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Based on interview and document review, the hospital failed to obtain a physician order for the use of restraints for 2 of 4 patients (P41, P42) whose restraint use was reviewed.

Findings include:
P41 was admitted to intensive care unit (ICU) from the operating room on 9/28/15, at 7:25 p.m. following a surgical procedure on a ventilator. P41's flowsheet indicated soft wrist restraints in place on right and left wrist, however, the record did not include evidence a physician's order was obtained for the use of soft wrist restraints.

P42 was admitted to ICU from the post-operative care unit on 10/4/15, at 11:00 a.m. following a surgical procedure on a ventilator. P42's flowsheet indicated soft wrist restraints in place on right and left wrist, however, the record did not include evidence a physician's order was obtained for the use of soft wrist restraints until an order was placed on 10/5/15, at 1:13 p.m.
The hospital Restraint policy (reviewed 8/21/2014), directed staff as follows: "Restraints usage is via an order from the physician."
On 12/2/15 at 12:32 p.m. registered nurse (RN)-B verified P41 had soft wrist restraints in place when admitted to the ICU and did not have a physician's order authorizing the use of the soft wrist restraints. RN-B verified P42 had soft wrist restraints in place on 10/4/15 when admitted to the ICU and did not have a physician's order authorizing the use of soft wrist restraints until 10/5/15. RN-B stated a physician's order was needed to authorize the use of restraints.

Based on observation, interview, and document review, 1 of 4 outpatient clinics observed and 2 of 3 medication rooms failed to ensure drugs were stored in secured areas to prevent unauthorized persons from obtaining access.

Findings include:

A tour of the Heartland Orthopedic Specialist Clinic was conducted on 12/1/15, at 11:40 a.m. with the administrator director of Heartland clinic (ADHC)-A and the clinical coordinator (CC)-A. An orthopedic cast room had a medication cupboard that was unlocked. The unlocked medication cupboard contained the following:
· 2 vials Lidocaine 1% 20 milliliter (ml)
· Buvacaine 0.25% 10 ml vial
· Sensorcaine MPF 0.25% 10 ml
· 4 vials Kenalog 40 milligram (mg) 1ml vial
· Celestone 30 mg per 5 ml

An interview on 12/1/15, at 11:40 a.m. with CC-A stated the medication cupboard should not be unlocked in the cast room.

On the tour in examination room 18 there was a bottle of Ether chloride 3.5 fluid ounces with ¼ solution left in bottle sitting on the counter, no staff were present in the room.

An interview on 12/1/15, at 11:50 a.m. with CC-A stated the Ether chloride should not be left on the counter in the examination room.

A facility clinic Heartland Orthopedic Specialists policy dated 7/1/11, indicated all drugs are stored in a locked storeroom, locked exam room cabinet, locked central cabinet in clinic and/or locked fridge.




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Medication Rooms:
A tour of the medical/surgical floor was completed on 12/1/15, at 9:20 a.m. and it was noted that the infusion medication room refrigerator was not locked and contained a Succinylcholine (paralytic medication) 50 mg/ml-10 ml vial and a 5 ml vial of Rocuronium (neuromuscular blocking agent used as an adjunct to general anesthesia to facilitate tracheal intubation during routine sequence induction) 10 mg/ml. The registered nurse (RN) clinical director of the medical/ surgical floor confirmed that the medications were not locked or secured and all facility nurses, housekeeping staff, and building engineers were able to access the medication room.
A tour of the labor and delivery medication room was completed on 12/3/15, at 8:30 a.m. and it was noted that there were several medications sitting unlocked on the counter of the medication room that included: Zocor (lipid lowering medication), nicorette gum , and 2 syringes of intravenous Prilosec (medication used to treat post operative nausea). Additionally, in the unlocked refrigerator there were two IV bags that contained 100 ml of normal saline with Fentanyl (narcotic analgesic) 5mg/ml and 0.125 mg/ml of Bupivicaine (numbing medication) used for epidurals in laboring patients. These IV bags were in a locked compartment affixed to a wire shelf in the dorm room size refrigerator, however, the shelf could be easily taken out of the refrigerator by simply lifting up and out with the shelf. It was also noted the unlocked medication room refrigerator contained Succinylcholine 50 mg/ml-10 ml vial and a 5 ml vial of Rocuronium 10 mg/ml. The RN clinical manager of labor and delivery was interviewed on 12/3/15, at 8:30 a.m. and confirmed that all of the nurses, housekeeping staff, and building engineers had access to the medication room thus having access to these aforementioned medications that were unlocked.
The director of nursing (DON) was interviewed on 12/3/15, at 10:20 a.m. and confirmed that all medications should be kept locked, and confirmed that a system would be developed to keep all medications locked in the medication rooms.
A policy regarding the security of the refrigerated medications Succinylcholine and Rocuronium used for rapid sequence intubation was requested and 4 policies for security of medications were provided, however, none of the policy's address security of the refrigerated Succinylcholine and Rocuronium.

Based on observation and interview, the hospital was found to be out of compliance with Life Safety Code requirements. These findings had the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tag K0025, K0029 (Bldg 1), K0052, K0076 (Bldg 2), K0029, K0052, K0062, K0130 (Bldg 3), K0052 (Bldg 4), K0018, K0019, K0022 (Bldg 5) and K0147 (Bldg 8) for additional information.