HospitalInspections.org

Based on review of policy and procedures, interview and clinical record review, it was determined the facility failed to monitor two (#3 and #10) of four (#1, #3, #10 and #11) restrained patients as required by facility policy and procedure. Failure to monitor and assess restrained patients every two hours had the potential to allow patient injury or death and did not allow the patient to be assessed and released from restraints. The failed practice affected two (#3 and #10) current patients on 12/10/12. Findings follow:

A. Review of the clinical record of Patient #3 revealed no restraint monitoring from 0400 to 0800 on 12/05/12, 1200 to 1515 on 12/07/12 and 0200 to 0800 on 12/08/12. This was verified by the Vice President of Patient Care Services at 1230 on 12/14/12.
B. Review of the clinical record of Patient #10 revealed no restraint monitoring from midnight (0000) to 0400 on 12/07/12. This was verified by the Director of Clinical Informatics and Corporate Education at 0955 on 12/14/12.
C. Review of policy and procedure "Restraints and Seclusion-Section 4.16" revealed documentation was to occur every 2 hours and prn (as necessary) for non-violent/non self-destructive patients.

Based on Operating Room Policy and Procedure Manual review, Line Isolation Monitor testing preventative maintenance document review and interview, it was determined the facility did not meet Life Safety Code requirements related to monthly testing for 17 of 17 line isolation monitors.
Failure to test line isolation panels monthly had the potential to affect the health and safety of all patients in the surgical areas served by the monitors because proper functioning of the monitors to prevent electrical shock was not monitored and assured. The failed practice had the potential to affect all surgical patients. The facility performed an average of 380 surgical procedures per month. See CMS 2567, K130.

Based on clinical record review and interview, it was determined the facility failed to ensure the time of surgery was documented in the operative report for nine of nine (#8, #9, #11, #14-#18, and #24) surgical patients. The failed practice did not allow for determination of which operation came first in the event of multiple surgeries in one day and had the potential to affect all patients having surgery. Findings follow.

A. Review of clinical records revealed the time of surgery was not documented in the operative report for Patient #8, #9, #11, #14-#18, and #24.
B. Findings were confirmed by the Vice President of Patient Care Services/Chief Nursing Officer on 12/14/12 at 1335.