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Based on staff interviews, a review of facility documents and clinical records, it was determined the facility's nursing staff failed to ensure restraints were used in accordance with the order of a LIP (Licensed Independent Practitioner) for two (2) of five (5) patients sampled for a review of restraint use (Patient #4 and #5).

The findings were:

The surveyor reviewed the facility's "Restraint and Seclusion of Patients" Policy (Policy No. 0159). The policy read in part:
At item #3 "Initiation" under section a. "Restraints or seclusion will be initiated upon the order of the licensed independent practitioner (LIP)"...who is responsible for the ongoing care of the patient..."
At item #4 "Restraint Orders" under section d. "Non-Violent restraint orders..., and a new order must be entered each calendar day."

The review of Patient #4's closed clinical record provided evidence the patient was admitted on 01/25/19 after a suicide attempt. The record contained non-violent restraint orders dated 01/25/19 at 8:09 p.m., for "Limb" restraints to both upper extremities. The next restraint order was not given until 01/27/19 at 3:47 a.m. The record failed to contain evidence that a new order was given by a LIP for the calendar day of 01/26/19.

The review of Patient #5's closed clinical record provided evidence the patient was admitted on 01/12/19 to the Neurological Intermediate Care Unit. The record contained a "Violent Adult" restraint order dated 01/15/19 at 4:38 a.m., for restraints of "Four side rails; RUE [right upper extremity], LUE [left upper extremity], RLE [right lower extremity]. The next restraint order (dated 01/15/19 at 8:29 a.m.) was for non-violent restraints and it no longer included orders for the use of the four side rails. That same order was for "Limb" restraints only and were for the RUE [right upper extremity], LUE [left upper extremity], RLE [right lower extremity]. The record contained a "non-violent" restraint order dated 01/15/19 at 5:07 p.m., for the continuation of the "Limb" restraints to RUE [right upper extremity], LUE [left upper extremity], RLE [right lower extremity], but again did not include orders for the four side rails.

The care flowsheets contained entries by the RN dated 01/15/19 at 10:01 a.m. which documented the change in restraints (per the physician's order) and the removal of the "Four side rails" as part of the restraints in use. However, beginning at 12 noon on 01/15/19 and continuing through the time the restraints were discontinued (01/16/19 at 7:59 a.m.), the Registered Nurses hourly restraint monitoring documentation included the use of "Four side rails" as well as the "Soft cloth restraint" to the RUE, LUE, and RLE. The record failed to contain an order from a LIP for the use of the four side rails as restraints during the aforementioned time frame of 01/15/19 at noon to 01/16/19 at 7:59 a.m.

The surveyor discussed concerns regarding restraints, which were identified during the record reviews, with the Assistant Nurse Manager of the MICU, the Director of Accreditation, and the Coordinator of Accreditation, on 02/15/19 at 11:00 a.m. That discussion included the concern regarding restraints of four side rails documented in use after the physician had discontinued them, and the failure to give a new order each calendar day for non-violent restraints. The surveyor requested the leadership team make any additional evidence they may have, available for the surveyor to review.

The surveyor met with the Director of Accreditation and the Coordinator of Accreditation, again on 02/19/19 at 2:15 p.m., for a follow up discussion of the aforementioned concerns regarding restraints. Both the Director of Accreditation and the Coordinator of Accreditation acknowledged the surveyor's comments/findings. Though additional evidence was provided during the discussion to clarify other previously discussed concerns, there was no additional evidence provided related to this finding.

Based on a review of clinical records, facility documents, and staff interviews, it was determined that for one (1) of three (3) patients sampled for review of restraint use for management of violent behavior (Patient #6), the facility's staff failed to ensure the patient was seen face-to-face by the LIP (Licensed Independent Practitioner) within 1 hour after the initiation of the intervention.

The findings were:

The review of Patient #6's clinical record took place on 2/14/19 at 4:00 p.m., with SM (Staff Member) #12, who is the Assistant Nurse Manager of the MICU (Medical Intensive Care Unit), serving as navigator of the EHR (electronic health record). The record review provided evidence the patient was seen in the ED (Emergency Department), having arrived at 9:19 p.m. on 01/16/19, and was later admitted as an inpatient. The patient's clinical record documentation for the ED visit included in part, the following evidence:
- There were no ED physician progress notes found in the record by the surveyor or the navigator,
- A consultation note documented a psychiatric evaluation and assessment performed by the psychiatric physician on 01/16/19 at 10:31 p.m. That documentation provided evidence the patient was in the ED under an ECO (emergency custody order), was in handcuffs, and presented to the ED after the parent obtained the ECO for evaluation of SI (suicidal ideations). The physician documented the plan was for TDO and psychiatric inpatient admission after "labs are cleared in the ED.
- The ED RN documented on the care flowsheet dated 01/17/19 at 12:45 a.m., that restraints for the management of violent behavior were applied to both ankles, and at 1:30 a.m. documented the "handcuffs' were removed so the facility's restraints were placed on both wrists at that time as well.
- The first order for restraints was entered by the ED physician dated 01/17/19 at 1:43 a.m., and was for "Violent or self destructive behavior jeopardizing the immediate physical safety of staff" and ordered "Limb" restraints to all four (4) extremities.
- The ED care flowsheet provided evidence that restraints for the management of violent behavior were put in place from 12:45 a.m. (after the patient was seen by the psychiatric physician) and continued to 3:40 a.m., when the patient became cooperative and with "security at bedside" the restraints were discontinued.
- The record failed to provide evidence the patient was seen face-to-face by a LIP (Licensed Independent Practitioner) within 1 hour after the initiation of the restraint intervention. The next physician or LIP progress note found in the EHR, by both the surveyor and the navigator, was dated 01/18/19 at 7:54 a.m.

The surveyor reviewed the facility's "Restraint and Seclusion of Patients" Policy (Policy No. 0159). The policy read in part, as follows:
At item #4 "Restraint Orders" and on page 5, the policy read in part as follows: "Violent and/or Self-Destructive restraint orders shall require a face-to-face evaluation of the patient by the LIP responsible for the care of the patient. The LIP shall perform and document a face-to-face evaluation of the patient's physical and psychological status within one hour of the initiation of the restraint.

The surveyor discussed concerns regarding restraints, which were identified during the record reviews, with the Assistant Nurse Manager of the MICU, the Director of Accreditation, and the Coordinator of Accreditation, on 02/15/19 at 11:00 a.m. The surveyor requested the leadership team make any additional evidence they may have available for the surveyor to review.

The surveyor met with the Director of Accreditation and the Coordinator of Accreditation, again on 02/19/19 at 2:15 p.m., for a follow up discussion of concerns regarding restraints identified during the record reviews. The surveyor discussed the failure to ensure the face-to-face evaluation was completed as required for one patient. Both the Director of Accreditation and the Coordinator of Accreditation acknowledged the surveyor's comments/findings. Though additional evidence was provided during the discussion to clarify other previously discussed concerns, there was no additional evidence provided related to this finding.

Based on observations, interviews and document review, it was determined that hospital staff failed to follow infection control guidelines for the use of appropriate personal protective equipment (PPE) during a surgical procedure.

The findings include:

On 2/14/2019 at 10:45 a.m., the surveyor had an opportunity to tour the hospital operating room (OR) suites. Arriving at OR #4 the surveyor looked through the window in the OR door and noted
Staff Member (SM) #16 (later determined to be a resident in anesthesia) wearing a cloth cap that failed to cover his/her hair completely. SM #16 also had facial hair that was not covered. SM #16 left the room to transport the patient to the recovery area.

Upon his/her returned to the OR, the surveyor discussed with SM #16 the failure to completely cover his/her hair. SM #16 confirmed the hair should have been completely covered and he/she should have covered his/her facial hair as well.

Facility policy "Surgical/Procedural Attire" reads in part as follows: "Proper attire in the semi-restricted and restricted areas shall include: A. Disposable surgical caps. Cloth hats may be worn, if covered by a disposable cap when in the semi-restricted or restricted areas. a. Caps must cover all hair. b. Disposable hoods or beard covers must be worn by staff with facial hair."

The above findings were shared with management team at the end of day meeting on 2/19/2019. No further information was provided to the survey team.

Based on interviews and the review of documents, it was determined the facility's staff failed to ensure written guidance for the monitoring of post-operative TCV-ICU patients were in agreement with provider's expectations. (The TCV-ICU is the Thoracic-Cardiovascular Unit that provides the post-operative care for thoracic-cardiovascular surgery patients.)

The findings included:

Staff Member (SM) #11 (a nurse manager) was interviewed on the afternoon of 2/13/19. SM #11 was asked about the frequency of neurological (neuro) assessments for patients admitted to TCV-ICU. SM #11 initially reported that neuro-assessments were expected hourly for the first four (4) hours then every four (4) thereafter. During a later interview on the afternoon of 2/14/19, SM #11 reported to the survey team that written facility process/guidance does not require hourly neuro-assessments.

During an interview on the morning of 2/14/19, SM #26 (an assistant nurse manager) was asked about neuro-assessments for patients coming to the TCV-ICU immediately post coronary artery bypass grafting (CABG) procedure/surgery. SM #2 reported neuro-assessments would be completed hourly until the patient was fully awake.

Patient #1's clinical documentation was reviewed on 2/13/19 - 2/15/19. Documentation indicated Patient #1 was admitted to the TCV-ICU at approximately 12:48 p.m. The following neuro-assessments were documented by nursing staff:
- Patient #1's first neuro-assessment by nursing, after admission to the TCV-ICU, was documented for 1:00 p.m. This assessment indicated the patient's pupils were 2mm bilateral and sluggish. This assessment also noted no movement to painful stimulus for all four extremities.
- Patient #1 next neuro-assessment was documented for 4:00 p.m. This assessment indicated the patient's pupils were 2mm bilateral and sluggish. Movement of the patient's extremities were not documented as part of this assessment.
- Patient #1 had a neuro-assessment documented for 6:00 p.m. This assessment did not address the patient's pupils. This assessment indicated purposeful movement for both right side extremities but no movement to painful stimulus for both left side extremities.
- Patient #1 had a neuro-assessment documented for 7:15 p.m. This assessment indicated the patient's left pupil was 3mm, the right pupil was 2mm, and both pupils were sluggish. This assessment indicated purposeful movement for both right side extremities; the left upper extremity had both purposeful movement and no movement to painful stimulus documented; and the left lower extremity had no movement to painful stimuli documented.

The following documentation was entered by a nurse practitioner at 9:43 p.m.: "At approximately 1925 (7:25 p.m.) I entered (patient's name omitted) room to perform a shift assessment. Upon arrival I greeted and updated (the patient's spouse). (The spouse) expressed concern to me that (the patient) was 'not moving his left arm.' I immediately performed a neuro assessment and noted (the patient) followed commands consistently to the RUE (right upper extremity) and RLE (right lower extremity) but could not complete the same tasks on the left ... Priority 1 head CT was ordered and stroke alert ... placed (at) 1932 (7:32 p.m.). Head CT performed with resulting right MCA thrombus. (The patient) was transported to (another unit) for thrombectomy."

On the afternoon of 2/14/19, SM #11 (a nurse manager) was interviewed about expectation of care related to Patient #1. SM #11 stated he/she would do neuro-checks every hour, at a minimum a pupil check. SM #11 reported that a requirement for hourly neuro-checks is not written in facility guidance for staff. SM #11 reported the body assessments ordered for every four hours would include a neuro-assessment.

During an interview on the morning of 2/15/19, a physician (SM #21) was asked about the care of patients admitted to the TCV-ICU. SM #21 reported he/she would expect hourly neuro-assessment but acknowledge the assessments might not be consistently documented every hour. SM #21 reported a neuro-assessment would include assessment of the patient's pupils, ability to follow commands, and/or response to painful stimuli.

During an interview on the afternoon of 2/19/19, a physician (SM #33) was asked about the care of patients admitted to the TCV-ICU. SM #33 reported he/she did not know what the facility's written guidance was but for post-operative patients that he/she would expect routine neuro-checks.

On 02/14/19 and 02/15/19, a surveyor reviewed Patient #8's electronic medical record with two navigators (staff member - SM #26 and SM #23). This patient underwent coronary artery bypass surgery and moved to the facility's thoracic cardio vascular intensive care unit (TCV-ICU) post-operatively. Following changes in the patient's neurological assessment, the TCV-ICU's nurse practitioner (NP) wrote an order for a neurological consult, called a Stroke Alert, and the patient subsequently had a head CT scan (Computed tomography - an X-ray image). The CT showed multiple new infarcts with no acute intracranial hemorrhage. The neurological consult team's note, written after the head CT, recommended neuro checks in the TCV-ICU every hour overnight however, that recommendation did not become an order. Nurses documented neuro checks every four (4) hours following the CVA overnight and beyond. The TCV-ICU's Co-Director, a physician (SM #33), and one of the TCV-ICU's nurse practitioners (NP-SM #15) were interviewed on 2/21/19 at 10:30 a.m. The physician stated the TCV-ICU team does review the consultation notes and written orders reflecting the consult's recommendations however regarding neuro checks specifically, the expectation was neuro checks every one (1) hour whether written as a consult recommendation or not. The physician did not have an explanation why nurses documented neuro checks every four (4) hours instead of the expected every hour. The doctor stated that since nurses had one patient, they were in the room assessing patients' conditions continuously and there was no practical way to document everything they did however; he/she acknowledged there was a discrepancy between what was expected (hourly neuro checks) and what was documented (neuro checks every four hours). The NP stated neuro checks every hour would not necessarily need to be written as an order since that was expected. The NP also said he/she would be at the bedside with the registered nurse for a patient who had had a stroke and they assessed the patient constantly. The NP did not have an explanation why nurses documented neuro checks every four hours. Both the physician and NP stated verbal communication between the TCV-ICU team and any consult team was a more efficient method of communicating than a note written within the electronic medical record, especially for emergent recommendations.

The following facility documents were provided to the survey team: (1) Clinical Pathway: Cardiac Enhanced Recovery After Surgery (ERAS), (2) TCV Cardiac Surgery Patient Pathway, and (3) Standard Work for Inpatient Shift Documentation for Registered Nurses. No evidence was found by or provided to the surveyor to indicate the facility guidance/procedure required hourly neurological assessments for post-operative/recovery TCV-ICU patients.

The failure of the facility's documents guiding post-operative care for TCV-ICU patients to match the expectations of the medical providers was discussed during a survey team meeting with SM #8 (an accreditation employee) on the afternoon of 2/19/19.