HospitalInspections.org

Based on observation, interview and policy review the facility failed to document clinical justification and/or a physician order for the use of four side rails on patient beds (A161); and failed to ensure a physician order was obtained for the implementation of non-violent restraints (A168). The facility's active census was 561.

Based on observation, record review, interview and policy review, the facility failed to document clinical justification and/or a physician order for the use of all four side rails on patient beds. This affected two (Patients #8 and #9) of ten medical records reviewed. The facility census was 561.

Findings include:

1. Review of the medical record for Patient #8 revealed an admit date of 03/18/22 with a diagnoses including blindness to the right eye, pnuemothorax, and pleural effusion. Review of the physician documentation upon admission documented Patient #8 was alert and oriented and able to hold a conversation. The patient was admitted to the advanced pulmonary care unit for further evaluation/work up.

Review of the nursing flow sheets revealed Patient#8's bed had all four side rails up from 03/18/22 through 03/24/22 and on 03/30/22. The patient required minimal assistance and used the bedside commode for bowel elimination.

During tour of the advanced pulmonary care unit on 03/30/22 at 3:15 PM revealed all four rails on Patient #8's bed were up, restricting the patient from independently moving from the bed.

Review of the medical record revealed the side rails were documented by staff during safety rounds however lacked documented evidence of a physician order and/ or clinical justification for all four side rails to be raised.

2. Review of the medical record for Patient #9 revealed an admit date of 03/20/22 with a diagnosis of angioedema with anaphylaxis. The patient's airway was compromised due to swelling requiring mechanical ventilation. The patient was stabilized in the emergency department and transferred to the intensive care unit for continued monitoring.

Review of the physician documentation revealed Patient #9 was successfully extubated on 03/20/22 and the patient did not require further oxygenation. On 03/21/22 the physician documented the patient was thermodynamically stable for transfer out of the intensive care unit and was moved to the advanced pulmonary care unit. The patient was alert, holding conversations with the physician regarding what lead up to the anaphylaxis, up in the chair eating, and all extremities spontaneous and without deficit.

Review of the nursing flow sheets revealed all four side rails up from 03/24/22 through 03/30/22. The patient required minimal assistance and able to turn and position independently.

During tour of the advanced pulmonary unit on 03/30/22 at 3:15 PM, all four rails on Patient #9's bed were up, restricting the patient from independently moving from the bed.

Review of the medical record revealed the side rails were documented by staff during safety rounds however lacked documented evidence of a physician order and/ or clinical justification for all four side rails to be raised.

During interview on 03/31/22 at 2:48 PM, Staff S stated all four side rails may be used due to safety and not considered a restraint. The staff should document a rationale if and when the side rails are being used as a restraint.

Review of the facility policy titled "Premier Nursing Services Non-Violent Restraint", dated 04/19/19, stated the policy objective is established to ensure a high level of patient safety while preserving patient's dignity, rights, and well being. A restraint is defined as 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; or reduces the ability to have normal access to his or her body, or does not promote the patient's independent function. A side rail is considered a restraint only if the intent is to prevent the patient from voluntarily getting out of bed or attempting to exit the bed. A side rail is not considered a restraint if the intent is to prevent the patient from falling out of bed. If the patient does not have the capacity to get out of bed regardless of if the side rails are raised or not, then the use of side rails is not considered a restraint.

Based on record review, interview and policy review, the facility failed to ensure a physician order was obtained for the implementation of non-violent restraints. This affected two (Patients #4 and #6) of ten medical records reviewed. The facility census was 561.

Findings include:

1. Review of the medical record of Patient #6, recently diagnosed with COVID-19, revealed the patient presented to the Emergency Department on 08/31/21 at 9:34 PM with complaints of shortness of breath, weakness with ambulation, nausea, vomiting, fever, and cough. The patient was admitted to the facility for treatment.

The patient's oxygen demand continued to increase and on 09/05/21, the decision was made to intubate the patient and place on a ventilator. The flow sheet documented bilateral soft restraints were applied on 09/11/21 at 8:00 PM. The medical record lacked documentation of a physician order for the restraints.

During interview on 04/01/22 at 2:50 PM, Staff A and Staff S confirmed that the medical record lacked documentation of a physician's order for non-violent restraints as required by facility policy.


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2. Review of the medical record for Patient #4 revealed a admit date on 12/08/21 for pneumonia secondary to the Covid-19 virus. The nursing flow sheets documented Patient #4 was placed in non-violent bilateral soft wrist restraints on 12/08/21 at 3:25 PM for pulling of the lines and tubes. The restraints were removed on 12/09/21 at 8:00 AM and restarted on 12/09/21 at 8:00 PM with no evidence of a new physician order.

Review of the nursing flow sheets documented the patient was in non-violent bilateral soft wrist restraints on 12/13/21, 01/04/22, 01/09/22, and 01/10/22 for the pulling of lines and tubes. There was no evidence of a physician order on these dates.

During interview on 03/30/22 at 12:49 PM, Staff I confirmed there was no physician order for restraints on these dates.

The facility policy titled "Non-violent Restraints", effective 04/19/19, documented a non-violent/non self destructive restraint is utilized to protect the patient who demonstrates impaired safety judgement. A verbal order or electronic order is required from a qualified LIP or LIP's designee who is primarily responsible for the patient's care at the time or immediately (within a few minutes) after the restraint is applied. Authentication of a telephone/verbal order based on examination of the patient by a qualified LIP to be in EPIC within 24 hours of initiation. If a patients restraint is removed for any other reason than providing direct patient care a new order is required to apply restraints.

Based on record review, interview and policy review, the facility failed to ensure residents were repositioned, failed to ensure external catheters were assessed and failed to perform hourly rounding to offer toileting (A398). The facility's active census was 561.

Based on record review, interview and policy review, the facility failed to ensure patients were reposition, external catheters were assessed and that hourly rounding was performed to offer toileting. This affected one (Patient #6) of ten medical records reviewed.

Findings include:

Review of the medical record of Patient #6, previously diagnosed with COVID-19, revealed the patient presented to the Emergency Department on 08/31/21 at 9:34 PM with complaints of shortness of breath, weakness with ambulation, nausea, vomiting, fever, and cough.. The patient's oxygen demand continued to increase and on 09/05/21, the decision was made to intubate the patient and place on a ventilator. On 10/15/21, Patient #6 was transferred to the advanced pulmonary care unit where she remained until discharge on 10/28/21 at 11:02 AM.

Review of the nursing flow sheet revealed on 10/15/21 at 6:35 PM, Patient #6 was turned on her back. At 8:07 PM, the patient remained on her back.

On 10/16/21 at 12:31 AM the patient was turned to her left side. At 4:04 AM, the patient was turned to her back. At 9:00 AM, the patient was turned to her left side. At 12:00 PM and again at 2:00 PM, the patient was log rolled. At 4:00 PM, 6:00 PM, 9:22 PM, and 10:39 PM, the patient remained on her back.

On 10/17/21 at 12:00 AM, the patient remained on her back. At 12:15 AM, the patient was turned to her right side. At 5:36 AM, the patient was turned on her back. The patient remained on her back at 8:00 AM. At 10:00 AM, the patient was turned to her left side. At 8:34 PM, the patient was turned on her back.

On 10/18/21 at 6:17 AM, the patient was turned to her back. She remained on her back at 8:00 AM, 9:59 AM, 12:00 PM, and 2:00 PM. At 11:00 PM, the flow sheet documented the linen on the patient's bed was changed, the patient remained on her back.

On 10/19/21 at 9:30 AM, the patient was turned to her left side. The flow sheet documented the patient was positioned on her back from 2:00 PM to 12:30 AM.

On 10/20/21 at 12:30 AM the patient's position was changed to her right side. From 6:00 AM to 3:14 PM, the patient remained positioned on her back.

On 10/21/21 at 8:04 PM the patient was positioned from her right side to her back. According to the nursing flow sheet, the patient remained on her back until 10/22/21 at 9:33 AM.

On 10/23/21 at 6:35 AM, the patient remained positioned on her back until 1:27 PM.

During interview on 04/01/22 at 11:59 AM, Staff A and Staff S confirmed that the medical record lacked documentation the patient was turned every two hours as required by facility policy.

Review of the facility policy titled "Guidelines for Advanced Care Units", revealed staff members are instructed to perform the following tasks every 2 hours:

* Reposition patient with Braden score 18 or less, unless contraindicated by condition or the patient is independent with repositioning.
* Restraint documentation
* Vital signs and record
* Oral care for ventilated, trach, and NPO patients


2. Review of the medical record of Patient #6 revealed she was continent of urine when she presented to the Emergency Department on 08/31/21. Patient #6 was incontinent on 09/03/21 at 3:56 AM after the patient's oxygen demands continued to increase. A Purewick external female catheter was in place on 09/03/21 at 11:00 AM. Although the medical record lacked documentation of a specific reason the Purewick was removed, an indwelling urinary catheter was placed on 09/05/21 at 12:00 PM, when Patient #6 was intubated.

On 10/11/21 at 5:00 P.M., it was documented a Purewick external catheter was again placed. The medical record lacked documentation of an assessment of the external female catheter until 10/15/21 at 8:00 AM.

On 10/15/21 at 2:00 P.M., the nursing flow sheet documented the Purewick external catheter was changed on , four days after it's placement. The external catheter was leaking during an assessment at 8:00 PM.

On 10/16/21 at 4:01 P.M., it was still leaking. The external catheter was removed on 10/17/21 at 3:39 AM.

During interview on 04/01/22 at 11:59 AM, Staff A confirmed that the medical record lacked documentation of an assessment every two hours as indicated in the product's instructions for use and confirmed that the medical record lacked documentation the external catheter was replaced for four days.

The Purewick female external catheter instructions for use documented the catheter is intended for non-invasive urine output management. The instructions for use advise staff to assess device placement and patient's skin at least every two hours. Staff members are further advised to replace the Purewick female external catheter every 8-12 hours or when soiled with feces or blood.

3. Review of the medical record of Patient #6 revealed the nursing flow sheet documented toileting was offered to Patient #6 as she was incontinent of urine and stool.

On 10/15/21 at 6:35 PM the space for whether toileting was offered was blank.

On 10/17/21 from 1:52 PM to 9:22 PM, there was no evidence toileting was offered.

From 10/22/21 at 9:33 AM to 10/23/21 at 7:34 PM, the nursing flow sheet was blank in the space for whether toileting was offered.

From 10/26/21 at 10:30 AM to 8:04 PM the space was again blank for whether toileting was offered.

During interview on 04/01/22 at 11:59 A.M., Staff A and Staff S confirmed that the medical record lacked documentation toileting was offered.

The facility policy titled "Guidelines for Advanced Care Units" revealed staff members are instructed to perform hourly rounding and offer toileting.

Based on review of QSO memo 22-09-ALL, Attachment D, review of each staff member's vaccination status, review of facility COVID-19 vaccination policy, and staff interview, the facility failed to ensure 100 percent of staff were fully vaccinated or had been granted a medical or religious exemption; and failed to ensure a contingency plan and/or procedures were in place for unvaccinated staff (A792). The facility's active census was 561.

Based on review of QSO memo 22-09-ALL, Attachment D, review of the facility COVID-19 vaccination policy, review of each staff member's vaccination status, and staff interview, the facility failed to ensure a contingency plan and/or procedures were in place for unvaccinated staff, and failed to ensure 100 percent of staff were fully vaccinated or had a qualifying exemption or were identified as having a temporary delay. The facility's percentage of vaccinated staff for COVID-19 was 96.4 percent. This affected 199 of 5,574 staff members. The active census was 561.

Findings include:

Review of facility staff member's vaccination status revealed out of 5,574 staff members, 199 staff members who had direct patient contact were not vaccinated, did not have a religious or medical exemption or were identified as having a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC).

Review of the hospital policy titled "Premier COVID 19 Vaccination Policy", effective 02/14/22, revealed it's purpose is to improve patient and employee safety by preventing the transmission of the COVID-19 virus through required COVID-19 vaccination. The policy requires that all health personnel are fully vaccinated for COVID-19 or have been granted a religious or medical exemption as a condition of both initial and continued employment. The policy requires personnel to complete their primary vaccine series by 03/15/22. The policy failed to include a contingency plan and/or procedures for unvaccinated staff with direct patient care to prevent the spread of COVID-19

During interview on 03/31/22 at 10:45 A.M., Staff A, Staff G, Staff H, Staff M, Staff N, and Staff O confirmed that the facility is non-compliant under this rule as less than 100 percent of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple vaccine series, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the CDC. It was also confirmed the hospital's vaccination policy did not include a contingency plan and/or procedures for unvaccinated staff with direct patient care.