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Based on medical record reviews, staff interviews, and the review of facility policies, the facility failed to ensure a safe environment for care (A144) ensure all patients were free from restraint, ensure restraints were only used to ensure the physical safety of patients, and restraints were discontinued at the earliest possible time (A154) ensure the type of restraint used was the least restrictive intervention to protect the patient and others from harm (A165) ensure care plans were updated and/or modified following the initiation of restraint (A166) ensure physician's orders for physical restraints included the type of restraint, where the restraint was being applied, and a time limit for the intervention to be used (A167) ensure there was a valid physician's order for the use of restraints, the order was obtained prior to initiation of the restraints, and following release from restraints a new order was obtained (A168) ensure physical restraints were not documented as a standing order per policy and procedure (A169) ensure each order for restraint used for the management of violent behavior was renewed every four (4) hours up to a maximum of 24 hours (A171) ensure after 24 hours, before writing a new order for the use of restraint for the management of violent or self-destructive behavior, the patient was seen and assessed by either a physician or LIP (A172) and ensure the patient was restrained for the management of violent behavior was seen face-to-face within one hour after initiation of the intervention (A178). The cumulative effect of these systemic practices resulted in a risk to the health and safety of the facility's current 195 patients.

Based on observation of the adult psychiatric inpatient unit and staff interview it was determined the facility failed to ensure a safe environment for care. The following safety risk was observed in the dining area of the 20 bed adult psychiatric unit and had the potential to affect all 19 patients on the unit. The adult psychiatric facility census was 28.

Findings include:

On 05/11/16 at 3:00 PM observation of the dining area of the adult psychiatric unit revealed a large steam table used to serve meals to patients residing on the unit. The steam table was noted to be shut off but the top surface and lids felt hot to the touch. Hot water was also noted to be in the steam table reservoir.
Interview with Staff G at the time of the observation confirmed the steam table was shut off but still hot to the touch. Staff G stated the steam table was turned on about a half hour before meals are served and shut off immediately after.
Interview with Staff H at the time of the observation revealed the facility had not had any incident occur involving the steam table. Staff H stated the patients residing on the unit were more independent and lower acuity for aggressive behavior. Staff H confirmed the steam table was directly in front of the nurse's station for monitoring.
At 3:30 PM Staff J was observed using a digital thermometer to check the temperature of the water in the steam table reservoir. The temperature was noted to be 139 degrees Fahrenheit.
On 05/12/16 at 9:00 AM observation of the steam table on the adult psychiatric unit revealed a kitchen staff member draining the table of the hot water after use.
On 05/12/16 at 9:05 AM interview with Staff K confirmed the steam table was located in the dining area of the adult psychiatric unit with hot water in the reservoir which would be a safety concern. Staff K revealed the patients housed on the unit was assessed to be higher functioning, independent, non-aggressive (with no history of aggression) and had not displayed inappropriate behavior. Staff K stated the higher acuity, aggressive, and Alzheimer's patients were placed on the more aggressive locked unit for closer monitoring and safety. Staff K stated the area was monitored by nursing staff and video but could not confirm a nurse was noted at the station at all times. Staff K stated the facility had not had any incident occur involving the steam table.

Based on medical record reviews, staff interview, and the review of facility policy, the facility failed to ensure all patients were free from restraint, restraints were only used to ensure the physical safety of patients, and that restraints were discontinued at the earliest possible time. This affected two of five patients whose medical records were reviewed for the use of restraints for non-violent behavior, Patients' #2 and #3. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Restraint and Seclusion (effective November 1, 2014) was reviewed. Per page two, bullet point 1.1 and 1.2, "restraints or seclusion may not be used for staff convenience, retaliation, a means of coercion, or discipline" and "restraints may only be used to ensure immediate physical safety of a patient, staff member, or others."

Per page three, bullet point 1.7 specified "restraints or seclusion must be discontinued at the earliest possible time."

1) Patient #2 was placed in bilateral wrist restraints on 04/26/16 at 1:00 PM. The restraints were not discontinued until 8:10 AM on 04/29/16. Review of the order obtained on 04/26/16 at 1:31 PM documented the reason for the restraints as "maintain continuation of therapy." There was no documented evidence the restraints were being used to ensure the "immediate physical safety" of either Patient #2 or staff.

Review of the corresponding Restraint Flowsheet Data revealed during the two hour visual checks, staff documented Patient #2 was "subdued." There was no documented evidence of a continued need for restraints.

Patient #2 was then placed in bilateral wrist restraints again on 04/29/16 at 1:30 PM. The restraints were not discontinued until 05/03/16 at 4:00 PM. Review of the clinical justification for the use of restraints according to the nursing assessment was "ventilator." There was no documented evidence the restraints were being used to ensure the "immediate physical safety" of either Patient #2 or staff.

Review of the corresponding Restraint Flowsheet Data revealed during the two hour visual checks, staff documented Patient #2 was either "subdued", "oriented" or "alert." There was no documented evidence of a continued need for restraints.

Staff B was made aware of and confirmed these findings on 05/11/16 at 2:49 PM.

2) Patient #3 was placed in bilateral wrist restraints on 05/05/16 at 11:23 PM. The restraints were not discontinued until 05/09/16 at 7:24 PM. Review of an order obtained on 05/06/16 at 3:06 AM documented the reason for the restraints as "maintain continuation of therapy." There was no documented evidence the restraints were being used to ensure the "immediate physical safety" of either Patient #3 or staff.

Review of the clinical justification for use of restraints according to the nursing assessment was "ventilator." There was no documented evidence the restraints were being used to ensure the "immediate physical safety" of either Patient #3 or staff.

Review of the corresponding Restraint Flowsheet Data revealed during the two hour visual checks, staff documented Patient #3 was "subdued." There was no documented evidence of a continued need for restraints.

Staff B and Staff M were made aware of and confirmed these findings on 05/09/16 at 3:50 PM.

Based on medical record reviews, staff interviews, and review of policy, the facility failed to ensure the type of restraint used was the least restrictive intervention to protect the patient and others from harm. This affected two of five patients whose medical records were reviewed for the use of restraints for non-violent behavior, Patients' #2 and #3. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Restraint and Seclusion (effective date November 1, 2014) was reviewed. Page nine, bullet point 2.2 specified "patients who are in restraints and are non-violent or non-self-destructive must be re-evaluated by a RN at a minimum of every 24 hours to assess for any complications associated with the use of restraints and to determine if restraints or seclusion may be discontinued."

The assessment was to include:

2.2.1 A description of the patient's behavior
2.2.3 All alternative and less restrictive interventions attempted
2.2.4 The condition or symptoms that warrant the use of restraints
2.26 The rationale for continued use of the intervention

1) Patient #2 was placed in bilateral wrist restraints on 04/26/16 at 1:00 PM, and the restraints were not discontinued until 8:10 AM on 04/29/16. She was then placed in bilateral wrist restraints again on 04/29/16 at 1:30 PM, and the restraints were not discontinued until 05/03/16 at 4:00 PM.

There was no documented evidence the RN completed an assessment every 24 hours addressing Patient #2's behavior, except to describe her as "subdued", alternative and less restrictive interventions attempted, condition or symptoms warranting the use of restraints, or the rationale for continued use of bilateral wrist restraints.

Staff B was made aware of and confirmed these findings on 05/11/16 at 2:49 PM.

2) Patient #3 was placed in bilateral wrist restraints on 05/05/16 at 11:23 PM, and the restraints were not discontinued until 05/09/16 at 7:24 PM. There was no documented evidence the RN completed an assessment every 24 hours addressing Patient #3's behavior, except to describe her as "subdued", alternative and less restrictive interventions attempted, condition or symptoms warranting the use of restraints, or the rationale for continued use of bilateral wrist restraints.

Staff B and Staff M were made aware of and confirmed these findings on 05/09/16 at 3:50 PM.

Based on medical record review, staff interview and policy review it was determined the facility failed to ensure care plans were updated and/or modified following the initiation of a physical restraint. This affected four (Patient's #2, #3, #13 and #32) of five medical records reviewed for the use of restraint related to non-violent behavior. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Review of the Restraint and Seclusion Policy (effective date) 11/01/2014 states a modification to the patient plan of care should occur after a valid physician or LIP order has been obtained for the use of restraint or seclusion and a patient is placed in restraints or seclusion, the use of the intervention must be documented in the patient's plan of care.

The following information must be present in the patient's plan of care. The rationale for use of restraints or seclusion, the intervention (s) being used, the plan for monitoring the patient, including specific intervals and the plan for reassessment. The patient's plan of care will be re-evaluated and updated by a registered nurse at a minimum of every twenty-four hours.

1) Review of the medical record for Patient #13 revealed the patient was admitted to the critical care unit on 05/09/16 for diagnoses to include septic shock, polynephritis and metabolic acidosis. Per physician's orders a non-violent continuous restraint was applied on 05/10/16 at 1:21 AM. The medical record lacked evidence the plan of care was updated and/or modified following the restraint application per facility policy and procedure. Staff O confirmed this finding on 05/11/16 at 4:34 PM.

2) Review of the medical record for Patient #32 revealed the patient was admitted to the critical care unit on 05/10/16 following emergency surgery for a diverticular perforation. Per physician's orders a non-violent continuous restraint was applied at 05/10/16 at 1:00 AM with restraints being discontinued on 05/11/16 at 8:00 AM. The medical record lacked evidence the plan of care was updated and/or modified following the restraint application per facility policy and procedure. Further, the medical record lacked evidence the physical restraint was discontinued. This finding was confirmed with Staff O on 5/11/16 at 4:19 PM.

3) Patient #2 was placed in bilateral wrist restraints on 04/26/16 at 1:00 PM, and the restraints were not discontinued until 8:10 AM on 04/29/16. Patient #2 was then placed in bilateral wrist restraints again on 04/29/16 at 1:30 PM and the restraints were not discontinued until 05/03/16 at 4:00 PM.

This intervention was not addressed on the nursing plan of care until 04/28/16 and there was no documented evidence the plan of care was reviewed by a RN on daily basis.

Staff B was made aware of and confirmed these finding on 05/11/16 at 2:49 PM.

4) Patient #3 was placed in bilateral wrist restraints on 05/05/16 at 11:23 PM and the restraints were not discontinued until 05/09/16 at 7:24 PM. This intervention was not addressed on the nursing plan of care until 05/07/16, and there was no documented evidence the plan of care was reviewed by a RN on a daily basis.

Staff B and Staff M were made aware of and confirmed these findings on 05/09/16 at 3:50 PM.














32059

Based on medical record reviews, staff interviews and review of policy and procedure it was determined the facility failed to ensure physician's orders for physical restraints included the type of restraint, where the restraint was being applied, and a time limit for the intervention to be used. This affected four (Patient's #2, #3, #13 and #32) of five medical records reviewed for use of restraints related to non-violent behavior. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Review of the Restraint and Seclusion Policy (effective date) 11/01/2014 states the following elements must be included in the physician or Licensed Independent Practitioner (LIP) order for restraints or seclusion: restraint or seclusion initiation date and time, type of restraint to be used, time limit for intervention, and clinical justification for restraint or seclusion.


1) Review of the medical record for Patient #13 revealed the patient was admitted to the critical care unit on 05/09/16 for diagnoses to include septic shock, polynephritis and metabolic acidosis. Per physician's orders a non-violent continuous (until specified) restraint was applied on 05/10/16 at 1:21 AM. The type of restraints to be used was listed as two soft extremity cuffs for continuation of therapy. The physician's order failed to include where the restraints were to be applied and a time frame for the intervention.

2) Review of the medical record for Patient #32 revealed the patient was admitted to the critical care unit on 05/10/16 following emergency surgery for a diverticular perforation. Per physician's orders a non-violent continuous (until specified) restraint was applied at 05/10/16 at 1:00 AM. The type of restraints to be used was listed as two soft extremity cuffs for continuation of therapy. The physician's order failed to specify where the restraints were to be applied and a time frame for the intervention.

Interview with Staff N on 05/11/16 at 4:26 PM revealed the electronic medical record lacked evidence the physician's and/or (LIP) had the option to choose where restraints were to be applied. The drop down bar listed only the number of restraints to be applied. Staff N confirmed an option is not available for physician and/or (LIP) in the system to select where restraints are to be applied. Staff N stated it could be built into the system to ensure the physician and/or the (LIP) has to option to choose where restraints are to be applied.

Staff O stated in an interview on 05/11/16 at 4:23 PM the facility follows policy for continuous restraint orders for non-violent patients. The restraint policy for non-violent behavior states an order for restraint and/ or seclusion is used to ensure the physical safety for the non-violent or non-self destructive patient is valid the entire time the patient is in restraints. It also states a time limit for the intervention is to be included in the physician's order for restraints.


3) Per review of the physician's order obtained on 04/26/16 at 1:31 PM for a non-violent continuous (until specified) restraint, Patient #2 was placed in bilateral wrist restraints on 04/26/16 at 1:00 PM.

The type of restraints to be used was listed as two soft extremity cuffs for continuation of therapy. The physician's order failed to specify where the restraints were to be applied and a time frame for the intervention.

Staff B was made aware of and confirmed these findings on 05/11/16 at 2:49 PM.

4) Per review of the physician's order obtained on 05/06/16 at 3:06 AM for a non-violent continuous (until specified) restraint, Patient #3 was placed in bilateral wrist restraints on 05/05/16 at 11:23 PM.

The type of restraints to be used was listed as two soft extremity cuffs for continuation of therapy. The physician's order failed to specify where the restraints were to be applied and a time frame for the intervention.

Staff B and Staff M were made aware of and confirmed these findings on 05/09/16 at 3:50 PM.









32059

Based on medical record review, policy review, and staff interviews, the facility failed to ensure there was a valid physician's order for the use of restraints, the order was obtained prior to initiation of the restraints, and following release from restraints a new order was obtained. This affected one of five patients whose medical record was reviewed for the use of restraints for non-violent behavior, Patient #3. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Restraint and Seclusion (effective November 1, 2014) was reviewed. Page eight of the policy, under the section entitled Restraint for Non Violent Behavior stated "restraints or seclusion may only be used in accordance with a valid order given by a physician or licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion."

The policy also specified at bullet point 1.1, "prior to initiation of restraint or seclusion, a written, telephone, or verbal order must be obtained from a physician or LIP, unless there is a emergency situation."

Bullet point 1.2.1 specified "in the event that the patient is released from restraints or seclusion and it is determined that restraints or seclusion must be resumed, a new order must be obtained from the physician or LIP for the reimplementation of restraints or seclusion."

1) Review of the medical record for Patient #3 revealed the patient was placed in bilateral wrist restraints on 05/02/16 at 8:00 PM. The electronic medical record contained a physician's order dated 05/02/16 at 7:37 PM for restraints that was obtained "verbally" by the RN. The order had not been signed by the physician as of 05/09/16 at 3:50 PM. There was no documented evidence of a transcribed order in the patient's record.

Patient #3 remained in the restraints until 05/03/16 at 12:00 PM.

Patient #3 was then placed back into bilateral wrist restraints on 05/05/16 at 11:23 PM and remained in them until 05 09/16 at 7:24 PM. A physician's order for restraints was not obtained until 05/06/16 at 3:06 AM, approximately four hours after the restraints were applied. There was no documented evidence of a "emergency situation" that warranted applying the restraints before an order was obtained. The same order was noted to be "verbal", as documented by the RN, and as of 05/09/16 at 3:50 PM it had yet to be signed by the physician.

Staff B and Staff M were made aware of and confirmed these findings on 05/09/16 at 3:50 PM.

Based on medical record review, staff interview and policy review it was determined the facility failed to ensure physical restraints were not documented as a standing order per policy and procedure. This affected four of five medical records reviewed for the use of restraints related to non-violent behavior. (Patient's #2, #3, #13 and #32) A total of 36 medical records were reviewed and the census was 195.

Findings include:

Review of the Restraint and Seclusion Policy (effective date) 11/01/2014 states orders for restraints or seclusion that are written as a standing protocol or on an as needed (PRN) basis are strictly prohibited.

1) Review of the medical record for Patient #13 revealed the patient was admitted to the critical care unit on 05/09/16 for diagnoses to include septic shock, polynephritis and metabolic acidosis. Per physician's orders a non-violent restraint was applied on 05/10/16 at 1:21 AM. Review of order revealed the physical restraint is documented in the electronic medical record as a standing order with a continuous interval.

2) Review of the medical record for Patient #32 revealed the patient was admitted to the critical care unit on 05/10/16 following emergency surgery for a diverticular perforation. Per physician's orders a non-violent continuous restraint was applied at 05/10/16 at 1:00 AM with restraints being discontinued on 05/11/16 at 8:00 AM. Review of order revealed the physical restraint is documented in the electronic medical record as a standing order with a continuous interval.

3) Review of the medical record for Patient #2 revealed orders for "Restraints non-violent" on 04/26/16 at 1:31 PM and on 05/09/16 at 12:13 AM. Order details noted the frequency as "continuous" and duration as "until specified." Under the heading Standing Order Information, interval was noted as "continuous."

Staff B was made aware of and confirmed these findings on 05/11/16 at 2:49 PM.

4) Review of the medical record for Patient #3 revealed orders for "Restraints non-violent" on 05/02/16 at 7:37 PM and on 05/06/16 at 3:06 AM. Order details noted the frequency as "continuous" and duration as "until specified." Under the heading Standing Order Information, interval was noted as "continuous."

Staff B and Staff M were made aware of and confirmed these findings on 05/09/16 at 3:50 PM.








32059

Based on medical record reviews, staff interview, and review of facility policy, the facility failed to ensure each order for restraint used for the management of violent behavior was renewed every four (4) hours up to a maximum of 24 hours. This affected one of two patients whose medical record was reviewed for the use of restraints to manage violent behavior, Patient #30. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Restraint and Seclusion (effective date November 1, 2014) was reviewed. Per page 12 of the policy, "orders for restraint or seclusion utilized to manage a violent or self-destructive patient must be renewed by a physician or LIP according to time limit based on age as described below. These time lines may be followed up to 24 hours and the patient must be seen in person by the physician or LIP
Per the policy the time limit was " every four hours for adults age 18 years and older."

1) Four soft extremity, locked restraints were placed on Patient #30 at 12:20 AM on 05/04/16. Review of the medical record for Patient #30 revealed an order for "Restraints violent" on 05/04/16 at 1:23 AM. Patient #30 remained in the restraints for management of violent behavior until 05/05/16 at 5:30 AM, approximately 29 hours.

Renewal of the orders occurred at 9:14 AM and 10:53 PM on 05/04/16, approximately 13 and one half hours later.

Patient #30 was then placed back in four soft extremity, locked restraints on 05/05/16 at 6:30 AM. Orders for the restraints were renewed at 11:48 AM, five hours later.

They were renewed again at 2:25 PM on 05/06/16 and then not until 1:29 AM on 05/07/16, approximately 11 hours later.

Staff L, Behavioral Health RN, was made aware of and confirmed the orders for restraints were not renewed every four hours but should have been on 05/12/16 at 12:15 PM

Based on medical on medical record reviews, staff interview, and review of facility policy, the facility failed ensure after 24 hours, before writing a new order for the use of restraint for the management of violent or self-destructive behavior, the patient was seen and assessed by either a physician or LIP (licensed independent practitioner). This affected one of two patients whose medical record was reviewed for the the use of restraints to manage violent behavior, Patient #30. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Restraint and Seclusion (effective date November 1, 2014) was reviewed. Per page 12 of the policy, "orders for restraint or seclusion utilized to manage a violent or self-destructive patient must be renewed by a physician or LIP according to time limit based on age as described below. These time lines may be followed up to 24 hours and the patient must be seen in person by the physician or LIP."

1) Four soft extremity, locked restraints were placed on Patient #30 at 12:20 AM on 05/04/16 . Review of the medical record for Patient #30 revealed an order for "Restraints violent" on 05/04/16 at 1:23 AM. Patient #30 remained in the restraints for management of violent behavior until 05/05/16 at 5:30 AM, approximately 29 hours.

There was no documented evidence Patient #30 was seen and reassessed by either a physician or LIP after the 24 hours and before writing a new order for the continued use of restraints for the management of violent behavior.

Staff L, Behavioral Health RN, was made aware of and confirmed these findings on 05/12/16 at 12:15 PM.

Based on medical record reviews, staff interview, and review of policy, the facility failed to ensure the patient restrained for the management of violent behavior was seen face-to-face within one hour after initiation of the intervention. This affected one of two patients whose medical record was reviewed for the use of restraints to manage violent behavior, Patient #30. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Restraint and Seclusion (effective November 1, 2014) was reviewed. Per page 12 of the policy, "Patients in restraint or seclusion for the management of violent of self-destructive behavior must be evaluated and assessed face-to-face by the physician, LIP, or a Trained RN evaluator within one hour of restraint or seclusion."

1) Four soft extremity, locked restraints were placed on Patient #30 at 12:20 AM on 05/04/16 . Review of the medical record for Patient #30 revealed an order for "Restraints violent" on 05/04/16 at 1:23 AM. There was no documented evidence of a face-to face assessment and evaluation of Patient #30 within one hour of initiation of the intervention.

The restraints were removed 05/05/16 at 5:30 AM and then placed back on at 6:00 AM. Again there was no documented evidence of a face-to face assessment and evaluation of Patient #30 within one hour of initiation of the intervention.

Staff L, Behavioral Health RN, was made aware of and confirmed the above findings on 05/12/16 at 12:15 PM.

Based on medical record review, policy review, and staff interview, the facility failed to ensure the registered nurse followed physician's order for wound care and assessed the wound at the time wound care was provided. This affected one of one patient medical record reviewed for wound care, Patient #1. The facility also failed to ensure nursing staff followed physician's order for blood glucose testing and tube feeding administration. This affected one of one patient medical record reviewed for glucose testing and tube feeding, Patient #3. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Skin Care Management (effective March 1, 2013) was reviewed. Per policy, bullet point two, page two, "skin integrity assessment should occur at the time of admission and on a minimum of a daily basis, or per unit specific guidelines."

Bullet point five, page three noted "skin breakdown present on admission or breakdown that occurs during hospitalization will be appropriately documented and will include, but is not limited to, the following elements:

5.1 Location of the skin breakdown
5.2 Wound shape and size in centimeters
5.3 Presence of odor or drainage, unless obstructed by occlusive dressings
5.4 Description of the wound bed, area surrounding the skin, and the skin at the margins of the wound
5.5 Dressing and/or wound cleanser used
5.6 Any pain related to the wound and/or dressing changes
5.7 Staging of the wound

1) The medical record for Patient #1 was reviewed and revealed a 04/30/16 order obtained at 12:50 PM for Wound Care. This order specified "Unna boot zinc oxide strips to leg and toe wound with daily dressings of dsd cove." That order was based on DPM (doctor of podiatric medicine) assessment on 04/30/16 which revealed "chronic stasis ulceration left leg" and "wound plantar aspect left foot secondary to puncture wound." Ulceration was described as "full-thickness."

The nursing Wound Care Flowsheets for the period of time 04/30/16-05/09/16 were reviewed and revealed the following:

On 04/30/16 at 3:43 PM the nurse applied "4x4 gauze, Kerlix and Unna boot." There was no documented evidence the zinc strips were applied and no wound shape or size noted.

On 05/01/16 and 05/04/16 there was no documented evidence the zinc strips were applied and no wound shape or size noted.

On 05/02/16 there was no documented evidence of nursing assessment of the wound, including the wound bed, peri-wound area and wound drainage. There was no documented evidence the zinc strips were applied and no wound shape or size noted.

On 05/05/16 there was no documented evidence nursing provided wound care.

On 05/07/16 there was no documented evidence of wound care or nursing assessment of Patient #1's left foot wound.

Facility policy Venous Ulcer Protocol (effective date April 1, 2013) was reviewed. Per policy, page two, bullet points two and three reveal nursing staff are to assess the ulcer location, length, width, depth, drainage, surrounding tissue appearance, odor, and wound edges and the edema of the leg, measure widest portion of the calf and make sure to document location of measurement by the distance from the ankle.

There was no documented evidence nursing staff assessed the length, width or depth of Patient #1's left leg ulcer or measured his calf/calves during his admission.

Staff B was made aware of and confirmed these findings on 05/12/16 at 9:25 AM.

2) Review of the medical record for Patient #3 revealed a 05/05/16 physician's order for POCT (point of care testing) glucose checks every six hours.

Review of the Flowsheets revealed a check was done on 05/06/16 at 4:58 PM and then not again until 11:05 AM on 05/07/16, approximately 18 hours later. A check was done on 05/07/16 at 4:39 PM and then not again until 12:24 AM on 05/08/16, approximately 8 hours later. The next check was not done until 10:49 AM on 05/08/16, approximately 10 hours after the 12:24 AM check. A check was done on 05/09/16 at 12:11 AM and then not again until 10:57 AM, approximately 10 hours later.

Patient #3's record also contained a physician's order for NG (nasogastric) tube feeding dated 05/05/16. Per the order, Patient #3 was to receive Jevity tube feeding 1.2 at a rate of 16 milliliters per hour. The rate was to be increased by 7 ml/hour every 24 hours to goal of 45 ml/hr.

The tube feeding was started on 05/05/16 at 10:25 AM and continued per order until 05/07/16 at 11:30 PM. At that time the tube feeding was stopped, and the NG tube was clamped. There was no documented physician's order to stop the tube feeding or to clamp the NG tube.

On 05/08/16 there was a physician's order to resume previous tube feeding at previous rate and formula. Patient #3 was noted to now pave a PEG (Percutaneous endoscopic gastrostomy) tube. The tube feeding was then resumed at 4:00 PM on 05/08/16 at a rate of 10 ml/hr. At 6:00 PM the rate was increased to 20 ml/hr. On 05/10/16 at 12:25 AM the rate was increased to 30 ml/hour, and at 9:37 AM the rate was increased to 40 ml/hr. The rate increases were not done per physician's order.

Staff E was made aware of and confirmed these findings on 05/10/16 at 3:20 PM.

29377

Based on medical record review, policy review, and staff interview, the facility failed to ensure every patient had a nursing plan of care, the plan of care addressed all of the patients identified problems, and the plan of care was reviewed on a daily basis. This affected six of 15 in-patient medical records reviewed for a nursing plan of care. (Patients' #2, #3, #6, #13, #27 and #32) A total of 36 medical records were reviewed and the census was 195.

Findings include:

Facility policy Plan of Care (effective September 1, 2014) was reviewed. Per policy, "All patients at Genesis HealthCare System will have an individualized plan of care developed by a registered nurse that guides nursing and clinical interventions for the patient's care." Page two, bullet point eight of the policy specified "plans of care will be reviewed at a minimum on a daily basis to revise, update and evaluate the effectiveness of the plan."

The RN was to imitate the plan of care "within 8 hours of admission to the unit" for those patients admitted to Behavioral Health, CCU/CVIU, labor and delivery, medical-surgical, newborn nursery, pediatrics, and post-partum nursing areas.

1) Patient #2 was admitted to the hospital on 04/26/16 with a diagnosis of Perforated Sigmoid Colon. Review of the electronic medical record revealed a nursing plan of care was not imitated until 04/27/16 and addressed only the following identified "problems": safety, daily care, nutrition, skin integrity, and pain.

Patient #2 was noted to be on a ventilator and in non-violent restraints on 04/26/16, however, this was not addressed on the nursing plan of care until 04/28/16.

The plan of care was not reviewed by the RN on daily basis.

Staff B was made aware of and confirmed these finding on 05/11/16 at 2:49 PM.

2) Patient #3 was admitted to the hospital on 05/02/16 with a diagnosis of Acute on Chronic Hypercapnia. Patient #3 was noted to be in non-violent restraints on 05/05/16-05/09/09/16, however, this was not addressed on the nursing plan of care until 05/07/16.

The plan of care was not reviewed by the RN on a daily basis.

Staff E was made aware of and confirmed these findings on 05/10/16 at 3:20 PM.

3) Patient #6 was admitted to the hospital on 05/08/16 with a diagnosis of Hyperglycemia. At the time of the electronic medical record review on 05/12/16, there was no nursing plan of care.

Staff B was made aware of and confirmed this finding on 05/12/16 at 9:54 AM.

4) Review of the medical record for Patient #13 revealed the patient was admitted to the critical care unit on 05/09/16 for diagnoses to include septic shock, polynephritis and metabolic acidosis. Per physician's orders a non-violent restraint was applied on 05/10/16 at 1:21 AM. The medical record lacked evidence the registered nurse included restraints in the plan of care. Staff O confirmed this finding on 05/11/16 at 4:34 PM the patient remained in restraints throughout the survey.

5) Review of the medical record for Patient #32 revealed the patient was admitted to the critical care unit on 05/10/16 following emergency surgery for a diverticular perforation. Per physician's orders a non-violent continuous restraint was applied at 05/10/16 at 1:00 AM with restraints being discontinued on 05/11/16 at 8:00 AM. The medical record lacked evidence the registered nurse included restraints in the plan of care. This finding was confirmed with Staff O on 5/11/16 at 4:19 PM.

6) Review of the medical record for Patient #27 revealed the patient was admitted on 05/06/16 with a temporary loss of vision due to lack of blood flow. On 05/09/16, Patient #27 had surgery for a right carotid endarterectomy (surgery to correct stenosis of narrowing artery). The form titled Multi-Disciplinary Problems for Patient #27 revealed no active problems on file. Review of the medical record on 05/10/16 revealed no nursing care plan in the patient record.

On 05/12/16 at 11:30 AM, Staff P confirmed there was no care plan developed for Patient #27.






32059

Based on observation, interview, and documentation review the facility failed to maintain a safe environment from fire related to failure to ensure building separation walls were free from penetrations, maintain the fire rating of vertical openings, ensure exit signage was identified, fire rated smoke walls were maintained, hazardous areas were protected, failed to maintain exit access corridors and exit corridor width, failed to maintain delayed egress doors, ensure fire drills included transmission to offsite monitoring company, sprinklers were maintained, and ensure linen/trash chute rooms complied with NFPA 101. This has the potential to affect all patients receiving services from the facility. (A 704) The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of the patients. The facility's census was 195.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The facility census was 195.

Findings include:

Building 1 of 4
1. The facility failed to ensure building separation walls were free of penetrations. Please refer to life safety code findings at K11.
2. The facility failed to maintain the fire rating of the vertical openings. Please refer to life safety code findings at K20.
3. The facility failed to ensure exits were appropriately identified. Please refer to life safety code findings at K22.
4. The facility failed to ensure fire rated smoke barriers were maintained. Please refer to life safety code findings at K25.
5. The facility failed to ensure hazardous area protection is maintained. Please refer to life safety code findings at K29.
6. The facility failed to maintain exit egress corridors. Please refer to life safety code findings at K33.
7. The facility failed to maintain the width of exit egress corridors. Please refer to life safety code findings at K39.
8. The facility failed to maintain delayed egress doors. Please refer to life safety code findings at K40.
9. The facility failed to ensure fire drills included transmission of a fire alarm signal to the offsite monitoring company. Please refer to life safety code findings at K50.
10. The facility failed to maintain sprinkler heads in the linen/trash chutes. Please refer to life safety code findings at K62
11. The facility failed to maintain the fire rating around linen/trash chute rooms. Please refer to life safety code findings at K71.
Building 2 of 4
1. The facility failed to ensure fire rated smoke barriers were maintained. Please refer to life safety code findings at K25.
2. The facility failed to ensure hazardous area protection is maintained. Please refer to life safety code findings at K29.
3. The facility failed to ensure fire drills included transmission of a fire alarm signal to the offsite monitoring company. Please refer to life safety code findings at K50.
Building 3 of 4
1. The facility failed to ensure the facility is divided into at least two smoke compartments and failed to ensure the rating around medical gas storage is maintained. Please refer to life safety code findings at K130.
Building 4 of 4
1. The facility failed to maintain hazardous area protection, failed to ensure there is no more than one action in exit egress doors, and failed to ensure fire extinguishers are inspected appropriately. Please refer to life safety code findings at K130.

Based on observation and review of policy and procedures it was determined the facility failed to ensure crash carts were consistently monitored on the nursing units and at the offsite ambulatory surgical center. The census was 195.

Findings include:

Review of the Policy and Procedure for Crash Cart and Emergency Maintenance (effective date 05/01/14) revealed the Registered Nurse or designee (e.g. LPN, PCT, MST) is responsible for checking the portable monitor/defibrillator, portable suction apparatus, and crash cart every day to ensure that all items required for immediate patient care are in place and in usable condition. Findings must be recorded on the Emergency Equipment Checklist.

1) During a tour of the offsite ambulatory surgery center on 05/11/16 at 10:00 AM review of the Emergency Equipment Checklist lacked evidence the crash cart located by the surgical suites was checked on 05/04/16. This finding was confirmed with Staff Z on 05/11/16 at 10:35 AM. Per policy crash carts/emergency equipment are to be monitored and logged daily.

2) Tour of the in-patient unit 3W (Medical/Surgical) was conducted on 05/09/16 at 2:14 PM. Observation of the unit's Emergency Equipment Checklist located on top of the crash cart revealed daily checks were not being performed. The cart was not checked 03/01/16, 03/17/16, 03/25/16, 03/28/16, 04/24/16 and 04/26/16.

Staff C confirmed these findings during tour of the unit.

3) Tour of in-patient unit 3S (CVIU) was conducted on 05/09/16 at 1:50 PM. Observation of the unit's Emergency Equipment Checklist located on top of the crash cart revealed daily checks were not being performed. The cart was not checked on 03/22/16, 04/15/16, 04/16/16, 04/23/16 and 04/24/16.

Staff D confirmed these findings during tour of the unit.




32059

Based on observation, interview and review of policies and procedures, the facility failed to ensure staff cleaned patient care equipment after use and failed to ensure staff performed hand hygiene before patient care for one (Patient #34) of one patient observed with blood glucose testing. The facility failed to repair or replace surgical equipment for one of one outpatient surgical sites observed. The census was 195.

Findings include:

Review of the policy and procedure for Handwashing and Hand Antisepsis for Healthcare Personnel, effective date February 2016, revealed hand hygiene is to be performed before patient care. Review of the policy and procedure for Whole Blood Glucose - Accu-Chek Inform II, reviewed on 02/19/15, revealed the Accu-Chek glucose meter should be cleaned after each use with a germicidal wipe.

1) On 05/12/16 at 7:55 AM, Staff Q was observed entering the room of Patient #34 to perform a blood glucose test using an Accu-Chek Safe T Pro (blood glucose meter). Upon entering the room, Staff Q put on his/her gloves. Staff Q performed the blood glucose test. After Staff Q removed his/her gloves and washed hands, Staff Q was observed taking the blood glucose meter to the soiled utility room. Staff Q put the glucose meter in the case and came out of the soiled utility room.

On 05/12/16 at 8:00 AM, Staff Q confirmed he/she had not washed his/her hands before applying gloves upon entering the patient's room. Staff Q also confirmed he/she had not cleaned the blood glucose meter before putting the meter in the case. Staff P was present during the observation and interview.


32059

2) Review of the Policy for Maintenance, Engineering and Bio-Medical Equipment, Infection Control guidelines (effective 09/01/15) was provided upon request however lacked evidence of how surgical equipment was maintained according to standards. The policy states biomedical engineering provides corrective and preventative maintenance on a variety of medical devices. Devices that do not have appropriate clean- in place methods may jeopardize patient safety with a lack of good sanitation practice. Torn environmental surfaces cannot be properly cleaned and/or disinfected in accordance with the facility's policy and procedure.


3) During a tour of the ten bed ambulatory surgery center on 05/11/16 at 10:00 AM observation revealed surgical suites six and seven had torn arm board restraints. Staff Z confirmed this finding and stated the surgical room suites are cleaned between each case and terminal cleans occur nightly.

Based on medical record review and staff interview, the facility failed to ensure staff followed physician's order for mechanical ventilation. This affected one of one patient reviewed for mechanical ventilation, Patient #2. A total of 36 medical records were reviewed and the census was 195.

Findings include:

Patient #2 was admitted to the hospital on 04/26/16 with a diagnosis of Perforated Sigmoid Colon. Review of the electronic medical record revealed a 04/26/16 physician's order at 1:31 PM for mechanical ventilation. The order specified assist control mode, rate of 12, tidal volume of 450, CPAP/PEEP of 5.0 and FiO2 of 60%.

Review of the Ventilator Documentation Flowsheets beginning on 04/26/16 at 3:01 PM revealed the tidal volume was set at 400 and not 450 by the respiratory therapist. The tidal volume remained set at 400 from 04/26/16 at 3:01 PM until 04/29/16 at 1:29 PM. There was no documented physician's order for the change.

A new order for mechanical ventilation was obtained on 04/29/16 at 4:41 PM. The order specified assist control mode, rate of 14, tidal volume 450, CPAP/PEEP of 5.0 and FiO2 of 50%. The respiratory therapist adjusted the ventilator settings to match the order at 4:34 PM on 04/29/16.

At 7:21 PM the respiratory therapist reduced the FiO2 to 40%. There was no documented order for this change. On 04/30/16 at 11:00 AM the respiratory therapist changed the rate from 14 to 12 without a documented physician's order. And at 11:24 AM on 04/30/16 the respiratory therapist changed the CPAP/PEEP from 5 to 7 without a documented physician's order to do so.

The respiratory therapist continued to set the FiO2 at 40%, the rate at 12, and the CPAP/PEEP at 7 until the order was discontinued on 05/02/16 at 7:37 AM. There were no documented orders for these changes.

Staff F, respiratory therapist, was made aware of and confirmed these findings on 05/11/16 at 3:45 PM.