HospitalInspections.org

Based on records review and interview, the facility failed to ensure that all direct patient care employees maintained current Cardio Pulmonary Resuscitation (CPR) certification in accordance with applicable Federal, State and local laws and regulations.

Findings were:

Review of employee files on the afternoon of 11/08/16 revealed that two (2) of six (6) direct patient care employees did not have a current CPR certification.

Review of #13's Employee File revealed no current CPR certification.

Review of #15's Employee File revealed no current CPR certification.

The above findings were confirmed by the Chief Nursing Officer on the afternoon of 11/08/2016.

Based on review of facility documents and interview, the facility failed to ensure services furnished under contract were evaluated.

Findings included:

Facility documents revealed the following contracts with the date of implementation:
· Dietician - 8/25/11
· Radiology - 8/27/09
· Speech Therapy - 3/16/15
· Lab - 4/1/09
· ER Physician - 6/1/09
· MRI - 2/21/12
· Blood Bank - 6/22/09
In an interview with the CEO at 5:25 pm on 11/8/16, when asked when the last time contracts were reviewed or evaluated, she stated, "We don't do that."

Based on review of facility documents, review of medical records and staff interview, the hospital failed to ensure each patient had the right to be free from physical restraints and to ensure each medical record reflected significant changes in patient condition, progress, and response to medications and services.

Findings included:

Facility policy titled "Use of Restraints" stated in part, "Documentation:
Documentation will be recorded in the nursing notes and/or on the restraint flow sheet. Information to be included are as follows:
*reason restraint became necessary
*Measures to promote safety, comfort and compliance
*Patient/family teaching
*Type of restraint ordered/used
*Observations every fifteen minutes
*Release of restraints every two hours
*Body part restrained
*Repeat assessment, and discontinuance of restraints (discontinue as soon as possible) ..."

Review patient #7's medical record revealed doctor's orders for use of restraint starting on 11/3/16 at 10:25 pm. There was no further documentation on restraints. The doctor discontinued restraints on 11/4/16 at 3:16 am. There was no documentation on restraint use, patient/family education, observations, assessments, etc.

In an interview with the CNO on the afternoon of 11/8/16, she stated, "We just went to the new [electronic medical record] system." When asked about restraint documentation, she stated, "There should be somewhere, but I'm not finding it."

The above was verified at the exit conference on 11/8/16 with the CEO and other department heads.