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Based on policy review, clinical record review and interview, it was determined the Facility failed to ensure physician orders were obtained for restraints for two (#7 and #10) of seven (#7-#13) patients in restraints. Failure to obtain physician orders for restraints did not allow the physician to be knowledgeable of the patient's need for restraints. The failed practice had the potential to affect any patient in restraints. Findings follow.

A. Review of policy titled "Restraint and Seclusion" stated, "Orders for non-violent restraints must be renewed daily."

B. Review of the clinical record for Patient #7 revealed he was in restraints from 1933 on 08/18/15 through 1200 on 08/28/15. The clinical record revealed no evidence of a physician order for restraints on 08/19/15 and 08/20/15.

C. Review of the clinical record for Patient #10 revealed he was in restraints from 0200 on 08/03/15 through 2200 on 08/13/15. The clinical record revealed no evidence of a physician order for restraints on 08/05/15, 08/11/15 and 08/13/15.

D. Registered Nurse #3 confirmed the lack of physician orders for restraints during the time of clinical record review on 09/09/15 from 1410 through 1430.

Based on observations and interviews, it was determined the Facility failed to ensure the proper cleaning, disinfecting techniques, storage and OR (operating room) attire were utilized by Facility staff. Failure to ensure equipment was cleaned and disinfected as well as ensuring OR staff were utilizing correct attire had the potential to allow the development and spread of infections. The failed practice affected Patient #14, #15, #16 and any patient who received intravenous medications from Certified Registered Nurse Anesthesist #2. Findings follow:

A. During the Facility tour at 11:00 AM (ante-meridian) on 09/08/15, the following supplies were observed to be sitting on the floor of the clean supply room on the 4E Unit: Similac soy three unopened cases;
Similac Neosure one unopened case, three four-packs in a case; and
Three cases of Capri Plus Maxi (160 per case).
During an interview at 11:00 on 09/08/15 with the Director of 4 E she verified the findings in A.

B. During observation of the cleaning of an occupied room (Patient #14 in Room #3006) at 1340 on 09/08/15, Housekeeper #2 was observed to use a wipe to clean the toilet and then use the same wipe to clean up the piping and flush handle.
During an interview at 1340 on 09/08/15 with Housekeeper #2 and the Manager of Environmental Services they verified the findings in B.

C. During observation of a ventilator treatment (Patient #16 in Surgical Intensive Care Unit #4) at 1520 the Respiratory Therapist was observed to listen to the patient's lungs before and after the ventilator treatment. Respiratory Therapist was asked when she exited the room when she cleaned her stethoscope as she had not yet cleaned it. The Respiratory Therapist stated she cleaned it after every second or third patient.
During an interview with the Chief Nursing Officer at 1530 on 09/08/15 she verified the findings in C.

D. During observation of a Peripherally Inserted Central Catheter (PICC) for Patient #15 at 1550 on 09/08/15 Registered Nurse (RN) #1 was observed to don exam gloves, tear the perforated end off of the sterile pack and place the perforated strip in the trash can. RN #1 picked up the trash can with her right gloved hand and moved it closer to the over-bed table. RN #1 then reached into the sterile pack with her right hand and removed it from the outer clear package - without changing the glove on her right hand. During an interview with the Vice President of Women and Children's Services and RN #1 at 1640 on 09/08/15 they verified the findings in D.

E. During observation of Patient #17's surgical procedure (left total knee) at 1145 on 09/09/15 RN #2, CRNA #1, student nurse (D) and physician's assistant were all observed to be wearing cloth hair covers. During an interview with RN #2 at 1315 she was asked how her cloth hair cover was laundered and she stated she took it home and washed it. During an interview with CRNA #1 at 1400 she was asked how her cloth hair cover was laundered and she stated she pitched it in the dirty basket in the locker room. After the procedure was completed CRNA #2 was setting up for his patient and was asked how his cloth hair cover was laundered. CRNA #2 stated he had a clean one for each day and took them all home on Friday, laundered them and brought them back on Monday.
During an interview with the Infection Control Nurse and Vice President of Women and Children's Services at 1500 on 09/09/15 they were asked how the cloth hair covers should be laundered. The Infection Control Nurse stated the cloth hair covers should be laundered by the Facility as they were covered under the policy for OR attire.

F. Observation of CRNA #2 at 1400 on 09/09/15 revealed he removed the cap from medication vials of Versed, Fentanyl, Propofol, Rocuronium, Ephedrine and Phenylephrine then withdrew the medications with needles/syringes without cleansing the top of the vials first. During an interview with the Director of Surgical Services at 1405 on 09/09/15 he stated the vials should be cleansed before the needle was inserted and verified the findings in F.
An interview was conducted with the Director of Pharmacy at 1435 on 09/09/15 and he stated all medication vials should be cleansed with alcohol before the medication was removed.