HospitalInspections.org

Surveyor: 28267
Based on record review and interview the facility failed to ensure that restraint orders were complete and/or accurate for 8 of 15 restrained patients (#4, #5, #6, #7, #16, #18, #24, #30). Findings include:

On 9/7/10 between the hours of 0900 and 1530 during a tour of the patient units on Campus A the following was noted on "Safety/Medical Restraint Order" forms for the below listed patients:

Patient # 4- On the orders dated 9/6/10 and 9/7/10 physiologic etiologies were not addressed.
Patient # 5- On the order dated 8/31/10 physiologic etiologies were not addressed and no date and time when the physician signed the order was present.
Patient #6- On the order dated 9/1/10 the section titled " Behavior Required for Release " was incomplete. On the order dated 9/7/10 the physiologic etiologies or conditions prior to selection of restraints that would place the patient at greater risk during restraint were not addressed.
Patient #7- On the orders dated 8/30/10 and 8/31/10 physiologic etiologies were not addressed.
Patient #16- On the orders dated 9/6/10 physiologic etiologies were not addressed.

On 9/7/10 between the hours of 0900 and 1530 during a tour of the patient units on Campus A the following was noted regarding the "Behavior Management Order" restraint order form for Patient #18:
1) On all four order forms dated 9/4/10, the section titled "Behavior Required for Release " was not completed.
2) On the order form dated 9/4/10 and timed 2325 the telephone order by the RN when received and the physician ' s signature authenticating the order was documented at the same time.
3) No face to face evaluation within one hour was documented.
4)The "Prescriber Reorder/RN assessment after the initial four hours by telephone order " was signed, dated, and timed by both the RN and the physician with the same time.
5) On the order form dated 9/4/10 and timed 0725, no clinical justification was documented, no date and time of face to face was recorded and the telephone order by the RN did not indicate which doctor phoned the order was discussed with.
6) The telephone order date and time by the RN has the same date and time the physician authenticated the telephone order.
7) The order dated 9/4/10 at 1125 does not have a physician ' s signature, only a printed name, no other signatures are present. In addition, the clinical justification section was not addressed.
8) On the order form dated 9/4/10 at 1525 do not have a physician ' s signature, and the clinical justification section had no entry.

These findings were confirmed by Staff #A at the time of each finding.

On 9/8/10 at between the hours of 1100 and 1500 during a tour of the patient units on Campus B the following was noted regarding restraint orders:

Patient #24-On the forms titled " Safety/Medical Restraint Order " dated 9/7/10 and 9/8/10 no date and time of the physician ' s signature was present. This was confirmed by staff #N.
Patient #30- On the form titled " Restraint/Seclusion Order Form " the telephone order taken by the RN was not completed with a time limit for the 4-point leather behavioral restraint order. This was confirmed by staff #B and staff #U at the time of the finding.

On 9/9/10 at approximately 0900 upon review of the facility ' s policy titled " 612 Restraint of Patients on Non-Behavioral Health " it is written under section 3.1 " Patients should be assess for previous physical abuse, underlying medical conditions that would place the patient at greater risk for injury if they needed to be restrained, and known techniques/methods that would help the patient control his/her behavior. " Under section 4 it is written " A clinical assessment should be conducted for the purpose of ruling out physiological causes of agitation or maladaptive behavior. This assessment should be completed and documented at the time of the initial application and with every reapplication. " Under section 11.2 it is written " Specific behavioral goals should be included to promote release at the earliest opportunity. "

Based on record review and interview the facility failed to monitor a patient who is restrained according to hospital policy for 2 of 2 behavioral management restrained patients (#18, #30). Findings include:

The hospital policy, titled "Behavioral Health Services Restraint Policy", states in Section 3.1, "A patient in restraint must be personally checked and have the circulation of each extremity checked by nursing staff every 15 minutes. Documentation of the patient's behavior and responses to restraint and the circulation status of each extremity will be recorded on the Seclusion/Restraint Record every 15 minutes."

In Section 3.2 of the same policy, it states, "A registered nurse (RN) shall assess the mental/physical state of the restrained patient at least two times during an eight hour shift. This assessment includes an evaluation of the patient's response to restraint and readiness for release."
On 9/7/10 at approximately 1150 during a tour of the Psychiatric Unit on Campus A, staff #A stated that they are reporting a death that occurred earlier this morning (9/7/10) of patient #30. Patient #30 had been in behavioral management restraints a couple days prior to death. Upon review of the restraint order and monitoring, it was noted that on 9/4/10 while the patient was in 2 point leather restraints, there was no monitoring of the patient documented for the time 0200 to 0246, 0300 to 0400, 0400 to 0500, 0500 to 0600, and from 0600 to 0700.

On 9/8/10 at approximately 1500 during a tour of the Psychiatric Unit on Campus B, staff #U when queried regarding the frequency of assessment of a patient in 4-point leather restraints replied " it once a shift, what the doctor ordered on admission " then Staff #U was queried about what the restraint policy had written and replied " The restraint policy does not mention any timeframes. " Upon review of patient #30 ' s medical record at approximately 1500 due to presently being in 4-point leather restraints, one set of vital signs had been taken on the patient and that was at 0600. No other assessment regarding the mental/physical state of the patient by a registered nurse was documented in the medical record. In addition, the only time the patient ' s circulation was assessed between 0600 and 1400 was documented at 1215.

Based on observation, interview, and policy and procedure review the facility failed to ensure that outdated, mislabeled, or unusable medications and biologicals located on patient care units were not available for patient use. Findings include:

On 9/7/10 between the hours of 0900 and 1530 during a tour of the patient care units on Campus A the following was found:

Emergency Department
1) Zone One Nurses Station
a) Amoxicillin Clavunalate 250mg/625mg per 5 ml, 75 ml bottle that was reconstituted and dated 9/2/10 was found in the medication cupboard. The manufacturer ' s instructions specifically states once reconstituted the medication " MUST BE REFRIGERATED " . Staff #D confirmed the finding.

Fast Track
1) Medication counter
a) One open vial of Sodium Chloride was found and the manufacturer ' s label indicated " Single use vial " . Staff #D confirmed the finding and stated " I ' ll just get rid of that. "

Observation Unit adjacent to the Emergency Department
1) Medication station
a) A vial of Lidocaine 1% 20 ml was found open and not dated. Staff #D confirmed the finding.

Intensive Care Unit
1) Medication Station
a) Approximately 30 laboratory blood collection tubes with a red and clear rubber top were found in a cupboard and had expired in 2/2010. Staff #E confirmed the finding.

Unit 7 West
1) Medication Room
a) A gallon size Ziploc bag was found on the third shelf next to some papers and office supplies with a 60cc syringe labeled by pharmacy with a patient label that was no longer admitted to the unit that contained Dextrose and two vials of Hydralazine. Staff # J confirmed the finding and stated " I don ' t why that is there, that patient isn ' t here anymore, that should not be there. "

Campus B the following was found:

Intensive Care Unit
1) Medication Room
a) A 16 ounce bottle of Hydrogen Peroxide was found in the medication cupboard open and not dated.
b) A 16 ounce bottle of Isopropyl Alcohol was found in the medication cupboard open and not dated.
These findings were confirmed by Staff # B and stated " When these are opened they should be dated and are only good for 28 days. "

Unit 6 Tower
1) Patient Room 602
a) An orange tablet with a mushroom T shape was found on the patient ' s over-bed table in a plastic medication cup. The patient room was found empty and staff #S stated " the patient is probably in surgery. "

On 9/7/10 at approximately 1615 upon review of the facility ' s policy titled " Multiple Dose Vials " it is written under section 2 " Whenever an MDV is first opened, the individual opening the vial shall indicate the date (month/day/year) on the vial by either writing directly on the vial label or attaching a label with this information. " And under section 3 " All vials which require refrigeration must be kept in the refrigerator when not in use "

On 9/9/10 at approximately 1000 upon review of the facility's policy titled "Drug Storage In The Hospital" under section 4 it is written, " Drugs are to be kept in secure storage areas."

This citation was not verified as corrected during the 9/9/10 revisit survey.
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Adequate lighting was not provided to support various tasks as listed below:

1. Levels of artificial illumination were measured and did not meet standards at the Oakland campus as follows:
a. Only 60 - 80 footcandles (fc) in operating room #5 versus the required 150 fc;
b. Only 12 fc in radiology room #2 versus the required 30 fc;
c. Only 7 fc in the 5th floor common shower versus the required 30 fc.

2. Levels of artificial illumination were measured and did not meet standards at the Macomb campus as follows:
a. Only 45 - 95 footcandles (fc) in operating room #7 versus the required 150 fc;
b. Only 2 fc in 4 Center and 5 Center equipment storage rooms versus the required 20 fc;
c. Only 6 fc in the 5 Center common shower versus the required 30 fc;
d. Only 7 fc in the toilet room serving patient room 553 versus the required 30 fc;
e. Only 4 fc in the 5 West common shower versus the required 30 fc;
f. Only 23 fc in the 4 Center common shower versus the required 30 fc;
g. Only 4 fc in the 4 West common male shower versus the required 30 fc.