HospitalInspections.org

Based on document review and interview it was determined for 1 of 3 (Pt. #26) patients in restraints, the Hospital failed to ensure non violent restraint orders were renewed every calendar day as per policy.

Findings include:

1. The Hospital policy titled, "Restraints and Seclusion (8/2/16)" was reviewed on 11/2/16. The policy required, "Obtain physician medical restraint order ... Duration of restraint use (maximum of one calendar day). Another order needs to be obtained prior to end of each calendar day".

2. The clinical record of Pt. #26 was reviewed on 11/2/16. Pt. #26 was a 75 year old male admitted on 10/24/16 with the diagnosis of altered mental status. The clinical record included physician orders for restraints dated 10/24/16 at 7:06 PM, 10/26/16 at 11:10 AM and a discontinuation order on 10/27/16 at 10:25 AM. The clinical record lacked documentation of an order on 10/25/16. Pt. #26 remained in restraints from 10/24/16 through 10/27/16 per the restraint flow sheet.

3. During an interview on 11/3/16 at approximately 10:00 AM, the Clinical Director of Critical Care (E#11) stated, "The computer triggers a reminder to renew the order after 24 hours. In this case the order was not written on 10/25/16".

Based on document review and interview, it was determined for 2 of 3 (Pt. # 25 and Pt. #26) patients in restraints, the Hospital failed to ensure patients were monitored every 2 hours while in restraints as per policy.

Findings include:

1. The Hospital policy titled, "Restraints and Seclusion (8/2/16)" was reviewed on 11/2/16. The policy required, "Frequency of monitoring and assessing may be changed based upon patient need, but occurs at a minimum of every two hours using EMR (electronic medical record) Non Violent or Non Self Destructive Behavior restraint flow sheet".

2. The clinical record of Pt. #25 was reviewed on 11/2/16. Pt. #25 was a 68 year old male admitted on 10/26/16 with the diagnosis of alcohol abuse. The clinical record included physician orders for bilateral wrist restraints from 10/27/16 at 7:54 PM to 10/29/16 at 7:15 PM. The restraint flow sheets lacked documentation of monitoring on 10/28/16 from 2:00 PM - 8:00 PM (4:00 PM and 6:00 PM missing) and 10/29/16 from 12:00 PM - 4:00 PM (2:00 PM missing).

3. The clinical record of Pt. #26 was reviewed on 11/2/16. Pt. #26 was a 75 year old male admitted on 10/24/16 with the diagnosis of altered mental status. The clinical record included physician orders for bilateral wrist restraints from 10/24/16 at 7:06 PM to 10/27/16 at 10:25 AM. The restraint flow sheets lacked documentation of monitoring on 10/26/16 from 12:00 PM - 4:00 PM (2:00 PM missing).

4. During an interview on 11/3/16 at approximately 10:00 AM, the Clinical Director of Critical Care (E#11) stated, "The nursing staff is responsible for documenting the assessments. Some of the assessments are missing in these records".

Based on document review and interview, it was determined the Hospital failed to ensure the medical records were completed as required by the Medical Staff Rules and Regulations.

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (approved 01/24/14) were reviewed on 11/02/16 and required, "... Completion of Medical Records... e. The patient's medical record shall be complete, including all signatures, within twenty-one (21) days of discharge..."

2. On 11/03/16, the Manager of Clinical Documentation (E #9) provided a letter of attestation which included, "As of November 2, 2016, there are 233 delinquent records."

3. On 11/2/16 at approximately 2:00 PM, E # 9 stated that the medical record should be complete within 21 days after discharge.

B
ased on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on October 31 thru November 2, 2016, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Sample Validation conducted on October 31 thru November 2, 2016, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated November 2, 2016.

A. Based on document review, observational tour, and interview, it was determined, for 6 of 12 endoscopes in storage cabinets 3 and 4, the Hospital failed to ensure endoscopes were not touching one another in storage cabinets, potentially affecting approximately 50 patients undergoing endoscopic procedures per week.

Findings include:

1. On 11/1/16 at 11:20 AM, Hospital procedure #ENDO 0009, titled, "High Level Disinfection and Endoscopic Scope Processing", effective 4/28/16, was reviewed. The procedure required, "D. High Level Disinfection... 10. All scopes should be hung vertically in a protected closet with caps and buttons off." The procedure did not indicate scopes should not touch.

2. On 11/1/16 at 11:25 AM, ANSI (American National Standards Institute) / AAMI (Association for the Advancement of Medical Instrumentation) ST91: 2015 Flexible and semi-rigid endoscope processing in health care facilities guidelines were reviewed. The guidelines included: "10.1 General Considerations: The endoscope should be hung vertically with the distal tip hanging freely ... There should be a sufficient space between and around scopes to prevent them hitting into one another, which can cause damage to the scopes..."

3. On 11/1/16 from 9:45 AM to 10:30 AM, an observational tour was conducted in endoscopic procedure and reprocessing area. In endoscope storage cabinet #3, 2 of 8 endoscopes were touching and in storage cabinet #4, 4 of 6 endoscopes were touching.

4. On 11/1/16 at 11:20 AM, an interview was conducted with the Clinical Manager (E #4) of the Endoscopic Area. E #4 stated the Hospital follows AAMI standards and hanging scopes should not be touching.

B. Based on document review, observational tour, and interview, it was determined, for 1 of 1 Radiology Technician (E #7), the Hospital failed to ensure staff did not place uncovered hands and arms over a sterile field.

1. On 11/2/16 at 3:10 PM, Hospital policy # X.0, titled, "Surgical and Sterile Aseptic Technique", effective 6/27/16, was reviewed. The policy required, "VI. Procedure... e. Unsterile persons do not reach across a sterile field..."

2. On 11/2/16 at 9:00 AM, an observational tour was conducted in interventional radiology room # fluro 1. A Patient (Pt. #21) was undergoing a lumbar puncture. At 9:35 AM, a Radiology Technician (E #7) placed her uncovered hands and arms over the sterile table while holding a medication vial.

3. On 11/2/16 at 9:52 AM, an interview was conducted with E #7. E #7 stated uncovered hands and arms should not be above a sterile field.


30195


C. Based on document review, observation, and interview it was determined for, 5 of approximately 9 (E #1, E #2, E #3, MD #1), and Product Representative (PR) (PR #1) people observed in sterile OR #8 and OR #10, and 1 of 3 doctors (MD #2) in sterile operating room (OR) #1, the Hospital failed to ensure adherence to dress code. This potentially affected the 6 patients undergoing surgical procedures in OR #1, #8, and #10 on 11/1/16.

Findings include:

1. Hospital policy entitled, "Surgical Attire and Traffic Patterns in the Perioperative Area and Sterile Processing" (approved 08/2016) required, "...Surgical Attire:... 6. Jewelry including earrings, necklaces, watches, and bracelets that cannot be contained or confined within the surgical attire are not worn... 7. All Personnel are to cover head and facial hair, when in the semi restricted and restricted area... 8. All individuals entering the restricted areas will wear a surgical mask when open sterile supplies and equipment are present..."

2. During an observational tour of the Surgical Department on 11/1/16 between 9:30 AM and 11:15 AM, the following was observed:

In OR #8 at 9:50 AM, a registered nurse (RN) (E #1) with a beard exposed below his surgical hat; PR #1 with a beard exposed below his surgical hat.

In OR #10 at 10:00 AM, an RN (E #2) with a beard exposed below his surgical hat; at 10:45 AM, an RN (E #3) with a beard exposed below his surgical hat; and a surgeon (MD #1) entered the OR room while tying his mask.

In OR #1 at 11:15 AM, the attending surgeon (MD #2) was wearing hoop earrings.

3. During an interview on 11/1/16 at approximately 11:30 AM, the Clinical Director of the OR (E #10) stated jewelry should not be worn, beards should be covered, and masks should be secured prior to entering the OR.