HospitalInspections.org

Based on medical record review, document review and interview the facility has not ensured that education regarding the use of restraints was provided to the patient or family member in 4 of 5 patients requiring the application of restraints.

Findings include:

Review of Policy #TX.10 " Restraints " on 12/4/15 revealed for all restraint implementation, educate patient/family regarding the purpose of restraints, type of restraint, condition for maintaining use of restraints, duration of use of restraint, and collaboration with providers to resolve behavior requiring restraints.

Review of 12/2/15 of the Restraints Order Set for Patients J, K, L and S revealed the area related to patient/family notification on the facility's restraint policy and indication for use are blank.

Interview with Staff #14 on 12/4/15 verified that there was a lack of documentation in the medical record related to patient/family education on the use of restraints.

Based on observation, document review and interview the facility did not ensure staff were compliant with the facility's personal protective equipment (PPE) policy during blood draw. Failure to adhere to PPE policy could potentially place patients or staff at risk of infection.

Findings include:

Review on 12/4/15 of Policy #TX.44-A " Blood Collection for the Purpose of Obtaining Specimens, Including Blood Cultures- Adult Patients " last revised 2/2012, revealed that the procedure is outlined in steps and methods to safely collect blood sample(s) for laboratory analysis, and the steps for obtaining blood cultures. Unsterile and/or sterile gloves are a prerequisite prior to all blood collection procedures.

Observation of Staff #19 on 12/1/15 at 10:30am revealed that while in the process of a blood draw on Patient I, Staff #19, was found not to be wearing gloves.

Interview with Staff #5 on 12/1/15 at 10:30am verified the above finding.