HospitalInspections.org

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Based on staff interview, policy review and record review, the facility failed to ensure that a physician or other licensed independent practitioner (LIP-a nurse practitioner, licensed independent mental health practitioner) wrote the order for non-violent soft limb wrist restraints for one patient (Patient 21). The order for a medical restraint (soft wrist ties to stop a patient from pulling at essential tubes) was written and renewed by a Physician's Assistant (PA-A). A Physician's Assistant works under the supervision of a physician and not classified as an licensed independent practitioner.

Findings are:

Patient 21 was admitted on 11/8/19 with acute hypoxic respiratory failure (a sudden onset of the body's inability to take in enough oxygen) and critical respiratory acidosis (the body's inability to get rid of enough carbon dioxide-the byproduct of breathing). Patient 21 was admitted to the intensive care unit and placed on a BIPAP (Bilevel Positive Airway Pressure-a machine to assist in breathing by forcing oxygen into the lungs and helps with exhalation.) and had multiple IV's (intravenous medications administered directly into the patiet's vein) running with medications to help stabilize the patients condition.

On 11/8/19 at 19:48 (7:48 PM), PA-A ordered non-violent soft limb wrist restraints to prevent the patient from pulling off the BIPAP or pulling out the IV's. PA-A renewed the order for the non-violent soft limb wrist restraints on 11/9/19 and 11/13/19.

On 11/13/19 at 3:15 PM Registered Nurse (RN) T verified that the Physician's Assistant wrote the initial order for the non-violent restraints and renewed the order on 2 occasions.

Review of the policy "Restraint and Seclusion" last updated 11/2018 revealed, "The treating LIP's time-limited order, written for a specific episode must be obtained for the use of any type of restraint."

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Based on staff interview, policy review and record review; the facility failed to ensure that a licensed independent practitioner (LIP) or a trained registered nurse (RN) performed a face-to-face assessment within 1 hour after the initiation of a locked violent restraint (a restraint used in an emergency or crisis situations when unanticipated, severely aggressive or violent/destructive behavior presents an immediate, serious danger to the patient safety or that of others). The order for a locked violent restraint (a mechanical restraint that is used to secure the ankles and/or wrists by utilizing restraints that require a key to unlock) for Patient 22 was initiated on 10/20/19 at 1820 (6:20 PM) in the emergency room. The facility failed to document the 15 minute monitoring for 45 minutes during the transferring of the Patient 22 from the emergency room to the intensive care unit.

Findings are:

Patient 22 was brought to the emergency room on 10/20/19 by the police due to the patient was exhibiting destructive behaviors, having delusions, and having aggressive behaviors. While in the emergency room the patient continued to be aggressive, hitting, punching kicking at others and acting out uncontrollably.

Review of Patient 22's orders for violent restraint and restraint documention revealed:
10/20/19
-1820 (6:20 PM) the initial order for locked (mechanical) 4 point (bilateral ankles and wrists) restraints were ordered for unanticipated were aggressive behaviors.
-1847 (6:47 PM) the restraints were removed, due to the patients behaviors improved.
-1908 (7:08 PM) the violent locked 4 point restraints were reordered due to the recurring unanticipated aggressive behaviors that were dangerous to self and others.
-1908-1952 (7:08-7:52 PM) Patient 22 was observed and documented on every 10-15 minutes.
-1955 (7:55 PM) Patient 22 was transferred out of the emergency room to intensive care. The patient was accompanied by the registered nurse and security for the transfer.
-THE RECORD LACKED THE FACE TO FACE ASSESSMENT BY A LICENSED INDEPENDENT PRACTITIONER OR A TRAINED RN WITHIN THE HOUR OF APPLICATION OF THE VIOLENT RESTRAINTS
-2045 (8:45 PM) admission documentation indicates that the patient arrived in intensive care. Patient 22 remained in violent locked 4 point restraints.
-2134 (9:34 PM) an order for the violent locked 4 point restraints was entered. (Due to change in status from the emergency department to the in patient intensive care)
-2218 (10:18 PM) a trained RN documented the face to face assessment
10/21/19
-0200 (2:00 AM) the violent restraints were discontinued.

Interview with RN P on 11/14/19 at 11:45 AM revealed, "I looked into the missing documentation from the time (Patient 22) left the emergency room at 1955 and when the documentation resumed in the intensive care at 2045. The patient was taken from the ER to x ray for a scan before going upstairs to intensive care." RN P verified that the record lacked a face to face assessment within an hour after the violent 4 point restraints were applied at 1908; the lacked the every 15 minute monitoring documentation during the transport/scan/arrival to intensive care from 1955-2045 while remaining in the 4 point violent restraints.

Review of the policy "Restraint and Seclusion" last updated 11/2018 revealed:
-"The LIP or Trained RN will perform a face to face assessment on the patient's physical and psychological status WITHIN ONE HOUR of the initiation of the restraint. The face to face assessment is performed even in those situations where the person is released early (prior to one hour). The assessment shall include and be documented in the medical record: 1) the patient's immediate situation; 2) the patients reaction to the intervention; 3) the patient's medical and behavioral condition."
-Violent/Self-destructive Restraint Monitoring and Documentation Guidelines include, "Monitor and Document the following every 15 minutes. Staff members within the scope of their practice or licensure may assist with the data collection and documentation of these components: 1) restraint status/evaluation of continued need; 2) Restraint site assessment (Circulation/Skin Integrity); 3) Behavioral status; 4) Respiratory Status.

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Based on observations, interviews and record reviews conducted by State Fire Marshal survey staff; the facility failed to meet life safety code regulations which had the potential to place all patients, staff and visitors at risk in the main hospital and multiple hospital offsite locations.

This resulted in the Condition of Participation for Physical Environment not being met.

See deficiencies written at A701, A715 and A717.

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Based on a observations, record reviews and interviews conducted by the State Fire Marshal's office; the facility failed to ensure the overall physical environment of the hospital was maintained in a manner to assure the safety and well-being of patients in the Methodist Hospital Cancer Center, the Methodist Hospital North Tower, the Methodist Hospital South Tower and the Methodist Women's Hospital buildings. These deficient practices could potentially impede or delay egress from the facility in case of fire or other emergency or could result in fire or other emergency situations posing a risk to patients utilizing the facility.

Findings are:

Building 2 - Methodist Hospital Cancer Center:
-On 11-13-2019, observation revealed the facility failed to ensure that the exterior exit door on the northwest stairwell level 1 ½ was able to be opened with 15 pounds of force applied. Interview confirmed this observation.
-On 11/12/2019, the observation revealed the facility failed to ensure electrical junction boxes were equipped with cover plates above the ceiling on the lower level north hall which was confirmed by staff interview.

Building 6 - Methodist Hospital North Tower:
- On 11-13-2019 observation revealed the facility failed to sprinkle the fabric canopy attached to the exterior of the North Tower near the compactor. Interview and record review revealed the facility had no documentation of fire resistance for the fabric canopy.
- On 11-12-2019, a chair was observed in the corridor outside the clinical specialist office.
- On 11/13/2019, observations revealed the magnetically locked exit door failed to activate unlocking signal after pressure was applied; delayed egress operating instruction signage was not installed near the hardware, at hardware height or posted on the doors in multiple areas; a smoke door with delayed egress hardware failed to open; and 3 of 3 sliding doors failed to break open when the power was turned off. These observations were confirmed by interview.
- Observation on 11/12/2019 revealed the facility failed to provide directional exit signs creating a dead end in the north corridor and created a dead-end in the south corridor by construction barriers. These observations were confirmed by staff interview.
- Observation on 11-12-2019 revealed a door equipped with self-closing devices failed to close and latch within the doorframe due to a coat hook being over the door which was confirmed by staff interview.
-Observation on 11-13-2019 revealed multiple rooms without self-closing devices on the doors; several rooms that had self closing devices that failed to close and latch within the doorframe; several doors that had self closing devices obstructed or covered; several 2 hour fire doors that had excessive gaps between the doors; and a pallet jack obstructing a fire door in the compactor area. These observations were confirmed by interview.
- Observations on 11/12/2019 revealed wood that was used in several areas on three floors were not stamped to indicate their were fire treated and the facility had no documentation that the wood was fire treated. This was confirmed by staff interview.
- Observation on 11/13/2019 revealed an open circuit breaker in panel 4L1 in the west electrical closet which was confirmed by staff interview.
- Observations on 11-13-2019 revealed a portable heating device in the central supply, inventory coordinator's office. Interview confirmed the facility did not have the manufacturer's specifications for the heater and could not confirm the heating element did not exceed 212 degrees Fahrenheit.
- Observations on 11/13/2019 revealed a 30-amp non-hospital grade receptacle in a patient's room. This observation was confirmed by staff interview.
- Observations on 11-12-2019 revealed a power strip used in multiple locations. These observations were confirmed by staff interview.

Building 7 - Methodist Hospital South Tower:
- Record review revealed no testing for multiple emergency lights to ensure functionality. Interview with facility staff confirmed the findings.
- Observation on 11-13-2019 revealed the 2nd floor stair tower door did not positively latch when self closed which was confirmed by staff interview.
- Observation on 11-13-2019 revealed the range hood suppression nozzles were out of alignment and were pointing away from the cooking surface which was confirmed by interview;
- Observation on 11-12-2019 revealed a missing escutcheon ring around a sprinkler head in the physical therapy gym which was confirmed by staff interview.
- Observations on 11-12-2019 revealed multiple patient room corridor doors that did not latch within the door frame and multiple patient room corridor doors that did not seal to resist the passage of smoke which were confirmed by staff interview.
- Observation on 11-13-2019 revealed a power cord running through a door; electrical disconnects and electrical panels blocked by equipment and obstructed; a cover not installed above the fire sprinkler riser in the basement; and electrical junction boxes in multiple locations were not equipped with cover plates. These observations we're confirmed by staff interview.
- Observation on 11-13-2019 revealed multiple power strips utilized in several areas and locations throughout the facility which were confirmed by staff interview.

Building 15: Methodist Women's Hospital:
- Observations on 11-18-2019 revealed no self-closing device on the the door separating the construction area near the 3rd floor elevator lobby which was confirmed by staff interview.
- Observations of exit doors next to the Electrical Room had 'No Exit' signage posted on the door which was confirmed by staff interview.
- Observation on 11-19-2019 revealed medical equipment blocking the corridor near patient rooms which was confirmed by staff interview.
- Observations on 11-18-2019 revealed a door with a thumb lock, magnetic lock and door hardware required to exit one area; doors that failed to provide delayed egress signage in multiple areas; and several doors with delayed egress which failed to sound an alarm when suppressed which were confirmed by staff interview.
- Observation on 11-18-2019 of a range hood suppression system nozzle which was missing a cap which was confirmed by staff interview.
- Observation that the direct vent gas fireplace in the cafeteria did not have a wire mesh panel or screen in front of it, and there was no carbon dioxide detector installed which was confirmed by staff interview.
- Observation of an unattended recycling container with a capacity greater than 32 gallons in the exit corridor near the stair well which was confirmed by staff interview.
-Observation on 11-18-2019 revealed two electrical disconnects blocked by storage; two power cord plugs that were bent from equipment pushed up against them; and an electrical unction box which which was did not have a cover plate and was open. These observations were confirmed by staff interview.
- Observation on 11-18-2019 of an extension cord used for a refrigerator in lieu of permanent wiring which was confirmed by staff interview.

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Based on observation, interviews and record reviews by the State Fire Marshal's office, the facility failed to ensure inspections were completed and documentation of inspections regarding emergency generator batteries, emergency light fixtures and non-hospital grade electrical receptacles were maintained in the Methodist Hospital Cancer Center, the Methodist North Tower, the Methodist South Tower and the Methodist Women's Hospital buildings. These deficient practices could result in a fire, lack of generator service when needed for life support equipment or could result in a delay in egress from the facility in case of fire or other emergency.

Findings are:

Building 2 - Methodist Hospital Cancer Center:
- Record review of facility documentation revealed that the facility failed to provide proper monthly testing and recording of the emergency generator starting batteries which was confirmed by staff interview.

Building 6 - Methodist Hospital North Tower:
- Observation on 11-13-2019 revealed a 30-amp non-hospital grade receptacle in a patient room which had not been tested and verified. This was confirmed by interview with staff.
- Record review of facility documentation revealed that the facility failed to provide proper monthly testing and recording of the maintenance free battery for the emergency generator which was confirmed by staff interview.

Building 7 - Methodist Hospital South Tower:
- A review of facility documentation revealed no evidence of testing on for battery operated emergency light fixtures for one emergency light on multiple occasions which was confirmed by staff interview.

Building 15: Methodist Women's Hospital:
- Record review of facility documentation failed to show the maintenance free batteries used to start the generators were tested monthly which was confirmed by staff interview.

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Based on observations, record review and interviews conducted by the State Fire Marshal's staff, the facility failed to ensure that sprinkler systems were tested and maintained in a manner to assure the safety and well-being of patients in the Methodist Hospital Cancer Center, the Methodist Hospital North Tower, and in the Methodist Hospital South Tower buildings. These deficient practices had the potential to cause a larger fire should a fire occur in these areas of the facility.

Findings are:

Building 2 - Methodist Hospital Cancer Center
- Observation on 11/13/2019 revealed an acoustical ceiling tile was missing in the southeast stair tower at Level B. This observation was confirmed by staff interview.

Building 6 - Methodist Hospital North Tower
- Observation on 11/13/2019 revealed a fabric awning attached to the building near the trash compactor, which was in excess of four feet wide. The facility failed to provide documentation of fire resistance in the fabric. This was confirmed by staff interview.
- Observation on 11-12-2019 revealed unsealed penetration around the sprinkler escutcheon above elevator #13; paint covering the sprinkler in the Janitor closet; a missing sprinkler escutcheon in the Staff Lounge; missing ceiling tile in the North staff lounge and an obstruction to the sprinkler in the closer of the staff lounge. These observations were confirmed by staff interview.
- Observation on 11-13-2019 revealed a missing sprinkler escutcheon in the Duplicating Room and near the clinical offices; Wires attached to the sprinkler pipe in the north cage storage area, in the walkway in the cage storage room and attached to the sprinkler pipe in the south cage storage; foreign matter on the sprinkler in the Dialysis area; and missing ceiling tiles in the janitor closet and by the social workers office. These findings were confirmed by staff interview.

Building 7 - Methodist Hospital South Tower
- Observation on 11/13/2019 revealed six fire sprinklers in the kitchen staff locker room that were obstructed by a light fixture; the east half of the basement room did not have fire sprinkler coverage installed; and fire sprinkler protection was not installed in the doctor parking exhaust shaft. These findings were confirmed by staff interview.

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Based on record review and staff interview; the facility failed to ensure staff notified the Organ Procurement Organization (Live On Nebraska- the contracted organization that assesses and coordinates potential organ or tissue donors) following 1 of 2 patient deaths (Patient 12) at the hospital.

Findings are:

Review of Patient 12's record revealed that the patient arrived via the ambulance on 7/25/19 at 8:12 AM with CPR (Cardio Pulmonary Resuscitation) in progress. After attempted resuscitation and treatment, Patient 12 did not survive and the declared death time was at 8:27 AM.

Review of Patient 12's medical record lacked notification of Live On Nebraska to evaluate if the patient would be a potential organ or tissue donor.

An interview with registered nurse (RN T) on 11/13/19 at 2:47 PM verified that Patient 12's record lacked death notification to the Organ Procurement Organization/Live On Nebraska.

Review of the policy titled "Organ/Tissue Donation and Procurement: Donation After Circulatory Death" last updated 2/2019 revealed:
-TIMELY REFERRAL: The referral to Live On Nebraska is made within required timeframe: a) 60 minutes of a patient meeting imminent death; b) 60 minutes of pronouncement of cardiac/circulatory death.

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Based on record review, staff interview and policy review the facility failed to ensure that 1 of 7 surgical records (Patient 25) included verification that the physician examined the patient and reviewed the history and physical prior to the surgical procedure.

Findings are:

Patient 25 was admitted to the hospital on 11/11/19 at 5:13 AM for surgery. The patient received a pre-op history and physical by the surgeon on 11/6/19 in the doctors office. The medical record lacked pre-operative documentation verifying that the surgeon examined the patient, reviewed the history and physical and determined that the patient remained stable to proceed with surgery.

Review of the facility policy titled "History and Physical" last updated 8/2017 revealed:
-A history and physical shall be completed within 24 hours of admission on all inpatients and observations admissions, all inpatient and outpatient surgery patients prior to the surgical procedure when anesthesia/sedation is administered, when an outpatient diagnostic procedure is preformed with moderate or deep sedation or under anesthesia.
-If a thorough history and physical has been completed within 30 days prior to admission such as in a medical office.
-An updated examination of the patient, including any changes in the patient's condition, shall be completed and documented within 24 hours after admission or registration, but IMMEDIATELY prior to surgery or a procedure requiring anesthesia services.

Interview with Registered Nurse (RN) T on 11/14/19 at 12:55 PM verified that the record lacked the pre-op documentation by the surgeon immediately prior to Patient's 25's surgery.