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Based on observation, staff interview, and review of manufacturer's directions titled "DeRoyal Patient Care, Wrist Restraint Application Instruction", it was determined the hospital failed to ensure wrist restraints were applied in a safe manner and in accordance with the manufacturer's directions for one of one restrained patient in the cardiac/thoracic intensive care unit (Patient 6). There were nine patients in the cardiac/thoracic intensive care unit. The hospital census was 258.

Findings include:

On 07/20/11 at 11:20 AM Patient 6 was seen lying in bed with bilateral wrist restraints in place. Observations with Staff E on 07/20/11 at 11:20 AM revealed the left wrist restraint strap was placed underneath the patient's back and was tied to the strap on the right wrist restraint at the patient' right side. Interview with Staff E at this time revealed the restraints had been applied in this fashion when Staff E came on duty at 7:00 AM on 07/20/11. Staff E further stated when questioned the placement of the wrist restraint strap under the patient's body prevented the patient from raising their arms and pulling out the medical tubes (intravenous lines and tracheostomy tube). When questioned further, Staff E stated wrist restraints were not usually applied in this fashion. Staff E stated restraints were usually secured to the patient's bedframe. At 11:21 AM Staff D verified the placement of the patient's wrist restraints. Staff D stated on 07/20/11 at 11:21 AM the patient's wrist restraints were not applied properly/safely or in accordance with the hospital protocol. Staff D further stated restraints were to be secured to the bedframe and tied in a manner that allowed one motion quick release.

The manufacturer's directions titled "DeRoyal Wrist Restraint Application Instruction" was reviewed on 07/20/11. The written instructions titled "Application Instructions" stated to secure the straps to the portion of the bedframe that moves with the patient. Under "Warning" the instructions stated incorrect use of this device can result in injury or death. Secure the restraint appropriately

Based on observation and staff interview, it was determined the hospital failed to ensure the Registered Nurse provided care using non expired dialysis solution to one of one patients receiving peritoneal dialysis (Patient 37) on the cardiac/thoracic intensive care unit. The unit census was nine. The hospital census was 258.

Findings include:

On 07/19/11 at 3:00 PM Patient 37 was seen lying in bed with Staff D in attendance. There were three large bags of dialysis solutions of varying dextrose concentrations (1.5%, 4.25%) seen hanging from a metal pole. Staff D stated the bags were tagged as being hung on 07/16/11 at 5:30 AM. When questioned on 07/19/11 at 3:00 PM Staff D stated dialysis solution bags are good for 72 hours after being pierced/opened. Staff D verified at this time the three bags of dialysis solution were expired and new bags should have been placed on 07/19/11 at 5:30 AM. On 07/20/11 at 10:30 AM Staff D stated they had verified with the dialysis unit nurses the policy regarding dialysis solution stability for use. Staff D stated the policy for stability/use after opening the dialysis solution was 72 hours. Staff D stated on 07/20/11 at 10:30 AM they had flushed the patient's dialysis catheter with 20 cc (cubic centimeters) of solution from the expired solution of 1.5% Dextrose on 07/19/11 at 10:00 AM. Staff D stated they had changed the bags of dialysis solutions on 07/19/11 at 7:30 PM.

Based on observation and staff interview, it was determined the hospital failed to ensure patient medical records for patients continuing to be seen in the dental operating area in the last two years were stored in a manner that protected the medical records from destruction/damage in the event of activation of the sprinkler system. There were approximately 50-75 patient medical records. The hospital census was 258.

Findings include:

On 07/21/11 at 10:10 AM an overhead shelf in the receptionist area of the dental surgery area was seen to have 50-75 hardcopy patient medical records stored on an open shelf. Interview with Staff X and Y at this time revealed these were patient medical records of patients that had continued to be seen with follow ups in the last two years that were not in the new computer/electronic medical record system. Staff X and Y verified these patient records were not protected against potential water damage/destruction in the event the sprinkler head located over the patient records was activated.

Based on medical record review and staff interview, the facility failed to ensure all medical records were completed within 30 days of discharge from the facility. This affected Patient 48. The facility census was 258.

Findings include:

The medical record for Patient 48 was reviewed on 07/22/11. The patient expired on 06/11/11. The medical record lacked documentation of a completed discharge summary. On 07/22/11 at 2:00 PM, Staff S verified the discharge summary was not completed.

Per interview with Staff II, the Director of Health Information Management, on 07/22/11 at 09:50 AM, June 2011 data reflected there were 213 delinquent records. A delinquent record is one not completed within 30 days of a patient's discharge. This reflects 20% of patient records for that time period.

Based on interview and observation, the facility failed to ensure sprinkler inspections, emergency lighting testing, exit lighting, delayed egress doors, two fire doors, and corridor windows met the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 258 patients in the facility.

Findings include:

See A710.

Based on observation and interview, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 258 patients in the facility.
Findings include:

K019 of the life safety code requirement was found not to be met in building #1 and #7. The facility failed to ensure that vision panels in corridor walls were fixed window assemblies in approved frames.


K025 of the life safety code requirements was found to not be met. In building #5 on 07/21/11 the surveyor determined there was penetration in a smoke/fire wall. The facility failed to ensure the smoke barriers were constructed with at least a one hour fire rated construction according to the third floor architectural plans.

K038 of the life safety code was found not to be met. The facility failed to ensure the exit access was readily available in regard to one exit access door equipped with a 15 second delay latching mechanism in building #3.

K044 of the life safety code requirements was found to not be met in building #7. The facility failed to ensure that two of two fire doors in the horizontal exit on the first floor between the JW building and the adjacent building closed properly when tested.


K046 of the life safety code requirements was found to not be met in building #3 and #7. The facility failed to ensure the emergency battery operated egress lights were tested on a monthly basis as required by the National Fire Protection Association (NFPA) 101, Chapter 7.9.3, and failed to ensure that emergency lighting of at least one and one-half hour duration was provided at one of two exits from the first floor of the building.

K062 of the life safety code was found not to be met. The facility failed to ensure that the sprinkler system was inspected/tested during the second quarter of 2011 in building #4.