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Based on observation, interview, record review and document review, the facility failed to ensure the use of restraints was in accordance with the plan of care for 1 of 82 sampled patients (Patient #34).

Findings include:

Patient #34 was admitted 6/1/10, with diagnoses including gunshot wound to head, gunshot wound to the left lower extremity, and gunshot wound to the right extremity thigh.

On 6/15/10 in the morning, it was observed the patient had a right wrist restraint.

On 6/17/10, the patient had a right wrist restraint.

On 6/18/10 in the morning, the patient had a mitt over the right hand and was secured with tape around the wrist.

On 6/18/10 in the morning, the Charge Nurse indicated the purpose of the mitt was to prevent the patient from pulling out the tracheostomy tube and IV (intravenous) line. The Charge Nurse further indicated the facility did not consider the mitt as a physical restraint, due to the fact the patient was still able to move her hand and arm from side to side.

On 6/18/10 in the early afternoon, the Chief Nursing Officer (CNO) verified the facility did not consider the use of a mitt as a physical restraint.

The written plan of care regarding the restraint documented the following:

Date: 6/2/10;
Identified Need/Problem: Potential for Injuries;
Goal/Outcome: Pt will remain free from injury during hospitalization;
Interventions: Monitor for orientation, initiate fall precaution. Restraint prn (as needed). Follow restraint protocol...

The Restraint Policy and Procedure (Effective - 12/90, and revised 10/09) stated as follows:

"Definitions: Restraint: Any manual, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient of (sic) move his arms, legs, and body or head freely.

Implementation: Use of Restraint:...Use of restraint requires at minimum a written modification/review to the patient's plan of care with each assigned nurse's daily assessment to determine: The patient's reaction to the intervention; the patient's medical and behavioral condition; the need to continue or terminate the restraint.

Performance Improvement:
1. Restraint use is documented in the medical record and includes the following:
...Description of patient's behavior and intervention used...-Any alternatives or less restrictive interventions attempted...-Revision to the plan of care... "

There was no documented evidence of a written plan of care specifically regarding the use of the wrist restraint and hand mitt for Patient #34, as well as the specific measures and goals/outcomes. There was no documented evidence of a written updated care plan after the type of restraint was changed from the right wrist restraint to the mitt.

Based on observation, record review, and document review, the facility failed to ensure there was a physician's order for the use of restraints for 2 of 82 patients (Patient #34 and #26).

Findings include:

1. Patient #34 was admitted 6/1/10, with diagnoses including gunshot wound to the head, gunshot wound to the left lower extremity, and gunshot wound to the right extremity thigh.

On 6/15/10 in the morning, Patient #34 was observed with a right wrist restraint.

On 6/17/10, the patient was observed with a right wrist restraint.

On 6/18/10 in the morning, the patient was observed with a mitt over the right hand and secured with tape around the wrist.

The Restraint Policy & Procedure (Effective 12/90 and revised 10/09) stated as follows:

"...Attending Physician or Licensed Independent Practitioner's Role:
2. Determine that restraints are appropriate and necessary and less restrictive treatment is not feasible.
3C. If necessary, provides a new written order.

Performance Improvement:
1. Restraint use is documented in the medical record and includes the following:
...-Identity of physician/LIP who ordered restraint, -Orders for restraint...

Assessment and Documentation Guidelines:
Order may be written or verbal and is valid for a maximum of 24 hours if written by physician...
MD (Doctor of Medicine) Face-to-Face Re-evaluation: Must occur a minimum of every 24 hours..."

The Restraint Assessment Forms indicated the following:

6/5/10: Right wrist restraint. No documented evidence of a physician's order.
6/7/10: Left and right wrist restraint: No documented evidence of the date and time of the physician's order.
6/9/10: Left and right wrist restraint. No documented evidence of a physician's order.
6/11/10: Right wrist restraint: No documented evidence of a physician's order.

6/18/10: Right hand mitt: No documented evidence of a physician's order. The Interdisciplinary Progress Notes IPOC Evaluation Record (completed by the RN (Registered Nurse), dated 6/18/10, 0900 (9:00 AM), stated, "R (right) hand/wrist restraint dc'd (discontinued). Changed to mittens. Explained to the pt (patient). Pt understood gave us a thumbs up. We'll continue monitoring."


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2. Patient #26 was admitted to the facility on 5/30/10, with diagnosis including burns to bilateral lower extremities.

The Restraint Assessment and Physician Orders, dated 6/12/10, contained documentation where two Registered Nurses had signed the form for the use of a left wrist restraint. There was no documentation on the form regarding the medical justification for the use of the restraint, whether a telephone order or verbal order had been received for the wrist restraints or a physician's signature with the time a date for the use of the wrist restraint. The document contained a statement underneath the line for the physician's signature indicating, "By my signature, I attest the need for restraints and have done a face-face assessment."

The restraint assessment and physician orders, dated 6/13/10, contained documentation where two Registered Nurses had signed the form for the continued use of bilateral wrist restraints. There was no documentation regarding the medical justification for the use of the restraint, whether a telephone or verbal order had been received for the bilateral wrist restraints, or a physician's signature with the time a date for the use of bilateral wrist restraints. The document contained a statement underneath the line for the physician's signature indicating,
"By my signature, I attest the need for restraints and have done a face-face assessment."

The facility's policy and procedure entitled, Use of Restraints, last revised on 10/09, documented: "...An order is obtained/written when in the clinical judgment of a nurse, attending physician and /or qualified licensed independent practitioner the patient meets the criteria for restraint...The attending physician or an independent practitioner must provide a written or verbal order for the non-violent or non self destructive behavior patient with in 24 hours."

Based on record review, and interview, the facility failed to ensure a care plan was developed and updated to ensure the needs of one out of 82 patient records reviewed was met (Patient #44).

Findings include:

Patient #44 was a 3 year old who was admitted on 6/14/10, with diagnoses including second degree burns on her hand.

The physician's History and Physical, dated 6/14/10, indicated, "...circumstances around this injury are largely unknown as is the timeline. The patient's father reports this happened yesterday, but Child Protective Services believes this may have happened as much as 1 week ago."

The Discharge Planning Notes by the Licensed Social Worker (LSW), dated 6/15/10, revealed Child Protective Services (CPS) was notified and were following the case. The LSW notes indicated the patient was not on a hold for discharge. The LSW documented the parents do not live together and it was all right for the patient to be discharged to the mother. Additional notes indicated this case was being referred to the police for further investigation.

The Nursing Care Plan, dated 6/14/10, identified the problem - Discharge Planning. The interventions included - CPS/Police hold clearance. There were no interventions listed which indicated the patient was only to be released to the care of the mother.

There was no problem listed with interventions to maintain the safety of the patient by monitoring or limiting the father's visits.

On 6/17/10 in the afternoon, the charge nurse indicated she was aware CPS was involved with this patient. The charge nurse did not know if there were any restrictions regarding visitation or discharge arrangements.

Based on interview, record and document review, the facility failed to follow their policy and procedure on Blood Transfusions for 3 (Patient #8, #25 and #82) of 82 patient records reviewed.

Findings include:

1. Patient #82 was admitted to the facility on 6/15/10, with diagnoses including status post exploration/removal of hardware T-12 - L1, T-11, T-12, Lumbosacral disc degeneration.

The physician's order sheet, dated 6/16/10, had an order to transfuse 2 units of PRBC
(Packed red blood cells). The Physician's order lacked a specific reason for the transfusion and the rate of infusion.

On 6/17/10 at 8:20 AM, a Registered Nurse verbalized if a physician did not specify over how many hours the blood was to be transfused, we follow our hospital policy and procedure, which was to transfuse over 4 hours.

The facility's policy on Administration of Blood transfusions, last revised on 7/09, documented: "There will be a written physician order specifying the reason for the transfusion (restoration or circulating blood volume, replacement of clotting factors, improving oxygen carrying capacity), the component and amount to be transfused, the rate of infusion, and any special requirements."


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2. Patient #8 was admitted to the facility on 6/8/10, with diagnoses of a subarachnoid hemorrhage and bilateral open tibial fractures due to a motor vehicle accident. Patient #8 was intubated on a ventilator.

The physician's orders, dated 6/11/10 at 2:30 AM, indicated, "Transfuse 2U (units) PRBC's (Packed Red Blood Cells)." The order did not specify the length of time to transfuse the PRBC's.

Documentation on the Transfusion Service Product Form, dated 6/11/10, indicated the patient received the blood as follows:
- Unit 1 transfusion started 6/11/10 at 0410 (4:10 AM); Ended 6/11/10 at 0430 (4:30 AM); Amount transfused - 295 ml (milliliters);
- Unit 2 transfusion started 6/11/10 at 0420 (4:20 AM); Ended 6/11/10 at 0430 (4:30 AM); Amount transfused - 293 ml.

The physician's orders, dated 6/11/10 at 14:30 (2:30 PM), "Transfuse 1 unit of PRB now." The order did not specify the length of time to transfuse the PRBC.

Documentation on the Transfusion Service Product Form, dated 6/11/10, indicated the patient received the blood as below:
- Unit 1 transfusion started 6/11/10 at 14:51 (2:51 PM); Ended 6/11/10 at 16:45 (4:55 PM); Amount transfused - 283 ml.

The physician's orders, dated 6/12/10 at 0140 (1:40 AM), indicated, "Transfuse 2U (units) PRBC." The order did not specify the length of time to transfuse the PRBC's.

Documentation on the Transfusion Service Product Form, dated 6/12/10, indicated the patient received the blood as below:
- Unit 1 transfusion started 6/12/10 at 1520 (3:20 PM); Ended 6/12/10 at 1600 (4:00 PM); Amount transfused - 278 ml;
- Unit 2 transfusion started 6/12/10 at 1628 (4:28 PM); Ended 6/12/10 at 1800 (6:00 PM); Amount transfused - 325 ml.

On 6/15/10 in the afternoon, the RN (Registered Nurse) on the unit indicated if there was no order by the physician that specified the rate of the transfusion, the nurse followed the hospital policy, which was to transfuse the blood over two hours, but not longer than four hours.


3. Patient #25 was admitted to the facility on 6/6/10, with diagnoses including aortic dissection with aortic root replacement.

The physician's order, dated 6/15/10, indicated to give 2 units PRBC (Packed Red Blood Cells). The order did not specify the length of time to transfuse the PRBC.

Documentation on the Transfusion Service Product Form, dated 6/15/10, indicated the patient received the blood as below:
- Unit 1 transfusion started 6/15/10 at 2040 (8:40 PM); Ended 6/15/10 at 2115 (9:15 PM); Amount transfused - 325 ml (milliliter);
- Unit 2 transfusion started 6/15/10 at 2130 (9:30 PM); Ended 6/15/10 at 2205 (10:05 PM); Amount transfused - 325 ml.

On 6/16/10 in the morning, the nurse on the unit indicated if there were no physician's order regarding the rate of infusion, the nurse would use her judgement.

Based on record review and document review, the facility failed to ensure physician telephone orders were signed by the physician within the designated timeframes for 2 of 82 patients (Patients #27 and #47).

Findings include:

1. Review of the medical record on 6/16/10, for Patient #27 revealed telephone orders were written on 6/11/10 at 22:05 (10:05 PM) and 6/11/10 at 22:15 (10:15 PM). The physician had not signed off the telephone orders.

2. Review of the medical record on 6/18/10, for Patient #47 revealed telephone orders were written on 6/11/10 at 1256 (12:56 PM) and 6/13/10 at 1826 (6:26 PM). The physician had not signed off the telephone orders.

The facility policy titled, "Verbal/Telephone Orders/Critical Results Read Back and Verified," last revised 8/09 specified: "...c) All other orders given over the telephone or through a verbal order process are to be co-signed by the practitioner as soon as possible, but not to exceed 48 hours..."

Based on interview, record review and document review, the facility failed to ensure a history and physical, authenticated by the physician was completed prior to surgery for one of 82 patient records reviewed (Patient #80).

Findings include:

A review of Patient #80's record revealed the patient had a surgical procedure done on 06/17/10. The history and physical located in the record lacked the physician signature, physician license number, and the date and time the history and physical was completed.

On 06/18/10 in the afternoon, the Associate Administrator of Clinical Interventions and Quality Management reviewed the record and confirmed the history and physical lacked the physician's signature, physician license number and the date and time the history and physical was completed.

The Medical And Dental Staff Bylaws, approved by the Board of Hospital Trustees on April 20, 2010, documented the following, "...Article III Medical Records...E. All clinical entries in the patient's medical record shall be accurately timed, dated and authenticated. Authentication means to establish authorship by legible hand written or electronic signatures..."

Based on the review of the Physicist's Report from 8/25/09, and interviews with the director of the radiology department and the manager of the radiology department, a potential hazard identified by the physicist was not corrected by the department.

Findings include:

Members of the radiology department pointed out the recommendation from the physicist on the physicist's report regarding the Trauma Siemens OH (serial number 0154) stating, "no tape measure, crosshairs off center" as the type of hazard which would require correction, but they were unable to locate documentation of correction of the issue.

Based on a review of the pathology department policy, "Histology Gross Only Specimens," and interviews with laboratory personnel, the medical staff was not included in the determination of the specimens that may be submitted for gross only examination when the policy was revised in 2009.

Findings include:

Laboratory personnel confirmed that the pathology department policy, "Histology Gross Only Specimens," was revised on 2/19/09, resulting in a change to the list of gross only specimens (deleted specimens, revised ages), by the laboratory director (a pathologist) without being submitted to the medical staff for input prior to the revision.

Based on a review of the pathology department's "Lookback, Recall and Market Withdrawal Procedure" the hospital did not have a complete Lookback policy.

Findings include:

The facility's Lookback policy did not include reference to:

a) Documentation in the patient's medical record of the inability to locate a patient if the patient had not been located within 12 weeks.
b) A list of programs or places where the person could obtain HIV or HCV testing and counseling, including any requirements or restrictions the program might impose.
c) Provision for the notification of a legal representative of relative, as outlined by the regulation.

Based on observation, interview and document review, the facility failed to ensure the policy and procedure for glucometer cleaning and transmission-based precautions were implemented by facility staff and appropriate materials were disposed of in the sharps container.

Findings include:

1. On 06/15/10 at 1:50 PM, observation of blood glucose monitoring revealed the glucometer was not cleaned after use on a patient.

On 06/15/10, a Licensed Nurse and a Nurse Manager indicated the glucometer was cleaned daily with Sani-master wipes.

On 06/16/10 in the morning, a Licensed Nurse indicated the glucometer was cleaned once a week with Sani-wipes, unless the glucometer was visibly soiled.

On 06/16/10 at 1:00 PM, the Director of Infection Control and a Infection Preventionist indicated the glucometer was to be cleaned after each patient use, per the facility policy.

On 06/18/10 at 11:00 AM, the Clinical Education Coordinator indicated the facility followed The Joint Commission recommendations. Nursing staff was educated during initial nursing orientation and during annual training to clean the glucometer after each patient use, per The Joint Commission recommendations.

The facility "Blood Glucose Monitoring Quality Control and Technique" policy, dated 3/97, and revised on 2/09, documented the following: "...Maintenance and Cleaning: Note: The Joint Commission recommends cleaning after each patient for infection control..."


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On 6/15/10 in the afternoon, observed a Licensed nurse (LN) check a patient's blood sugar using a glucometer. The LN washed her hands and applied gloves. The patient was in Contact Isolation. The LN placed a plastic sleeve over the glucometer. The top of the glucometer, where the testing strip was inserted, remained open. The LN did not wash down the glucometer before or after she checked the patient's blood sugar.

The LN verbalized there were no wipes available to clean off the glucometer. She added, in the past, the LN cleaned the glucometer with alcohol swabs, but now must use the PDI - Super Sanitizer wipes. The LN was unable to locate those wipes on the unit.


2. Patient #24 was admitted to the facility on 6/15/10, with diagnoses including chest pain, shortness of breath, diabetes and Lupus.

Review of the patient's history and physical, dated 6/15/10, revealed the patient was having diarrhea 3-4 episodes a day. The physician's assessment/plan documented, "... 2. Regarding the diarrhea, due to recent antibiotic exposure, Clostridium difficile (C-Diff) is going to be obtained..."

The physicians's order, dated 6/16/10 at 10:00 AM, included, "Stool cultures, WBC (White Blood Cell), C-Diff ."

On 6/16/10 at 3:00 PM, Patient #24 was in her room. There were no Isolation Precautions in place including a sign outside the patient's room or personal protective equipment, such as gowns and gloves.

The charge nurse indicated she had seen the order for the stool for C-diff in the morning.

The staff nurse indicated Patient # 24 was having liquid stools, but she had not been able to obtain a stool specimen.

The Director of Infection Control, who was on the unit, verbalized a patient should be placed on Contact precautions as soon as C-Diff was suspected. The facility did not wait until a stool specimen came back positive. The Director of Infection Control instructed the charge nurse to place Patient #24 on Contact Precautions.

On 6/17/10 at 1:00 PM, there was no Isolation protective equipment noted outside of Patient #24's room.

On 6/18/10 at 8:00 AM, there was no Isolation protective equipment outside of Patient #24's room.

On 6/18/10 at 2:00 PM, the Isolation cart was observed outside of Patient #24's room. There was also a sign which indicated, "Contact Precautions."

The nurse on the unit confirmed the Contact precautions were initiated the morning of 6/18/10.

The facility policy titled, "Contact Precautions," last revised 12/09 indicated:
- "Instances where contact precautions apply are as follows:
A. When a patient is suspected, colonized and/or infected with multiple drug-resistant (MDRO) organisms.
B. When a particular organism is identified as being potentially hazardous because of its pathogenicity, virulence, or epidemiologic characteristics, e.g. rotavirus, Shigella sp., Clostridium difficile, etc..."
-"Personal Protective Equipment (PPE)
1. Follow Standard Precautions.
2. Wear gowns and gloves for all contact with the patient, the patient's bedside equipment. PPE must be worn upon crossing the threshold to the room/isolation space.
3. Wear a disposable gown for all contact with the patient, or the patient's bedside equipment."


3. On 6/15/10 at 11:00 AM, in the Trauma Resuscitation unit, a very large sharps container was observed near the nurse's station. The sharps container was full with dressings, suture materials and syringes. The top was open and the needles and syringes were accessible.

The nurse on the unit indicated all the items should not have been placed in the sharps container. She added there had just been a trauma case and the residents had placed everything in the container.

Based on interview, record review and document review, the facility failed to ensure a history and physical, authenticated by the physician, was completed prior to surgery for one of 82 patient records reviewed (Patient #80).

Findings include:

A review of Patient #80's record revealed the patient had a surgical procedure done on 06/17/10. The history and physical located in the record lacked the physician signature, physician license number, and the date and time the history and physical was completed.

On 06/18/10 in the afternoon, the Associate Administrator of Clinical Interventions and Quality Management reviewed the record and confirmed the history and physical lacked the physician's signature, physician license number and the date and time the history and physical was completed.

The Medical And Dental Staff Bylaws, approved by the Board of Hospital Trustees on April 20, 2010, documented the following, "...Article III Medical Records...E. All clinical entries in the patient's medical record shall be accurately timed, dated and authenticated. Authentication means to establish authorship by legible hand written or electronic signatures..."

Based on interview, record review and document review, the facility failed to ensure an operative report was completed for one of 82 patient records reviewed (Patient #80).

Findings include:

A review of Patient #80's record revealed the Post Operative report, dated 06/17/10, lacked a description of the findings, complications due to procedure and/or sedation, estimated blood loss, specimens obtained and if the patient had any drains.

On 06/18/10 in the afternoon, the Associate Administrator of Clinical Interventions and Quality Management reviewed the record and confirmed the operative report was missing a description of the findings, complications due to procedure and/or sedation, estimated blood loss, specimens obtained and if the patient had any drains.

The Medical and Dental Staff Bylaws, approved by the Board of Hospital Trustees on April 20, 2010, documented the following, "...Article III Medical Records...M. Operation Report: 1. Upon completion of the operation and prior to the patient leaving the operating suite, the surgeon shall note briefly in the progress notes the operation performed and the absence or presence of complications, to include: a) Name of primary surgeon and assistants, b) Findings, c) Procedure(s) performed and description of procedure, d) Estimated blood loss, e) Specimen(s) removed and specimen disposition, f) Post-operative diagnosis, g) Date and time of progress notes..."

Based on the observation of a respiratory department staff member with an unlabeled arterial blood specimen in her hand in the blood gas laboratory, the respiratory care unit did not meet the applicable requirements for laboratory services.

Findings include:

A respiratory department staff member entered one of the hospital blood gas laboratories in the presence of the surveyor and a member of hospital administration with an unlabeled syringe containing a patient arterial blood specimen. The staff member had a label for the specimen in her hand along with other paperwork related to the specimen, but she had not put the label on the specimen at the patient's bedside.