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Based on observation, interview, and record review, the hospital failed to update the nursing plan of care for one of 19 sampled patients (Patient 6) when Patient 6 was physically restrained, both wrists and hands, and the nursing plan of care did not reflect this. This failure had the potential to result in patient injury and the use of unnecessary restraints.

Findings:

On 8/11/14 at 12:04 pm, Patient 6 was observed in the intensive care unit (ICU). Patient 6 was intubated (a plastic tube passed through the mouth or nose into the windpipe to assist with breathing for the patient), had multiple intravenous (IVs) lines for medications and fluids, a urinary catheter (a flexible tube inserted into the bladder to drain urine), two large abdominal dressings which covered surgical incisions, three tubes coming from the incisions to drain fluid from the previous surgical sites and a nasal gastric tube (a plastic tube inserted into the nose into the stomach).

Patient 6's record was reviewed on 8/11/14. Patient 6 was admitted to the hospital on 8/5/14, and underwent extensive abdominal surgery to remove cancer of the pancreas (an organ in the abdomen). On 8/9/14, Patient 6 required a repeat surgery. The record revealed Patient 6 continued to be intubated after the second surgery, was restless, and attempted to pull at the tubes connected to her body.

On 8/9/14, the physician ordered restraints for Patient 6's hands and wrists. The order instructed soft wrist restraints and hand mitts to be released every two hours. The record indicated the restraints were applied to prevent Patient 6 from pulling at the tubes, IVs and dressings necessary to support her condition. Patient 6's pain medication was also increased to manage her pain, provide sedation, and decrease her restlessness.

On 8/11/14 at 12:10 pm, Registered Nurse E stated Patient 6 was restrained because she would become very restless and confused, and pull at her tubes, IVs and dressings.

On 8/11/14 at 2:27 pm, Patient 6's record was reviewed concurrently with Administrative (Admin) Nurse C. Patient 6's plan of care did not reflect that Patient 6 required both wrists and hands to be restrained, the goal in the use of the restraints, or a plan when restraint reduction could be initiated. Admin Nurse C acknowledged the above finding and stated the nurses' plan of care was based on the patient's assessment which was performed multiple times daily by the nurse. She stated the nurses' plan of care was the tool the nurses used to document patient care, and Patient 6's plan of care needed to be updated.

A hospital policy, dated 8/2013, titled, Use of Restraints, instructed on page four, "Any changes in the patient's behavior or clinical condition are documented. Potential for physical injury is initiated on the Multidisciplinary Plan of Care and updated at least every 24 hours on all restrained patients. Patient/family teaching is documented ... "

A 12 page undated document titled, "Intensive Care Unit Patient Documentation Guidelines (Adult)" instructed, the "Interdisciplinary Plan of Care is reviewed every shift: Update and individualized daily. All restraint patients MUST have a plan of care."

Based on observation, interview and document review, the hospital failed to conduct active surveillance and obtain infection control data for all areas of the facility. This had the potential to result in an ineffective infection control program and expose patients to infectious organisms.

Findings:

1. During an interview with Infection Control Practitioner (ICP) and ICPB on 8/13/2014 at 10:00 a.m., both confirmed consistent formal or informal documentation (rounding tools, surveillance tracking tools) of infection control surveillance were not available. Both ICP and ICPB acknowledged that Central Supply does not supply information to the ICP nor does the ICP conduct active surveillance in that area.

During an interview on 8/13/2014 at 2:10 p.m., Infection Control Medical Doctor (ICMD) and ICP, specified that the facility policy required regular environmental surveillance rounds to all areas by ICP.

2. On 8/13/2014 at 3 pm, a record review of Infection Control policies and procedures indicated that three out of four polices did not have signature approvals and four out of four were missing the reference to the national recognized standard relied on when developing the policy and procedure.

In an interview on 8/13/2014 at 11 am, ICP verified, per facility policy, that policy and procedures are to be reviewed and updated every two years by the appropriate committees. Some policy and procedures had not been reviewed since 2011.