. S/he confirmed nursing staff had only reviewed policies and there was no documentation "that any nursing staff have received initial or annual training on restraint use and application".

e) On 10/11/17 at 3:58 p.m. an interview was conducted with the ED Director (Physician #3). S/he confirmed oversight of all ED physicians credentialed by the facility and was ultimately responsible for the education of those physicians. Physician #3 stated s/he had never received training from the facility on the use and application of restraints but had helped place patients in restraints. Physician #3 stated it was important orders were placed in the medical record so that people were not doing things without correct oversight or treating patients outside of their practice. Orders also ensured the physician was aware the patient was placed in restraints. Restraint education was "just one of those things that's easily overlooked because you simply velcro something and tie it to the bed".

Based on observations, interviews and document review the facility failed to maintain appropriate infection control processes in the area of hand hygiene. Specifically, the facility failed to ensure credentialed medical staff adhered to facility policies on appropriate hand hygiene indications and opportunities.

The failure created the risk for patient exposure to healthcare associated infections.

FINDINGS

POLICY

According to the policy Aseptic Technique-Hand Hygiene, the purpose was to provide guidance to perioperative personnel for performing hand hygiene for operative and other invasive procedures. Hand hygiene is the primary method of decreasing health care associated infections. All perioperative personnel will follow CDC (Centers for Disease Control) established practices for hand washing. Perform hand washing upon arrival to the healthcare facility; before and after every patient contact; before putting on gloves and after removing gloves or other personal protective equipment (PPE); any time there is the possibility that there has been contact with blood, body fluids, or other potentially infectious materials or contaminated surfaces; before and after eating; before and after using the restroom; before leaving the facility; and whenever hands are visibly soiled.

According to the policy Hand Hygiene, all personnel will use the hand hygiene techniques as set forth in the procedure. Facility staff will follow CDC (Centers for Disease Control) recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol-based hand rub. Indications for hand washing and hand antisepsis are:

Upon entering and exiting patient room.
Before having direct contact with patients.
After contact with patients.
Before donning and after removing gloves.
Before handling food.
Before eating and after using the restroom.
Before inserting invasive devices that do not require a surgical procedure.
After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings.
When moving from contaminated body sites to clean body site during patient care.
After contact with inanimate objects in the immediate vicinity of the patient.

1. The facility failed to ensure all clinical care team members adhered to hand hygiene practices.

a) On 10/10/17 Physician #6 was observed providing care in the Pre-operation/Post-anesthesia care unit (Pre-op/PACU). At 9:04 a.m. Physician #6 entered the room of Patient #1 with his/her personal clothing in hand. Without performing hand hygiene, Physician #6 touched the foot and arm of Patient #1. Physician #6 touched a bandage on his/her arm and stated "I got to be a patient today" then marked the right eye Patient #1 for surgery. Physician #6 departed the room without performing hand hygiene

At 9:39 a.m. Physician #6 entered Bay #3 to obtain consent from Patient #11. Physician #6 administered Neo-Synepherine eye drops into Patient #11's right eye at 9:42 and 9:43 a.m. No hand hygiene was performed by Physician #6 upon entry or exit of the bay.

b) An interview was conducted with Infection Control Nurse (ICN) #5 on 10/10/17 at 12:57 p.m. ICN #5 stated all clinical staff were expected to perform hand hygiene before and after gloving, before and after performing direct patient care using soap and water if hands are visibly soiled and alcohol rub if no visible soil is present. Physicians were expected to maintain established standards for infection control. S/he confirmed physicians were provided infection control training on an annual basis with the last training conducted in December, 2016.

According to INC #5, Physician #6 had not received the facility Infection Control Training book that was usually given to physicians upon hire. S/he had not been able to coordinate training with Physician #6 due to the physician's time constraints. Physician #6 would not return to the facility for scheduled surgeries until 10/05/17. According to INC #5, Physician #6 should have performed hand hygiene after touching his/her bandaged site and prior to touching any patient's eye to prevent cross-contamination to the patient.

c) On 10/10/17 at 2:54 p.m. an interview was conducted with Chief Medical Officer (CMO) #4. S/he stated Physician #6 was credentialed to provide care in the facility for the last 2 years but had not been in the facility in that time period. The expectation was surgeons performed hand hygiene at the required times. CMO #4 stated physician hand hygiene audits were performed by myself and any non-compliance was addressed directly with the offending physician. If non-compliance continued, the physician would be referred for peer review and possibly asked not to return.