HospitalInspections.org

On September 17th, 2012; surveyor #14105 observed that the facility had the following deficiencies:

K-17 (smoke-tight openings into the corridors),
K-27 (smoke-tight openings-smoke compartments),
K-38 (minimum force to open a door)
K-39 (clear aggregate width-corridor),
K-51 (fire alarm system),
K-56 (sprinkler system),
K130 (miscellaneous items)
K-147 (electrical system)

Please refer to the full description of the deficient practice at the cited -tags: This observed situation was not compliant with 42 CFR 485.623. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff B and C.

Based on observation and staff interview in 2 of 7 departments observed (Emergency Department and Inpatient unit), this facility does not ensure that the physical environment is maintained in a way that protects patients, families, and visitors from harm. Failure to maintain a safe environment has the potential to affect all patients, families, and visitors in the facility.

Findings include:

A tour of the Emergency Department (ED) was conducted on 9/18/2012 at 7:30 a.m. accompanied by Mgr A.

It was noted that the soiled utility room, an unlocked room, contained chemical cleaning agents (Sani-wipes infused with chemicals indicating to keep out of reach of children), a bin of Cidex (strong disinfecting cleaning agent) which contained soaking instruments used for ED patient's procedures, among other hazardous equipment. These items were not secured from patients or families who might enter this unlocked room.

Several of the treatment rooms were found to have Sani-wipes under the sinks which would be accessible to patients and families, notably children, who could cause injury to themselves with the chemical wipes.

These findings were confirmed with Mgr A at the time of discovery.


26390

On 9-17-2012 at 10:04 AM a tour with Mgr. Pt. Care Services, A was completed.

The clean Utility room #326 on the inpatient care unit was noted to be unlocked with unsecured cleaning chemicals inside.
The soiled utility room #343 on the inpatient care unit was noted to be unlocked with unsecured chemicals.
The Mgr. Pt. Care Services A explained the doors are never locked.

On September 17th, 2012; surveyor #14105 observed that the facility had the following deficiencies:

K-17 (smoke-tight openings into the corridors),
K-27 (smoke-tight openings-smoke compartments),
K-38 (minimum force to open a door)
K-39 (clear aggregate width-corridor),
K-51 (fire alarm system),
K-56 (sprinkler system),
K130 (miscellaneous items)
K-147 (electrical system)

Please refer to the full description of the deficient practice at the cited -tags: This observed situation was not compliant with 42 CFR 485.623. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff B and C.

Based on review of the Emergency Department (ED) log, MR review in 7 of 7 ED patients (Pt. #1, 2, 3, 4, 5, 13, and 14) out of a total of 30 MR reviewed, review of the ED Guidelines, Medical staff rules and regulations, and staff interview, this facility 1. Fails to capture the arrival time of all potential patients presenting for care at the ED, and 2. Failed to reassess Pt. #3 in a timely manner. Failure to keep an accurate log of ED patients and provide timely reassessments has the potential to affect all patients presenting for care at this facility.

Findings include:

ED Arrival Time
The facility's Medical Staff Rules and Regulations, dated 2011, were reviewed on 9/18/2012 at 7:30 a.m. On page 12 under Emergency /Urgent Care Services they state in part in #3, "An appropriate medical record shall be kept for every patient receiving emergency/urgent care service and be incorporated in the patient's Hospital, record if such exists. The record shall include:....(b) information concerning the time of the patient's arrival..."

Review of the ED log for the purpose of patient selection took place on 9/17/2012 at approximately 9:30 a.m. It was noted that this facility did not have any entries for "Left without being seen."

MR reviews for Pt.s # 1, 2, 3, 4, and 5 were completed on 9/17/2012 between 1:50 p.m. and 3:30 p.m. and MR reviews for Pt.s #13 and 14 were completed on 9/18/2012 between 1:40 p.m. and 2:45 p.m.

During the review of the MR's it was noted that the time the patient arrived is not documented.

In an interview with Mgr A on 9/18/2012 at 7:55 a.m. Mgr A stated that when a patient presents to the ED for treatment, they give the receptionist their name and their initial complaint. The receptionist then notifies the ED staff who, as soon as possible, go to meet the patient and take them to a room for "triage."

Mgr A states that patients are not put into the ED log until they are discharged from the ED and the time that is indicated as their arrival time is the time triage occurred.

Mgr A also confirmed that if a patient was in the waiting room and staff could not attend to them timely and that patient left, there would be no record that the patient was there.

These findings were confirmed with Mgr A during the time of the interview, and also with Dir. D during the review of MR findings on 9/19/2012 between 9:47 a.m. and 10:15 a.m.

ED Reassessments
The facility's "Emergency Department Guidelines, Vitals/Assessment/Reassessment," dated 9/2011 was reviewed on 9/19/2012 at 10:20 a.m. The guidelines do not address protocol for reassessments of patients who have had tests/procedures completed and are waiting for results and/or consultation with the MD.

Pt. #3 presented to the ED on 6/8/2012 with complaints of abdominal distention and shortness of breath accompanied by a family member. Arrival time is not noted, but triage time indicates Pt. #3 was triaged at 8:06 a.m. At 8:10 a.m. the RN did an assessment. The MD was notified of Pt. #3's arrival at 8:20 a.m. and saw Pt. #3 at 8:50 a.m. Blood tests were ordered and obtained.

At 10:15 a.m. Pt. #3 was discovered to be missing from the ED. There is no indication that staff made contact with Pt. #3 between the time the MD saw #3 and the discovery of #3 missing, a time period of approximately 1 hour and 20 minutes.

This finding was confirmed with Dir. D during the review of MR findings on 9/19/2012 between 9:47 a.m. and 10:15 a.m.

Based on observations in 3 of 5 departments with medications (Emergency Department, Clinic, and Inpatient unit), staff interviews (A, D, K), and P&P review, this facility failed to follow its own policies regarding dating of medications/biologicals and securing medication carts. Failure to maintain standards for medication safety has the potential to affect all patients in the facility.

Findings include:

The facility's policy titled, "Medication Administration and Documentation," dated 5/2012, was reviewed on 9/19/2012 at 9:30 a.m. The policy states on page 1, #6: "Medication carts and medication rooms are to be kept secured at all times."

In a policy titled, "Intravenous (IV) Therapy," dated 6/2011, (reviewed 9/19/2012 at 11:14 a.m.) the policy refers to dating multi-dose medication vials with an expiration date of 28 days from when the vial was opened.

There was no policy presented that outlines guidance to staff regarding the requirement to date opened bottles of non-IV medication with the expiration date.

A tour of the Emergency Department (ED) was conducted on 9/18/2012 at 7:30 a.m. accompanied by Mgr A.

There was a crash cart (emergency cart that contains medication) noted in the trauma room and in room 512 that was equipped with a breakaway loop and not always under the supervision of ED staff. Patients and/or families could potentially enter the cart and access the medications. In an interview during the tour, Mgr A stated A was aware of this requirement from the prior day from touring with another Surveyor.

These findings were confirmed at the time of discovery by Mgr A.

A tour of the attached primary care clinic was conducted on 9/19/2012 at 7:00 a.m. accompanied by Dir. D. and Dir. K.

In several of the examination rooms bottles of opened normal saline and/or sterile water were found to either be expired or did not have a date on them for when they would be considered expired after opening.
Normal Saline: one bottle expired 8/31 (no year), 3 bottles not dated.
Sterile Water: 4 bottles not dated.
During the tour, in a conversation regarding the dating requirement, Dir. D confirmed the date to be written on the bottles is the 28 days from opening when it would be considered to be expired.

These findings were confirmed at the time of discovery by Dir. D and K.



26390

On 9-17-2012 at 10:04 AM a tour of the inpatient area was completed with Mgr. Pt. Care Services, A . The acute care crash cart with a plastic breakaway loop was noted in the endoscopy hallway. Mgr. Pt. Care Services A acknowledged it is not in direct staff supervision at all times.

Based on 3 of 4 observations of patient care (Pt. #12, 18 and 33, Staff D, O, G, L, M, and N), P&P review, Nationally accepted standards of practice, and staff interview, the facility does not ensure that standards of practice are followed and that patients are protected from potential contaminants. Failure to follow standards of practice and protect patients from contaminants has the potential to affect all patients receiving care in the facility.

Findings include:

The facility's policy titled, "Medication Administration and Documentation," dated 5/2012, was reviewed on 9/19/2012 at 9:30 a.m. An attached document to the policy titled, "Process Standard IX, Medication," #16 states, "The patient can expect that the area where medications are prepared will be sprayed prior to med prep [medication preparation] with 70% isopropyl alcohol, and the area allowed to dry for one minute. This procedure will be repeated after med prep."

On 9-19-2012 at 8:48 AM a review of the hospital P&P titled, Hand Hygiene/Handwashing was completed. The P&P states in part, "4. At a minimum, staff will wash their hands during the following times: ....After removing gloves."

According the to the Centers for Disease Control (CDC), a recognized authority on standards of practice in the health care setting, the following recommendations for hand hygiene were published in the October 25, 2002 edition of the WMMR (Weekly Mortality and Morbidity Report; www.cdc.gov ):
IV. Standard Precautions Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.
IV.A. Hand Hygiene IV.A.1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. IV.A.3. If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the clinical situations described in IV.A.3.a-f. The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub immediately following handwashing with nonantimicrobial soap may increase the frequency of dermatitis. Perform hand hygiene: IV.A.3.a. Before having direct contact with patients. IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings. IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient). IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . IV.A.3.f. After removing gloves.

A tour of the Emergency Department (ED) was conducted on 9/18/2012 at 7:30 a.m. accompanied by Mgr A. During the tour, a computer on wheels (computer on a wheeled stand) was noted to have a build up of dust both on the key board and the stand. Mgr A confirmed these findings at the time of the discovery.

During an observation of RN G in the ED at 8:42 a.m. providing care to Pt. #12 who arrived in the ED with complaints of chest pain, RN G was observed to not wear gloves and not wash hands on numerous occasions between 8:42 a.m. and 8:54 a.m. when gloves were put on. During this 12 minute time span RN G left and re-entered the ED room several times and gave several IV medications.

At approximately 9:00 a.m. RN G was observed preparing a dose of IV medication (TNKASE-Teneteplase, to reduce the potential to form blood clots) without washing hands or applying gloves and coughed over the area of the medication preparation.

These findings were discussed on 9/18/2012 at 4:30 p.m. with Dir. D and Mgr A present.



26390

On 9-18-2012 at 7:07 AM RN, O was observed in room #310 with oral medications for pt. #18. RN, O used the top of the COW (computer on wheels) to prepare the medications. RN, O did not follow the hospital's P&P for cleaning of the surface before and after medication preperation.

On 9-19-2012 from 6:55 AM to 8:06 AM RN, M; RN, N and Surgeon L were observed in the pre-procedure area and the endoscopy procedure rooms. Pt. #33 was scheduled for a colonoscopy. RN, N was observed with pt. #33 in recovery room #340. RN, N was observed establishing an IV line in pt. #33's left hand. When completed RN, N removed gloves and did not perform hand hygiene. Hand hygiene was not performed by RN, N through out the entire procedure, after numerous glove changes.

RN, M was also observed during the procedure on pt. #33. RN, M did not perform hand hygiene after numerous glove changes.

MD, Surgeon L, was observed during the procedure on pt. #33. After the procedure, at 7:50 MD, L removed gloves and gown, with no hand hygiene proceeded to document in the paper record. At 7:58 AM MD, L left the procedure room without performing hand hygiene.

These above findings were shared with Mgr. Pt. Care Services A on 9-19-2012 at 10:35 AM.

Based on observations in the kitchen, nationally recognized standards of practice, and staff interview (E, F), this facility failed to follow recognized dietary practices by failing to, 1. Maintain a diet manual that is approved by the Medical Staff and Dietician, 2. Failed to keep trash/refuse receptacles covered, 3. Failed to contain all facial/head hair while in a food preparation area, and 4. Maintained an unwalled janitor closet in the kitchen. Failure to follow recognized dietary practices affects all patients, staff, and visitors who eat in the hospital.

Findings include:

Diet Manual:
In an interview with Dietary Mgr E on 9/17/2012 at 11:40 a.m. Mgr E identified the diet manual used by the facility and stated that the evidence of approval of the manual by the facility was in the binder in this facility's sister facility. At 2:30 p.m. this evidence was produced by Dietician F, however was found not to be approved by the Medical Staff. In an interview with Dietician F at 2:30 p.m. on 9/17/2012, Dietician F confirmed the signature on the approval was not a member of the Medical Staff.
These findings were discussed and confirmed on 9/17/2012 at 4:15 p.m. where Dir. D and Mgr A were present.

Trash/Refuse Receptacles:
According to the 2009 Food and Drug Administration Food Code, Receptacles and waste handling units for REFUSE, recyclables, and returnable's shall be kept covered:
(A) Inside the FOOD ESTABLISHMENT if the receptacles and units:
(1) Contain FOOD residue and are not in continuous use; or
(2) After they are filled;

During the tour of the kitchen area with Dietary Mgr E on 9/17/2012 at 12:00 p.m. several trash/refuse receptacles were noted not to have covers on them throughout the kitchen area. Mgr E confirmed these observations at the time they were made.

Hair Restraints
The 2009 FDA Food Code, states "Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles."

During the tour of the kitchen area with Dietary Mgr E on 9/17/2012 at 12:00 p.m., Dietary Mgr E was noted to have a hair cover that was above the ears and allowed for exposure of head hair on the sides and back of the head. Also, Mgr E had a beard and mustache that was not covered. This was confirmed by Mgr E during the tour. In an interview with Dietician F at 2:30 p.m. on 9/17/2012, Dietician F agreed that all hair needs to be covered.

Separation of Clean and Dirty
The 2009 FDA Food Code, states POISONOUS OR TOXIC MATERIALS shall be stored so they cannot contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE SERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning.

Also noted during the tour of the kitchen was an open (unwalled) janitor closet area that had a floor drain, water pipes and hoses, a mop and bucket with extra mop heads, and a set up of cleaning chemicals mounted on the wall (for the mop bucket) along the wall in the food preparation area. The area of the kitchen is approximately 17 feet by 24 feet. Potential for spray from water/chemicals in a food preparation area exists. This finding was confirmed by Mgr E during the tour.

Based on MR review in 2 out 7 ED MRs (Pt's. #2 and 3) and 3 out of 5 Death MRs (Pt.s # 13, 14, and 17)out of a total of 30 MR reviewed, and P&P review, this facility failed to ensure that the information in the MR is accurate and complete. Failure to maintain accurate, complete medical records has the potential to affect all patients who receive care in this facility.

Findings include:
The facility's policy titled, "Patient's Right to Refuse Treatment/AMA," [against medical advice] dated 5/2011, was reviewed on 9/19/2012 at 10:15 a.m. On page 1, #4.b. the policy states, "When a patient refuses treatment, he/she should sign the "Release from Responsibility for Discharge" form (see attached). This must be completed by staff, signed by the patient and then witnessed by staff." This same policy also addresses AWOL (absent without leave) patients and staff responsibility for documenting same.

A MR review was completed on Pt. #2's closed ED record on 9/17/2012 at 2:12 p.m. Pt. #2 arrived at the ED on 7/8/2012 and left AMA, not wanting to wait for blood test results. There is no form signed by patient or staff releasing the facility from responsibility of Pt. #2.

A MR review was completed on Pt. #3's closed ED record on 9/17/2012 at 2:50 p.m. Pt. #3 arrived at the ED on 6/8/2012 and is documented in the ED log as leaving AMA (not AWOL), which was not discovered for 1 hour and 20 minutes after the last documented contact with the patient. There is no form signed by patient or staff releasing the facility from responsibility of Pt. #3 as staff were not aware that Pt. #3 left.

MR reviews for the closed death records of Pt. #13, 14, and 17 were completed on 9/18/2012 between 10:12 a.m. and 11:40 a.m. On the death record of all these patients it is not indicated if they were determined to be suitable donors by the Organ Procurement Organization. These forms are incomplete.

These findings were confirmed by Dir. D during review of findings on 9/19/2012 between 9:47 a.m. and 10:15 a.m.

Based on MR review of 27 out of 27 MRs requiring consents out of a total of 30 MRs reviewed (Pt.s # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32), review of Medical Staff Rules and Regulations, P&P review, and staff interview, this facility failed to obtain properly authenticated (signed, dated and timed) consent forms for general care and for surgical procedures, and also failed to properly authenticate transfer forms. Failure to obtain properly authenticated consents has the potential to affect all patients receiving care in this facility.

Findings include:

The Medical Staff Rules and Regulations, dated 2011, were reviewed on 9/18/2012 at 7:30 a.m. On page 6, part D, General Consent of Care, #1 states in part, "A general consent form signed by or on behalf of every patient receiving services from the hospital must be obtained at the time of registration."
On page 9, regarding "General Rules Regarding Surgical Care," #4 states in part, "An Informed Consent form should be signed by the patient, legal custodian, or guardian except in cases of emergency. Written, signed, informed surgical consents are required prior to the operative procedure..."

On 9-18-2012 at 3:59 PM a review of the hospital P&P titled, Informed Consent was completed. The P&P states in part, "Policy: 1. Free and informed consent of a person or the person's legal representative is required prior to the performance of operative and/or invasive procedure, 2. Signed consent forms become a permanent part of the medical record."

MR reviews for Pt.s #1-5 were completed on 9/17/2012 between 1:50 p.m. and 3:30 p.m.
MR reviews for Pt.s # 13-22 were completed on 9/18/2012 between 10:12 a.m. and 4:00 p.m.

General Consents
The time the general consents for care were signed for Pt.s # 1, 2, 3, 4, 5, 13, 15, 18, 19, 20, 21, and 22 is not indicated on any of these forms.

In an interview with Dir. D on 9/19/2012 at 10:00 a.m. during the review of MR findings, it was concurred that because there is not a line indicating the time is needed on the form it is not being documented.

The consent form for Pt. #15 is also missing a signature, date, and time from a witness to #15's signature.

These findings were confirmed by Dir D on 9/19/2012 between 9:47 a.m. and 10:15 a.m.

Transfer forms
Pt. #1 and Pt. #4 were transferred from the ED to an Acute care facility for more advanced care. On the transfer form there is no signature, date, or time of the staff member who obtained the signature on the form.

In an interview with Mgr A on 9/18/2012 at 9:20 a.m., A stated that the ED technician, acting as the unit clerk, is the designated person to get transfer forms signed after the MD discusses risks and benefits with the patient. There is no where on the form for the ED technician to authenticate the form.

These findings were confirmed by Dir D on 9/19/2012 between 9:47 a.m. and 10:15 a.m.




26390


Findings include:

Surgical Consents
On 9-18-2012 at 11:50 AM a review of pt. #31's record was completed. The record shows pt. #31 had a colonoscopy on 6-13-12. The record did not contain a consent for the procedure.

On 9-18-2012 at 3:05 PM a review of pt. #32's record was completed. The record shows pt. #32 had a colonoscopy on 8-8-12. The record did not contain a consent for the procedure.

On 9-19-2012 at 9:53 AM the above findings were reviewed with RN Quality Coor.,J.
At 11:15 AM RN Quality Coor.,J confirmed the consents were not available.

General Consents
On 9-17-12 at 2:59 PM record review for pt. #8 revealed an admit date of 8-1-2012 and a discharge date of 8-11-2012. The record did not contain a consent for treatment form.

On 9-17-2012 from 1:30 PM to 4:10 PM record reviews were completed for pt. ' s #6, 7, 9, & 10. In all of the records were consents for treatment with no time next to the pt. and witness signatures.

On 9-18-2012 from 7:40 AM to 3:20 PM record reviews were completed for pt. ' s #23, 24, 25, 26, 27, 28, 29, 30, 31, and 32. In all of the records the consent for treatment documents did not include the time next to the pt. and witness signatures.

The above findings were confirmed by Quality Coordinator, J on 9-19-2012 at 9:53 AM.

Based on MR review in 3 out 7 Emergency Department (ED) MRs (Pt's. #5, 13, and 16) , and 1 out of 3 Swing Bed MRs (Pt. #21) out of a total of 30 MR reviewed, Medical Staff Rules and Regulations, this facility failed to secure orders and obtain proper authentication for orders. Failure to obtain orders and complete proper authentication for orders has the potential to affect all patients receiving care in the facility.

Findings include:

The Medical Staff Rules and Regulations, dated 2011, were reviewed on 9/18/2012 at 7:30 a.m. Page 4, #11 states in part, "All clinical entries in the patient's medical record shall be time-dated and authenticated with the name and title of the person making the entry. The responsible Practitioner shall countersign clinical entries when they have been made by Medical Staff affiliates or medical preceptees."
On page 6, #3 states in part, "All verbal and telephone orders shall be authenticated (signed and time-dated) no later than 48 hours after entry..."

A MR review was completed on Pt. #5's closed ED record on 9/17/2012 at 3:20 p.m. Pt. #5 arrived at the ED on 4/17/2012 with complaints of an arm injury. An x-ray was completed, however there is no order for the x-ray in the MR.

A MR review was completed on Pt. #13's closed ED record on 9/18/2012 at 10:12 a.m. On 4/14/2012 Pt. #13 had orders for blood work and an intravenous line which are not timed or dated by the MD.

A MR review was completed on Pt. #21's closed Swing Bed record on 9/18/2012 at 3:27 p.m. The admission orders to Swing Bed on 3/19/2012 do not include a proper date (missing the year) and do not have a time the MD signed the order.

A MR review was completed on Pt. #16's closed ED record on 9/18/2012 at 11:03 a.m. On 6/20/2012 Pt. #16 had several medication orders taken as verbal orders from the RN due to a code blue situation that were not cosigned/dated/or timed by the MD.

These findings were confirmed by Dir. D on 9/19/2012 between 9:47 a.m. and 10:15 a.m.

Based on review of the Quality Assurance (QA) program, and staff interviews (D, J), the facility failed to ensure that it's quality improvement program include all hospital services furnished under contract or arrangement. This deficiency had the potential to affect all patients treated in the facility during the survey between 9/17/2012 through 9/19/2012.

Findings include:

A review of the Quality plan for the facility was completed on 9/18/2012 at 3:30 p.m. It was noted that services the facility contracts for, most notably the laundry service, were not included in the overall Quality plan for the facility.

In an interview regarding Quality for the facility, conducted on 9/19/2012 at 7:40 a.m. with Dir. D and Coordinator J, it was determined that departments in the facility gather data regarding services they contract with, however this data is not aggregated and included in the overall Quality plan for the facility.

These findings were confirmed during the interview with Dir. D and Coordinator J.

Based on MR review, review of Swing Bed rights and responsibilities and admission packet, and staff interview (A, H) this facility uses restraints (side rails) without physician orders or documented necessity in 3 of 3 Swing Bed MRs reviewed (Pt. #20, 21, and 22). The use of restraints without MD orders has the potential to affect all patients receiving care in this facility.

Findings include:

In an interview with Mgr A and RN H on 9/18/2012 at 1:04 p.m., both staff indicate that restraints are not used in Swing Bed.

The admission packet for Swing Bed patients was reviewed on 9/19/2012 at 6:15 a.m. A blank consent for use of side rails was noted to be in the admission packet. The form was initially dated 4/2008 and updated 1/2012. The consent form explains that side rails are considered a restraint. It does not indicate the reason patient's would need to have these restraints, for how long they would be applied, or what alternative measures would be taken to avoid the restraint.

MR reviews for Pt.s #20, 21, and 22 were completed on 9/19/2012 between 8:30 a.m. and 9:15 a.m. It was discovered during these record reviews that all of these patients had signed a consent to use side rails while a patient in the Swing Bed program.

There are no physician orders indicating the need for these restraints in any of the Pt.s MRs.

These findings were confirmed with Dir. D on 9/19/2012 between 9:47 a.m. and 10:15 a.m.