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Based on medical record review, staff interview and facility policy review it was determined the facility failed to ensure orders were obtained per facility policy for the use of physical restraints. This affected one (#26) of seven patients reviewed for the use of restraints of a total of 40 records reviewed. The facility census was 86.

Findings include:

Patient #26 was admitted to the facility on 02/22/14 for diagnoses that included acute respiratory failure. Review of the medical record completed on 03/05/14 at 2:00 P.M. revealed physician progress notes documenting that shortly after arrival to the hospital the patient was intubated and placed on a ventilator to support his respiratory functions.

Review of the medical record noted nursing notes dated 02/23/14 which documented the patient was confused and pulling at his tubes. The nursing notes revealed bilateral wrist restraints were applied for his medical protection at 7:20 P.M.. Further review of the medical record revealed there was no physician order for the use of the bilateral wrist restraints between the hours of 5:37 P.M. on 02/25/14 and 7:11 A.M. on 02/26/14; and again between the hours of 4:30 A.M. on 03/01/14 through 3:18 P.M. on 03/02/14. Documentation in the nursing notes during these time periods indicate the restraints were being utilized for the patient's protection.

Review of the facility policy, "Use of Restraints," effective August 16, 2013, noted on page four under the heading "Ongoing Orders," at the first bullet: "A renewal restraint order will be obtained for each calendar day while the patient is in restraints."

The above findings were verified during an interview with Staff E at 2:00 P.M. on 03/05/14.

Based on medical record review, staff interview and facility policy review it was determined the facility failed to monitor a restrained patient according to the facility policy. This affected one (#26) of seven patients reviewed for the use of restraints of a total of 40 records reviewed. The facility census was 86.

Findings include:

Patient #26 was admitted to the facility on 02/22/14 for diagnoses that included acute respiratory failure. Review of the medical record completed on 03/05/14 at 2:00 P.M. revealed the presence of physician progress notes documenting that shortly after arrival to the hospital the patient was intubated and placed on a ventilator to support his respiratory functions. Nursing notes dated 02/23/14 documented the patient was confused and pulling at his tubes.

Review of the facility policy, "Use of Restraints," dated effective August 16, 2013, noted on page four under the heading, "Care of the Patient," at item 2: "The patient in restraints for physical safety (non-violent, non- self destructive behavior) will be assessed by the Registered Nurse at least every 2 (two) hours and documented in the medical record. Although specific portions of this monitoring may be performed and recorded by PSA's (Patient Services Assistant), the assessment must be performed by the registered nurse."
Review of the medical record completed on 03/05/13 at 2:00 P.M. noted nursing notes which revealed the patient was placed in restraints at 7:20 P.M. on 02/23/14 with an assessment for circulation and skin condition completed at 8:00 P.M. Further review of the nursing notes reveal the patient was not assessed for circulation, skin condition and provided range of motion (ROM) exercises again until 12:50 A.M. on 02/24/14. The next assessment was to include the circulation and skin checks as well as ROM, and was not completed until 4:02 A.M. on 02/24/14. The following assessment was not performed until 8:10 A.M. on 02/24/14. The assessments were then completed according to policy until 4:50 P.M. on 02/24/14. The next assessment was performed at 8:30 P.M. on 02/24/14.

Review of nurses notes for 02/25/14 reveal no circulation assessment or skin checks or ROM were performed between 8:00 A.M. and 4:22 P.M. or between 7:30 P.M. and 11:30 P.M.

With the previous circulation and skin checks performed on 02/25/14 at 11:30 P.M., the next assessment in the nursing notes was not completed until 3:30 A.M. on 02/26/14. Additionally, nursing notes reveal no circulation or skin checks were documented from 7:47 P.M. on 02/26/14 until 2:00 A.M. on 02/27/14 and then no further skin and circulation checks were performed until 8:10 A.M. on 02/27/14. Skin checks were performed approximately every two hours until 7:50 P.M. No further documentation of skin and circulation checks were performed until 8:15 A.M. on 02/28/14.

Review of nursing notes for 03/02/14 reveal the facility failed to assess the patient's circulatory and skin condition between 7:00 A.M. and 10:13 A.M. and 10:30 P.M. on 03/02/14 through 1:25 A.M. on 03/03/14.

Review of nursing notes for 03/04/14 reveal the facility failed to assess the patient's circulatory and skin condition between the hours of 2:30 A.M. and 5:30 A.M.

The above findings as well as the policy requirement for skin and circulation checks to be performed every two hours were verified during an interview with Staff C at 1:50 P.M. on 03/06/14.

Based on record review, staff interview and policy review, the facility failed to ensure verbal orders were signed promptly by the prescribing practitioner. This affected one (#39) of seven patients reviewed for restraint use. The survey sample size was 40.

Findings include:

The medical record of Patient #39 was reviewed on 03/06/14 with Staff C. Review of the admission record reveal the patient was admitted to the facility on 02/24/14. Review of physician's orders reveal on 02/25/14 a verbal order obtained from the physician for the use of bilateral soft wrist restraints to avoid treatment interruption. Review of the nurses notes reveal the patient was transferred from the facility on 02/25/14. Review of the physician orders reveal the verbal order had yet to be signed by the ordering physician at the time of the record review on 03/06/14. This was verified with Staff C on 03/06/14 at 1:15 PM.

Review of the facility's policy titled: Physician Orders, Number P-128.014 reveal at #8, "Verbal orders must be signed as follows: A. Verbal orders for restraints must be signed by the Practitioner within 24 hours and renewed every 24 hours."

This CONDITION is not met as evidenced by:

Based on observations, review of the facility's building schematics and facility's documentation and staff verification during the life safety code inspection, it was determined this facility failed to ensure it was maintained in a manner safe from fire in regard to the penetrations in the common wall between non-conforming buildings, patient room doors not constructed to resist the passage of smoke, penetrations in the smoke barriers, smoke barrier doors having gaps greater than one eighth inch between door leafs, doors being propped open with unapproved devices, penetrations in hazard rooms, no safe access to paved common way, smoke detectors mounted near air flow devices and fire extinguishers not mounted properly. Please see A710 for details. The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients were safe from the potential injury from fire.

Based on observation, review of the facility's building schematics and facility's documentation and staff interview it was determined this facility failed to ensure it was maintained in a manner safe from fire. This had the potential to affect all patients, staff and visitors. The patient census at the beginning of the survey was 86.

Findings include:

The facility failed to ensure all penetrations in the two hour common wall between non-conforming buildings were properly sealed. Please see K-11.

The facility failed to ensure all patient room doors were constructed to resist the passage of smoke in regard to gaps between door leafs when in the closed position and positive latching. Please see K-18.

The facility failed to ensure all penetrations in the smoke barriers were properly sealed. Please see K-25.

The facility failed to ensure all smoke barrier doors were constructed to resist the passage of smoke, latching properly if equipped with a position latch device and not propped open with an unapproved device. Please see K-27

The facility failed to ensure all hazardous areas were constructed with at least a one hour fire resistance rating in regard to penetrations not properly sealed and doors not propped open with unapproved devices. Please see K-29.

The facility failed to ensure a safe access to a paved common way in regards to three exit discharges. Please see K-38.

The facility failed to ensure all smoke detectors were not mounted near air flow devices. Please see K-52.

The facility failed to ensure all portable fire extinguishers were mounted properly. Please see K-64.

Based on observation, documentation review and staff interview, the hospital failed to maintain a sanitary environment in the kitchen where food is prepared for patients and staff and where food is heated for patients on the nursing care units. This potentially affects all patients serviced by the hospital. The patient census at the time of the survey was 86.

Findings include:

1. Tour of the medical-surgical nursing unit on 3E was conducted on 3/03/14 at 2:05 PM. Two microwave ovens located on the unit were available for heating up food for patients. Both microwaves were inspected for cleanliness. Both were noted to have splattered food debris throughout the inside. This finding was verified with Staff B on 3/03/14 at 2:11 PM.

2. Tour of the surgical nursing unit on 4E was conducted on 3/03/14 at 2:50 PM. Two microwave ovens located on the unit were available for heating up food for patients. Both microwaves were inspected for cleanliness. Both were noted to have splattered food debris throughout the inside. This finding was verified with Staff B on 3/03/14 at 2:55 PM.

A return visit was made to 4E on 3/04/14 at 8:10 AM. Both microwaves located on the unit were again inspected for cleanliness. Both remained soiled with food splattering. This finding was verified with Staff C on 3/04/14 at 8:10 AM.

3. Interview with Staff A on 3/04/14 at 9:40 AM revealed the hospital does not maintain a written policy for cleaning the microwaves. The environmental services department of the hospital holds the responsibility for cleaning microwaves. Staff A presented a "checklist" to be used by the environmental services department of all tasks to be completed every evening. Included on the list is "microwaves", indicating microwave cleaning is to be addressed every evening.


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Tour of the dietary department was conducted on 03/04/14 between 7:45 A.M. and 8:40 A.M. with Staff D who verified all findings during interview at the time of discovery.

4. During tour of the cook's station, Staff D was requested to check the concentration of the solution in the sanitation bucket utilized to disinfect work surfaces. Staff D was observed to properly time the strip exposure to the solution. The test strip was observed to barely register a change in color noting the concentration to be well below 150 parts per million.

Review of the information sheet from the dietary management company dated 12/01/11 which included directions for checking the sanitizer concentration noted on page one under the heading, "Verify proper concentration of the Quat solution," stated at the first bullet, "Concentration should be in the range of 150 to 400 parts per million." Documentation further explained under the heading "Why check sanitizer concentrations?,"on page two, "Pathogenic microorganisms and physical and chemical contaminants can cause foodborne illness, injury or allergic reactions (bullet three): "Chemicals used to sanitize food-contact surfaces are not at the proper concentration."

5. Observation of the stacked pans located in the storage areas as well as the food preparation areas revealed moisture present between the pans with some having enough moisture that water trickled down the side of the pan when the pans were separated. Staff D verified that pans were not to be stacked until completely dry.

Review of the facility policy, "Manual Washing of Pots and Pans," effective 05/01/11 revealed under the heading, "Procedure," at item number 3: "Once the pots and pans have been cleaned and sanitized, they are to be stored in a shingled method for the purpose of air drying. Pots and Pans are NOT to be stored wet at anytime."

6. Observation of the industrial mixer revealed the presence of dried, discolored splatters on the underside of the mixer head and on the protective guard.

Review of the cleaning schedule provided by the facility noted that the industrial mixer is to be cleaned weekly on Friday. Review of the undated facility document, "Food and Nutrition Services Cleaning Procedures Volume 3, #27, Procedure for Cleaning the Mixers," noted at item 3b: "...Pay particular attention to underside of mixer heads, corners, handles and underneath rolled rims."

7. Observation of the counter can opener revealed the presence of an accumulation of sticky food debris. After putting the device through the dishwasher, the device was noted to still contain a large amount of food debris in the lower corner near the blade tip.

Review of the cleaning schedule provided by the facility noted the can opener is scheduled to be cleaned daily. Review of the undated facility document, "Food and Nutrition Services Cleaning Procedures Volume 3, #6 - Procedure for Cleaning the Can Opener," noted at item 1: "Inspect the cutting blade. If the blades are allowed to become gummed with food they will not cut and may contaminate food..."

8. Observation of the refrigerator near the cook's station revealed the presence of spills on the rails that support the trays as well as on the bottom of the cart. Staff D verified that spills were to be immediately cleaned by the person who had made the mess.

9. Observation of the drain on the steam cart revealed an accumulation of old food debris in the tray and at the drain grate.

Review of the cleaning schedule revealed the steamer is to be cleaned monthly on the fifth. Review of the undated facility document, "Food and Nutrition Services Cleaning Procedures Volume 3, #40 Procedure for Cleaning the Steamers," revealed at the area "Note": "Be sure entire exterior and area underneath and behind equipment is cleaned."

10. Observation of the fire suppression hood over the cooking surface / grill area revealed a heavy accumulation of grease adhering to the inside surfaces and the vents. Observation of the hood in the steamer area revealed the presence of droplets adhering to the front panel of the hood which were determined to be of a grease nature. Review of the facility "Task Analysis - Cleaning Schedule" form revealed the afternoon Patient Cook was responsible for cleaning the hoods weekly on Wednesday and the morning Patient Cook was responsible for cleaning the hoods weekly on Sundays which also includes cleaning of the back wall. The undated facility document, "Food and Nutrition Services Cleaning Procedures Volume 3, #53 Procedure for Cleaning the Hoods," revealed the staff was to remove the vents and run them through the dish machine, spray the hoods with grease cutter, obtain warm water and clean the hoods utilizing a nylon brush to remove hard soil, rinse and wipe down the hoods and polish them with a stainless steel polish.

11. Observation revealed the trash can was half-full with the lid securely placed in an upright position behind the trash can. Staff D verified the lid was to be placed on the can. Additionally, an uncovered plastic tub was observed on a stool near the hand washing sink containing food scraps. When questioned, Staff D stated that food waste is saved, weighed, recorded, and then disposed of.

Review of the facility policy, "Trash/Waste Disposal," dated effective May 1, 2011, revealed under the heading "Procedure" at item 1b: "All garbage containers will be covered at all times with a tight fitting cover when not in use."

12. Observation of the microwave oven in the cook's area revealed the presence of a large accumulation of old food splatters over the entire upper inner surface.

Review of the facility, "Task Analysis - Cleaning Schedule" form, revealed the microwave is to be cleaned and sanitized on a daily basis.