HospitalInspections.org

Based on review of hospital policy and procedure, medical record review and staff interview for 2 of 4 patients (patient #'s 7 and 37), it was determined the governing body failed to ensure the medical staff followed hospital policy and procedure, and standards of practice for restraint.

Findings include:

Review of hospital policy and procedure titled "Restraint and Seclusion" required: "...Each order for restraint or seclusion used for the management of violent self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of twenty-four (24) hours: ...Two (2) hours for children and adolescents 9 to 17 years of age...the patient must be seen face-to-face within one (1) hour after the initiation of the intervention only by a physician or other licensed independent practitioner (LIP)...minimal assessment frequency for Behavioral Restraint and Seclusion is once every 15 minutes...is once every 5 minutes if the client has a medical condition that may be adversely impacted by restraint or seclusion...one-on-one if other clients have access to the client...if a patient requires the initiation of restraint or seclusion following the restraint or seclusion being discontinued, a new order must be obtained and the practitioner who is responsible for the care of the patient must be notified...Physicians and other licensed independent practitioners authorized to order restraint or seclusion at a minimum must have a working knowledge of the use of restraint or seclusion as specified by this policy...documentation of Medical Staff training will be maintained by the Medical Staff Office...."

Patient # 7
Medical record review for patient # 7 indicated admission to the Emergency Department on 4/27/2014 at 0210 hours. Physician # 2 signed a Physician's Certificate of Emergency and Necessity on 4/27/2014 at 0210 hours. Physician # 2 diagnosed patient # 7 with altered mental status, ETOH (ethanol) intoxication and methamphetamine intoxication. RN # 22 documented at 0229 hours: "... notified doctor, upper limb and lower limb restraints applied, reason for restraint danger to others..." RN # 22 documented patient ambulatory assessments every 15 minutes to 30 minutes until 0700 hours. On 4/27/2014 at 0700 hours, RN # 23 assumed care for the patient. RN # 23 documented that patient #7 refused to have vital signs (VS) taken and bites at cuff. RN # 23 documented ambulatory assessment every 15 minutes until patient discharge 4/27/2014 at 1029 hours. The medical record for patient # 7 indicates one set of vital signs completed 4/27/2014 at 0228 hours.

On 4/27/2014 at 0814, physician # 2 submited an order for patient # 7 as behavior restraints for 2 hours. No other order is found in the medical record for patient # 7. The medical record does not contain a documented, one hour face-to-face assessment after restraints, by a physician or LIP.

Patient # 37
Medical record review for patient # 37 indicated admission to the Emergency Department on 6/4/2014 at 0841 hours. Physician # 7 diagnosed patient # 37 with a seizure disorder and seizures. Physician # 7 ordered 4 point soft restraints on 6/4/2014 at 0957 hours and again at 1046 hours for violent behavior toward staff. RN # 24 documented ambulatory assessment at 0905, 1018 hours and 1100 hours. The medical record does not contain a documented, one hour face-to-face assessment after restraints, by a physician or LIP.

RN # 19 confirmed in an interview conducted on 8/7/2014 that the policy and procedure for restraints was not followed by physician # 2, that the order for restraints was six hours after patient admission to the emergency department, and that the medical record did not have evidence that a physician or LIP conducted a one hour face-to-face after restraints applied. Additionally, RN # 19 confirmed that vital signs were not assessed after the first set taken upon admission, and that RN # 22 did not conduct an ambulatory assessment every 15 minutes.

RN # 19 confirmed in an interview conducted on 8/7/2014 that the policy and procedure for restraints was not followed by physician # 7 or RN # 24. The medical record did not have evidence that a physician or LIP conducted a one hour face-to-face assessment after restraints were applied. Additionally, RN # 24 did not conduct an ambulatory assessment every 15 minutes.

Based on manufacturer's recommendations, hospital policies and procedures, hospital documents and staff interviews, it was determined the CAH failed to require that:

The high-level disinfectant solution was properly monitored and documented when soaking the ultrasound vaginal probe prior to each patient's use for ultrasound procedures located in the Radiology department of the hospital and the provider based entity Physician's Office located at 200 East Lee Street, Winslow, Arizona 86047.

Findings include:

Manufacturer's recommendations for Cidex OPA revealed: "...Cidex OPA solution be tested before each usage with the CIDEX OPA Solution test strips in order to guard against dilution..." Cidex OPA directions for use revealed: immerse for minimum of 12 minutes at 20 degrees C (68 degrees F)...."

LOGIQ 5 Basic User Manual recommends the Ultrasound probes be handled with care: " ...In order for liquid chemical germicides to be effective, all visible residue must be removed ...observe the specified immersing time by the germicidal manufacturer strictly...extended soaking may cause probe damage .... "

Hospital policy titled "Cidexplus Disinfecting Solution " requires: " ...contaminated probes will first be cleaned with Enzy clean detergent.... "

Hospital policy titled "Cidex OPA Disinfecting Solution " requires: " ...Immerse probes...12 minutes...Solution is to be discarded in 14 days or when indicated by the test strips...test solution...Read results...in 90 seconds by comparing the pad to the color chart.... "

Cidex OPA Solution Chart from Radiology, dated 04/01/14 through 08/15/14, revealed two columns titled: Start date and Ending date. The Chart did not contain documentation of a patient name, immersion time, temperature or results of the test strips (pass/fail).

The hospital Ultrasound Technician (employee #11) confirmed during an interview conducted 08/06/14, that he did not use an enzymatic to clean the contaminated probe after each patient. The Technician confirmed he does not document a patient name, immersion time, temperature or results of the test strips on the Cidex OPA Chart.

The Director of Radiology and the Director of the provider based entity confirmed the above findings.

Based on review of Governing Body meeting minutes and staff interviews, it was determined that the governing body did not assess the services provided under agreement or arrangement.

Findings:

Review of Governing Body meeting minutes from 1/2013 through 6/2014 indicated that services provided by contracts, agreement or arrangement were not evaluated.

The Interim Chief Executive Officer and the Director of Nursing confirmed in an interview conducted on 8/8/2014 that service contracts have not been evaluated.

Based on hospital policy and procedure, medical records and interview, it was determined the CAH failed to ensure the nursing staff meet the patients needs for pain reassessment in 6 of 6 patients (Patients 5, 14, 18, 28, 29 and 36).

Findings include:

Hospital policy titled "Management of Acute and Chronic Pain" requires: "...After any method of pain control has been used, reassessment will occur at frequent intervals...until pain is controlled to patient's satisfaction...Notify the physician of ineffective pain management...."

Patient #5 was seen in the emergency department on 08/22/12 after a motor vehicle accident. The patient received three doses of 5mg (milligrams) of Morphine intravenous for complaints of pain. There was no documentation of any pain reassessments.

Patient #14 was admitted to the hospital on 08/06/14 for complaints of nausea/vomiting and abdominal pain. The patient complained of pain 8 of 10 on the pain scale and received one mg of Dilaudid intravenous on 08/07/14 at 0800. There was no documentation of any pain reassessments.

Patient #18 was admitted to the hospital on 08/03/14 for laparoscopic cholecystectomy. The patient complained of pain 5 of 10 on the pain scale and received one mg Dilaudid on 08/06/14 at 1728 hours. The patient received a pain reassessment at 1950 hours. The patient complained of pain 7 of 10 on the pain scale and received one mg Dilaudid on 08/07/14 at 0400 hours. There was no documentation of a pain reassessment.

Patient #28 was admitted to the hospital on 08/05/14 for chest pain. The patient complained of pain 8 of 10 on the pain scale and received one mg Dilaudid on 08/07/14 at 0800 hours. There was no documentation of a pain reassessment.

Patient #29 was admitted to the hospital on 08/05/14 with mastitis. The patient complained of pain 6 of 10 on the pain scale and received 650 mg of Acetaminophen on 08/07/14 at 0716 hours. There was no documentation of a pain reassessment.

Patient #36 was admitted to the hospital on 08/07/14 with chest pain. The patient complained of pain 9 of 10 on the pain scale and received two Lortabs on 08/06/14 at 1700 hours. The patient complained of pain 7 of 10 on the pain scale and received two Lortabs on 08/07/14 at 0043 and 0636 hours. There was no documentation of a pain reassessment.

RN #12 confirmed the nursing staff did not follow the facility policy for pain reassessment.









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Based on review of hospital protocol, policy and procedure, medical records, and interview, it was determined the Hospital failed to ensure the nursing staff obtained clarification of a physician's medication order for patient # 16 prior to administration.

Findings:

Review of hospital protocol titled "Heparin Protocol - Standard Order" requires prior to starting Heparin-Baseline protime (PT), partial prothrombin time (PTT) and complete blood count (CBC) with platelet count...STAT PTT 6 hours after Heparin started, 6 hours AFTER each dosage change and each bag change...change PTT to Daily when two consecutive PTTs are therapeutic...adjust IV Heparin based on sliding scale PTT values...discontinue all previous orders for Heparin (excluding flushes)...."

Review of hospital policy requires baseline labs including PTT...order PTTs per protocol...a;adjust Heparin infusion rate according to protocol sliding scale is which is based on PTT results...."

Review of medical record for patient # 16 indicates that physician # 8 ordered continuous intravenous (IV) Heparin at 1000 units/hour. Instructions on the order require serial PTT lab values to titrate the Heparin to a therapeutic dose. Patient # 16 was admitted to the hospital telemetry under the care of physician # 9. On 8/6/2014 at 1211, physician # 9 ordered Heparin 5,000 units subcutaneous every 12 hours. Physician # 9 did not continue the Heparin infusion order . Patient # 16 continued to receive IV Heparin at 1000 units/hour and Heparin 5,000 units subcutaneous. No PTT was obtained prior to the Heparin infusion or during the Heparin infusion.

RN # 9 confirmed that patient # 16 received a Heparin infusion without a baseline or follow-up PTT lab, and there was no order to follow the Heparin protocol. Additionally, RN # 9 confirmed that pharmacy and the nursing staff should have questioned the order for Heparin subcutaneous, Heparin protocol and PTT labs.

The Director of Nursing confirmed in an interview conducted on 8/7/2014 that RN # 25 caring for patient # 16 requested a doctor order for PTT labs. Physician # 9 did not order a PTT.

Based on review of Medical Staff Bylaws, Rules and Regulations, Swing Bed patients' medical records, and staff interviews, it was determined that the CAH failed to require comprehensive documentation for two (2) of 2 Swing Bed patients (Patients #24 and 25)

Findings include:

The hospital's Medical Staff Bylaws, Rules and Regulations, require: "...History and Physical Examinations must be completed no more than 30 days before or 24 hours after admission. History and Physical must be completed prior to surgery or any procedure requiring anesthesia services...Progress notes must be written concurrently during patient's inpatient hospitalization...Discharge summaries are to be completed within 30 days of discharge...."

Swing Bed Patient #24 was admitted to Swing Bed status on 04/21/14, following acute inpatient hospitalization for heel wound care, diabetes, and cellulitis, according to the medical record. She was discharged home on 06/09/14.

Documentation did not include:

Physician's Discharge Progress notes referencing Swing Bed placement,
Physician's History and Physical for Swing Bed placement,
Physician's Admission notes until 04/28/14 (when the Operative report was documented); and
Discharge documents/information provided to the patient.

Patient #25 was admitted to Swing Bed status on 02/28/14, post acute care hospitalization for septic endocarditis, according to the medical record.

The physician documented the Admission History and Physical on 03/08/14 at 0857, the same day the patient was discharged home (03/08/14 at 0902). In addition, the Admission History and Physical and the Discharge summary were the same documentation.

The QA Director confirmed the deficient documentation findings during the medical records reviews and interview conducted on 08/07/14.