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Based upon record review, interview and observations, the hospital failed to ensure that restraints were used in accordance with physicians orders for Patient #11.

The findings included:

During observations on the medical unit on 9/22/11 at approximately 2:50 P.M., Patient #11 was observed seated in a geri chair with a tray locked in place. When approached, the patient was asked why the tray was in place and answered in nonsensical manner. When asked to release the tray, the patient was not able to follow commands or understand what to do. Review of the medical record in the presence of hospital staff, confirmed that the patient was not able to independently release the tray on command and therefore prohibited the free movement of the patient which constituted a restraint. Staff confirmed they had not considered the device a restraint and therefore had no order from the physician.

During the entrance conference, SP #4 was asked about restraint audits that were to be done according to the plan of correction with a completion date of 8/28/11. It was stated that no record audits were conducted because the facility had no patients in restraints.

Based on interview the facility failed to assure medications utilized are subject to review and correlation with medication orders by a pharmacist and that medications orders get to the pharmacy and medications get back to the patient promptly.

The findings included:

1. During an interview on 9/20/11 at approximately 1:40 P.M. while answering questions on pharmacy systems and operations, SP #12 acknowledged that current pharmacy systems /procedures did not include a 100% reconciliation of all medications obtained by nursing from the Omnicell medication dispensing system with physician drug orders processed by pharmacy in the Meditec h system. Staff Person #12 further acknowledged that such a situation could result in medication use without pharmacy review.
The pharmacy uses the Meditech system for patient pharmacy information and medication management. And it is through the use of the Meditech that medication orders are linked with a patient and receive clinical screening and analysis through pharmacy review.
2. Record review for Patient #12 showed an order for Procrit 20,000 units sc (sub cutaneous) every week was written on 8/10/11. The Medication Administration Record (MAR) contained no evidence that Patient #12 had received this medication. During an interview on 9/23/11 at approximately 11:45 A.M. , SP #12 stated that Procrit is not a formulary item and the procedure for processing this order would be to communicate Procrits nonformulary status to the unit to have the physician rewrite the order for a therapeutically equivalent product on the formulary. SP#12 could produce no evidence that this order had been received or addressed by pharmacy. Please refer to A0395.

Based on observation, staff interview and record review conducted from 9/19/11 through 9/23/ 11, it was determined that facility failed to maintain a log of incidents related to infectious and communicable diseases.

The findings included:

During an interview with SP # 23 conducted on 9/21/11, it was revealed that the facility failed to maintain a log of incidents appropriately documenting infectious and communicable diseases. SP #23 was asked to produce a list of patients with corresponding room numbers as well as the isolation procedure used and the infectious pathogen of concern on a daily basis for surveillance purposes. The response was the hospital did not have that information.

On 9/21/11 during a tour of the hospital and record review, it was noted that following patients were placed on isolation by the nursing staff:
Room 2321 -Non sampled Patient #19 - MRSA of the surgical wound.
Room 2327 - Non sampled Patient # 24, - MRSA of the blood.
Room 3119 - Patient # 13 - MRSA of the blood .
Room 3129 Patient # 15 - VRE.
Room 3121 - Patient # 17, - MRSA of the wound.
Room 3096A - Non sampled Patient #20 - MRSA of the wound.
Room 3096B- Non sampled Patient #21 - MRSA of the wound.
Room 3090- Non sampled Patient #22 - Chicken-Pox.
None of the above listed patients and their corresponding infectious disease process were included in the infection control log.