HospitalInspections.org

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Based on observation and interview, the hospital failed to ensure the quality of the contracted outside laboratory service staff regarding infection control practices and personal privacy. A phlebotomist (person trained in withdrawing and obtaining blood specimens) was observed not to wear gloves during the procedure to draw blood and did not wash their hands before or after contact with three patients (Patients 15, 23 and 28). For Patient 23, the procedure was not conducted in private, but in the lounge activity room in full view of nine other patients. In addition, no documentation was provided to show a mechanism was in place to monitor the infection control practices of the contracted laboratory's phlebotomists entering the hospital. This resulted in the patients being at risk for the spread of infection.

Findings:

In 2007, the Centers for Disease Control (CDC) published an article titled: Prevention of Transmission of Infectious Agents in Health Care Settings. The article documents hand hygiene being cited as the single most important practice to reduce the transmission of infectious agents in healthcare settings. The article adds that during patient care, transmission of infectious organisms can be reduced by adhering to principles of working from "clean" to "dirty" and confining and limiting contamination of surfaces that are directly needed for patient care. It may be necessary to change gloves during the care of a single patient to prevent cross contamination of body sites.

The article showed gloves are used to prevent contamination of healthcare personnel hands when 1) anticipating direct contact with blood or body fluids, mucous membranes, non-intact skin and other potentially infectious material 2) having direct contact with patient's who are colonized or infected with germs transmitted by the contact route e.g. VRE, MRSA, RSV or 3) handling or touching visibly contaminated patient care equipment and environmental surfaces.

Hand hygiene following glove removal further ensures hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hand during glove removal. In addition, the article documents improvement requires that the organizational leadership make prevention an institutional priority and integrate infection control practices into the organization's safety culture.

Phlebotomist A was observed in the Activity Lounge on 3/15/11 beginning at 0840 hours. The phlebotomist was preparing to draw blood from Patient 23. Patient 23 was sitting in her wheelchair in the front of the room watching TV. Nine other patients were sitting behind her, also watching TV. The phlebotomist knelt down on her knees in front of Patient 23, inspected her arm and hand and proceeded to draw bloodwork from the patient. The phlebotomist did not wear gloves to draw the patient's blood. When finished, the phlebotomist completed her paperwork and put the vials of blood in a box sitting on a wheeled table. The phlebotomist then pushed the table out of the lounge.

At 0846 hours, Phlebotomist A was observed to leave the Activity Lounge and enter Patient 15's room. The phlebotomist did not wash her hands before entering the patient's room. The phlebotomist inspected the patient's arm and placed a tourniquet on the arm. The phlebotomist selected her supplies from a tray of equipment and proceeded to draw the patient's blood. The phlebotomist did not wear gloves during the procedure. A licensed nurse entered the room to check on the patient during the procedure but did not intervene. The phlebotomist did not wash her hands before leaving the patient's room.

At 0900 hours, the phlebotomist then entered Patient 28's room with her supplies. The phlebotomist did not wash her hands before entering the room. The phlebotomist inspected the patient's arm. At this time she left the patient and entered the bathroom inside the room to wash her hands. The phlebotomist applied a tourniquet and drew the patient's blood without wearing gloves. The phlebotomist put the blood vials into a plastic bag and then dropped the bag and the paperwork on the floor. She picked the bag and paper off the floor and put them into her supply box and exited the room without washing her hands.

The phlebotomist entered the nursing station and filed her laboratory requisition papers in a notebook.

Phlebotomist A was interviewed on 3/15/11 at 0910 hours. The phlebotomist was informed she was observed drawing bloodwork from patients without wearing gloves and washing her hands before and after contact. The phlebotomist stated she had brought only powdered gloves with her and she was unable to wear them. When asked if she had requested gloves from the hospital, she did not reply. The phlebotomist stated she had a hand gel with her to sanitize her hands, but when informed she was not observed to use it, confirmed she had not. When asked, the phlebotomist stated she had drawn blood from seven patients that morning.

During an interview on 3/16/11 at 1020 hours, the Director of PI and the Director of Infection Control were asked to state how oversight of contracted service staff was conducted. The Director of PI stated the contracted laboratory staff were usually in the hospital on the night shift. The night shift staff would let her know if there were problems and she would follow up. The Director of PI stated the Governing Body was informed only if there were problems. When asked if there was documentation of the oversight, the Director stated, no, there was no formal evaluation done on the contracted service for lab.

Based on interview and record review, the hospital failed to ensure a process was in place to ensure patients with cognitive deficits were represented by a legal guardian, or if none, by a multidisciplinary team during the consent process for admission and treatment and the use of mood altering medications. For 6 of 30 sampled patients reviewed (Patients 1, 3, 9, 10, 23 and 25) with documented diagnoses of dementia, verbal consent was obtained for admission to the hospital and the permission to use mood altering medications with two licensed nurses as witnesses. In addition, documents showed Patient 1's chief complaint and reason for admission was that he was not speaking and; for Patient 10, a non English speaking patient, there was no documentation to show the English consent forms were translated to the patient. This resulted in the potential for patients not to be fully informed of their rights regarding his/her care.

Findings:

Review of the P&P for Informed Consent dated 4/21/10, showed the purpose of the policy was to safeguard and protect the rights of the patient and to ensure their understanding of planned treatment. Nursing staff were instructed to obtain written consent from the patient or legal guardian at the time of admission on the Voluntary Admission Form and Conditions of Admission. The physician was to inform patients who were to receive mood-altering medications (tranquilizers, anti-psychotics, anti-depressants, sedatives, hypnotics, memory enhancers and mood stabilizers) of the side effects, risks, benefits and alternatives to medication therapy. Every patient had the right to refuse medications unless deemed incompetent to be able to make his/her own decisions by the court. The physician was to sign the medication consent form indicating that the patient was aware of the medication(s) recommended and consented to take them. The licensed nurse would witness the patient's signature to take the medications by signing the consent form. A translator was to be provided if the patient did not understand or speak English.

1. The medical record for Patient 23 was reviewed on 3/14/11. The patient was admitted to the hospital on 3/9/11. Review of the nursing admission assessment showed the patient was oriented to self only, was easily distracted and inattentive. When the RN attempted to assess the patient's memory deficit, the patient did not verbally respond to the questions. The nurse documented the patient only laughed. When asked the reason for her admission to the hospital, the patient stated "I don't know."

Review of the Conditions of Admission, Request For Voluntary Admission and Authorization For Treatment, Notification of Patient's Admission, Consent to Release Information, Advance Directive Acknowledgment, and Notice and Acknowledgement of Patients Rights showed the two licensed nurses documented verbal consent had been received by Patient 23 on 3/9/11. The Informed Patient Consent to Receive Psychiatric Medications form showed the physician and two licensed nurses had obtained verbal consent from the patient on 3/10/11.

2. The medical record for Patient 9 was reviewed on 3/14/11. The patient was admitted to the hospital on 3/12/11. Review of the physician's history and physician dated 3/12/11, showed the patient was alert, but oriented to person only.

Review of the Conditions of Admission, Request For Voluntary Admission and Authorization For Treatment, Notification of Patient's Admission, Consent to Release Information, Advance Directive Acknowledgment, and Notice and Acknowledgement of Patients Rights showed two licensed nurses documented verbal consent had been received by Patient 9 on 3/12/11. The Informed Patient Consent to Receive Psychiatric Medications form showed the physician and two licensed nurses had obtained verbal consent from the patient on 3/12/11.

RN 10 was interviewed on 3/15/11 at 0955 hours. The RN was asked to review Patient 9's medical record. The RN confirmed the patient was confused and oriented to self only. The RN was asked if the patient was able to understand the admission and medication consent process when explained to her. RN 10 stated the patient was not really able to understand, "the patient is cooperative and she is able to say yes when asked."

3. The medical record for Patient 10 was reviewed on 3/14/11. The patient was admitted to the hospital on 2/28/11. Review of the nursing admission assessment dated 2/28/11, showed the patient was non English speaking, did not answer questions and demonstrated behaviors of yelling.

Review of the Conditions of Admission, Request For Voluntary Admission and Authorization For Treatment, Notification of Patient's Admission, Consent to Release Information, Advance Directive Acknowledgment, and Notice and Acknowledgement of Patients Rights showed two licensed nurses documented verbal consent had been received by Patient 10 on 2/28/11. The Informed Patient Consent to Receive Psychiatric Medications form showed the physician and two licensed nurses had obtained verbal consent from the patient on 3/1/11. There was no documentation found on any of the consent forms to show a translator was used in the process of obtaining the patient's consent.

RN 6 was interviewed on 3/14/11 at 1410 hours. The RN confirmed Patient 10 was non English speaking. When asked to review the medical record for Patient 10, the RN was unable to state the witnesses to the patient's verbal consent had explained the information to the patient in Spanish. RN 6 stated the explanation would have had to be a simple one, as the patient was confused and may not have been able to understand. RN 6 stated she was not always sure how to handle the consent process when a patient was confused and there was no legal guardian to assist in the decision making for the patient.

During an interview with the DPCS on 3/16/11 at 0830 hours, the Informed Consent P&P was reviewed. When asked, the DPCS confirmed the hospital did not have a process in place to determine who could make decisions for a patient with cognitive deficits who were potentially unable to understand the information provided and give fully informed written consent for admission and treatment.


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4. Patient 25''s medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11. Review of the face sheet showed two names were listed as emergency contact and second conservator.

Review of the Conditions of Admission, Request For Voluntary Admission and Authorization For Treatment, Notification of Patient's Admission, Consent to Release Information, Advance Directive Acknowledgment, and Notice and Acknowledgement of Patients Rights showed two licensed nurses documented "v/c" (verbal consent) had been received by Patient 25 on 2/11/11. The Informed Patient Consent to Receive Psychiatric Medications form showed the physician and two licensed nurses had obtained verbal consent from the patient on 2/11/11.

Review of the internal medicine consultation dictated on 2/22/11, showed the patient was a very poor historian secondary to underlying dementia (chronic personality disintegration, confusion, disorientation, deterioration of intellectual capacity and function, and impairment of control of memory, judgment and impulses) and had very poor insight into her medical problems.


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5. On 3/15/11 a review of Patient 1's clinical record began and showed Patient 1 was admitted to the hospital on 3/11/11. The initial psychiatric evaluation showed Patient 1's chief complaint was that he "was not speaking." Review of the presenting illness showed Patient 1 was non-directable, had impaired insight and judgement, was easily agitated, and was refusing treatment. The psychiatrist documented Patient 1 to have dementia with behavioral disturbance.

Social Worker 1 documented Patient 1's thoughts were confused and disorganized and he was oriented to self only. Additionally, the social worker documented Patient 1's cognitive skills were diminished and he presented no insight and his judgement was poor.

Consents for voluntary admission dated 3/11/11 at 1300 hours, listed Patient 1 as having given verbal consent for admission and treatment, next of kin notification, release of information, advanced directives, the Notice of Privacy Practices, and Patient Rights.

6. On 3/15/11 a review of Patient 3's clinical record began and showed Patient 3 was admitted to the hospital on 3/11/11. Consents for voluntary admission dated 3/11/11 at 1300 hours, listed Patient 3 as having given verbal consent for admission and treatment, next of kin notification, release of information, advanced directives, Notice of Privacy Practices, and Patient Rights.

A form titled Informed Patient Consent to Receive Psychiatric Medications showed a space left blank where Patient 1 was to sign. Medications listed on the document included Depakote (mood stabilizer) and Exelon a drug used primarily for the treatment of dementia from Alzheimer's disease. A check box with a hash mark through it showed Patient 1 refused to sign, but provided verbal permission. A signature by LVN 3 served as the only witness to this document.

Based on observation and interview, the hospital failed to ensure the right to personal privacy was respected for one of 30 sampled patients (Patient 23) when laboratory bloodwork was drawn during an activity in a room full of other patients.

Findings:

Phlebotomist A was observed in the Activity Lounge on 3/15/11 beginning at 0840 hours. The phlebotomist was preparing to draw blood from Patient 23. Patient 23 was sitting in her wheelchair in the front of the room watching TV. Nine other patients were sitting to her back also watching TV. The phlebotomist knelt down on her knees in front of Patient 23, inspected her arm and hand and proceeded to draw bloodwork from the patient. A CNA was in attendance in the lounge throughout the procedure and did not intervene.

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting in regards to infection control practices observed. A phlebotomist (person trained in withdrawing and obtaining blood specimens) was observed not to wear gloves during procedures and did not wash hands before or after contact with three patients (Patients 15, 23 and 28). A CNA was observed to collect and handle soiled linens from several rooms without washing his hands before passing out clean water pitchers. A licensed nurse was observed to prepare medications for a patient on a contaminated surface. This resulted in the potential for the spread of bacteria and infection throughout the hospital.

Findings:

In 2007, the Centers for Disease Control (CDC) published an article titled: Prevention of Transmission of Infectious Agents in Health Care Settings. The article documents hand hygiene being cited as the single most important practice to reduce the transmission of infectious agents in health care settings. The article adds that during patient care, transmission of infectious organisms can be reduced by adhering to principles of working from "clean" to "dirty" and confining and limiting contamination of surfaces that are directly needed for patient care. It may be necessary to change gloves during the care of a single patient to prevent cross contamination of body sites.

1. Phlebotomist A was observed in the Activity Lounge on 3/15/11 beginning at 0840 hours. The phlebotomist was preparing to draw blood from Patient 23. The phlebotomist knelt down on her knees in front of Patient 23, inspected her arm and hand and proceeded to draw blood work from the patient. The phlebotomist did not wear gloves to draw the patient's blood. When finished, the phlebotomist completed her paperwork and put the vials of blood in the box sitting on a wheeled table. A CNA was in attendance in the lounge throughout the procedure and he did not intervene. The phlebotomist then pushed the table out of the lounge.

At 0846 hours, Phlebotomist A was observed to leave the Activity Lounge and enter Patient 15's room. Phlebotomist A was observed preparing to perform venipuncture. The phlebotomist was wearing no gloves as she performed her inspection of the arm for suitable veins. She touched the arm, held it in her bare hands, and placed a blue tourniquet around the left arm as she continued her inspection. The phlebotomist had a tray that contained equipment for drawing blood specimens and transporting laboratory specimens. From the tray, she was observed to handle needles, blood collection tubes, and other equipment. She prepared the site on the patient's arm to obtain the blood specimen without wearing gloves.

The phlebotomist did not wash her hands before entering the patient's room. The phlebotomist inspected the patient's arm and placed a tourniquet on the arm. The phlebotomist selected her supplies from a tray of equipment and proceeded to draw the patient's blood. The phlebotomist did not wear gloves during the procedure. A licensed nurse entered the room to check on the patient during the procedure and did not intervene. The phlebotomist did not wash her hands before leaving the patient's room.

At 0900 hours, the phlebotomist then entered Patient 28's room with her supplies. The phlebotomist did not wash her hands before entering the room. The phlebotomist inspected the patient's arm. At this time she left the patient and entered the bathroom inside the room. The phlebotomist applied a tourniquet and drew the patient's blood without wearing gloves. The phlebotomist put the blood vials into a plastic bag and then dropped the bag and the paperwork on the floor. She picked the bag and paper off the floor and put them into her supply box and exited the room without washing her hands.

The phlebotomist entered the nursing station and filed her laboratory requisition papers in a notebook. She touched laboratory request logs, records, and other objects in the nursing station and then left the nursing station. She was not observed to wash her hands.

Phlebotomist A was interviewed on 3/15/11 at 0910 hours. The phlebotomist was informed she was observed drawing blood work from patients without wearing gloves and washing her hands before and after contact. The phlebotomist stated she had brought only powdered gloves with her and she was unable to wear them. The phlebotomist stated she had a hand gel with her to sanitize her hands, but when informed she was not observed to use it, stated no she had not. When asked, the phlebotomist stated she had drawn blood from seven patients that morning.

2. On 3/15/11 at 0900 hours, a CNA was observed pushing a cart containing 14 clean water pitchers and a stack of wash clothes with one hand and with the other hand he pulled a soiled linen/trash cart. The CNA was observed to enter a four bed room where he straightened bed linen and then exited the room carrying washcloths which he placed in the soiled linen cart. The CNA then picked up a clean water pitcher and wash clothes and reentered the room. The CNA was not observed to wash his hands in between the handling of soiled linen and the clean water pitcher. During the observation the CNA repeated this procedure for the remaining patients in the room and then proceeded to the next room to do the same. At no time did the CNA wash his hands.


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3. On 3/15/11 at 0920 hours, observation showed LVN 3 preparing medications for Patient 28. At 0928 hours, LVN 3 exited the Patient 28's room with washcloths in her hand, placing the washcloths on the top of the medication cart. The LVN pushed the cart to the nursing station. The LVN washed her hands in the sink inside the nursing station. Close observation of the washcloths showed two washcloths had a pinkish substance on them. After washing her hands the LVN picked up the washcloths from the top of the medication cart and placed them in the soiled linen container in the hallway. At 0930 hours, when asked what the washcloths were used for, the LVN stated she used them to absorb a spill from Patient 28's GT when administering his medications. Continuous observation did not show the LVN sanitized the top of the medication cart where the soiled washcloths had been placed.

On 3/15/11 at 0935 hours, observation showed the LVN placed a medication patch directly on the top of the medication cart to write on it. When asked, the LVN stated the medication patch was prepared for Patient 29.

Based on observation, interview and record review, the hospital failed to ensure devices used to prevent five of 30 sampled patients from getting up unassisted by staff were not restraints for those patients (Patients 1, 3, 9, 23 and 25 ). The hospital failed to conduct a comprehensive individualized assessment of the patients prior to the use of lap buddies and gerichairs to ensure the least restrictive devices were used. A lap buddy is a cushion that fits across the patients lap and is attached to the arms of a wheelchair which can prevent a patient from getting out of the chair. A gerichair is a reclining chair which can prevent the patient from getting out of the chair. Without a comprehensive assessment prior to the use of lap buddies and gerichairs, there was the potential for unnecessary physical restraints to be used for patients and the additional risk of physical injury from the use of the devices.

Findings:

Review of the P&P for Seclusion/Behavioral Restraints, last revised 4/1/10, showed by definition, "a restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body, or head freely." Documentation showed "this did not include lap pads which may be utilized by patients for support." Exclusions also included "devices used to protect the patient from falling out of bed."

Review of the P&P for Postural Devices effective date 2/15/11, showed the purpose of the postural device was to maintain the proper posture of a patient to prevent injury or the psychological fear of falling. A postural device was defined as "any device used primarily to maintain the posture of the patient who was limited by physical injury or illness." The devices listed included lap buddies. Documentation showed "it was the policy of the hospital that postural devices were not considered a physical or behavioral restraint." The procedure included a RN assessment of the patient to ascertain if they required additional assistance to maintain proper posture when out of bed. The CNA was to monitor the patient to ensure the device was fitted properly and the patient was comfortable.

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the physician's orders for Patient 23 did not show an order for the use of a lap buddy. Review of the CNA Flowsheets dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient. Review of the Licensed Nursing Notes and Interdisciplinary Progress Notes dated 3/9 to 3/14/11, did not show documentation of the use of a lap buddy for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. When asked, the RN stated a physician's order was not required for the lap buddy to be used on a patient. When asked to review nursing documentation, RN 6 stated she was unable to locate documentation to show the lap buddy was used for the patient.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair. When asked, the CNA stated the patient was unable to remove the lap buddy by herself.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

LVN 4 was interviewed on 3/15/11 at 1345 hours. The LVN was asked to state the definition of a restraint. The LVN stated a restraint was a device which impeded the voluntary movement of a patient. The LVN was asked if Patient 23 was unable to remove her lap buddy when up in the wheelchair, could the lap buddy be considered a potential restraint. The LVN stated, she was not sure, but the lap buddy could potentially be a restraint for the patient. The LVN confirmed no assessment of Patient 23 had been conducted prior to the use of the lap buddy. The LVN stated she could see how the patient could need frequent reassessments as she had good and bad days and her condition would change. The LVN confirmed no physician's order had been required for the lap buddy to be used for the patient. The LVN stated she had been trained by the hospital that lap buddies and other devices used for safety were not considered restraints and therefore did not require an assessment or a physician's order prior to their use.

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the medical record showed a care plan developed to address the risk of falls for Patient 9. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. There was no physician's order found for a lap buddy for the patient. There was no documentation in the medical record to show the use of a lap buddy was assessed for the patient.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1420 hours, during an interview, CNA 5 stated Patient 25 was placed in the gerichair in the morning until after lunch, about 0700 hours to 1300 hours. On 3/14/11 at 1514 hours, during a follow up interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair. When asked if the patient could remove the lap buddy, the CNA did not answer, stating the patient did not have the lap buddy with the gerichair and could not get out of the gerichair. The CNA stated she was unable to recall how long Patient 25 had used the gerichair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia. Review of the physician's orders did not show a physician's order for the use of a gerichair or a lap buddy. There was no documentation located to show nursing assessments had been conducted for the patient prior to the use of the devices.

Review of 24-Hour Licensed Nursing note dated 2/24/11, showed Patient 25 had episodes of restlessness, constantly calling "madame," and tried to remove the lap buddy. Review of the Interdisciplinary Progress Notes dated 2/25/11 at 1630 hours, showed the patient was observed sitting up in the wheelchair, fidgeting with the lap buddy. On the 24-Hour Licensed Nursing Note dated 3/2/11, the licensed nurse documented the patient was in the wheelchair at 1430 hours, was confused, screaming loudly and was disruptive.

The Patient Progress Record dated 3/7/11 at 1530 hours, showed Patient 25 was in the gerichair, yelling, wanting to go to bed. Review of the Master Interdisciplinary Treatment Plan Review dated 3/10/11, showed the IDT documented the patient attended most morning groups but was excused for bed rest in the afternoon under Groups/ Milieu participation.

Review of the plan of care showed a care plan was developed on 2/21/11, to address the risk of fall for Patient 25. Interventions included the use of a lap buddy for safety. The use of the gerichair was not addressed in the plan of care.

On 3/14/11 at 1630 hours, RN 9 was interviewed regarding Patient 25's use of lap buddy in the wheelchair. The RN stated the staff always used a lap buddy for Patient 25 when she was up in the wheelchair. When asked the purpose of the lap buddy, the RN stated the patient attempted to get up, and the lap buddy kept her in the wheelchair. The observation of the gerichair in Patient 25's room and the observation of Patient 25's being in the gerichair in the morning were shared with the RN. When asked how long Patient 25 had been using the gerichair, RN 9 did not answer. RN 11 entered the room at this time. RN 11 stated there was no physician's order needed for a gerichair. RN 11 stated when the patient was in the wheelchair for a long time she was not comfortable and would become tired and restless, and would yell out. RN 9 stated when the patient was in the gerichair there was no need to use the lap buddy, as the patient could not get out of the gerichair. When asked if the patient was able to remove the lap buddy, RN 9 did not answer, but stated Patient 25 would try to remove it. RN 9 stated, when staff saw the patient was not comfortable in the wheelchair they offered the gerichair to the patient. When asked which staff, the RN 9 stated the CNAs would do this.

On 3/15/11 at 0825 hours, Patient 25 was observed coming out from the shower room. Staff had placed her in the gerichair. At 0926 hours, the patient was observed sleeping in the gerichair. The recline of the gerichair was observed at about 45 degrees.

On 3/15/11 at 1315 hours, Patient 25 was observed in the gerichair talking to a staff member. The head of the gerichair was reclined at about 45 degrees. A staff member was observed to adjust the angle of the back of the gerichair to a more upright position. Patient 25 was observed to rise up in the gerichair. LVN 4 was observed to approach the patient and lower the angle of the chair back to 45 degrees. Patient 25 was then observed to be unable to sit up and began talking loudly. At 1320 hours, staff moved the patient to her room.

On 3/15/11 at 1625 hours, CNA 6 was interviewed. When asked how long Patient 25 would be in the gerichair during the day, the CNA stated if the patient was in the gerichair when the shift began, the evening shift staff would not place the patient back in bed until after dinner, at about 1900 hours.

4. On 3/14/11 at 0900 hours, Patient 1 was observed in his room sitting in a wheelchair with a lap buddy device in place.

Review of the medical record for Patient 1 began on 3/15/11, and showed he had a left hemiparesis (weakness on left side). There was no documentation in the medical record Patient 1 was assessed for use of the lap buddy. There was no physician's order for the use of the device. In addition, there was no nursing documentation to show the application, use, or need for the device.

An interview with CNA 4 was conducted in the lounge area. He was asked about the lap buddy being applied to Patient 1. The CNA stated the lap buddy was used for postural support and proper positioning of Patient 1. He stated if Patient 1 did not have the lap buddy in place he would slump forward.

5. On 3/14/11 at 0930 hours, Patient 3 was observed in his room sitting in a wheelchair with a lap buddy device in place. Review of the medical record began on 3/15/11, and showed the pre-admission screening showed no mention for the requirement for a lap buddy device. In addition, physician admission orders failed to list a lap buddy as a device to be used for postural support. Review of the interdisciplinary patient admission assessment showed Patient 3 demonstrated poor impulse control but there was no reference documentation for the application, use, and need for a lap buddy device.

The DPCS was interviewed on 3/16/11 at 0940 hours. The DPCS confirmed the hospital's P&P for the use of physical restraints addressed behavioral restraints only, and the use of a device such as a lap buddy was not considered a restraint. The DPCS stated some patients could remove the lap buddy and therefore it did not meet the definition of a restraint. The DPCS was informed review of the medical records did not indicate if the devices were or were not restraints for the patients, as no assessments had been conducted. The DPCS stated that was true.

Based on observation, interview and record review, the hospital failed to ensure the use of devices to prevent three of 30 sampled patients from getting up unassisted by staff were care planned for those patients (Patients 9, 23 and 25). The plan of care for the patients did not reflect an individualized process of assessment, intervention and evaluation when devices such as lap buddies and gerichairs were used. Without an individualized care plan there was the potential for the devices to be used improperly.

Findings:

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the physician's orders did not show an order for the use of a lap buddy. Review of the CNA Flowsheets dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. The RN stated, when used, the lap buddy would be listed as an intervention in the fall risk care plan. Review of the care plan for Patient 23 with RN 6 did not show the use of a lap buddy was selected as an intervention to help prevent falls for the patient.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair. When asked, the CNA stated the patient was unable to remove the lap buddy by herself.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the medical record showed a care plan developed to address the risk of falls for Patient 9. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. However, there were no interventions listed to show when and how the lap buddy was to be used and for what reason. There was no plan developed to ensure the patient had planned times without the device.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1420 hours, during an interview, CNA 5 stated the Patient 25 was placed in the gerichair in the morning until after lunch, about 0700 hours to 1300 hours. On 3/14/11 at 1514 hours, during a follow up interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair. When asked if the patient could remove the lap buddy, the CNA did not answer, stating the patient did not have the lap buddy with the gerichair and could not get out from the gerichair. The CNA stated she was unable to recall how long Patient 25 had used the gerichair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia.

Review of 24-Hour Licensed Nursing note dated 2/24/11, showed Patient 25 had episodes of restlessness, constantly calling "madame," and tried to remove lap buddy. Review of the Interdisciplinary Progress Notes dated 2/25/11 at 1630 hours, showed the patient was observed sitting up in the wheelchair, fidgeting with the lap buddy. The 24-Hour Licensed Nursing Note dated 3/2/11, the licensed nurse documented the patient was in the wheelchair at 1430 hours, was confused, screaming loudly and was disruptive.

The Patient Progress Record dated 3/7/11 at 1530 hours, showed Patient 25 was in the gerichair, yelling, wanting to go to bed. Review of the Master Interdisciplinary Treatment Plan Review dated 3/10/11, showed the IDT documented the patient attended most morning groups but was excused for bed rest in the afternoon under Groups/ Milieu participation.

Review of the plan of care showed a care plan was developed on 2/21/11, to address the risk of fall for Patient 25. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. However, there were no interventions listed to show when and how the lap buddy was to be used and for what reason. There was no plan developed to ensure the patient had planned times without the device. The use of the gerichair was not addressed in the plan of care.

On 3/15/11 at 1625 hours, CNA 6 was interviewed. When asked how long Patient 25 would be in the gerichair during the day, the CNA stated if the patient was in the gerichair when the shift began, the evening shift staff would not place the patient back in bed until after dinner, at about 1900 hours.

Based on observation, interview and record review, the hospital failed to ensure physician's orders were obtained for devices such as lap buddies and gerichairs used to prevent 5 of 30 sampled patients (Patients 1, 3, 9, 23 and 25) from getting up unassisted by staff. This resulted in the potential for restraints to be used on patients without a physician's order.

Findings:

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the physician's orders did not show an order for the use of a lap buddy.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. When asked, the RN stated a physician's order was not required for the lap buddy to be used on a patient.

LVN 4 was interviewed on 3/15/11 at 1345 hours. The LVN was asked to state the definition of a restraint. The LVN stated a restraint was a device which impeded the voluntary movement of a patient. The LVN was asked if Patient 23 was unable to remove her lap buddy when up in the wheelchair, could the lap buddy be considered a potential restraint. The LVN stated, she was not sure, but confirmed the lap buddy could potentially be a restraint for the patient. The LVN confirmed no physician's order had been required for the lap buddy to be used for the patient. The LVN stated she had been trained by the hospital that lap buddies and other safety devices were not considered restraints and therefore did not require an assessment or a physician's order prior to their use.

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances. There was no physician's order found for a lap buddy for the patient.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the physician's orders for Patient 9 did not show an order for the use of a lap buddy had been obtained.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1420 hours, during an interview, CNA 5 stated the Patient 25 was placed in the gerichair in the morning until after lunch, about 0700 hours to 1300 hours. On 3/14/11 at 1514 hours, during a follow up interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair. When asked if the patient could remove the lap buddy, the CNA did not answer, stating the patient did not have the lap buddy with the gerichair and could not get out from the gerichair. The CNA stated she was unable to recall how long Patient 25 had used the gerichair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia. Review of the physician's orders did not show a physician's order for the use of a gerichair or a lap buddy.

4. On 3/14/11 at 0900 hours, Patient 1 was observed in a wheelchair with a lap buddy device in place. Review of the medical record for Patient 1 began on 3/15/10, and showed he had a left hemiparesis (weakness on left side). There was no physician order for the use of the device.

5. On 3/14/11 at 0930 hours, Patient 3 was observed in his room sitting in a wheelchair with a lap buddy device in place. Review of the medical record began on 3/15/11, and showed the pre-admission screening showed no mention for the requirement of a lap buddy device. There was no physician order for the use of the device.

The DPCS was interviewed on 3/16/11 at 0940 hours. The DPCS confirmed the hospital's P&P for the use of physical restraints addressed behavioral restraints only, and the use of a device such as a lap buddy was not considered a restraint. The DPCS stated some patients could remove the lap buddy and therefore it did not meet the definition of a restraint. The DPCS was informed review of the medical records did not indicate if the devices were or were not restraints for the patients, as no assessments had been conducted. The DPCS stated that was true.

Based on observation, interview and record review, the hospital failed to conduct reassessments of five of 30 sampled patients (Patients 1, 3, 9, 23 and 25) when devices such as lap buddies and gerichairs were used. Ongoing monitoring and assessments would ensure the devices, which had the potential to be a restraint for the patients, were used for the shortest time possible if the needs of the patient's changed.

Findings:

Review of the P&P for Seclusion/Behavioral Restraints, last revised 4/1/10, showed by definition, "a restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body, or head freely." Documentation showed "this did not include lap pads which may be utilized by patients for support." Exclusions also included "devices used to protect the patient from falling out of bed."

Review of the P&P for Postural Devices effective date, 2/15/11, showed the purpose of the postural device was to maintain the proper posture of a patient to prevent injury or the psychological fear of falling. A postural device was defined as "any device used primarily to maintain the posture of the patient who was limited by physical injury or illness." The devices listed included lap buddies. Documentation showed "it was the policy of the hospital that postural devices were not considered a physical or behavioral restraint." The procedure included a RN assessment of the patient to ascertain if they required additional assistance to maintain proper posture when out of bed. The CNA was to monitor the patient to ensure the device was fitted properly and the patient was comfortable.

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the CNA Flowsheets dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient. Review of the Licensed Nursing Notes and Interdisciplinary Progress Notes dated 3/9 to 3/14/11, did not show documentation of the use of a lap buddy for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. When asked to review nursing documentation, RN 6 stated she was unable to locate documentation to show the lap buddy was used for the patient.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair. When asked, the CNA stated the patient was unable to remove the lap buddy by herself.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

LVN 4 was interviewed on 3/15/11 at 1345. The LVN was asked to state the definition of a restraint. The LVN stated a restraint was a device which impeded the voluntary movement of a patient. The LVN was asked if Patient 23 was unable to remove her lap buddy when up in the wheelchair, could the lap buddy be considered a potential restraint. The LVN stated, she was not sure, but the lap buddy could potentially be a restraint for the patient. The LVN confirmed no assessment of Patient 23 had been conducted prior to the use of the lap buddy. The LVN stated she could see how the patient could need frequent reassessments as she had good and bad days and her condition would change.

Review of the Interdisciplinary Progress Notes dated 3/15/11 at 1345 hours, RN 6 documented the patient was sitting up in the wheelchair with a "lap buddy for postural support. Patient confused and restless keeps trying to get out of chair."

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the medical record showed a care plan was developed to address the risk of falls for Patient 9. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. There was no documentation in the medical record to show the use of a lap buddy was assessed for the patient prior to, or subsequent to it's use.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1420 hours, during an interview, CNA 5 stated Patient 25 was placed in the gerichair in the morning until after lunch, about 0700 hours to 1300 hours. On 3/14/11 at 1514 hours, during a follow up interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair. When asked if the patient could remove the lap buddy, the CNA did not answer, stating the patient did not have the lap buddy with the gerichair and could not get out of the gerichair. The CNA stated she was unable to recall how long Patient 25 had used the gerichair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia. There was no documentation located to show nursing assessments had been conducted for the patient prior to the use of the devices.

Review of 24-Hour Licensed Nursing note dated 2/24/11, showed Patient 25 had episodes of restlessness, constantly calling "madame," and tried to remove lap buddy. Review of the Interdisciplinary Progress Notes dated 2/25/11 at 1630 hours, showed the patient was observed sitting up in the wheelchair, fidgeting with the lap buddy. The 24-Hour Licensed Nursing Note dated 3/2/11, the licensed nurse documented the patient was in the wheelchair at 1430 hours, was confused, screaming loudly and was disruptive.

The Patient Progress Record dated 3/7/11 at 1530 hours, showed Patient 25 was in the gerichair, yelling, wanting to go to bed. Review of the Master Interdisciplinary Treatment Plan Review dated 3/10/11, showed the IDT documented the patient attended most morning groups but was excused for bed rest in the afternoon under Groups/ Milieu participation.

On 3/14/11 at 1630 hours, RN 9 was interviewed regarding Patient 25's use of lap buddy in the wheelchair. The RN stated the staff always used a lap buddy for Patient 25 when she was up in the wheelchair. When asked the purpose of the lap buddy, the RN stated the patient attempted to get up, and the lap buddy kept her in the wheelchair. The observation of the gerichair in Patient 25's room and the observation of Patient 25's being the gerichair in the morning was shared with the RN. When asked how long Patient 25 had been using the gerichair, RN 9 did not answer. RN 11 entered the room at this time. RN 11 stated when the patient was in the wheelchair for a long time she was not comfortable and would become tired and restless, and would yell out. RN 9 stated when the patient was in the gerichair there was no need to use the lap buddy, as the patient could not get out of the gerichair. When asked if the patient was able to remove the lap buddy, RN 9 did not answer, but stated Patient 25 would try to remove it. RN 9 stated, when staff saw the patient was not comfortable in the wheelchair they offered the gerichair to the patient. When asked which staff, RN 9 stated the CNAs would do this.

On 3/15/11 at 1625 hours, CNA 6 was interviewed. When asked how long Patient 25 would be in the gerichair during the day, the CNA stated if the patient was in the gerichair when the shift began, the evening shift staff would not place the patient back in bed until after dinner, at about 1900 hours.

On 3/15/11 at 1315 hours, Patient 25 was observed in the gerichair talking to a staff member. The head of the gerichair was reclined at about 45 degrees. A staff member was observed to adjust the angle of the back of the gerichair to a more upright position. Patient 25 was observed to rise up in the gerichair. LVN 4 was observed to approach the patient and lower the angle of the chair back to 45 degrees. Patient 25 was then observed to be unable to sit up and began talking loudly. At 1320 hours, staff moved the patient to her room.

4. On 3/14/11 at 0900 hours, Patient 1 was observed in a wheelchair with a lap buddy device in place.

Review of the medical record for Patient 1 began on 3/15/10, and showed he had a left hemiparesis (weakness on left side). There was no documentation in the medical record Patient 1 was assessed for use of the device. There was no documentation by the licensed staff of least restrictive measures being utilized for purposes of postural support.

An interview with CNA 4 was conducted in the lounge area. He was asked about the lap buddy being applied to Patient 1. He stated the lap buddy was used for postural support and proper positioning. He stated if Patient 1 did not have the lap buddy in place he would slump forward.

5. On 3/14/11 at 0930 hours, Patient 3 was observed in his room sitting in a wheelchair with a lap buddy device in place. Review of the medical record began on 3/15/11, and showed the pre-admission screening showed no mention for the requirement of a lap buddy device. Review of the interdisciplinary patient admission assessment showed Patient 3 demonstrated poor impulse control but failed to document the use or the need for application of a lap buddy device.

The DPCS was interviewed on 3/16/11 at 0940 hours. The DPCS confirmed the hospital's P&P for the use of physical restraints addressed behavioral restraints only, and the use of a device such as a lap buddy was not considered a restraint. The DPCS stated some patients could remove the lap buddy and therefore it did not meet the definition of a restraint. The DPCS was informed review of the medical records did not indicate if the devices were or were not restraints for the patients, as no assessments had been conducted. The DPCS stated that was true.

Based on observation, interview and review of the medical record, the hospital failed to ensure the use of a lap buddy device was documented in the medical record for one of 30 sampled patients (Patient 23). The device, if unable to be removed by the patient, had the potential to be a restraint for the patient.

Findings:

Review of the P&P for Seclusion/Behavioral Restraints, last revised 4/1/10, showed by definition, "a restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body, or head freely." Documentation showed "this did not include lap pads which may be utilized by patients for support."

Review of the P&P for Postural Devices effective date, 2/15/11, showed the purpose of the postural device was to maintain the proper posture of a patient to prevent injury or the psychological fear of falling. A postural device was defined as "any device used primarily to maintain the posture of the patient who was limited by physical injury or illness." The devices listed included lap buddies. Documentation showed "it was the policy of the hospital that postural devices were not considered a physical or behavioral restraint." The procedure included a RN assessment of the patient to ascertain if they required additional assistance to maintain proper posture when out of bed. The CNA was to monitor the patient to ensure the device was fitted properly and the patient was comfortable.

Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the CNA Flowsheets dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient. Review of the Licensed Nursing Notes and Interdisciplinary Progress Notes dated 3/9 to 3/14/11, did not show documentation of the use of a lap buddy for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. When asked to review nursing documentation, RN 6 stated she was unable to locate documentation to show the lap buddy was used for the patient.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair. When asked, the CNA stated the patient was unable to remove the lap buddy by herself.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

Based on observation, interview and record review, the hospital failed to ensure devices used to prevent five of 30 sampled patients from getting up unassisted by staff were not restraints for those patients (Patients 1, 3, 9, 23 and 25). The hospital failed to conduct a comprehensive individualized assessment of the patients prior to the use of lap buddies and gerichairs to ensure the least restrictive devices were used. Without a comprehensive assessment prior to the use of lap buddies and gerichairs, there was the potential for unnecessary physical restraints to be used for patients and the additional risk of physical injury from the use of the devices.

Findings:

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair. When asked, the CNA stated the patient was unable to remove the lap buddy by herself.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

LVN 4 was interviewed on 3/15/11 at 1345. The LVN confirmed no assessment of Patient 23 had been conducted, or any less restrictive measures attempted, prior to the use of the lap buddy. The LVN stated she could see how the patient could need frequent reassessments as she had good and bad days and her condition would change. The LVN stated she had been trained by the hospital that lap buddies and other safety devices were not considered restraints and therefore did not require an assessment prior to their use.

Review of the Interdisciplinary Progress Notes dated 3/15/11 at 1345 hours, RN 6 documented the patient was sitting up in the wheelchair with a "lap buddy for postural support. Patient confused and restless keeps trying to get out of chair."

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the medical record showed a care plan developed to address the risk of falls for Patient 9. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. There was no documentation in the medical record to show the use of a lap buddy or less restrictive measures for safety were assessed for the patient.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1420 hours, during an interview, CNA 5 stated the Patient 25 was placed in the gerichair in the morning until after lunch, about 0700 hours to 1300 hours. On 3/14/11 at 1514 hours, during a follow up interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair. When asked if the patient could remove the lap buddy, the CNA did not answer, stating the patient did not have the lap buddy with the gerichair and could not get out from the gerichair. The CNA stated she was unable to recall how long Patient 25 had used the gerichair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia. There was no documentation located to show nursing assessments for less restrictive restraining measures had been conducted for the patient prior to the use of the devices.

On 3/15/11 at 1315 hours, Patient 25 was observed in the gerichair talking to a staff member. The head of the gerichair was reclined at about 45 degrees. A staff member was observed to adjust the angle of the back of the gerichair to a more upright position. Patient 25 was observed to rise up in the gerichair. LVN 4 was observed to approach the patient and lower the angle of the chair back to 45 degrees. Patient 25 was then observed to be unable to sit up and began talking loudly. At 1320 hours, staff moved the patient to her room.

4. On 3/14/11 at 0900 hours, Patient 1 was observed in a wheelchair with a lap buddy device in place. Review of the medical record for Patient 1 began on 3/15/10, and showed he had a left hemiparesis (weakness on left side). There was no documentation in the medical record Patient 1 was assessed for use of the device. There was no documentation by the licensed staff of least restrictive measures being utilized for purposes of postural support.

5. On 3/14/11 at 0930 hours, Patient 3 was observed in his room sitting in a wheelchair with a lap buddy device in place. Review of the medical record began on 3/15/11, showed the pre-admission screening showed no mention for the requirement of a lap buddy device. Review of the interdisciplinary patient admission assessment showed Patient 3 demonstrated poor impulse control but failed to document the use or the need for application of a lap buddy device and any less restrictive devices attempted prior to using the lap buddy.

The DPCS was interviewed on 3/16/11 at 0940 hours. The DPCS confirmed the hospital's P&P for the use of physical restraints addressed behavioral restraints only, and the use of a device such as a lap buddy was not considered a restraint. The DPCS stated some patients could remove the lap buddy and therefore it did not meet the definition of a restraint. The DPCS was informed review of the medical records did not indicate if the devices were or were not restraints for the patients, as no assessments had been conducted. The DPCS stated that was true.

Based on observation, interview and record review, the hospital failed to ensure staff received the education and training to individually assess a patient and choose the least restrictive intervention possible to ensure the safety of five of 30 sampled patients (Patients 1, 3, 9, 23 and 25) when devices such as lap buddies and gerichairs were used. This had the potential for unnecessary physical restraints to be used for patients and the additional risk of physical injury from the use of the device.

Findings:

Review of the P&P for Seclusion/Behavioral Restraints, last revised 4/1/10, showed by definition, "a restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body, or head freely." Documentation showed "this did not include lap pads which may be utilized by patients for support." Exclusions also included "devices used to protect the patient from falling out of bed."

Review of the P&P for Postural Devices effective date, 2/15/11, showed the purpose of the postural device was to maintain the proper posture of a patient to prevent injury or the psychological fear of falling. A postural device was defined as "any device used primarily to maintain the posture of the patient who was limited by physical injury or illness." The devices listed included lap buddies.

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the CNA Flowsheets dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. When asked to review nursing documentation, RN 6 stated she was unable to locate documentation to show an assessment for the lap buddy used for safety.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

LVN 4 was interviewed on 3/15/11 at 1345. The LVN confirmed no assessment of Patient 23 had been conducted prior to the use of the lap buddy. The LVN stated she could see how the patient could need frequent reassessments as she had good and bad days and her condition would change. The LVN stated she had been trained by the hospital that lap buddies and other safety devices were not considered restraints and therefore did not require an assessment prior to their use.

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the medical record showed a care plan developed to address the risk of falls for Patient 9. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. There was no documentation in the medical record to show the use of a lap buddy was assessed for the safety of the patient.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1514 hours, during an interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia. There was no documentation located to show nursing assessments had been conducted for the patient prior to the use of the lap buddy or gerichair.

4. On 3/14/11 at 0900 hours, Patient 1 was observed in a wheelchair with a lap buddy device in place. Review of the medical record for Patient 1 began on 3/15/10, and showed he had a left hemiparesis (weakness on left side). There was no documentation in the medical record Patient 1 was assessed for use of the device. There was no documentation by the licensed staff of least restrictive measures being utilized for purposes of postural support.

An interview with CNA 4 was conducted in the lounge area. He was asked about the lap buddy being applied to Patient 1. He stated the lap buddy was used for postural support and proper positioning. He stated if Patient 1 did not have the lap buddy in place he would slump forward.

5. On 3/14/11 at 0930 hours, Patient 3 was observed in his room sitting in a wheelchair with a lap buddy device in place.

Review of the medical record began on 3/15/11. Review of the pre-admission screening did not show the use of a lap buddy device was needed. Review of the interdisciplinary patient admission assessment showed Patient 3 demonstrated poor impulse control but failed to document the use or the need for application of a lap buddy device.

An interview was conducted with the DPCS and the Director of PI on 3/16/11 at 1000 hours. The yearly staff training in restraint use was discussed. The DPCS provided the Key Competency Checklist for Restraints and test form used in the training. Review of the training did not show staff were trained in the use and/or assessment of devices such as lap buddies and gerichairs considered safety devices by the hospital. The DPCS, when asked, confirmed competency for use of these devices was not assessed in the training.

Based on observation, interview and record review, the hospital failed to ensure the use of devices to prevent three of 30 sampled patients from getting up unassisted by staff were care planned for those patients (Patients 9, 23, and 25). The plan of care for the patients did not reflect an individualized process of assessment, intervention and evaluation when devices such as lap buddies and gerichairs were used. Without an individualized care plan there was the potential for the devices to be used improperly.

Findings:

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the physician's orders did not show an order for the use of a lap buddy. Review of the CNA Flowsheets dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. The RN stated, when used, the lap buddy would be listed as an intervention in the fall risk care plan. Review of the care plan for Patient 23 with RN 6 did not show the use of a lap buddy was selected as an intervention to help prevent falls for the patient.

CNA 7 was interviewed on 3/14/11 at 1510 hours. The CNA stated the lap buddy was used for Patient 23 to keep the patient in the wheelchair. When asked, the CNA stated the patient was unable to remove the lap buddy by herself.

Patient 23 was observed on 3/15/11 at 0815 hours, alone in her room and again at 0845 hours in Lounge A with a CNA in attendance. During both observations, the patient was sitting in a wheelchair with a lap buddy in place.

2. Patient 9 was observed on 3/14/11 at 1400 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair interacting with staff during an activity. No lap buddy was observed in use.

The medical record for Patient 9 was reviewed on 3/14/11 at 1430 hours. The patient was admitted to the hospital on 3/12/11 with diagnoses which included dementia with behavioral disturbances.

Patient 9 was observed on 3/15/11 at 0830 and 1100 hours in Lounge A with a CNA in attendance. The patient was sitting in the wheelchair with a lap buddy in place.

Review of the medical record showed a care plan developed to address the risk of falls for Patient 9. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. However, there were no interventions listed to show when and how the lap buddy was to be used and for what reason. There was no plan developed to ensure the patient had planned times without the device.

3. On 3/14/11 at 1345 hours, Patient 25 was observed sitting in a gerichair calling out for a nurse. At 1350 hours, staff members were observed to move Patient 25 back to her room.

On 3/14/11 at 1420 hours, during an interview, CNA 5 stated the Patient 25 was placed in the gerichair in the morning until after lunch, about 0700 hours to 1300 hours. On 3/14/11 at 1514 hours, during a follow up interview, CNA 5 stated a lap buddy was also used to protect the patient from falling from the wheelchair. When asked for more specific information on how the lap buddy protected the patient from a fall, CNA 5 stated the patient would try to get out of the wheelchair. When asked if the patient could remove the lap buddy, the CNA did not answer, stating the patient did not have the lap buddy with the gerichair and could not get out from the gerichair. The CNA stated she was unable to recall how long Patient 25 had used the gerichair.

Patient 25's medical record was reviewed on 3/14/11. The patient was admitted to the hospital on 2/21/11 with diagnoses which included dementia.

Review of 24-Hour Licensed Nursing note dated 2/24/11, showed Patient 25 had episodes of restlessness, constantly calling "madame," and tried to remove lap buddy. Review of the Interdisciplinary Progress Notes dated 2/25/11 at 1630 hours, showed the patient was observed sitting up in the wheelchair, fidgeting with the lap buddy. The 24-Hour Licensed Nursing Note dated 3/2/11, the licensed nurse documented the patient was in the wheelchair at 1430 hours, was confused, screaming loudly and was disruptive.

The Patient Progress Record dated 3/7/11 at 1530 hours, showed Patient 25 was in the gerichair, yelling, wanting to go to bed. Review of the Master Interdisciplinary Treatment Plan Review dated 3/10/11, showed the IDT documented the patient attended most morning groups but was excused for bed rest in the afternoon under Groups/ Milieu participation.

Review of the plan of care showed a care plan was developed on 2/21/11, to address the risk of fall for Patient 25. The pre-printed list of interventions on the care plan included the use of a lap buddy for safety. However, there were no interventions listed to show when and how the lap buddy was to be used and for what reason. There was no plan developed to ensure the patient had planned times without the device. The use of the gerichair was not addressed in the plan of care.

On 3/15/11 at 1625 hours, CNA 6 was interviewed. When asked how long Patient 25 would be in the gerichair during the day, the CNA stated if the patient was in the gerichair when the shift began, the evening shift staff would not place the patient back in bed until after dinner, at about 1900 hours.

Based on interview and medical record review, the hospital failed to ensure the medical record for two of 30 sampled patients (Patients 1 and 23), documented the use of lap buddy devices, which had the potential to be restraints for the patients.

Findings:

1. Patient 23 was observed in her room on 3/14/11 at 0815 and 0950 hours. The patient was sitting in a wheelchair with a lap buddy in place.

The medical record for Patient 23 was reviewed on 3/14/11 at 1025 hours. The patient was admitted to the hospital on 3/9/11 with confusion and disorientation.

Review of the CNA Flowsheets for Patient 23 dated 3/9 to 3/14/11, showed the patient's behavior was confused, she was able to change position in bed by herself, and she ambulated with a wheelchair. There was no documentation a lap buddy was used for the patient. Review of the Licensed Nursing Notes and Interdisciplinary Progress Notes dated 3/9 to 3/14/11, did not show documentation of the use of a lap buddy for the patient.

RN 6 was interviewed on 3/14/11 at 1045 hours. The RN stated a lap buddy was used for Patient 23 because the patient would rock forward and try to get up out of the wheelchair. The RN stated the patient was a fall risk. When asked to review nursing documentation, RN 6 stated she was unable to locate documentation to show the lap buddy was used for the patient.

2. On 3/14/11 at 0900 hours, Patient 1 was observed in his room sitting in a wheelchair with a lap buddy device in place.

Review of the medical record for Patient 1 began on 3/15/11, and showed he had a left hemiparesis (weakness on left side). There was no documentation in the medical record Patient 1 was assessed for use of the lap buddy. In addition, there was no nursing documentation to show the application, use, or need for the device.

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Based on observation, interview and record review, the hospital failed to ensure one of one sampled patients receiving tube feedings (Patient 23) received the amount of nutrition via her GT (gastrostomy tube, a feeding tube inserted through the skin and the stomach wall, directly into the stomach) as ordered by the physician, resulting in the potential for the patient to experience weight loss and poor nutrition.

Findings:

Review of the P&P for Tube Feeding dated 10/15/10, showed a physician's order would be obtained for GT feeding. The patient would be assessed for residual (amount of formula remaining in the stomach), if greater than 100 ml, the feeding would be held and the physician notified. The type and total amount of the GT feeding administered per shift would be documented on the MAR (Medication Administration Record).

During an initial tour of the hospital on 3/14/11 at 0815 hours, Patient 23 was observed sitting in a wheelchair in her room. At her bedside was a tube feeding set up. A 1500 ml bottle of Jevity 1.2 formula was hanging with 750 ml left in the bottle. The bottle was labeled as hung on 3/13/11 at 0710 hours and was to infuse at a rate of 65 ml per hour. The GT feeding was not connected to the patient at this time. A sign at the patient's bedside indicated she was to have nothing by mouth.

The medical record for Patient 23 was reviewed on 3/14/11. Review of the physician's orders showed an order dated 3/10/11 for GT feedings of Jevity 1.2 at 65 ml per hour for 20 hours daily, in order to provide 1560 Kcal and 1300 ml. If the residual was more than 100 ml, the feedings were to be held for one hour, than resume the feeding.

RN 6 was interviewed on 3/14/11 at 1045 hours. When asked, the RN stated GT feedings were turned off at 0800 hours and resumed at 1200 hours. The RN was asked to review Patient 23's MAR to show documentation of the amount of feeding received by the patient since 0710 hours on 3/13/11. After reviewing the MAR the RN stated the amount of feeding received by the patient had not been documented. The RN stated the licensed nurses only documented when a new bottle of formula was hung and/or when a feeding was started and stopped. RN 6 stated she had not been taught by the hospital to document the total amount of feeding received by the patient in the medical record. Review of the 24 Hour Licensed Nursing Note dated 3/13/11 at 1450 hours, showed the noon feeding was held as the patient had a residual of more than 120 ml. The feeding was resumed prior to the end of the shift. Review of the MAR showed the feeding was resumed at 1400 hours. Review of the licensed nurse documentation for the 3/13/11 evening and night shifts, did not show documentation the feedings were interrupted for an increased residual.

On 3/14/11 at 1050 hours, RN 6 was asked to observe the GT set up for Patient 23 with the surveyor. The RN confirmed, if the bottle was hung at 0710 hours on 3/13/11, at an infusion rate of 65 ml per hour, the patient should have received approximately 1235 ml over the possible 19 hours. The RN confirmed only 750 ml were infused during that same time period. RN 6 stated she did not know why the patient did not receive the tube feeding as ordered.

The DPCS was interviewed on 3/14/11 at 1100 hours. The DPCS confirmed the hospital's P&P required the licensed nurse to document the total GT feeding received by a patient for each shift on the MAR. The DPCS stated she had inserviced staff in January, 2011, during staff meetings.

Review of the POC (plan of correction) dated 10/28/10, for the previous CMS Recertification survey, exit date 10/29/10, showed the hospital would inservice the licensed nurses to document the amount of tube feeding each shift on the MAR. The RN would calculate the amount of tube feeding administered each shift was accurate. If a different amount was administered for a particular reason, the justification would be documented in the Interdisciplinary Progress Notes and the information would be communicated to the next shift.

During a follow up interview with the DPCS on 3/16/11 at 0835, the DPCS was asked to confirm no inservices regarding the P&P for Tube Feeding had been conducted for the licensed nurses until January, 2011. The DPCS stated she would attempt to locate documentation. In addition, the DPCS stated the 3/13/11, evening shift RN for Patient 23 had been contacted. The DPCS stated the RN had stated Patient 23 had a residual formula of over 100 ml and the feedings had been held as per physician's order. However, the DPCS confirmed there was no documentation in the patient's medical record to show the GT feedings were not being tolerated by the patient.

The COO was interviewed on 3/16/11 at 0900 hours. The COO stated no inservicing of the licensed nurses had been done previous to the POC date of 10/28/10. The COO stated the survey document was not received by the hospital until February, 2011, to know the details of the deficiency. When the COO was informed the revision date on the P&P for Tube Feedings was dated 10/15/10, he did not answer.

Based on observation, interview and record review, the hospital failed to ensure the P&Ps for hand hygiene and the handling of body secretions were implemented to protect patients from cross contamination by healthcare workers. A phlebotomist was observed drawing blood samples from patients without wearing proper gloves. The phlebotomist failed to wash her hands after having direct, physical contact with patients. A CNA was observed handling clean water pitchers while collecting soiled linens from patient rooms without sanitizing his hands prior to the handling of the water pitchers. A LVN was observed to place soiled washcloths removed from a patient's room on top of a medication cart before discarding them. The LVN then used the top of the medication cart to prepare medications for another patient without sanitizing it.

Findings:

The hospital P&P Hand Hygiene showed handwashing was the single most effective measure to prevent transmission of infection. Handwashing was to be done prior to and following patient contact and contact with any potentially infectious material.

The P&P for Standard Precautions showed this policy applied to all patients receiving care in the hospital, regardless of their diagnosis. Handle used patient care equipment soiled with body fluids in a manner that prevents exposure and transfer of microorganisms to other patients and environments. Environmental surfaces were to be adequately cleaned and disinfected.

These P&Ps were not implemented as follows:

1. Phlebotomist A was observed in the Activity Lounge on 3/15/11 beginning at 0840 hours. The phlebotomist was preparing to draw blood from Patient 23. The phlebotomist knelt down on her knees in front of Patient 23, inspected her arm and hand and proceeded to draw blood work from the patient. The phlebotomist did not wear gloves to draw the patient's blood. When finished, the phlebotomist completed her paperwork and put the vials of blood in the box sitting on a wheeled table. A CNA was in attendance in the lounge throughout the procedure and he did not intervene. The phlebotomist then pushed the table out of the lounge.

At 0846 hours, Phlebotomist A was observed to leave the Activity Lounge and enter Patient 15's room. Phlebotomist A was observed preparing to perform venipuncture. The phlebotomist was wearing no gloves as she performed her inspection of the arm for suitable veins. She touched the arm, held it in her bare hands, and placed a blue tourniquet around the left arm as she continued her inspection. The phlebotomist had a tray that contained equipment for drawing blood specimens and transporting laboratory specimens. From the tray, she was observed to handle needles, blood collection tubes, and other equipment. She prepared the site on the patient's arm to obtain the blood specimen without wearing gloves.

The phlebotomist did not wash her hands before entering the patient's room. The phlebotomist inspected the patient's arm and placed a tourniquet on the arm. The phlebotomist selected her supplies from a tray of equipment and proceeded to draw the patient's blood. The phlebotomist did not wear gloves during the procedure. A licensed nurse entered the room to check on the patient during the procedure and did not intervene. The phlebotomist did not wash her hands before leaving the patient's room.

At 0900 hours, the phlebotomist then entered Patient 28's room with her supplies. The phlebotomist did not wash her hands before entering the room. The phlebotomist inspected the patient's arm. At this time she left the patient and entered the bathroom inside the room. The phlebotomist applied a tourniquet and drew the patient's blood without wearing gloves. The phlebotomist put the blood vials into a plastic bag and then dropped the bag and the paperwork on the floor. She picked the bag and paper off the floor and put them into her supply box and exited the room without washing her hands.

The phlebotomist entered the nursing station and filed her laboratory requisition papers in a notebook. She touched laboratory request logs, records, and other objects in the nursing station and then left the nursing station. She was not observed to wash her hands.

Phlebotomist A was interviewed on 3/15/11 at 0910 hours. The phlebotomist was informed she was observed drawing blood work from patients without wearing gloves and washing her hands before and after contact. The phlebotomist stated she had brought only powdered gloves with her and she was unable to wear them. The phlebotomist stated she had a hand gel with her to sanitize her hands, but when informed she was not observed to use it, stated no she had not. When asked, the phlebotomist stated she had drawn blood from seven patients that morning.

2. On 3/15/11 at 0900 hours, a CNA was observed pushing a cart containing 14 clean water pitchers and a stack of wash clothes with one hand and with the other hand he pulled a soiled linen/trash cart. The CNA was observed to enter a four bed room where he straightened the bed linen and then exited the room carrying washcloths which he placed in the soiled linen cart. The CNA then picked up a clean water pitcher and wash clothes and reentered the room. The CNA was not observed to wash his hands in between the handling of soiled linen and the clean water pitcher. During the observation the CNA repeated this procedure for the remaining patients in the room and then proceeded to the next room to do the same. At no time did the CNA wash his hands.

3. On 3/15/11 at 0920 hours, observation showed LVN 3 preparing medications for Patient 28. At 0928 hours, LVN 3 exited the room with washcloths in her hand, placing the washcloths on the top of the medication cart. The LVN pushed the cart to the nursing station. The LVN washed her hands in the sink inside the nursing station. Close observation of the washcloths showed two washcloths had a pinkish substance on them. After washing her hands the LVN picked up the washcloths from the top of the medication cart and placed them in the soiled linen container in the hall way. At 0930 hours, when asked what the washcloths were used for, the LVN stated she used them to absorb a spill from Patient 28's GT when administering his medications. Continuous observation did not show the LVN sanitized the top of the medication cart where the soiled washcloths had been placed.

On 3/15/11 at 0935 hours, observation showed the LVN placed a medication patch directly on the top of the medication cart to write on it. When asked, the LVN stated the medication patch was prepared for Patient 29.

During an interview with the Director of PI and the Director of Infection Control on 3/16/11 at 1020 hours, the survey team discussed concerns with the observation of the CNA not washing hands. The findings of the previous CMS Recertification survey at the hospital, exit date 9/29/10, contained similar findings. The Director of Infection Control stated audits of staff observed for hand washing were initiated in February, 2011. Statistics were reported and showed staff was washing hands 71% of the time. Before care of patients the staff washed hands only 53% of the time. When asked how the observer handled the non compliance, the Director of Infection Control stated the staff was immediately corrected.


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