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Based on staff interviews, a review of facility documents and clinical records, it was determined the facility's staff failed to ensure restraints used for violent behaviors were used in accordance with the order of a LIP (Licensed Independent Practitioner). This deficient practice was identified for one (1) of two (2) patients sampled for review of restraints used for violent behaviors (Patient #7).

The findings were:

The surveyor reviewed the facility's "Restraints and Restraint Alternatives" Policy (Policy No. 02.01 (11/2018). The policy read in part, as follows:
At section B "Orders" under item #1, "Must be ordered by a LIP [Licensed Independent Practitioner]..." and at item #2 "The order will be entered into the EHR [Electronic Health Record]..."

The surveyor reviewed the closed clinical record of Patient #7 on 06/04/19 at 3:50 p.m., with the Inpatient Clinical Director (Staff Member SM #23) and the Clinical Director of the Adult Observation Unit (SM #22) serving as navigators of the EHR. That review provided evidence the patient was seen in the facility's ED (Emergency Department) and admitted to the hospital on 04/03/19. The patient's "chief complaint" upon arrival to the ED was listed as "Suicidal thoughts." While still in the ED the patient exhibited violent behaviors requiring the use of restraints. The record contained orders from the ED physician for the patient to be restrained using "4 Point Restraint" [meaning all 4 extremities to be restrained] for violent self destructive behaviors. That order was entered by the physician on 04/03/19 at 7:33 p.m. The record contained evidence that on 04/03/19 at 7:30 p.m., the ED nursing staff applied "restraints on bilateral [both right and left] arms" only and not 4 point restraints as ordered. That documentation was found on the assessment flowsheet entries by the nursing staff dated 04/03/19. Those same flowsheet entries provided evidence the patient was in the "restraints on bilateral arms" until they were discontinued on 04/03/19 at 8:30 p.m., at which time the patient's violent behaviors subsided and he/she no longer required the use of restraints. The record failed to contain documentation or other evidence to explain why the restraint used (restraints on bilateral arms) was not in accordance with what the physician had ordered (4 point restraints). SM #22 was also unable to find documentation to explain the discrepancy between the restraint ordered and the restraint used.

The surveyor discussed the concerns identified during the review of Patient #7's clinical record with SM #23 and SM #22 on 06/04/19, during, and at the conclusion of the review. Both were informed that if additional documentation or evidence existed, they could provide it the next morning for the surveyor to review.

The surveyor met with SM #23 and the Director of Quality (SM #5) on 06/05/19 at 8:40 a.m., for a follow up discussion of the aforementioned concerns regarding the restraints applied for Patient #7 were not what was ordered by the physician. SM #5 stated that most likely the nurse and physician discussed the patient and agreed upon the use of the bilateral arm restraints, but acknowledged there was no documentation of that. SM #5 stated the problem was a "system problem" with EPIC, the facility's EHR software system in that it did not allow the physician a choice other than 4 point restraints. Both SM #23 and SM #5 stated that for restraints used for violent behaviors, the only options that populate as choices for the physician to enter were "4 Point Restraint" or "Seclusion (BH only)" and explained that "Seclusion (BH only)" was for use only when the patient is in the facility's Behavioral Health unit. SM #5 acknowledged that since Patient #7 was still in the ED when the restraints were ordered, the only option the EHR software populated for the physician would have been for 4 point restraints. SM #5 acknowledged the physician order entry also did not allow any free text entries by the physician for that particular order set.

The surveyor met with the Chief Medical Officer (CMO) on 06/05/19 at 10:50 a.m., to discuss the aforementioned concerns regarding physician's orders for restraints. The CMO acknowledged the aforementioned order set, used for ordering restraints necessary because of violent behaviors, had been the same one in use for quite some time. The CMO was asked if any physicians or other LIPs had made the CMO or other administrative staff aware of the order entry limitations. The CMO stated he/she was not aware of any physicians or LIPs having made the issue known. The CMO stated his/her first awareness of the issue/concern was when this survey process identified the concern. The CMO acknowledged the concerns and stated the issue could and would be corrected by the facility's EHR software provider.

Based on observation, staff interview, and review of facility documents, it was determined the facility staff failed to ensure:

The maintenance of a sanitary environment by ensuring the proper handling of clean linens,

That surfaces were maintained in a manner which allowed adequate disinfection, and;

That all surfaces were cleaned and disinfected when patient rooms were cleaned after patient discharge.

The findings included:

1. On 6/4/19 at 10:55 a.m. during a tour of the CCW Unit, the surveyors, accompanied by Staff Members # 6 (Regulatory) and 12 (Nurse Manager), observed a EVS (Environmental Services Staff/Housekeeping) Staff Member carrying clean linen from the "linen storage room". The Staff Member was holding the clean folded linen against the front of (his/her) uniform. The surveyor pointed out the staff member to the facility representatives and #6 stated, "No, that's not the way the linen should be handled". The surveyor requested a copy of the facility policy and procedure for the handling of linens which was not provided by the end of the survey.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), "Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends: ..."As hygienically clean linen is distributed throughout
a medical facility, staff members must take care that it remains as clean as when it was laundered. They must presume that linen storage covers, cabinets, door handles or anything they contact are contaminated. Staff Members should follow proper hand hygiene procedures and sanitize prior to handling healthcare textiles and after touching potentially contaminated surfaces. Avoiding the transfer of pathogens and other contaminants from a staff person to the hygienically clean HCTs (Hygienically Clean Textiles) is critical. More than 60 percent of health workers ' uniforms sampled by researchers tested positive for pathogens while they wore them at work, according to a 2011 study published in the American Journal of Infection Control. Staff members should avoid pressing HCTs to their uniforms at any time, including:
· Unloading from laundry bins or trucks onto racks
in a clean linen storage area
· Moving HCTs from storage area to carts
· Removing HCTs from linen carts to a patient
room
· When HCTs are being used to make a patient bed it is especially important that clean HCTs do not come in contact with an employee's uniform below the waist level. Many potentially contaminated surfaces are below waist level, such as beds, hampers, chairs and other furniture, making it more likely this part of the uniform could be contaminated. Staff members should never carry clean or contaminated linen cradled in arms, for the same reason-pathogens may be transferred to the linen. The skin comes in contact with textiles more often in a hospital than many people realize.... Carry clean linen away from your uniform. When changing a pillow case, do not hold the pillow against your body or truck it under your chin. Avoid shaking clean linen. Wash your hands before handling clean linen. Keep the clean-linen cart covered." www.CDC/guidelines/infectioncontrol/industrystandards/whitepaper

The observation was discussed with multiple facility administrative staff, including Staff Members # 1 (CMO), #5 (Director of Quality), #6 (Regulatory) and #7 (CNO) on 6/5/19 at 4:00 p.m. in an end of the day meeting.

On 6/4/19 at 10:50 a.m. during a tour of the CCW Unit, the surveyors, accompanied by Staff Members # 6 (Regulatory) and 12 (Nurse Manager), observed multiple cushions on furniture in patients rooms what were worn/torn and unable to be adequately disinfected. Staff Member #6 stated, "The furniture is scheduled to be replaced."

On 6/5/19 at 3:00 p.m., Staff Member # 21 (Director Quality) stated, "It (furniture) was ordered and is being delivered in waves starting at the tower and working their way through the building. Unfortunately the CCW units are on the lower floors and they haven't gotten to them yet." The surveyor examined a "invoice" for the ordering of the furniture that was dated 10/23/18.

The surveyor discussed the concern that the furniture on the unit, at the time of the observation on 6/4/19, had surfaces which were not intact and were unable to be disinfected, and the concern of the period of time between the ordering of the furniture and the observation (approximately 7 months).

The observation was discussed with multiple facility administrative staff, including Staff Members # 1 (CMO), #5 (Director of Quality), #6 (Regulatory) and #7 (CNO) on 6/5/19 at 4:00 p.m. in an end of the day meeting.


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2. On June 3, 2019 at 4:00 p.m., the surveyor conducted observations on the medical intensive care unit (MICU) with Staff Members #19 and #21. An observation of a contracted housekeeping staff revealed the staff departed the room with three (3) blue bags and one (1) red biohazard bag. The top of one (1) of the blue bags had not been tied or secured. The contracted staff proceeded to dragged the bags, including the red bag down the hallway with the bags in contact with the hallway floor for approximately 150 feet. At 4:23 p.m., the surveyor interviewed the contract staff. The surveyor asked the contracted staff to explain training received regarding transport of bags with soiled items and red biohazard bags. The contracted staff reported his/her training included transporting the blue bags and red biohazard bags by hand. The contracted staff acknowledged he/she had dragged the blue and red bags related to the weight of the bags. The contracted staff denied he/she were trained to transport bags with soiled items and/or red biohazard bags in a cart.

On June 3, 2019 at 4:28 p.m., the surveyor conducted observations on the CICU (Cardiac Critical Care Unit) with Staff Member #19. Staff Member #19 and the surveyor observed a staff member leave a patient's room with two (2) blue plastic bags of soiled linens. The staff member sat the bags on the floor outside of the soiled utility room, in order to open the soiled utility room's door. The surveyor asked Staff Member #19 regarding the facility's process for handling blue bags with soiled items. Staff Member #19 reported soiled linens were to be placed in the blue bags and transported in a cart to the soiled utility room. Staff Member #19 acknowledged sitting the potentially contaminated bags on the floor in the hallway increased the risk of spreading infectious agents.

A review of the training for contracted staff included: "... Always carry waste away from your body.
-Biohazardous waste must be transported in a covered cart..."


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3. On 6/4/19 at 10:45 a.m. the surveyors toured the CCW-2 unit accompanied by facility staff, and observed housekeeping staff cleaning room #37, which had been vacated by a patient. The housekeeping staff failed to: 1) clean the underside of the mattress, springs, frame, or wheels, 2) open the recliner chair to allow complete cleaning and disinfection, 3) wipe down the entire surface of the IV (intravenous) pole, 4) clean the legs of the bedside commode (BSC) or put a band across the lid of the BSC, 5) clean the computer station on wheels, which remains in the room, 6) clean the posey mats leaning against the wall; Staff Member #13 stated "It's (the mat) is probably still wet on the inside; when opened up, the mats had fuzzy lint hanging on them), 7) clean the walker hanging on the wall behind the door, 8) clean the beside table, sharps container, or clean or replace the suction canister on the wall behind the bed.

The surveyor observed Staff Member #13, a RN, take down used IV bags and lines hanging on the IV pole and pour the excess fluid left in the bags into the sink in the room used for handwashing.

An interview was held with SM #50 on 6/4/19 at 11:10 a.m. to discuss housekeeping duties during room turnover between patients, and he/she stated "EVS (environmental health services) cleans all the equipment in the room. All surfaces get wiped down from top to bottom, for regular cleaning. In an isolation room, bleach is used to clean".

The facility's procedure 7.02: Discharge Room Cleaning Procedure, issued 10/1/18 was reviewed, and stated in part: "...4. Using germicidal cleaner and a micro fiber clean cloth (or hospital designated cloth or wipe), sanitize all patient contact surfaces, starting with the bed...Using the bed controls, raise the head and foot of the bed. Clean the underside of the bed beginning wish the springs, and clean all under parts of the bed. Clean wheels, removing all strings and debris, using putty knife if necessary. Proceed to clean overbed table, bedside table, phone, chairs, low ledges and counter, light switches and door knobs...".

Concerns related to cleaning of the patient room were discussed with SM #50 at the time of the observation, and with members of administration on 6/6/19 at 11:00 a.m.