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Based on observation, interview, and document review, the facility's Governing Body failed to monitor services and policies of the facility in 4 of 4 services provided (dietary, swingbed services, pharmacy, and infection control).


Refer to 0241

Based on observation, interview and record review, the facility's Governing Body failed to monitor services and policies of the facility in 4 of 4 services provided (dietary, swing bed, pharmacy, and infection control).


This deficient practice had the likelihood to effect all services provided within the facility.


Findings:

1. Dietary services:

Food Prepared for Patients:

On 12/10/2018, the initial tour of the dietary department identified a very pungent odor in the patient waiting area and hallway leading to the dietary department. Upon entry, the lead dietary tech, staff #14, was warming food for patients in the oven and preparing a separate catered meal on a single burner hot plate. Staff #14, was stirring a dark liquid in a stewer. Staff #14 explained, the liquid was the sauce for chicken she was preparing for the catered meal. The sauce was ( balsamic vinegar, rosemary, and other strong spices) There was no vent in the food preparation room. The odor was strong and not pleasant to breath.


Further observation revealed, the facility purchased pre-cook/packaged meals. The large pans of pre-made food was thawed and heated in a small oven and then transferred to a three well steam table. The census for 12/10/2018 was #13. The menu indicated lasagna was the entree. The pans of lasagna served 12 people. A second pan of lasagna was prepared and one serving was removed. Upon the return of passing patient trays no seconds were requested and the entire pan of lasagna was tossed in the trash as it could not be reheated and stored in the refrigerator. The Lead tech confirmed that tossing the pan of lasagna was a waste. She further confirmed the Registered Dietician had signed off on the meal plans but was not sure if she was aware of the amount that went into the trash.


Food preparation room

Staff #16 was observed to enter into this room without her hair covered. She walked into the clean dish room and was told by the lead dietary staff, #14, to please put a hair bonnet on her hair. This practice had the likelihood to cross contaminate food with loose hair.

Staff #16 was also reminded, by the lead dietary staff, to wash her hands after using oven mitts and before she touch food services utensils. Staff #16 questioned, the lead dietary staff, if she really needed to do that? This practice had the likelihood to cross contaminate food and clean surfaces with hands that were contaminated while wearing the oven mitts

Multiple (greater that 6) heavy duty fabric pot holders were stored on the top surface of the oven where pre-made food was heated in preparation for serving to patients. This practice had the likelihood of one of the potholders becoming hot enough to cause combustion within the serving area.


Clean dish storage

While touring this area three (3) 5-gallon containers were observed resting on the floor near the commercial dish washing machine. The commercial dish washing machine could be seen through the opening in the wall where the clean dishes would be removed and kept separate from the dirty dishes in the adjoining room. Each container was observed with a translucent hose protruding from the open bottle neck. The first bottle was labeled "Detergent", the second was "Sanitizer" and the third was labeled "Rinse". These three containers of chemicals were being stored and accessed in the clean storage room. Within 8 inches of the container which held rinse solution was a three tiered cart with an open basket of coffee condiments in paper wrappers for individual use (sugar, creamer, etc). This practice had the likelihood to contaminate the product inside the paper wrappers with splash/spillage from the chemical in the container tabled "Rinse".

A clear rectangular container of bananas was observed on the floor. The lid was loosely fitted on the container. A clear container of crackers was also observed on the floor with the lid affixed to the top of the container.

The stainless steel rack used to dry and store plates, and other serving utensils was observed with 10 or more serving scoops stored in a rectangular basket. The basket was too small for the many serving scoops causing two or more to have been positioned with the bowl up which would permit water to be retained in scoop. The practice had the likelihood of bacteria to grow the moisture retained in the bowl of the scoop.

A white blanket was observed tossed on top of a storage shelf.

The clean storage room was also serving as the work station for record keeping and other necessary paper work for the department.

The above observations were confirmed by staff #14 and staff #10, the supervisor.

Review of facility policy "1-1.0 Safety Program Food Service Department" revealed,

"3.4.10, Keep work place clean and tidy. Do not let utensils, tables drawers, or equipment protrude into aisle or forget to pick up dropped utensils, rags, etc. Allow sufficient space for traffic and access to equipment."


Dirty dish room

Upon entering this room a stainless steel rack was observed with canned foods stored next to cleaning supplies which were adjacent to the dirty dish line used to rinse dishes prior to placing in the dishwasher. This practice had the likelihood to contribute to cross contamination of clean foods stored within the cans.

A review of the facility policies for the Dietary department did not identify a policy addressing separation of nutritional items from cleaning chemicals.


Registered Dietician:

Interview with the Lead dietary tech revealed the Registered Dietician (RD) comes weekly. She spent a great deal of time in the kitchen but primarily reviewed nutritional needs and conducts interviews with patients on the patient care unit.

The above remarks were confirmed by staff #13, who confirmed the RD documents her findings, interviews and dietary recommendations in the patient medical record (MR).

Staff #11 was interviewed and confirmed the RD did not leave a document summarizing her weekly visits. The RD's complete record was documented in the individual patient MR. Staff #11 was questioned as to how the RD's services were reviewed and how was information, left by the RD, communicated to the lead diet tech who worked in the dietary department, not on the patient care unit.

Staff #11 indicated if the RD recommended nutritional diets or supplements to be changed the RN on the floor would write the order from the physician and provide the Dietary department with the information. The RD did not normally communicate this information with the dietary staff. Staff #11 further indicated since there was no written summary of services provided by the RD the RN on the floor communicated to there director if they had concerns.

There was no formal process for quality oversight of the RD services for the dietary department.


Staff #11 confirmed the RD placed her comments into the Medical record but there was not a practice of reviewing her documentation for the quality program.


Housekeeping closet (within the Dietary department)

Gallon containers of cleaning supplies were being stored on the floor.

The entire dietary department was very small and seemed ill suited for the services being provided. Interview with the lead dietary staff confirmed she had told her supervisor that more shelving was needed to keep supplies off the floor. Especially where the cleaning and food storage was observed.

A review of facility policy "1-1.0 Safety Program Food Service Department" revealed,
"3.3.1 Needed repair orders are submitted to maintenance following standard procedures."
(Standard procedure were not explained).


The lead dietary tech and manager confirmed the crowding of work and storage space was normal in the dietary department. The storage of clean and dirty, as well as food supplies stored near chemicals was an ongoing practice related to the small space.


The Lead Dietary tech indicated she verbally told the Integrated Services Manager of the need for shelving in the dietary department and called to remind him using the phone. No written documentation of request could be provided.


2. Swing Bed Activities:

Observation of the swing bed unit between the mid morning and mid afternoon identified no distinct activities being offered. Interview with patients #1, #2, #4, and #5 confirmed they spent most of their day watching TV.

Interview with staff #34 and #35 confirmed, they were primarily care techs. Both of these employees described their responsibilities as shared between, patient direct care and personal care needs, stocking supplies that came in during the shift, assisting with meals, and asking if the patient would like to "do something other than watch TV". Both staff #34 and #35 spoke of occasionally taking a patient up front to sit in the lobby if they wanted to get out of the room. They also indicated they had puzzles and books to offer the swing bed patients, but sometimes their just wasn't enough time to get the activity portion offered to the patients.

Interview with staff #11 confirmed, the patient care techs were responsible for implementing the Activity program. Staff #11 indicated the OT (Occupational Therapist) was the oversight for the activity program.

Interview with the OT staff #36 confirmed, he was aware he was the oversight for the activities for the swing bed patient population. During this interview he verbalized his understanding to be focused on motor skill recovery. He confirmed social activity skills were offered as part of the daily patient tech duties. Staff #36 had no clear plan other than "it's offered as the techs meet the daily needs of the patients during bathing, linen change and as time allows through out the day".

A re-interview with staff #11 confirmed, there was not structured activity program that included when the activities would be provided. There was no written plan or policy on how to accomplish the objective of providing social activities for long term swing bed patients and no method to track success with measurable data.


3. Pharmacy services, drug destruction:

On the afternoon of 12/10/2018, an interview with staff #37 confirmed that drugs were destroyed by placing them into the red bio-hazard sharps container. She further explained that both liquids (narcotics) and tablets were placed in the bio-hazard container, if destruction was required.

Observation of the content on the bio-hazard container identified 3-4 solid oral medication that were still in the unit dose blister pack, and had been dropped into the bio-hazard sharps container. These drugs could have be removed without risk of interval contamination. Staff #37 explained liquids would be "squirted" into the bio-hazard containers for destruction.

On the same afternoon, an interview with staff #10 explained the bio-hazard containers, used within the pharmacy, would be removed when filled to the recommended limit, by an employee of the contracted biohazard destruction company, and stored on the facility ground in a secure closet until the volume of material to be destroyed made a load. He further explained, all of the maintenance department had a key to the room and closet where the bio-hazard containers were stored, so who ever was on duty when the bio-hazard pick up occurred could get to the bio-hazard containers.

Later in the afternoon a telephone interview with the lead pharmacist, staff #24, confirmed he was aware of drug destructions being done, by simply emptying the drug into the bio-hazard containers. He further confirmed no other form of adulteration of the drug occurred prior to placement into the bio-hazard container.


4. Infection Control:

Emergency Department: 56 expired purple top blood tubes were identified as expired. These tubes were identified in the cabinet at the nurses station. The finding was confirmed by staff #21, the department manager.

Dietary patient tray pass:

On 12/10/2018 the noon meal patient tray pass was observed. The meal trays were distributed to in room patients by the dietary staff. Dietary staff #16 was observed delivering 5 trays, one tray was delivered to an isolation patient. Staff #16 was closely observed and failed to sanitize her hands between as she entered and exited the patient's room. This failed practice had the likelihood to effects all patients by cross contamination

Based on review and interview the facility failed to:


1.) A. Document narcotic use wastage. A review of the log titled, "All Controlled Activity Report" for month of September 2018 revealed the staff did not document wastage or witnessed narcotic wastage.

B. Further review of the narcotic record revealed there were narcotics being signed out with no documentation of the narcotic being administered.

C. The facility failed to have a facility procedure to ensure that narcotic discrepancies and wastage are tracked and reviewed with the department managers and pharmacist; to address patterns of narcotic removal and failure to waste narcotics as per hospital policy to avoid drug diversion issues.

D. The facility failed to ensure narcotics were wasted in a manner to render them unusable and irretrievable.

Refer to Tag A0276


2.) Properly identify and document a reason for administration of chemical restraints.

Document any nursing interventions attempted to calm, or redirect the patients, before a chemical restraint was administered.

Document an assessment after the administration of chemical restraints for effectiveness, side effects, and neurological/behavioral status.

Educate the patient /caregiver on the administration of a psychoactive medication in 2(#8 and #11) of 2 patient charts reviewed that had received a chemical restraint.

Refer to Tag A0297

Based on record review, observation, and staff interview, the facility staff failed to:

A. Document narcotic use wastage. A review of the log titled, "All Controlled Activity Report" for month of September 2018 revealed the staff did not document wastage or witnessed narcotic wastage.

B. Further review of the narcotic record revealed there were narcotics being signed out with no documentation of the narcotic being administered.

C. The facility failed to have a facility procedure to ensure that narcotic discrepancies and wastage are tracked and reviewed with the department managers and pharmacist; to address patterns of narcotic removal and failure to waste narcotics as per hospital policy to avoid drug diversion issues.

D. The facility failed to ensure narcotics were wasted in a manner to render them unusable and irretrievable.

Findings included:

A. A review of the log titled, "All Controlled Activity Report", for the month of the September 2018 revealed that there were 16 occurrences where narcotics had been removed from the automated dispensing cabinet (ADC) in which wastage was not documented and signed by 2 witnesses.

B. Narcotics were removed from the ADC and there was no documentation in the patient chart that the narcotic was administered. Pharmacy personnel tracked when wastage was not documented in the ADC.

C. The pharmacy tracked when medications were removed and not documented as being administered in the patient medical record. The facility failed to monitor, track, and analyze the data obtained from the pharmacy.


A review of the facility's policy titled, "Comprehensive Controlled Substances Management" revealed the following:

IV. Return and Waste Medications:

"A witness is required for returning all controlled medications to the ADC or wasting all controlled medications in the ADC."

E. Proactive Diversion Prevention

I. Controlled Substance Transaction Random Audits

1. Random audits of controlled substances transactions will be conducted for all ADCs.
2. Errors identified through these audits will be provided to the Clinical Director or other appropriate nursing leader, lead CRNA, or Chief of Anesthesia with responsibility for the clinical area where the error occurred.
3. Error trends will be reviewed by the Controlled Substance Diversion, Detection and Prevention Program Committee.

II. Controlled Substance Utilization Review

1. Database program reports (RX Auditor) shall be reviewed monthly to identify activity that may indicate diversion of controlled substances or other dangerous drugs.
2. A more detailed review of a specific ADC user's controlled substance transactions maybe completed to further evaluate risk of diversion activity.
3. Errors identified through this transaction review will be provided to the Clinical Director or other appropriate nursing leader, lead CRNA, or Chief of Anesthesia with responsibility for that ADC user."

Interview with Staff #2 and #24 on 12/12/2018 at 1:00PM confirmed the facility did not have a procedure in place for addressing narcotic wastage or usage discrepancies with clinical managers and staff.

D. An interview with staff #24 and staff #37 confirmed that narcotics are wasted in the sharps container and there is no other destruction system in place to render meds unusable and irretrievable.

A review of the letter from the U.S. Department of Justice dated October 17, 2014 stated:

" In the disposal final rule, the DEA stated that a "controlled substance dispensed for immediate administration pursuant to an order for medication in an institutional setting remains under the custody and control of that registered institution even if the substance is not fully exhausted (e.g., some of the substance remains in a vial, tube, transdermal patch, or syringe after administration but cannot or may not be further utilized, commonly referred to as 'drug wastage' and 'pharmaceutical wastage'). Such remaining substance must be properly recorded, stored, and destroyed in accordance with DEA regulations (e.g., § 1304.22(c)), and all applicable Federal, State, tribal, and local laws and regulations, although the destruction need not be recorded on a DEA Form 41." 79 Fed. Reg. 53,521. The DEA further stated that "pharmaceutical controlled substances remain under the custody and control of the DEA registrant if they are dispensed by a practitioner for immediate administration at the practitioner's registered location (such as a hospital) pursuant to an order for medication. If that substance is not fully exhausted (e.g., some of the substance remains in a vial, tube, or syringe after administration but cannot or may not be further utilized), then the DEA registrant is obligated to destroy the remaining, unusable controlled substances, and record the destruction in accordance with § 1304.22(c). The DEA registrant shall not place such remaining, unusable controlled substance in a collection receptacle as a means of disposal. Hospital/clinic staff must also not dispose of any controlled substances in inventory or stock in a collection receptacle." 79 Fed. Reg. 53,523 (emphasis added)."








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On 12/10/2018 in the afternoon, an interview with staff #37 confirmed that drugs were destroyed by placing them into the red bio-hazard sharps container. She further explained that both liquids (narcotics) and tablets were placed in the bio-hazard container, if destruction was required.

Observation of the content on the bio-hazard container identified 3-4 solid oral medication that were still in the unit dose blister pack, and had been dropped into the bio-hazard sharps container. These drugs could have be removed without risk of internal contamination. Staff #37 explained liquids would be "squirted" into the bio-hazard containers for destruction.

That same afternoon, an interview with staff #10 explained the bio-hazard containers, used within the pharmacy, would be removed when filled to the recommended limit, by an employee of the contracted biohazard destruction company, and stored on the facility ground in a secure closet until the volume of material to be destroyed made a load. He further explained all of the maintenance department had a key to the room and closet where the bio-hazard containers were stored, so who ever was on duty when the bio-hazard pick up occurred could get to the bio-hazard containers.

Later in the same afternoon, a telephone interview with the lead pharmacist, staff #24, confirmed he was aware of drug destructions being done by simply emptying the drug into the bio-hazard containers. He further confirmed no other form of adulteration of the drug occurred prior to placement into the bio-hazard container.

Based on record review and interview nursing failed to:

Properly identify and document a reason for administration of chemical restraints.

Document any nursing interventions attempted to calm, or redirect the patients, before a chemical restraint was administered.

Document an assessment after the administration of chemical restraints for effectiveness, side effects, and neurological/behavioral status.

Educate the patient /caregiver on the administration of a psychoactive medication in 2(#8 and #11) of 2 patient charts reviewed that had received a chemical restraint.


Patient #11
Review of patient #11's chart revealed he arrived at the Emergency Department (ED) at 8/15/18 at 1330 (1:30PM) for Manic behavior.

Staff #38 (ED Physician) documented on 8/15/18 at 1338 (1:38PM). Staff #38 stated, "49 y/o male bipolar presenting to the ED with concern manic behavior. States that he has not been sleep (sic) for 5 days. Notes that he has not been able to sleep as he believes his medications are not appropriately dosed. Pt is somewhat difficult historian with pressured speech and disorganized thoughts.

Review of Systems Psychiatric/Behavioral: Positive for sleep disturbance. Negative for agitation, behavioral problems, dysphoric mood, hallucinations, self-injury and suicidal ideas. The patient is nervous/ anxious. The patient is not hyperactive. Given active manic episode; pt was provided with Ativan and Haldol." The physician documented that the patient has a history of epilepsy (seizure disorder).

There was no documentation found of the patient's home medications or what psychotropic medications he had been taking.

Review of Patient #11's chart revealed physician orders for the following psychotropic medications and administration:
8/15/18 1413 (2:13PM) Ativan 2mg Intravenous (IV). Administered to the Patient #11 at 1425 (2:25PM).
8/15/18 1456 (2:56PM) Ativan 1mg tablet by mouth. Administered to the Patient #11 at 1500 (3:00PM).
8/15/18 1505 (3:05pm) Haldol 5mg Intramuscular (IM). Administered to the Patient #11 at 1510 (3:10PM).
8/15/18 1611 (4:11pm) Haldol 5mg Intramuscular (IM). Administered to the Patient #11 at 1615 (4:15PM).
8/15/18 2006 (8:06pm) Haldol 5mg Intramuscular (IM). Administered to the Patient #11 at 2010 (8:10PM).

Review of Patient #11's nurse's notes revealed the following:
a.) There was no documented indication of why the injections were given.
b.) There was no documentation where on the body the injections were administered.
c.) There was no documentation if the patient was explained why the medication was given.
d.) There was no documentation that any nursing interventions were attempted to calm, or redirect the patient, before a chemical restraint was administered.
e.) There was no documentation that the patient was assessed after the medication for effectiveness, side effects, neurological/behavioral status and no vital signs were obtained until 1610 (4:10PM).
f.) There was no documentation that the patient was offered any food, water, bathroom, or any basic safety needs after receiving 3 psychotropic IM medications and 1 Intravenous (IV) 2mg Ativan.

Review of Patient #11 ED physician notes dated 8/15/18 at 1:38PM Staff #39 documented, "I independently interviewed ___ (Patient #11) separately from ___ (staff #38) and agree with the above. Briefly, 49 yo here for manic behavior. Had been accepted to BHC but there was a staff assault overnight and now there are no beds. He has flight of ideas, pressured speech, and grandiose ideas (speaks of the oppression of the Roman Empire, speaks German at times, discusses religious topics). He seems to be more comfortable standing at the door singing. His father had been up here at one point. He is usually redirectable (sic) but had several doses of Haldol to try and keep him in his room." There was no documentation that Patient #11 was ordered a sitter, given redirection, provided with nursing interventions, nor had a physician order for seclusion. The patient was medicated to "keep him in his room" for staff convenience.

According to the insert of Haldol Lactate- "Haldol (haloperidol lactate) is an antipsychotic drug that decreases excitement in the brain. However, the action is unknown. It's thought to block postsynaptic dopamine receptors in brain and increase dopamine turnover rate, inhibiting signs and symptoms of psychosis.

Administration 2-5 mg q4-8hr PRN; may require q1hr in acute agitation; not to exceed 20 mg/day should monitor closely with the use of Ativan. Half-life: 21-24h Max: 20 mg/day.

Since there is no antidote for Haldol it is important for the provider to monitor and assess the patient for complications for hypotension; use with caution in diagnosed CNS depression, subcortical brain damage, or cardiac disease; if history of seizures, benefits must outweigh risks; Use caution in patients receiving anticonvulsant medications, with a history of seizures, or with EEG abnormalities; haloperidol may lower convulsive threshold; if indicated, adequate anticonvulsant therapy should be concomitantly maintained."

Review of the nurses notes on 8/16/18 revealed Patient #11 was monitored at 0035 (12:35AM), 0140 (1:40AM), 0230 (2:30AM), 0335 (3:35AM), 0432 (4:32AM). The nurse documented, "In room, sleeping, cooperative."

Review of Patient #11's physician orders revealed an order for Haldol 10mg Intramuscular (IM) on 8/16/18 at 0742 (7:42AM). There was no documented reason on the order for the psychotropic medication.

Review of Patient #11's chart Medication Administration Record (MAR) revealed the following psychotropic medications and administration on 8/16/18 at 0742 (7:42AM). "Haldol 10mg Intramuscular (IM). Administered to the Patient #11 at 0745 (7:45AM)."

Review of Patient #11's nurse's notes revealed the following:
a.) There was no documented indication of why the injection was given.
b.) There was no documentation where on the body the injection was administered.
c.) There was no documentation if the patient was explained why the medication was given.
d.) There was no documentation that any nursing interventions were attempted to calm, or redirect the patient, before a chemical restraint was applied.

Patient #11 was given a meal tray at 0749 (7:49AM) four minutes after his injection and was documented to have a "good appetite" able to feed himself, clean himself, go to the restroom without any behavioral issues documented. There was no documentation concerning the effects of the administered psychotropic medication. The patient was discharged to a psychiatric facility on 8/16/18 at 10:41AM.

Review of the policy and procedure "Restraints or Seclusion" revealed the policy gave a definition for chemical restraints but there was no procedure to follow for after the chemical restraint was administered, how the patient should be monitored, and for how long.

An interview was conducted at 9:20AM on 12/10/18 with staff #2. Staff #2 confirmed that she had not been keeping a log of restraints. Staff #2 stated that it was a recommendation to have a list of restraints from her JCAHO (Joint Commission on Accreditation of Healthcare Organizations) visit. Staff #2 confirmed there was not a list or record of chemical restraint administration and was not tracking the chemical restraint in Quality at this time. Staff #2 reported that the EPIC computer system had a built in program for restraint administration. Staff #2 reported that the chemical restraints should be placed in the computer system as a restraint. This would assist the nurse in monitoring needed for restrained patients. Staff #2 was unable to provide any training or monitoring that had been given or performed on chemical restraints. Staff #2 reported she was still working on those issues.

Patient #8
Review of patient #8's chart revealed he arrived at the Emergency Department (ED) on 12/05/18 at 1559 (3:59PM) for Suicidal and Homicidal ideation, Amphetamine abuse, and Back spasms.

Review of the physician assistant (PA) notes dated 12/5/18 at 4:42PM stated, "Pt with hx of schizophrenia, seen here 2 days ago for same. He has been off all medication. He states he is now feeling homicidal and suicidal and needs to get out of his current living situation because there are too many drugs around. He states he is having back pain and spasms as well. At last visit, pt was seen by ACCESS and discharged to follow up with them outpt. Pt states he went the next day and filled out paper work but they will not see him again for another week and he can not (sic) wait that long.

Mental Health Problem Presenting symptoms: aggressive behavior, agitation, bizarre behavior, disorganized speech, disorganized thought process, hallucinations, homicidal ideas, suicidal thoughts and suicidal threats."

Review of the chart revealed there was no documentation of what medications Patient #8 had taken for his mental health issues.

Review of the PA orders revealed on 12/5/18 at 1644 (4:44PM) the following medications were ordered:
Diphenhydramine (Benadryl) 25 mg IV once.
Haloperidol lactate (Haldol) 5 mg IV once.

Review of Patient #8's MAR revealed the patient was given the Haldol and Benadryl IV on 12/5/18 at 1645 (4:45PM). There was no reason documented on the orders for the psychotropic medications or why it was ordered IV.

According to the Prescriber's Digital Reference (PDR) concerning Haldol Lactate "The intravenous route is not FDA approved and is generally not recommended except when no other alternatives are available. Intravenous administration appears to be associated with a higher risk of QT prolongation and torsade de pointes (TdP) than other forms of administration. The manufacturer recommends ECG monitoring for QT prolongation and arrhythmias if IV administration is required. A dose in the range of 1 to 5 mg IV has been suggested, with the dose being repeated at 30 to 60 minute intervals, if needed. A maximum IV dose has not been established. The lowest effective dose should be used in conjunction with conversion to oral therapy as soon as possible."

Review of the nurse's notes revealed a psychosocial was completed by the RN on 12/5/18 at 1717 (5:17PM) 32 minutes after Patient #8 was medicated with psychotropic medications. The nurse documented, "Mood- Anxious: Labile; Irritable. Affect- Exaggerated; Heightened; Overly dramatic. General Attitude- Suspicious; Cooperative." There was no physician or nursing documentation of any patient behaviors that required a chemical restraint.
Review of the nurses note dated 12/5/18 at 1626 (4:26PM) revealed the patient was on a heart monitor. Patient #8 had a pulse rate of (160 abnormal.) According to the American Heart Association "A normal resting heart rate for adult's ranges from 60 to 100 beats per minute." Patient #8's EKG showed "sinus tachycardia" (fast heart rate). There was no documentation that patient #8's elevated pulse rate was addressed and if the patient was symptomatic.

Review of Patient #11's nurse's notes revealed the following:
a.) There was no documented indication of why the IV psychotropic medications were given.
b.) There was no documentation if the patient was explained why the medication was given.
c.) There was no documentation that any nursing interventions were attempted to calm, or redirect the patient, before a chemical restraint was administered.
e.) There was no documentation that the patient was assessed after the medication for effectiveness, side effects, neurological/behavioral status.
f.) There was no vital signs obtained after 1626 (4:26PM). There were no vital signs documented after Patient #8 was administered IV Haldol and Benadryl.

Based on observation, record review, and interview, the surgical staff failed to:

A.) Ensure surgical counts were performed and the surgical "Time-Out" process was completed per the facility's policies in 1 (#18) of 2 patients.

B.) Ensure a sanitary environment in 2 of 3 (Operating Room, Pre-op area, and Post Anesthesia Recovery Area) surgical areas.



The deficient practice had the likelihood to cause harm to all patients.


Findings:


A. During an observation of patient #18's surgical procedure on 12/11/2018 at 10:10 AM with staff #7; observed surgical staff #29, #30, and #31 failed to perform 2 of 3 surgical counts for needles, sutures, blades, and surgical sponges per the facility's policy.

An interview with staff #2 and #7 on 12/18/2018 at 8:00 AM during a review of patient #18's completed and closed document, confirmed that the only count performed was the initial surgical count.

Review of facility's policy and Procedure titled, "Prevention of Unintentionally Retained Surgical Items--Sponges, Sharps, and Instrument Counts" with a review date of 6/7/2018 revealed the following:


" ...Sponges and sharps should be counted on all procedures in which the possibility exists that a sponge or sharp could be retained.

3.1 Sponges and Sharps counts are performed:

a. Before procedure to establish a baseline

b. Before closure of a cavity (peritoneum, thoracic cavity) or a cavity within a cavity (uterus, bladder)

c. Before wound closure begins

d. At skin closure or end of procedure

e. At time of temporary or permanent relief of either scrub person and! or circulating nurse. (Direct visualization of all items may not be possible if procedure is in progress.)

3.2 Initial sponges and sharps counts should be performed and recorded, including for minimally invasive procedures such as Laparoscopy and Thoracoscopy ..."


B. During observation of patient #18's surgical procedure with staff #7; surgical staff #29, #30, #31, #32, and #33 failed to perform 1 of 4 (patient identification) steps during the "Time-out" procedure per facility's policy.

Review of the facility's policy and procedure titled, "Correct patient, Site, and Procedure Verification Policy" revealed the following:

"8.6 Once the timeout is initiated all other activities are suspended, noise is controlled, to the extent possible without compromising patient safety, so that all relevant team members are focused on the active confirmation of the elements of the time-out checklist.

8.6.1 Confirmation of the patient identity

8.6.2 Confirmation of the procedure to be done

8.6.3 Confirmation that the correct site and laterality are marked

8.6.4 Confirmation that the pre-procedure site marking is clearly visible (laterality-dependent procedures only).

8.7 Final verification that information obtained during the pre-procedure timeout is consistent with information contained in the procedure consent form and the surgeon's order lies with the circulating nurse or other authorized and designated member of the procedure team.

8.8 All team members use active verbal communicating to express agreement with information communicated during the preprocedure timeout ..."


C. On 12/12/2018 at 8:00 AM a tour of the facility revealed the following:

Operating Room #1

During a tour of the Surgery department 12/11/2018 at 8:00 AM with staff #7, observed in operating room #1 the wheel casters were rusted on a rolling cart and the metal wall rack that holds the patient transfer device was rusted.


Post Anesthesia Care Area

In the Post Anesthesia Recovery Area, observed a mini fridge that contained patient nutrition (juices/soda) showed spilled liquids and a 3-inch tear in the rubber seal around the top.


Medical Surgical Unit

There was an Emergency Crash Cart for Pediatric patients next to the Nurses Desk. In the drawer labeled "Emergency Airway" there were 4 non-disposable LMA's (Laryngeal Mask Airway). LMA's are used to intubate and maintain an airway in surgery or emergency resuscitation. The LMA's had been sterilized in individual sterilization peel packs. The packs did not have a sterilization date on them. There was no way to determine when the LMA's were sterilized. Also, the facility could not provide documentation on how many times the LMA's had been sterilized to ensure they were following manufacturer recommendations on sterilization. Staff #13 confirmed the findings.

A review of the manufacturing guidelines revealed the following:

"The Classic Laryngeal Mask Airway (LMA; Laryngeal Mask Co., Henley-on-Thames, U.K.) is an airway device currently available in two forms, a single use polyvinyl chloride LMA and a reusable silicone LMA. Manufacturers currently suggest that the reusable LMA, with adequate cleaning and sterilization, can be used up to a maximum of 40 times (1). Several recent studies have shown that residual proteinaceous material is detectable on sterilized LMAs (2-4). This finding raises concerns about possible iatrogenic transmission of proteins and specifically prion proteins via reusable LMAs."

Based on chart review and interview the facility failed to identify, monitor, measure, evaluate, and report physical and chemical restraint usage in Quality Assessment Performance Improvement (QAPI) program.


Review of the Medical Executive Committee Meeting Minutes dated 10/11/18 and the Performance Improvement Meeting dated 10/17/18 revealed there was no documentation of restraints. There were no restraints identified, monitored, measured, or evaluated.

Review of patient charts #8 and #11 revealed the facility failed to identify the following:

Properly identify and document a reason for administration of chemical restraints.

Document any nursing interventions attempted to calm, or redirect the patients, before a chemical restraint was administered.

Document an assessment after the administration of chemical restraints for effectiveness, side effects, and neurological/behavioral status.

Educate the patient /caregiver on the administration of a psychoactive medication.

An interview was conducted at 9:20AM on 12/10/18 with staff #2. Staff #2 confirmed that she had not been keeping a log of restraints. Staff #2 stated that it was a recommendation to have a list of restraints from her JCAHO (Joint Commission on Accreditation of Healthcare Organizations) visit. Staff #2 confirmed there was not a list or record of chemical restraint administration and was not tracking the chemical restraint in Quality at this time. Staff #2 reported that the EPIC computer system had a built in program for restraint administration. Staff #2 reported that the chemical restraints should be placed in the computer system as a restraint. This would assist the nurse in monitoring needed for restrained patients. Staff #2 was unable to provide any training or monitoring that had been given or performed on chemical restraints. Staff #2 reported she was still working on those issues.