HospitalInspections.org

Based on document review and interview, the hospital failed to ensure 1 of 10 patients (patient #2) was free from additional restraint (medication and physical/ventilator) after the patient was sedated with medication and restrained in 4-way lockable restraints.

Findings include:

1. Review of the policy titled Behavioral Emergency Restraint or Seclusion, approved 4/19, indicated the following:
Policy: Restraint and seclusion will be used, as a last resort only for patient safety or the safety of others and will not be used for purposes of convenience or patient discipline.
Definitions:
Behavioral Emergency Restraint: Emergency restraints may include:
1. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely;
2. Drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
Limiting Use of Restraints or Seclusion to Emergencies
Restraint or seclusion is not permitted for any other purpose, such as coercion, discipline, convenience, or retaliation by staff.

2. Review of the medical record (MR) of patient #2 indicated the following:
The Code Strong Evaluation dated 7/19/20 (sic), Time Initiated 2111 hours, indicated the following: Patient had a sitter at bedside. Sitter stated patient sat up in bed then broke the soft bilateral wrist restraints and jumped over the bed rail...landing on knees and face... Patient became combative and kicked staff...Patient grabbed upper thigh on (two other staff members) RN and PCT (Patient Care Technician)... Security arrived...Patient then started to fight with security and security put handcuffs on the patient... Lockable restraints were obtained and applied... Handcuffs were taken off...Patient was still resisting and trying to hit. That is when Geodon was ordered and administered. Patient then became more relaxed and not fighting the restraints.
Physician Hospital Progress Note dated 7/19/20 at 1100 hours indicated the following: Patient was alert and oriented, cooperative on admission. Apparently after he/she was given benzodiazepine, patient became agitated, combative...given Haldol but did not help. Patient jumped out of the bed to the floor with face hitting the floor, sustained hematoma on the right supraorbital...He/she calmed down after Geodon 10 mg IM... Another dose of Geodon 10 mg IM given, which effectively calmed him/her down however did not last long. Due to concern that the patient could hurt the nursing staff, with (sic) decided to intubate the patient. Patient sedated with propofol.

3. The following was indicated in interview:
On 8/13/20, between approximately 11:30 AM and 12:30 PM, S8, ICU Shift Coordinator, indicated that intubation as a form of restraint/behavior control is not common, but can be done for control after agitation.
On 8/13/20, between approximately 2:45 PM and 3:00 PM, M2, CMO (Chief Medical Officer) indicated that physicians may intubate a patient if needed to "rescue" them related to decreased respirations after sedation. M2, after review of MR documentation for patient #2, indicated that he/she believed the physician sedated the patient which led to required intubation. M2 agreed the physician's Progress Note read as though the physician was sedated for intubation and intubated to control behavior.

Based on document review and interview, the hospital failed to ensure nursing care was evaluated for appropriateness and in accordance with acceptable standards for allergy verification and medication orders by the practitioner responsible for the patient's care for 2 of 10 patients (#5 and #6).

Findings include:

1. Review of facility policies indicated the following:
The policy titled Medication Ordering and Administration, last approved 10/19, indicated:
Medication Administration: If the potential for an allergy exists, the medication will be withheld and the prescribing physician contacted immediately.
Sequence, Intervention/Scientific Rational: Check for any allergies listed in the computer, on the patient's bracelet, and ask the patient before any medications are administered.
Assessment of Medication Effectiveness/Side Effects: Patients receiving PRN (as needed) or pre-procedure medication are to be assessed for the patient's initial response to the medication.

The policy titled Medication: Adverse Drug Event (ADE) and Potential Adverse Drug Events (PADE), last approved 9/18, indicated:
Adverse Drug Event (ADE): a deviation in the medication delivery system (transcribing, prescribing, dispensing, administering) or an undesirable clinical manifestation caused by the administration or omission of a medication.
Evaluation: Patient assessments documented in the patient record.

2. Medical record (MR) review indicated the following:
Review of the MR for patient #5 indicated the patient presented to ED on 7/10/20 at 0101 hours and was discharged to home on 7/11/20 at 1200 hours. Allergies were first recorded and indicated as "Verified" on 7/10/20 at 1:03 AM as "No Active Allergies". "No Active Allergies" were recorded as "Verified" again on 7/10/20 at 5:07 AM, 2:43 PM and 2:51 PM. The entry lacked documentation of how or with whom the information was reviewed and verified. On 7/10/20 at 2:52 PM, Omnicef (Cefdinir) was recorded as an "Allergen" with a reaction of "Rash". The MR lacked documentation of why the allergy status was changed and/or of the patient having developed a rash. The MAR indicated that on 7/10/20 at 0334 hours, cefazolin was administered IV.

Review of the MR for patient #6 indicated the patient presented to the ED on 7/12/20. Allergies included, but were not limited to Tramadol. MR documentation indicated that on 7/15/20 a nurse entered a verbal order for IV morphine with M1 as the ordering physician. The MR indicated that an alert requiring an override was created due to cross-sensitivity between morphine and Tramadol. The warning was indicated to have been overridden by the RN. The MR lacked documentation of the nurse having notified the physician of the warning/override or having consulted with the physician prior to overriding the alert. The MAR indicated the morphine was administered on 7/15/20 at 1005 hours. The MR lacked documentation of the administering nurse have checked for allergies with the patient before the medication was administered.

3. On 8/13/20, between approximately 2:45 PM and 3:00 PM, M2, CMO (Chief Medical Officer) verified that if a patient had a noted allergy/allergen, when adding an order to the MR, an alert would pop up requiring an override be completed by the physician. M2 further indicated that if the order were put in the computer as a telephone or verbal order, he/she believed the process should be that the nurse inputting the order should contact the doctor/provider.

Based on document review, observation and interview, the hospital failed to develop a system for controlling COVID-19 and infections/communicable diseases in adherence to nationally recognized infection prevention and control precautions by CDC (Centers for Disease Control) in a facility with known positive cases.

Findings include:

1. Review of CDC website for COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html, updated 8/4/2020,
indicates the following:
The outer surface (of the mask), the surface furthest from the wearer's face, presents the highest risk for pathogen transfer to the wearer.
A limited reuse strategy to reduce the risk of self-contamination
One strategy to reduce the risk of contact transfer of pathogens from the FFR (filtering facepiece respirator) to the wearer during FFR reuse is to issue five N95 FFRs to each healthcare staff member who care for patients with suspected or confirmed COVID-19. The healthcare staff member can wear one N95 FFR each day and store it in a breathable paper bag at the end of each shift with a minimum of five days between each N95 FFR use, rotating the use each day between N95 FFRs. This will provide some time for pathogens on it to "die off" during storage [8]. This strategy requires a minimum of five N95 FFRs per staff member, provided that healthcare personnel don, doff, and store them properly each day.
As a caution, healthcare personnel should treat reused FFRs as though they are contaminated.
CDC recommends limiting the number of donnings for an N95 FFR to no more than five per device. It may be possible to don some models of FFRs more than five times.

2. On 8/12/20, between approximately 10:00 AM and 12:30 PM, the following was observed during hospital tour in the presence of A4, Chief Nursing Officer (CNO) :
On the ICU, hanging on a wall, were multiple small (lunch bag size) open paper bags with staff names and dates. Inside the bags were PPE (personal protective equipment) items, including N95/FFRs, faceshields, surgical masks and hair nets. All PPE items of various types listed were inside each bag touching the other items, no separation of faceshields, FFRs or other items existed. Lying on a nursing station desk/counter, next to a computer, was a faceshield and N95 FFR.
On the rehabilitation unit, hanging on a wall, were multiple small (lunch bag size) open paper bags with staff names and dates. All PPE (personal protective equipment) items, including N95/FFRs, faceshields, surgical masks and hair nets, were in the bags together; no separation of faceshields, FFRs or other items was noted. During observation, a staff member was observed assisting a patient. The staff member was donned in PPE as follows: Gown, shoe covers, N95, faceshield and hairnet. Prior to exiting the room, the staff member removed their gloves and gown and performed hand hygiene. After exiting the room, the staff member removed the faceshield, N95 and hairnet; those items were placed all together in a small paper bag.

3. On 8/12/20, the following was indicated in interview:
Between approximately 10:45 AM and 11:00 AM, A4, CNO, verified that the bags contained PPE used by staff for interaction with COVID-19 positive patients and was the hospitals method for reuse of PPE. A4 indicated that PPE was placed in the bags each day for reuse at a later time. A4 indicated the bags were changed on a regular basis, described as "probably about every week". A4 indicated the policy on this process had not yet been approved. A4 verified that faceshields, FFRs and surgical masks all went in to the bag together, but that hairnets were only to be used for one shift. A4 indicated that the N95s could be reused for 3 shifts, no limit on number of uses per shift was noted.
Between approximately 10:45 AM and 11:00 AM, S1, ICU RN (Registered Nurse), verified the faceshield and N95 on the counter were those of his/hers being used for that day/shift. S1 indicated that he/she uses the same N95 for 3 shifts.
Between approximately 11:30 AM and 11:45 AM, S5, RN/charge nurse, indicated nursing staff reuse N95s for 3 days/shifts and at the end of each shift PPE is placed in a paper bag for reuse.
Between approximately 12:15 PM and 12:30 PM, S7, Nurse Manager of Rehabilitation, verified the combined storage of potentially contaminated PPE following patient interaction.