HospitalInspections.org

Based on a review of clinical records, all orders for restraint and seclusion were not ordered by a physician or other licensed independent practitioner responsible for the care of the patient.

Findings were:

Facility policy 5482211 titled "Restraints" states, in part:
"Purpose:
* To protect the dignity, rights and safety of inpatients, outpatients, staff and visitors through safe restraint processes.
* To identify patients at risk for restraint and provide alternatives to restraint use.
* To provide guidelines for use of least restrictive interventions to avoid restraint use.
...
Policy:
* Wilbarger General Hospital fosters a culture that supports a patient's right to be free from restraint or seclusion of any form.
* Restraint use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing and eliminating the use of restraints.
...
4. Order for Restraint:
* An order for restraint must be obtained from a LIP [licensed independent provider]/ physician responsible for the care of the patient prior to the application of restraint. The order must specify clinical justification, date and time ordered, duration of sue, type of restraint to be used and behavior-based criteria for release.
* An order for restraint may not be written as a standing order, protocol, as a PRN or "as needed" order
* If a patient was recently release from restraint, and exhibits behavior that can only be handled through reapplication of restraint, a new order is required
...
* When a LIP/physician is not available, a competent RN may initiate restraints based upon assessment of the patient. In emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after restraint application.
5. Order for Medical Restraint
* Duration of initial restraint orders must not exceed twenty-four (24 hours, and must specify clinical justification, date and time ordered, duration of use, type of restraint and behavior-based criteria for release.
* Although twenty-four (24) hours is the maximum duration, the physician may order a shorter period of time.
* Staffs assess, monitor and re-evaluate the patient regularly and release the patient from restraint when criteria are met.
* To continue restraint use beyond the initial order, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint is necessary.
* If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician.
...
8. Face-to-Face Assessment by a LIP/Physician:
* A face-to-face assessment by a LIP/physician within one hour of restraint initiation ...At the time of the face-to-face assessment, the LIP/physician will:
* Work with staff and patient to identify ways to help the patient regain control
* Evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint
* Revise the plan of care, treatment and services as needed
...
10. Discontinuation of Restraint/Seclusion:
* The patient in restraint is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period.
* When a RN determines that the patient meets the criteria for release, restraints are discontinued by a competent staff member.
* Once restraints are discontinued, a new order for restraint is require to reapply restraints.
* A temporary release that occurs during patient care, e.g. toileting, feeding or range or(sic) motion, is not considered a discontinuation of restraint."

According to https://www.painterfirm.com/a/360/What-can-nurse-practitioners-and-physician-assistants-do-in-Texas, "Unlike doctors, Texas law does not allow physician assistants and nurse practitioners to practice independently. Instead, both PA's and NP's require closely-regulated physician supervision.

Since Senate Bill 406 became effective in 2013, Texas has required supervising physicians to enter into a written, signed, and dated "prescriptive authority agreement" with PA's and NP's that they supervise."

During a review of clinical records for 4 patients that had been placed in medical restraints (patients #23-#26), orders for 2 of the 4 patients (patients #23 & #26) had been written by nurse practitioners.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 7-10-19.

Based on a review of clinical records, the restrained patients were not seen within 1 hour after the initiation of the intervention.

Findings were:

Facility policy 5482211 titled "Restraints" states, in part:
"Purpose:
* To protect the dignity, rights and safety of inpatients, outpatients, staff and visitors through safe restraint processes.
* To identify patients at risk for restraint and provide alternatives to restraint use.
* To provide guidelines for use of least restrictive interventions to avoid restraint use.
...
Policy:
* Wilbarger General Hospital fosters a culture that supports a patient's right to be free from restraint or seclusion of any form.
* Restraint use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing and eliminating the use of restraints.
...
4. Order for Restraint:
* An order for restraint must be obtained from a LIP [licensed independent provider]/ physician responsible for the care of the patient prior to the application of restraint. The order must specify clinical justification, date and time ordered, duration of sue, type of restraint to be used and behavior-based criteria for release.
* An order for restraint may not be written as a standing order, protocol, as a PRN or "as needed" order
* If a patient was recently release from restraint, and exhibits behavior that can only be handled through reapplication of restraint, a new order is required
...
* When a LIP/physician is not available, a competent RN may initiate restraints based upon assessment of the patient. In emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after restraint application.
5. Order for Medical Restraint
* Duration of initial restraint orders must not exceed twenty-four (24 hours, and must specify clinical justification, date and time ordered, duration of use, type of restraint and behavior-based criteria for release.
* Although twenty-four (24) hours is the maximum duration, the physician may order a shorter period of time.
* Staffs assess, monitor and re-evaluate the patient regularly and release the patient from restraint when criteria are met.
* To continue restraint use beyond the initial order, the LIP/physician must see the patient, perform a clinical assessment and determine if continuation of restraint is necessary.
* If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician.
...
8. Face-to-Face Assessment by a LIP/Physician:
* A face-to-face assessment by a LIP/physician within one hour of restraint initiation ...At the time of the face-to-face assessment, the LIP/physician will:
* Work with staff and patient to identify ways to help the patient regain control
* Evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint
* Revise the plan of care, treatment and services as needed
...
10. Discontinuation of Restraint/Seclusion:
* The patient in restraint is evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period.
* When a RN determines that the patient meets the criteria for release, restraints are discontinued by a competent staff member.
* Once restraints are discontinued, a new order for restraint is require to reapply restraints.
* A temporary release that occurs during patient care, e.g. toileting, feeding or range or(sic) motion, is not considered a discontinuation of restraint."

The clinical records for 4 patients (patients #23 - #26) were reviewed. The clinical records for 4 of 4 patients contained no documentation that a 1-hour face-to-face assessment had been performed.

Patient #23 was admitted to WGH [Wilbarger General Hospital] on 8-5-18. An order written on 8-5-18 at 10:58 am by staff #41 (nurse practitioner) read as follows: "4 point restraints". The patient was in restraints for approximately 5 hours. There was no documentation in the clinical record that a 1-hour face-to-face examination had been performed.

Patient #24 was admitted to WGH on 8-8-18. An order written on 8-9-18 at 1:00 pm by staff #37 (physician) read as follows: "Locked 4-point restraints". The patient was in restraints for approximately 12 hours. There was no documentation in the clinical record that a 1-hour face-to-face examination had been performed.

Patient #25 was admitted to WGH on 3-18-19. An order written on 3-20-19 at 9:52 am by staff #37 (physician) read as follows: "May use soft wrist restraints as needed for patient safety x [times] 24 hrs [hours]". The soft wrist restraints were applied, removed and reapplied throughout the day as ordered. There was no documentation in the clinical record that a 1-hour face-to-face examination had been performed.

Patient #26 was admitted to WGH on 4-19-19. An order written on 4-28-19 at 12:08 pm by staff #39 (nurse practitioner) read as follows: Place in 4 point wrist/ankle restraint NTE [not to exceed] 24 hours for prevention of harm to self; climbing out of bed, high fall risk, pulling out IV [intravenous access], removing telemetry monitor". Patient #26 was placed in 4-point restraints on 4-28-19. There was no documentation in the clinical record that a 1-hour face-to-face examination had been performed.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 7-10-19.

Based on a review of credentialing files, facility correspondence and an interview with staff, the medical staff failed to follow all applicable bylaws, rules and regulations.

Findings were:

During a review of credentialing files, the following was noted:

* 1 of 3 Nurse Practitioners (staff #40) held CPR [cardiopulmonary resuscitation] certification issued by an online provider, American Academy of CPR & First Aid, Inc. In the area marked "training site", the card stated "online training".

* 1 of 2 Certified Registered Nurse Anesthetists (staff #31) held CPR, ACLS [advanced cardiac life support] and PALS [pediatric advanced life support] certification, all issued by eMedCert. According to emedcert.com, their certifications are "100% online".

* 1 of 4 ER Physicians (staff #35) held PALS certification issued by Advanced Medical Certification and ACLS certification issued by ACLS Certification Institute. According to https://advancedmedicalcertification.com/?gclid=EAIaIQobChMIprn0_pio4wIVg4bACh0ZPgsoEAAYASAAEgJWjPD_BwE, "Get certified today. 100% online". According to the ACLS Institute at https://acls.com/, they offer "fast and accredited online certifications and renewals".

* 1 of 1 surgeon (staff #38) held CPR, ACLS and PALS certification issued after the appropriate cognitive and in-person skills evaluation, but all 3 certifications had expired 6-30-19.

Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements." Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541.

In an interview with staff #42 on 7-9-18, staff #42 provided the surveyors with a form letter mailed to providers in advance of the expiration of their appointment to the medical staff, listing the required certifications. Staff #42 stated that ER Physicians were required to carry current CPR, ACLS, PALS and ATLS [advanced trauma life support] certifications and the remainder of the providers on the medical staff were required to carry current CPR, ACLS and PALS certifications.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 7-10-19.

Based on a review of personnel files, the director of nursing failed to be responsible for the operation of the service, as 2 nurses carried CPR [cardiopulmonary resuscitation] certification issued by an online provider and therefore not appropriate or recognized by national standards.

Findings were:

Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements." Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541.

During the review of personnel files for 10 Registered Nurses and 3 Licensed Vocational Nurses, 1 RN (staff #28) and 1 LVN (staff #7) had received CPR certification from an online organization, NationalCPRFoundation. The job descriptions for staff #7 and staff #28 both required current CPR certification.

According to https://www.indeed.com/certifications/companies/national-cpr-foundation-QQGMNACH, "National CPR Foundation offers classes online only".

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 7-10-19.

Based on observations, interviews, and record reviews, the facility failed to ensure food and dietetic services organization requirements were met when:

1) kitchens areas were not maintained as required.
2) staff did not properly cover the hair while in the kitchen.

Findings included:

1) The following observations were made in the kitchen service area on 7/9/19 between 11:37 a.m. to 12:40 p.m.:
- "Baker's room station" storing cups and various serving plates had various residue and debris on the inside and outside surfaces.
- White Kenmore brand refrigerator storing fruits and vegetables had various debris on multiple surfaces inside.
- "Preparation station" storing serving station food cover lids and other containers had various white and brownish reside along with thin layer of dust.
- Green and red buckets labeled "detergent and sanitizer disinfective," with solution and wash cloth inside, were found on top shelf of rolling cart. Plastic knives and spoons were stored immediately next to these buckets on the same shelf.
- White funnel embedded inside a large tub storing sugar.
- Dry storeroom floors with various debris, condiment packets, crackers, and dead cockroach under the storage shelves.

In an interview on 7/9/19 at 11:37 a.m. to 12:40 p.m., Staff #25 confirmed the above findings and stated, "Baker's room station did not appear it had been cleaned for a while." Staff #25 stated the above areas observed should be cleaned and or mopped on daily basis. Staff #25 further stated refrigerator had not been checked for cleanliness since last Friday (7/5/19). When asked for cleaning records, Staff #25 stated, "there was no documentation or records." Staff #25 further stated the clean plastic utensils should not be stored next to the sanitizer buckets. Additionally, Staff #25 removed the white funnel inside the large tub and stated, "it should not be kept inside."

Review of facility policy titled Infection Control/Food Handling Safety Practices, with last reviewed date of 6/1/18, reflected under policy procedure: "4.b. keep storeroom clean, dry, well lighted and properly ventilated ... 4.c. keep refrigerators and freezers clean and at proper temperatures."

Review of facility policy titled Guidelines for Kitchen Sanitation, with last reviewed date of 6/1/18, reflected under procedure: "2.a. The Nutrition Services Supervisor shall record all cleaning and sanitation tasks for the department ... 2.e. The cleaning schedule shall be posted monthly with all cleaning tasks outlined, and employees shall initial the tasks when completed."

Review of facility policy titled Equipment/Floor Cleaning Schedule, with last revised date of 06/18, reflected all floors and preparation tables to be cleaned daily, and "shelves in bakery" cleaned weekly.

Review of facility policy titled Cleaning-Sanitizing Products, with last reviewed date of 6/1/18, reflected under procedure: "all cleaning supplies are received and stored, away from food, in provided area ..." There was no information related to storing cleaning supplies next to plastic utensils.

In an interview on 7/9/19 at 2:30 p.m., Staff #2 stated there was no additional policy related to cleaning supply storage in the kitchen.

2) In an observation in kitchen service area on 7/9/19 at 11:30 a.m., Staff #25 was observed with bangs and side hair sticking out of the blue hair restraint.

In an interview on 7/9/19 at 11:30 a.m., Staff #25 stated, "entire hair should be covered but the hair restraint slips down."

Review of facility policy titled Infection Control/Food Handling Safety Practices, with last reviewed date of 6/1/18, reflected under policy procedure: "2.a. to prevent spread of infectious agents by Nutritional Services Department Personnel: 2.a.2. Employee to report in clean uniform and hair net completely covering the hair ..."

Based on observations, interviews, and record reviews, the facility failed to ensure organized emergency services were provided when:

1) biohazard room, suture cart, and medical supplies were left unsecured
2) Expired medical supplies were available for use in supply room

Findings included:

1) The following observations were made in the emergency department area on 7/10/19 between 10:20 a.m. to 11:22 a.m.:
- Door to the biohazard room was found in unlocked state. The door did have a locking mechanism.
- Suture cart containing IV needles, suture needles, and other supplies were left unlocked and stationed on hallway near supply room
- The following items were found inside unlocked drawers in the Trauma room #2:
- 5 x 100 ml Normal Saline flush
- 2 x Medefil blunt needle
- 1 x BD 27 Gauge needle
- 1 x BD Blunt fill needle
- 1 x Smith Medical Lab 18 Gauge needle
- 1 x Smith Medical Lab 20 Gauge needle
- 1 x Medline EZ Lube Jelly

In an interview on 7/10/19 at 10:35 a.m., Staff #24 stated facility was in process of installing secured access with badge access capability to the biohazard room. Staff #24 admitted potential issue for patient safety when the door remained unlocked. Staff #24 further stated keys to the biohazard room was located at the nursing station. Regarding the suture cart, Staff #24 stated the cart has "always been there and remained opened but will keep in the supply room from now on."

In an interview on 7/10/19 at 10:50 a.m., Staff #24 confirmed the above items inside drawers in the Trauma room #2 and stated these items should not be stored in the Trauma rooms.

In an interview on 7/10/19 at 1:30 p.m., Staff #24 stated there was no policy related to biohazard room, suture cart, or mobile cart storage, but that suture cart should have been locked.

In an interview on 7/10/19 at 3:00 p.m., Staff #4 stated there was no policy related to suture cart or mobile cart storage.

Review of facility policy titled Hazardous Materials and Waste Management Plan, with last reviewed date of 3/20/19, reflected under section VI. Process for Managing the Risks:
- Inventory of Hazardous Materials and Waste- "The manager of each department has an inventory of hazardous or regulated waste and is responsible for managing their safe storage ..."
- Management of Hazardous Materials and Waste- "Regulated Medical Waste, including sharps ... the waste is secured for disposal ..."
- Separation of Waste Handling Areas- "WGH maintains appropriate handling and storage areas for hazardous wastes ... maintained to minimize the possibility of ... contact with staff, visitors or patients."

2) The following observations were made in the emergency department area on 7/10/19 between 10:20 a.m. to 11:22 a.m.:
- 2 x Radial Artery Catherization Kit, with use by date of 4/30/19, were found in the supply room.

In an interview on 7/10/19 at 11:04 a.m., Staff #24 stated ED nursing staff are expected to do weekly inventory checks for expiration of medical supplies. Staff #24 further stated expired medical supplies should be removed when found.

Staff #24 and #4 were unable to provide any policies related to the storing/inventory management of medical supplies.