HospitalInspections.org

Based on surveyor observation, record review, policy review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation: Nursing Services relative to ensuring that licensed nurses adhere to policies and procedures relative to urinary catheters, restraint monitoring, and storage of medications.

Findings are as follows:

1. The hospital failed to ensure a physician's order is in place prior to the insertion of a urinary catheter as well as continuation of a urinary catheter, Patient ID #s 1, 2, and 3, (Refer to A-0398).

2. The hospital failed to ensure nurses follow the hospital's policy titled, "Restraints: Non-Violent Behavior" which resulted in missing restraint assessments for physician ordered restraints for 1 of 1 patient reviewed, Patient ID #1, (Refer to A-0398).

3. The hospital failed to ensure that licensed nurses follow the hospital's policy titled, "Medication Administration" relative to returning refused or unused medications to the automated medication dispensing system regarding an unlabeled nicotine patch left out at the nurse's station, (Refer to A-0398).

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to ensure licensed nurses who provide services in the hospital adhere to hospital policies and procedures relative to ensuring a physician's order is in place prior to the insertion of a urinary catheter for 3 of 6 patients reviewed, Patient ID #s 1, 2, and 3, ensuring nurses document restraint assessments for physician ordered restraints for 1 of 1 patients reviewed, Patient ID #1, and ensuring refused or unused medications are returned to the automated medication dispensing system per hospital policy.

Findings are as follows:

1. The hospital's policy titled, "Catheter Associated Urinary Tract Infection (CAUTI) Prevention" last revised on 6/2022 states in part,

" ...Policy

1. Insertion of an indwelling urinary catheter requires an order from a physician or licensed independent practitioner ...

...Procedure

...4. Removal Procedure

...4.3 Discontinue the catheter at 48 hours of insertion unless the physician enters an order to maintain the catheter in the electronic medical record.

4.4 If reordered, physician/LIP must document/check off the reason to maintain the catheter ...

...Documentation:

6.1 document catheter insertion (including the criteria, date and time, size of catheter) ..."

Record review revealed that Patient ID #1 presented to the emergency department in March of 2023 and was subsequently admitted to the hospital due to altered mental status, fever, and diarrhea.

Review of a document titled, "Urethral Catheter Coude" for Patient ID #1 revealed that a urinary catheter was placed in the emergency department on 3/23/2023 at 5:11 PM by Employee A, Registered Nurse, and removed on 3/29/2023 at 2:53 PM.

Further review of Patient ID #1' record revealed that while on 1 East, a medical surgical unit, she/he continued with a urinary catheter in place from 3/24/2023 through 3/28/2023 without a physician's order.

Patient ID #1's record failed to reveal evidence that a physician's order was obtained prior to the insertion of a urinary catheter while the patient was in the emergency department or the criteria for placement of the catheter.
Additionally, the record failed to reveal evidence that an order was obtained to continue the catheter 48 hours after it was placed per hospital policy.

During a surveyor interview on 4/6/2023 at approximately 2:00 PM with Employee A, she acknowledged that there was not an order entered for the coude tipped catheter for Patient ID #1. She further stated that Employee B, Registered Nurse, left the room to obtain the coude tipped catheter and notify the physician that an order needed to be placed for a coude tipped catheter.

During a surveyor interview on 4/4/2023 with the Infection Control Nurse, she was unable to provide evidence of an order from a physician or licensed independent practitioner for the insertion of a urinary catheter for Patient ID #1.

Record review revealed that Patient ID #2 presented to the emergency department in March of 2023 due to weakness and was subsequently admitted to the Intensive Care Unit due to alcohol withdrawal.

Patient ID #2's record revealed that a urinary catheter was placed on 3/30/2023 at 5:35 AM while the patient was in the emergency department.

Patient ID #2's record failed to reveal evidence that a physician's order was obtained prior to the placement of a urinary catheter while the patient was in the emergency department.

During a surveyor interview on 4/6/2023 at approximately 11:20 AM with the Director of Practice Improvement, she was unable to provide evidence that a physician's order was obtained prior to the placement of a urinary catheter.

Record review revealed that Patient ID #3 presented to the hospital in March of 2023.

Patient ID #3's record revealed that a urinary catheter was placed on 3/31/2023 to measure his/her urinary output as she/he was critically ill.

Further review of Patient ID #3's record revealed a physician's order dated 4/6/2023 to continue the urinary catheter, approximately 6 days after the urinary catheter was placed, not within 48 hours of placement as specified in the hospital's policy.

During a surveyor interview on 4/6/2023 with the Director of Practice Improvement, she was unable to provide evidence that an order was obtained to continue the urinary catheter for Patient ID #3 48 hours after it was placed per hospital policy.

2. The hospital 's policy titled, "Restraints: Non-Violent Behavior" last revised on 4/2022 states in part,

" ...Non violent/Medical Restraints - Restraints used for medical and post-surgical care to support healing ...

...15. Nurse monitors, assesses, and documents on the patient every two (2) hours ..."

Record review of a "Restraint Summary" and a "Restraint Documentation Flowsheet" for Patient ID #1 revealed that she/he was applied a "Mitt" for "pulling tubes." This restraint type was documented as a non-violent restraint. The restraint was applied to the left hand continuously beginning at 3 PM on 3/26/2023 through 3/28/2023 at 6:00 AM.

Record review of Patient ID #1's restraint "Flowsheet" failed to reveal evidence that between 9:00 AM on 3/27/2023 through 8:00 PM on 3/27/2023 documentation relative to patient monitoring occurred every two hours per hospital policy.

During a surveyor interview with Employee C, Licensed Practical Nurse, she revealed that she was caring for Patient ID #1 on 3/26/2023 and entered the patient's room at approximately 9:00 AM to change a wound dressing with a student nurse. During the interview she acknowledged that Patient ID #1 had a mitt on his/her left hand and revealed she noticed a soft restraint was applied to the patient's wrist and was tied to the bed and "the mitt was over it."

During a surveyor interview on 4/6/2023 with the Director of Practice Improvement, she was unable to provide evidence of documentation relative to patient monitoring between 9:00 AM on 3/27/2023 through 8:00 PM on 3/27/2023.

3. The hospital 's policy titled, "Medication Administration" last revised on 1/2023 states in part:

" ...Administration of Medication

...10) If a patient refused a medication ...

...e. Return the refused packaged medication to the appropriate bin in the Omnicell [an automated medication dispensing system] ..."

During a surveyor observation of the Behavioral Health Unit on 4/5/2023 at approximately 9:15 AM, a nicotine patch was observed inside the nurse's station at a desk. The nicotine patch was not labeled with a patient's name.

During a surveyor interview with Employee D, Registered Nurse, subsequently following the above-mentioned observation, she was unable to explain why the nicotine patch was left outside of the medication room. She indicated that the nicotine patch should have been returned to the Omnicell.

During a surveyor interview on 4/5/2023 with the ICU Nursing Director at approximately 9:20 AM, who was covering for the Behavioral Health Unit, she acknowledged that the nicotine patch should not have been left outside of the medication room.