HospitalInspections.org

Based on staff interviews, and review of CDC guidance, it was determined that the facility failed to ensure that visitors are screened for COVID-19 with temperature checks and COVID-19 screening questions, prior to entry into the facility.

Findings include:

Reference #1: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations. html, updated February 10, 2021 states, "... Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 or exposure to others with suspected or confirmed SARS-CoV-2 infection... ."

1. Upon arrival to the facility on 4/8/2021 at 10:00 AM, the two (2) member survey team were greeted by the front desk staff, Staff #7. Staff #7 did not ask the survey team to complete a COVID-19 Questionnaire Evaluation form upon arrival to the facility.

a. On 3/9/21 at 10:29 AM, during an interview, Staff #1 stated the COVID-19 Questionnaire Evaluations are completed for each visitor. He/She requested that we complete the questionnaire. He/she stated, that the surveyors should have been asked to complete the questionnaire at the front desk.

2. The above findings were confirmed with Staff #1 on 4/8/2021 at 10:15 AM.

Reference #2: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html#conventional-capacity states, "Once availability of facemasks returns to normal, healthcare facilities should promptly resume conventional practices ... 2. When recommended for source control while they are in the healthcare facility, to cover one's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing."

1. Upon arrival to the facility on 4/8/2021 Staff #8, Security, was observed wearing a mask below his/her nose.

2 Staff #1 confirmed the above findings.

Based on three (3) of four (4) medical records, (Medical Records #1, #3 and #8) staff interviews, and review of facility documents, it was determined that the facility failed to ensure that family members are notified when their family member is placed in restraints, according to facility policy and procedure.

Findings include:

Reference #1: Facility policy titled, "Restrain/Seclusion Use of, In Acute Care" states, "...Content...Restraint, Violent or Self Destructive Behavior (BHS) - Documentation pg. 9...B. Initiation of restraint/seclusion: 1. The Registered Nurse: ... h. Reasonable attempts to notify family members when restraint/seclusion therapy is initiated are to be made promptly by staff..."

1. On 4/9/21, a review of Medical Record #1 revealed, on 3/26/21, that family was not contacted or debriefed when Patient #1 was placed in restraints.

a. Review facility of document, "Violent-Self Destructive Behavior RN Restraint /Seclusion Flow Sheet-1" dated 3/26/21, revealed that in section, "ADDITIONAL ACTION TO BE TAKEN IMMEDIATELY ... Family contacted/debriefed ASAP: ...", the designated completion box, date, and time for family notifications were not completed.

b. Upon review of Medical Record #1, it was revealed that on 3/29/21, family was not contacted or debriefed when Patient #1 was placed in restraints.

i. Review of document, "Post restraints/Seclusion Patient Debriefing (Form A)" revealed that section, "To be completed by staff: ... Reviewed with patient/family by staff members within 24 hours: Yes No If debriefing is contraindicated, explain: ..." were not completed.

2. On 4/9/21, a review of Medical Record #3 revealed, that on 3/20/21, family was not contacted or debriefed when Patient #3 was placed in restraints.

a. Review of document, "Violent-Self Destructive Behavior RN Restraint /Seclusion Flow Sheet-1" dated 3/20/21, revealed that in section, "ADDITIONAL ACTION TO BE TAKEN IMMEDIATELY ... Family contacted/debriefed ASAP: ...", the designated date, and time for family notifications were not completed.

3. On 4/9/21, a review of Medical Record #8 revealed that on 1/28/21, family was not contacted or debriefed when Patient #8 was placed in restraints.

a. Review of document, "Violent-Self Destructive Behavior RN Restraint /Seclusion Flow Sheet-1" dated 1/28/21, revealed that in section, "ADDITIONAL ACTION TO BE TAKEN IMMEDIATELY ... Family contacted/debriefed ASAP: ...", the designated completion box, date, and time for family notifications were not completed.

4. On 4/9/21, a review of facility document, "NURSING STAFF MEETING [no date]" stated, "....ATTENTION NURSES.... #2 NOTIFY FAMILY OR LEGAL GUARDIAN OF ANY BEHAVIOR THAT RESULTS IN GIVING PRN OR PHYSICALLY PLACING PATIENT IN THE QUIET ROOM. ALSO NOTIFY FAMILY OR LEGAL GUARDIAN OF ANY MEDICAL COMPLAINTS...EXPLAIN THE COMPLAINT AND THE ACTION THAT WAS TAKEN."

5. On 4/9/21, during an interview with Staff #7 at 11:30 AM, he/she confirmed that family of legal guardians of patients placed in restraints are required to be notified.

6. The above findings were confirmed on 4/9/21 at 12:55 PM with Staff #1, Staff #2, Staff #6, and Staff #7.

Based on one (1) of four (4) medical records reviewed (Medical Record #7) , staff interview, and review of facility documents, it was determined that the facility failed to ensure that Patient #7 received an in-person evaluation by the attending or designated physician, within one (1) hour of the initiation of restraints, as per facility policy.

Findings include:

Reference: Facility policy titled, "Restraint/Seclusion Use of, In Acute Care" states, "... Restraints/Seclusion: Violent or Self Destructive Behavior I. Policy A. Orders. 1. Initial Orders...c. An in-person evaluation, by the attending or designated physician needs to occur within one (1) hour of the initiation of restraint(s)/seclusion. The evaluation and documentation must include the following: i. An evaluation of the patient's immediate situation. ii. The patient's response to preventative interventions. iii. The patient's medical and behavioral condition. iv. The need to continue or terminate the restraint of seclusion..."

1. On 4/09/21, a review of Medical Record #7 revealed that the patient was placed in restraints on 11/2/20 at 6:40 AM and the patient was examined by the Resident Physician on 11/2/20 at 8:35 AM.

a. Progress Record PGY-2 Restraint Note in Medical Record #7 stated, "... Subjective PGY-2 RESTRAINT NOTE ... Restraints were placed at 6:40 AM because the patient was a danger to self, environment, and others, due to agitation and aggression. Restraints was removed at 7:30 AM. I personally examined this patient at 8:35 AM..."

2. The above findings were confirmed with Staff #6 on 4/9/21 at 12:16 PM.