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Based on observation, interview, and record review the facility failed to obtain an order for restraints for one of five patients (P-1), failed to document restraint use for one of five patients (P-1), and failed to assess a patient during restraint use for one of five patients (P-1), and failed to provide restraint training for one of four employees (staff Q) resulting in the improper use of restraints. Findings include:

The facility failed to ensure restraint orders, assessments, documentation occurred for a patient in restraint and failed to ensure all staff were trained in restraint use. See specific tag A-0154.

Based on observation, interview, and record review the facility failed to obtain orders for restraint use for one of five patients (P-1), failed to document restraint use for one of five patients (P-1), failed to assess for one of five patients (P-1) during restraint use, and failed to ensure one of four staff members (staff Q) received restraint training resulting in the potential for less than optimal outcomes for a patient in restraints. Findings include:

A record review of P-1's electronic medical record occurred on 2/7/2024 at 1300. The review failed to identify orders for restraint and failed to reflect documentation by nursing staff referencing restraint use.

A review of the facility's complaint and grievance log from 8/1/2023 to 2/7/2024 was conducted on 2/7/2024 at 1400. During review of the log the patient of concern (P-1) was identified on the log with a grievance filed on 11/6/2023. The grievance stated P-1's spouse and daughters filed a grievance regarding the use of restraint for P-1, and P-1 being held down during the night of 11/3/2023. Through the investigation of the grievance filed with the facility, staff M the unit manager was able to determine mitts were placed on the patient but "not tied" therefore the mitts had not been considered a restraint. Further documentation stated the patient "managed to bite them off" and that the nurse, staff Q "tried to replace the mitts," but was unsuccessful. Staff M was unable to establish P-1 was held down by 3-4 employees. Documentation of findings by staff M stated that a transfer of P-1 from a cart to his bed which involved 3 employees.

On 2/8/2024 at 1000, a tour of the post-surgical unit occurred. Observation of P-10 in restraints no concerns were identified.

On 2/8/2024 at 1010, while on tour staff were queried about restraint orders and restraint use. Staff were also queried if not tying restraints negated the need for a restraint order. Staff interviewed were able to explain the need for a restraint order, the proper use of restraints, and when restraints use were to be discontinued. No concerns were noted during the interviews. Staff Q was no longer employed by the facility.

On 2/8/2024 at 1025, an interview was conducted with staff M, the unit manager. Staff M was asked to explain her investigation findings. Staff M stated that on 11/9/2023 she had a conversation with staff Q, the nurse caring for P-1 on the night of 11/3/2023. Staff M stated that staff Q had explained P-1 had been pulling at his feeding tube and IV (intravenous catheter) line. According to staff M it was also revealed during her interview with staff Q that the staff member thought because she had not tied the mitts that it was not considered a restraint, so no order was received from the physician and no documentation occurred. Staff M was then asked what had been done to ensure staff were aware of the proper use of restraints including the need for an order, proper application of restraints, documentation of restraint use, and discontinuation of restraints. Staff M stated after doing her investigation the daily unit huddles both for day shift and night shift included review of restraints including need for an order, proper application of restraints, proper documentation of restraint use including assessments, and when to discontinue restraints. Staff M stated the topic was covered over a week at both daily huddles to ensure all staff were aware of the information shared. Staff M was then queried what was done to ensure staff Q was educated about the errors that were identified through her investigation of the incident. Staff M stated staff Q had been a contracted traveling nurse and her contract had been terminated.

On 2/8/2024 at 1300, a review of employee files was conducted to specifically identify restraint use training. When reviewing the file of staff Q the facility could not produce documentation of restraint training as part of the onboarding of contracted traveling nurses. The facility was unable to produce documentation prior to the end of survey.

Review occurred of the policy titled, "Restraints: Care of the Patient in Restraints," dated 5/31/2022, policy #8168, version 10 on 2/8/2024 at 1410. According to the policy it states, "IV. Use of Restraints, A. Ordering requirements, 1. Non-violent Restraints, letter D, it states, "In emergent situations, when the need for intervention occurs so quickly that an order cannot be obtained prior to application of physical restraints, an RN may initiate physical restraint based on assessment of the patient. The RN will notify the Provider within minutes of restraint application once the patient is safe and obtain the appropriate order. The assessment and restraint intervention must be documented by the RN." The policy further states, "2. Non-violent Restraint: Assessment and Documentation, a. On initiation and discontinuation, the RN will document that the restraint used is the least restrictive restraint intervention and that it was applied properly and safely."

The policy addresses staff education and use of restraints by stating, "V. Staff Education in the Use of Restraints, A. Direct patient care staff who provide care for patients in restraint will be educated, and able to demonstrate competency in the use of restraints: 1. as part of the orientation process, 2. prior to participating in the use of restraint, 3. on a periodic basis thereafter, B. Direct patient care staff will be educated and able to demonstrate competency in the following areas as appropriate to their role and responsibility: 1. Strategies to identify staff and patient behaviors, events and environment factors that may trigger restraint, 2. Use of non-physical intervention skills, 3. Choosing the least restrictive intervention based on an individual assessment, 4. Safe application of restraint (all types) including how to respond to distress, 5. Identification of behavioral changes that indicate restraint is no longer necessary, 6. Monitoring the physical and psychological well-being of the patient (e.g., respiratory and circulatory status, skin integrity, vital signs); and 7. Certification/recertification in cardiopulmonary resuscitation (CPR) C. Education will be: 1. Provided by qualified individuals as evidenced by education, training, and experience in techniques used to address patient behaviors, 2. Specific to patient population needs, 3. Documented in staff education records."

Based on interview and record review, the facility staff failed to test all endoscopes used in procedures for 485 patients from 9/29/2023 through 10/17/2023 resulting in the potential for the spread of infectious disease. Findings include:

A-0776 - Facility personnel failed to test endoscopes according to policy for the processing of endoscopes.

Based on interview and record review the facility staff failed to test all endoscopes used in procedures for 485 patients from 9/29/2023 through 10/17/2023 resulting in the potential for the spread of infectious disease. Findings include:

On 2/7/2024 at 1205, an interview took place with staff H, the nurse manager of the Sterile Processing Department (SPD). Staff H was queried if endoscopes were processed with ATP (Adenosine Triphosphate - ATP testing is used to assess the cleanliness of a surface and the effectiveness of cleaning procedures. ATP testing is not a test of sterility, but of organic contamination. ATP testing is a fast and accurate way to monitor and maintain cleaning standards). Staff H stated that in September 2023 there was a shortage of ATP test strips at the facility. Staff H stated that the facility had borrowed ATP test strips from the other hospital (child facility). Staff H stated it was then discovered there was a back order for the ATP test strips. Staff H was then asked to provide testing logs for endoscopes for the weeks when ATP test strips were not available.

On 2/7/2024 at 1445 an interview occurred with staff I, the lead sterile processing technician. Staff I was queried about the ATP testing of endoscopes and the availability of ATP test supplies. Staff I stated that ATP strips were not available in late September (2023) and that visual inspections were used until RESI testing strips (RESI testing is designed to perform rapid, sensitive (>1?g) and cost-effective residual protein testing. Provides you with a simple, practical and easy-to-interpret protein detection method.) were provided as a back-up to the ATP strips. Staff I stated that there had always been a supply of ATP testing strips in the refrigerator upstairs (Endoscopy unit). Staff I was queried if a supply inventory was kept for critical supplies for the processing of the endoscopes. Staff I stated that a previous manager had not kept a tracking system of supplies and that it was assumed all supplies had ample supply. Staff I was asked what type of testing occurred during the time of not having the ATP strips. Staff I stated only visual inspection of the scopes occurred.

On 2/8/2024 at 0840, an interview was conducted with staff H, the nurse manager of SPD and staff L, the Director of SPD. Staff H was asked the time period that scopes were not ATP tested. Staff H stated from 9/29/2023 through 10/17/2023. Staff H was then asked when the Infection Control Preventionist (staff K) was notified. Staff H stated staff K was notified on 10/17/2023. Staff H stated she was not aware that staff K needed to be notified.

On 2/8/2024 at 0900 an interview occurred with staff K, the facility Infection Control Preventionist. Staff K was queried about her knowledge of the lack of ATP testing for endoscopes in the SPD. Staff K stated that she was unaware that the SPD had not been testing endoscopes. She stated that her first knowledge of the lack of testing was on 10/17/2024. Staff K was asked what was done when she became aware of this information. Staff K stated she immediately met with the nurse manager and director of the SPD. She added that she immediately started gathering information for all procedures conducted with scopes not ATP tested including the patient names, procedures, and scopes used. She stated that she also let the nurse manager, staff H, and director, staff L, know that a backup test should be used if the ATP test strips were on back order. Staff K stated the SPD then reached out to the other facility (child facility) to find out what testing they were using in lieu of ATP testing. Staff K stated the SPD acquired RESI tests to replace ATP testing. Staff K was then asked if she knew how many patients and how many procedures were conducted without any test after cleaning and before disinfection. Staff K later provided information that 485 patients and 487 procedures were conducted with scopes that had not been tested by ATP or RESI testing.

On 2/8/2024 at 0925, a request was made for the policies for endoscope cleaning and ATP testing. On 2/8/2024 at 1440, a review occurred of the policy titled, "Flexible Endoscope Reprocessing," policy # 6300-957, dated 6/01/2022. According to the policy it states under section 5.25, "Procedure for visual inspection: ...Endoscopes shall be evaluated with a cleaning verification test called ATP. Follow the ATP manufacturer's IFU (instructions for use) for specific instructions." Further policy review included the policy titled, "Flexible Endoscope ATP Quality Testing," policy #6300-111, dated 5/2019. According to policy it states, "Procedure: 3. Frequency of testing: Because flexible endoscope reprocessing has a small margin of safety & given that the risk of pathogen transmission is high, we will monitor endoscopes as follows: ...Endoscopes types with high risk of pathogen transmission (e.g. duodenoscopes, EUS-endoscopic ultrasound scopes, bronchoscopes) shall be monitored after each manual cleaning cycle."

According to the AORN article titled, "Guideline Essentials: Flexible Endoscopes. AORN (Association of Operating Registered Nurses). Accessed April 26, 2023." (https://www.aorn.org/guidelines-resources/guidelines-for-perioperative-practice/guideline-essentials/processing-flexible-endoscopes.) "Because contamination is not always visible, AORN provides a conditional recommendation for assessing cleanliness through use of at least one of following tests: protein, hemoglobin, carbohydrate, and ATP."