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Based on policy and procedure review, open medical record review, and staff interviews, the facility staff failed to discontinue a restraint at the earliest possible time for 1 of 2 patient's in restraints. (Pt #1).

The findings include:

Review on 02/19/2014 of the hospital's policy and procedure, "Rights and Responsibilities, Patient", effective date 01/2013, revealed "...30. A patient has the right to be free from the use of seclusion and restraint, unless medically authorized by the physician. Restraints and seclusion will be used only as a last resort and in the least restrictive manner possible to protect the patient or others from harm and will be removed or ended at the earliest possible time..."

Review on 02/19/2014 of the hospital's policy and procedure "Restraints, Non-Violent/Non-Self Destructive Behavior" effective date 11/01/2012 revealed "...III. E. Restraint for Non-Violent/Non-Self-Destructive Behavior: A restraint used in order to allow the provision of medical or surgical care needed to improve the patient's well being and support medical healing...IV. Policy Statement: ...B. All patients have the right to be free from the use of restraint in any form that is not medically necessary or that is imposed as a means of coercion discipline, convenience or retaliation by staff ...3. Because of the risks and consequences, restraints are utilized only in those situations where it is required by medical necessity ...The least restrictive form of restraint will be utilized ...C ...3. Restraints are used only in clinically justified situations in which criteria have been met and less restrictive alternative measures have been judged ineffective. Staff is to use innovative and safe methods to avoid the use of restraints ...F. Discontinuation of Restraints: 1. The RN (Registered Nurse) assesses the patient to evaluate the patient's readiness for release based on the MD (Medical Doctor) order for criteria for release..."

Medical record review on 02/19/2014 of patient #1 revealed a 73 year old male admitted to the facility on 02/11/2014 with diagnosis of COPD (Chronic Obstructive Pulmonary Disease), Lung Cancer, Dementia and Hypertension. Review of the Physician's Order revealed an order for non-violent restraint on 02/18/2014 at 1641. Review of the order revealed "Non-Violent Restraint, interfering with medical care devices, soft, right arm and left arm. Release: no longer pulling tube/drains. Non-violent restraint order valid for episode..." Review of the RN Nursing documentation dated 02/18/2014 at 1640 revealed "Pt. (patient) pulling out medical devices ...taking off O2 (oxygen) which decreases Sat's (saturation)[oxygen measurements] to 70-80% (normal 95 - 100%), attempting to get out of bed without using call light, increased risk for falls and taking off medication patches. Increased confusion and Xanax (sedative) was given x 2 (two times)...". Review of the RN Nursing Restraint Monitoring Flow Sheet dated 02/18/2014 at 1700 revealed the application of soft wrist restraints to both wrists due to "agitation behavior, pulling at oxygen tubes and uncooperative..." Continued review of the restraint monitoring flow sheet assessment of the "patient's behavior while restrained" revealed on 02/18/2014 at 1850 "Impulsive, Restless". At 2100 "anxious, flat (affect), Impulsive". At 2305 "flat, restless". On 02/19/2014 at 0100 the patient behavior while restrained is documented "calm"; at 0300 "calm"; at 0500 "calm"; at 0700 "calm"; at 0900 "calm, cooperative"; at 1100 "appropriate, calm, cooperative". Continued review of the medical record revealed no documentation after 0100 that the patient was attempting to remove oxygen. Continued review of the restraint monitoring flow sheet revealed the restraints were discontinued on 02/19/2014 at 1127. (10 hours and 27 minutes after patient was no longer pulling at oxygen tube).

Interview on 02/19/2014 at 1300 with the Charge Nurse for patient #1 revealed "He (patient #1) was placed in restraints because he kept pulling off his oxygen and his saturations kept dropping to the 80's. According to the order we can remove restraints once the patient is no longer pulling off his oxygen. We removed his restraints at 1127 today (02/19/2014) because he had been calm through the night. According to the chart he'd been calm since 0100. Night shift reported he'd been calm and when I saw him this morning he was calm so I felt it safe to remove the restraints. The order says to remove the restraints once the patient is no longer pulling off his oxygen. According to the chart he was calm after 1 o'clock in the morning" Interview confirmed the nursing staff failed to remove the restraints at the earliest possible time.

Interview on 02/20/2014 at 0910 with the Nurse Manager revealed "Non-violent restraints are to be removed according to the physician's order. For this patient (#1) the restraints could be removed once he was no longer pulling his oxygen off. When I came to work yesterday morning the charge nurse told me (name of patient #1) was calm and she felt the restraints could be safely removed and we did that at 1127. According to the documentation he was calm on 02/19/2014 at 0100 and remained calm the rest of the night and morning. We probably should have removed the restraints no later than 0300 when it was identified that he had remained calm for two hours. He was calm for 10 hours so we should have removed the restraints earlier than we did." Interview confirmed the nursing staff failed to remove the restraints at the earliest possible time.

Based on policy and procedure review, open medical record review, and staff interviews the facility nursing staff failed to document turning every two hours for 1 of 3 patients at risk for skin breakdown (#13).

The findings include:

Review of the hospital's policy and procedure "Skin Breakdown Prevention Measure" effective date 05/29/2011 revealed "Policy Statement: 1. Patient's will be assessed for the risk of skin impairment on admission, every Monday and Thursday and prn (as needed) using the Braden Risk Assessment Tool. 2. Patients will be placed in groupings based on the Braden Risk Assessment score: a. Low risk (15-18); b. Moderate Risk (13-14); c. High Risk (12 and under) ...5. High-risk patients should have the same interventions as the Moderate Risk patient however; the high-risk patient should be turned and positioned every 1-2 hours unless mobile ..."

Medical record review on 02/19/2014 of patient #13 revealed a 70 year old male admitted on 02/05/2014 for J-tube (Jejunostomy) [feeding tube] replacement. Continued review revealed Patient #13 is a resident in a long term care facility. Continued review revealed the patient's medical history included multiple medical problems including strokes with dysphagia (difficulty swallowing), dementia, hypertension, COPD (chronic obstructive pulmonary disease), chronic respiratory failure, diabetes mellitus, and history of decubitus ulcers. Review of the Physician's Admission History and Physical dictated on 02/05/2014 revealed "...Musculoskeletal: Symmetric muscle wasting. There are contractures (shortened muscle lengthening preventing straightening of the arm) of the upper extremities noted ..." Review of the Nursing Braden Scale assessment revealed no documented Braden Score for 02/05/2014. Continued review of the Braden Scale Assessment dated 02/08/2014 revealed a score of "9" (High Risk) (3 days after admission). Continued review revealed a Braden Score of 12 (High Risk) on 02/12/2014. Review of the Wound Care Nurse's Progress Notes dated 02/10/2014 at 1242 revealed "Pt (patient) seen on 02/06/2014. Asked to see pt re (regarding) skin breakdown. (Name of patient #13) is a 70 y/o (year old) male adm (admitted on 02/05/2014 with nonfunctioning g (gastrostomy) & j (jejunostomy) tube. (Name of Long Term Care facility) resident with a pmh (past medical history) of chronic respiratory failure-trach (tracheostomy) [breathing tube in neck] on trach collar ...assessment revealed an alert aphasic male with right leg contracted ...pt adm with mult (multiple) ulcers to buttocks right buttock ulcer irregular in shape measuring approxi (approximately) 3.0 cm (centimeters) X 1.0 cm left buttocks ulcers measuring approx < (less than) 1.0 cm X 1.0 cm other turning surfaces and right heel intact..." Review of the Nursing Flow Sheet "Hourly Rounds - Turn" dated 02/13/2014 at 0600 revealed "repositioned to supine (back) position". Continued review revealed the next documented "turn" on 02/13/2014 at 0955 "Repositioned to left side" (3 hours [hrs] and 55 minutes [min] from last turn). Continued review of the documented patient turning revealed on 02/13/2014 at 1825 "repositioned to left side"; at 2000 "repositioned self". Continued review revealed the next documented "turn" on 02/14/2014 at 0840 "repositioned to head of bed" (12 hrs and 40 min from last documented turn). Continue review revealed on 02/17/2014 at 0247 "repositioned to left side". Continued review revealed the next documented turn at 0600 "repositioned to right side" (3 hrs and 2 min from last documented turn). Continued review of documentation on 02/17/2014 at 1142 revealed "repositioned to left side". Continued review revealed the next documented turn at 1920 "repositioned to right side" (7 hrs and 38 min from last documented turn). Continued review revealed a documented turn on 02/18/2014 at 0600 "repositioned to left side, repositioned to head of bed". Continued review revealed the next documented turn at 2027 "repositioned to left side" (14 hrs and 27 min from last turn).

Interview on 02/19/2014 at 1330 with the Charge Nurse revealed "(name of patient #13) presented with pressure ulcers. His Braden score is 12 which is High Risk for skin breakdown. He should be turned every 2 hrs. Yes the turning of the patient is to be documented. Some of the every 2 hour turns are not documented" Interview confirmed the facility nursing staff failed to document turning every two hours of a patient at high risk for skin breakdown.

Interview on 02/19/2014 at 1615 with the Primary RN (registered nurse) for Patient #13 revealed "I have cared for him (Pt #13) yesterday and today and on other previous admissions; he has a trach (tracheostomy), feeding tubes, and his arms are pretty contracted. He can use his right hand a little but the left hand is pretty contracted, he can't do his own care he is a total care patient. He's not able to turn himself, we must turn him. We have to do all of his turning and all of his mobility. Nursing staff does the every 2 hour turns he is not able to do that himself" Interview confirmed the facility nursing staff failed to document turning every two hours of a patient at high risk for skin breakdown.

Interview on 02/20/2014 at 0910 with the Nurse Manager revealed "This patient (#13) is high risk for skin break down and presented with pressure ulcers. He should be turned every two hours and it should be documented. I can see even though they are documenting positioned to head of bed that doesn't tell us if he was turned and they should be documenting their turning and positioning, whether it's right or left or supine." Interview confirmed the facility nursing staff failed to document turning every two hours of a patient at high risk for skin breakdown.

Based on current hospital policy review, observations during tour, and staff interviews the hospital's staff failed to develop and maintain the environment in a manner to assure the safety and well being of patients on the Behavioral Health Unit.

The findings include:
Review of current hospital policy "Environment of Care, Management of" Policy Number: CPH 430.33, revised 06/2013, revealed "...V. Policy Statement: A. It is the policy of....Hospital to provide an environment of care that ensures a safe, secure, accessible, effective, and efficient setting for patients, visitors and staff.... ...Focal areas include: * Control and reduction of environmental hazards and risks * Prevention of accidents and injuries * Maintenance of safe conditions of patients, visitors, and staff. 1. Management plans address utility systems, medical equipment, safety, security, control of hazardous materials and wastes, emergency preparedness, and life safety. ...2. General Identification ...11. Contraband Items a. Sharps or any items that could serve as a means of harming self or others are designated 'Contraband' including but are not limited to: ...2) Knives or other instruments that may be used as a knife (screwdrivers, ice picks, etc.). ...8) Glass items, except eyeglasses ...11) Metal cans and breakable hard plastic items ...19) Corded item of any kind, this includes....tape player, headset....other electrical equipment cord.... ...Hospital Provided Items with Staff Supervision ...2) Pen/pencil ...12. ...a. The Charge Nurse assigns nursing staff to make unit rounds in order to....ensure a safe environment. ...14. Unit Safety and Security ...d. Staff checks the unit at a minimum every shift....for safety hazards. This includes dayrooms, group rooms, patient rooms, and storage areas. Staff removes any identified contraband...f. Safety hazards are removed or noted for repair...."

Observations during tour on 02/19/2014 at 1415 of the hospital's Behavioral Health Unit "West" revealed the following:
1. Green vinyl chair with multiple tears/penetrations in cushion in common room.
2. Multiple interior wall surfaces with areas where wall paper seams have separated allowing exposed sheetrock (i.e. at exit door frame, at medication window, at patient room corridor near fire pull station, around/below common room windows).
3. Holes in walls allowing exposed sheetrock (i.e. under window in common room).
4. Unpainted sheetrock putty repair area on wall inside of enclosed nourishment/kitchen room adjacent to door.
5. Exposed electrical wires over door of room 221 (old call bell system, deactivated).
6. Hard plastic trash bin with large crack in side of bin, in common room.
7. Sharpened yellow No. 2 pencil lying on table in common room, unsupervised.
8. Hard plastic round clock with clear plastic face hanging on wall in common room, unsecured and removable from wall.
9. Built-in entertainment center in common room with multiple hard plastic video cassettes, stored unsecured on open shelves.
10. Video Cassette Recorder/Player with attached electrical cord, stored unsecured on open shelf of built-in entertainment center in common room.
11. Unsecured cabinets in common room containing various items (i.e. dominos and chess game pieces, board games, puzzles).
12. Multiple areas of ceiling with discolored "water mark/stains" (i.e. common room).

Interview during tour with Nursing Management staff revealed the Behavioral Health Units accept male and female patients from 18 years of age and older. Interview revealed patients are admitted involuntary (court ordered) or voluntary. Interview revealed the units accept patients who are suicidal or have aggressive/violent behaviors. Interview revealed the unit has "been taking more and more aggressive patients." Interview confirmed the above findings as potential safety and environmental hazards. Interview revealed the hospital does conduct environmental safety rounds. Interview revealed the Nursing Management staff was unaware if the above items observed had been identified as issues. Interview confirmed the hospital staff failed to develop and maintain the environment in a manner to assure the safety and well being of patients on the Behavioral Health Unit.

Based on current hospital policy review, observations during tours, Quality Control report review, Patient Testing report review, and staff interviews, the hospital's nursing staff failed to assure blood glucose monitoring instruments were maintained at an acceptable level of safety and quality by failing to ensure Quality Control (QC) solutions were not expired and bedside blood glucose monitoring tests were not performed on instruments that had QC checks performed with expired QC solutions on 1 of 3 inpatient nursing units toured.

The findings include:

Review of current policy "Blood Glucose Monitoring, Bedside" Policy Number: PC 210.148, revised 05/01/2013, revealed "I. PURPOSE ...To outline the policy and procedure for using the Nova Blood Glucose Monitoring Instrument. ...III. DEFINITIONS ...Quality Control - Process that checks an instrument or testing site to make sure it is reporting accurate results on patients. ...XIII. PROCEDURE ...C. Quality Control (QC) ...KEYPOINTS (page 5.) Check the expiration date on the control solution.... ...Solution vials are labeled with the expiration date when they are opened. The solution expires 90 days from when it is opened. ..."

Observations during tour on 02/19/2014 at 1415 of the hospital's Behavioral Health Unit "West" revealed one (1) Nova glucose monitoring instrument (#5132) used for bedside testing of patients' blood glucose levels. Observation within the instrument's storage case revealed two bottles of QC solution being stored. Observation of the Green Level 1 Low (Control Lot # 413095301) and Red Level 3 High (Control Lot #413116303) QC solution bottles revealed each bottle had a handwritten discard date of 02/15/2014 (4 days expired) written on the bottles' labels. Interview during tour with unit nursing staff revealed the blood glucose monitoring instrument was available for patient use. Interview revealed QC checks are performed every 24 hours, usually on night shift. Interview revealed QC checks are performed to ensure the accuracy of the test results and proper functioning of the instrument. Interview revealed the expiration (discard) date is written on the QC bottle's label when opened. Interview confirmed the QC bottle labels were dated 02/15/2014 (4 days expired). Interview revealed the staff member was unaware if the instrument had been used to test a patient's blood glucose level or if QC checks were performed using the expired QC solutions.

Review of a "Quality Control" report dated 02/19/2014 at 1519 (for Nova glucose monitoring instrument #5132) revealed a QC check was performed by nursing staff on the following dates/times after the QC solutions' discard date of 02/15/2014:
1. 02/16/2014 at 0222, Control Lot # 413095301 (Level 1 Low) [one day expired].
2. 02/16/2014 at 0223, Control Lot # 413116303 (Level 3 High) [one day expired].
3. 02/17/2014 at 0217, Control Lot # 413116303 (Level 3 High) [two days expired].
4. 02/17/2014 at 0218, Control Lot # 413095301 (Level 1 Low) [two days expired].
Review confirmed the nursing staff used expired QC solutions to perform four (4) separate QC checks (2 - Level 3 High and 2 - Level 1 Low). Further review of the QC report failed to reveal a QC check was performed on 02/18/2014, every 24 hours per policy.

Review of a "Patient Tests" report dated 02/19/2014 at 1517 (for Nova glucose monitoring instrument #5132) revealed a bedside blood glucose test was performed by nursing staff on one patient (Medical Record #467710) on the following dates/times after the QC solutions' discard date of 02/15/2014:
1. 02/16/2014 at 0619 (one day expired).
2. 02/16/2014 at 1110 (one day expired).
3. 02/16/2014 at 1637 (one day expired).
4. 02/17/2014 at 1147 (two days expired).
5. 02/17/2014 at 1633 (two days expired).
Review confirmed the nursing staff performed 5 separate bedside blood glucose monitoring tests using instrument #5132 after the instrument's QC solutions' discard date of 02/15/2014.

Further interview during tour on 02/19/2014 at 1530 with Nursing Management staff confirmed the QC solutions' labels for instrument #5132 had a handwritten discard date of 02/15/2014. Interview confirmed the QC solutions were expired. Interview confirmed the QC report revealed nursing staff had performed QC checks on the instrument using expired QC solutions. Interview confirmed the Patient Test report revealed nursing staff performed bedside blood glucose monitoring tests on a patient using an instrument in which the QC checks were performed with expired QC solutions. Interview confirmed the nursing staff failed to follow the hospital's policy.

Based on review of hospital policy and procedure, open medical record reviews, observations and staff interview, the hospital staff failed to follow their policy and procedure for 2 of 10 patients on isolation precautions (Patient #20 and #21).

The findings include:

Review of the hospital's "CONTACT PRECAUTIONS POLICY NUMBER IC- 2.18 LAST REVISION DATE: 11/22/11" revealed, "I. Purpose: To prevent the transmission of communicable diseases and/or microorganisms within the healthcare system among patients, healthcare personnel and visitors ...III. Policy Statement: Contact precautions are designed to reduce the risk of epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand to skin contact) or indirect contact (touching) with environmental surfaces or patient care items in the patient ' s environment ...Standard Precautions must also be used with all patients on Contact Precautions ...IV. Procedure: A ...Ensure that proper signage is displayed on the patient ' s door and a corresponding appropriately labeled yellow dot is visible on the spine of the patient ' s chart ...C. Gloves and Handwashing Wear gloves for all entry into the room. Hands should be cleaned with soap and water or by hand sanitizer prior to application of PPE (Personal Protective Equipment). Remove gloves before leaving the patient ' s environment and WASH HANDS IMMEDIATELY with an antimicrobial soap or a waterless alcohol based agent ...D. Gowns: Wear a gown for all entry into patient rooms ...L. Termination of Contact Precautions: Discontinue Contact Precautions after signs and symptoms of the infection have resolved or according to pathogen-specific recommendations. Removal of Contact Isolation requires a physician order..."

1. Observation on 02/19/2014 at 1500 revealed RN#2 entering Patient #20's room. Observation revealed a "contact precaution" sign on the door. Observation revealed RN#2 did not wash hands or don an isolation gown. Observation revealed the nurse touching items in the patient's room. Observation revealed the nurse did not perform hand hygiene upon exiting the room.

Review of the medical record of Patient #20 revealed a patient admitted to the hospital on 02/19/2014 for complaints of "RIGHT SIDE PAIN W/O (without) INJURY." Review of the record revealed, "Active: MRSA (METHICILLIN RESISTANT STAPH AUREUS) onset in 2009..."

Interview with RN #2 on 02/19/2014 at 1500 revealed the nurse discharging Patient #20 from the unit. Interview revealed, "The patient is being discharged. We do not have to wear gowns and gloves once the patient is discharged." Interview revealed RN #2 had "to look at my policy" in regards to hospital procedures when discharging isolation patients.

Interview with RN #3 on 02/19/2014 at 1515 revealed the primary nurse for Patient #20. Interview revealed, "I gown in and gown out with contact patients."

2. Observation on 02/20/2014 at 1330 revealed a nurse entering Patient #21's room. Observation revealed a "contact precaution" sign on the door. Observation revealed the nurse did not perform hand hygiene prior to donning gloves or an isolation gown. Observation revealed RN #1 did not perform hand hygiene prior to entrance or after exiting Patient #21's room. Observation revealed RN #1 did not don gloves or gown prior to entering Patient #21's room. Further observation revealed RN#1 returning (second) to Patient #21's room with sterile packaged gloves. Observation revealed RN#1 did not perform hand hygiene or don gloves prior to entering the room. Observation revealed RN #1 did not perform hand hygiene after exiting the room. Observation revealed RN #1 entering the room adjacent to Patient #21 and RN#1 did not perform hand hygiene prior to entry. Observation revealed the room adjacent to Patient #21 did not have a "contact precaution" sign on the door.

Review of the medical record of Patient #21 revealed a patient admitted to the hospital on 02/20/2014 for complaints of "GROIN PAIN." Review of the record revealed, "Active: VRE (VANCOMYCIN RESISTANT ENTEROCCOCUS) onset in 2013...E. coli: (ESCHERICHIA) onset in 2012. MRSA onset in 2006... "

Interview with nurse manager #1 on 02/19/2014 at 1510 revealed, "It is the expectation of all staff to gown and glove with all contact patients." Further interview on 02/20/2014 at 1400 revealed, "I just reeducated the staff on contact precautions during pre-shift and the charge nurse meeting."