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Based on observation, staff interview, clinical record and adverse incident review, it was determined the hospital failed to ensure all patients in restraints were assessed and reassessed by the registered nurse. This affected one patient of 2 restrained patients in the intensive care unit (#19 ) from the total of 6 patients in the unit. The hospital census was 108.

Findings include:

The clinical record review for Patient #19 was completed on 01/19/11. The patient was admitted to the hospital on 01/07/11 with a primary diagnosis of pneumonia. The patient presented to the emergency room with prompt intubation for assistance in breathing and transferred to the intensive care unit for ventilator support.

Patient #19 was observed in the intensive care unit of the hospital on 01/19/11 at 10:45 AM. The patient was observed on respiratory support of a ventilator. The patient was in a bariatric bed, due to obesity, with four side rails up. There was a gap between the four split side rails measuring 14 to 16 inches when in the 30 degree position and 24 inches in the flat position. The patient had both wrists restrained to prevent pulling out the ventilator.

Review of the nursing notes dated 01/8/11 at 1:00 PM revealed the nurse documented he/she had left the patient's room and "the patient was found sitting on the floor next to the bed. All four side rails were up on the bed. The patient was trying to get to the bedside commode. The intravenous tubing was out of the left arm. The PICC (Peripheral Intravenous Central Catheter) probably out of the left arm. Assisted back to bed with no visible injury noted. "

Staff F, the nurse on the unit, stated on 01/19/11 at 11:00 AM, the patient had fallen between the gap in the left side rails. The patient was assessed on the initial assessment of 01/08/11 as a high risk for falls. Staff F stated the nursing intervention after the fall was the physician's order for bilateral wrist restraints. Review of the nursing assessment revealed no assessment for the use of the bilateral wrist restraints. The patient remained in bilateral wrist restraints from 01/08/11, 01/09/11 and 01/10/11 and then the wrist restraints were discontinued. The next documented application of the restraints was on 01/17/11 at 9:00 AM. There was no documentation of an assessment by the registered nurse for these restraints.

The hospital policy (PC-KMC) Restraints and Seclusion, Section C, states" All patients in restraints are assessed, monitored and evaluated on an ongoing bases. An initial assessment at the time of the patient's admission and each successive episode requires an assessment to determine if a restraint is necessary." The record did not have documentation of these required assessments.

Further review of the clinical record revealed there were no physician orders for the use of these 4 side rails or documentation of a nursing assessment for the use of the side rails. The hospital's restraint policy (PC-KMC) titled, " Restraints and Seclusion" requires a physician order for the use of 4 side rails. The manufacturer's guidelines/specifications provided by the hospital staff for the use of Posey torso and limb restraining products states " for safety use side rail covers and gap protectors are to be used to help prevent the patient's body from going under, around, through or between the side rails. A failure to do so may result in serious injury or death if a patient becomes suspended of entrapped.". As a result of no protective measures being used per the guidelines/specification, the patient sustained a fall.

The above findings were verified with staff A and staff C on 1/21/2011 at 2:00 PM.

Interview of staff A and staff C stated that the facility did not implement any measures to prevent other restrained patients with four side rails up from falling out of the bed.

Based on observations, review of fire plan policies, and staff interviews, the Condition of Participation for Physical Environment is not met related to life safety from fire and dietary sanitation. This affected all staff, visitors, and patients in the facility. The total capacity was 110 and the patient census was 80 during this visit.

Finding include:

During this survey from 01/18/11 through 01/21/11, the facility failed to maintain the hospital in regard to the life safety code requirements related to access to exit access doors, exit discharges lacking a continuous surface to the common way, exit discharge lighting, smoke detector locations, oxygen storage rooms, and exit directional signage.

Please refer to 42CFR 482.41(b) Tag A709 and 42CFR 482.41 (b)(1)(2)(3) Tag 710 Life Safety From Fire.

The facility failed to have complete fire watch plans in place.

Please refer to 42CFR 482341(b)(7) A714 Fire Control Plans.

During a tour of the kitchen on 01/19/11 at 1:45 PM, the dishroom was observed with two air supply diffusers located in the ceiling over the dish machine area. The air supply diffusers were observed with rust on the majority of the perimeter surfaces. The posterior area of the fan grill was observed with a heavy coating of dust and dirt. A large fan was observed blowing toward the dish machine as they were being washed. This was verified with Staff G, N, and O during tour.

Based on observations and staff interviews, the facility failed to ensure Life Safety from Fire in regard to exit access doors being inaccessible, lacking a continuous surface to the common way, exit discharge lighting, smoke detector locations, oxygen storage rooms, and exit directional signage. The facility had a capacity of 110 and a census of 80 patients during this visit.

Findings include:

The facility failed to ensure two exit access doors in the operating room suite were arranged so that the exits were readily accessible at all times, failed to ensure 7 exit discharges and the exit discharge pathway leading from 3 exit discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness, failed to ensure smoke detectors were located at least 36 inches from air supply/return vents, and failed to ensure one medical gas storage room was protected in accordance with NFPA 99.

Please refer to 42CFR 482.41(b)(1)(2)(3) A710 Life Safety From Fire

The facility failed to have a written fire control plan that contained provisions for protection of patients, personnel and guests.

Please refer to 42CFR 482.41(b)(7) A714 Fire Control Plans.

Based on observations, and staff interviews, the facility failed to ensure the provisions of the Life Safety Code of the National Fire Protection Association, NFPA 101, 2000 edition of the Life Safety Code was met in regard to exit access doors being inaccessible, lacking a continuous surface to the common way, exit discharge lighting, smoke detector locations, oxygen storage rooms, and exit directional signage. The facility had a capacity of 110 and a census of 80 patients during this visit.

Findings include:

The facility failed to ensure two exit access doors in the operating room suite were arranged so that the exits were readily accessible at all times. Refer to K38.

The facility failed to ensure 7 exit discharges and the exit discharge pathway leading from 3 exit discharges were arranged so that failure of any single lighting fixture (bulb) would not leave the area in darkness. Refer to K45.

The facility failed to ensure smoke detectors were located at least 36 inches from air supply/return vents. Refer to K52.

The facility failed to ensure one medical gas storage room was protected in accordance with NFPA 99. Refer to K76.

Based on staff interviews and review of the fire watch plan, the facility failed to have a written fire control plan that contained provisions for protection of patients, personnel and guests. The facility had a total capacity of 110 and a census of 80 patients.

Findings include:

The facility failed to have a policy that included the person/persons responsible for performing the fire watch and failed to state the frequency of the actual fire watch in the event the fire alarm system is out of service for more than 4 hours in a 24 hour period. Refer to K154.

The facility failed to have a policy that included the person/persons responsible for performing the fire watch, and failed to state the frequency of the actual fire watch in the event the fire alarm system is out of service for more than 4 hours in a 24 hour period. Refer to K155.