HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to ensure:
*Every fifteen minute circulation checks were completed for one of one sampled patient (21) placed in a protective medical restraint.
*An assessment was documented for two separate episodes of restraint use for one of one sampled patient (21) who had a restraint.
Findings include:

1. Review and interview on 5/20/15 at 2:29 p.m. with nurse manager (NM) D regarding patient 21's restraint record documentation revealed:
*The patient had been placed in a protective medical restraint on 4/30/15 for refusing necessary medical treatment.
*The physician's protective medical restraint order dated 4/30/15 required bilateral wrist and ankles restraints attached to the bed.
*The protective medical restraint record required:
-Two staff for toileting care.
-One-to-one monitoring at all times during the protective medical restraint.
-Range of motion every two hours for no less than ten minutes.
-Circulation checks every 15 minutes.
*There was no documentation on the protective medical restraint record for circulation checks every 15 minutes.
*He agreed the staff caring for the patient should have documented circulation checks every fifteen minutes.

Review and interview on 5/20/15 at 2:29 p.m. with NM D of patient 21's medical record and the physical restraint/chemical restraint/seclusion initiation note forms revealed:
*The patient was an insulin dependant diabetic and required regular fingerstick blood sugar (FSBS) testing to determine the amount of insulin that might be needed. The patient's finger would be used to obtain a blood sample and tested to determine if insulin was required.
*On 4/29/15 at 6:34 a.m. for two minutes and again on 4/29/15 at 10:16 a.m. for one minute the patient had been placed in a physical hold restraint to obtain a FSBS.
*The physical restraint/chemical restraint/seclusion initiation note forms under the Post RN (registered nurse) assessment revealed "Pt [patient] refused vitals" had been documented for both restraint episodes.
*No RN physical assessment at the conclusion for either restraint episode were located in the nurses notes.
*He confirmed a physical assessment should have been completed after the restraints had ended. A physical assessment note could not be found in the nurses notes for either restraint episode.
*The RN had documented a behavior note on 4/29/15 at 2:45 p.m.:
-"Patient was placed in a physical control hold at 6:34 a.m." The patient's FSBS was obtained, and the hold was ended at 6:36 a.m. There was no documentation of a physical assessment by the RN.
*The RN had documented a behavior note on 4/30/15 at 9:03 a.m.:
-"Staff placed patient in a physical control hold at 10:16 a.m. to obtain a FSBS."
-"Patient was released from physical control hold at 10:17 a.m."

Review of the provider's 5/5/14 Physical Restraint - Manual Restraint Policy (Medical Staff) revealed:
*A manual restraint "May also be used to safely administer medication and/or lab work as deemed necessary by the physician who is refusing the medication or lab work at that time of its administration."
*"A RN shall document all assessments made for the release of the patient."

Based on record review, interview, and plan review, the provider failed to ensure a quality assurance performance improvement program (Quality Council) included:
*Infection control.
*Contracted services (dietary, anesthesia, dental services, and speech therapy).
*Restraint and seclusion (Human Rights).
*Organ Procurement Organization (OPO [organ procurement after death]). Findings include:

1. Interview on 5/21/15 at 8:00 a.m. with the electronic convulsive therapy (ECT) nurse coordinator who was acting as the lead for Quality Council in the place of the director of nursing (DON) who had been on extended leave revealed:
*The DON usually had gathered all the required information for the Quality Council meeting.
*The Quality Council met quarterly during the year.
*She had a large pile of information from other departments in the hospital in her office that she had not had time to examine.
*There was not an integration (process) of all hospital departments in the Quality Council.
*Patient satisfaction surveys were given prior to discharge. Concerns received from the patients were given to the supervisor of that particular unit the patient had been placed on.
*There was no follow-up done by the Quality Council to ensure those concerns had been addressed, and procedures had been put in place to ensure those concerns were monitored for improvement.
*She agreed there were departments in the hospital that were not part of the Quality Council meetings.
*The Human Rights Committee had met regarding seclusion and restraints, but there was no information brought to the Quality Council for review.
*Infection control concerns or issues were not a part of the Quality Council for review.
*If there was a concern with the dietary department those concerns would have been brought to the dietary manager, but there was no follow-up regarding those concerns in the Quality Council.
*The only information the contracted speech therapy shared was a financial report.
*There was no information reported from the OPO.
*Laboratory submitted information to the Quality Council, but there were no acting projects or on-going assessments of any issues or concerns.
*She was unsure about information from radiology.
*There had been no involvement by the medical director in the scheduled Quality Council meetings. He had never attended the meetings. He had been sent the information, but she was unsure what he had done with that information.

Review of the Quality Council minutes from November and December 2014 and February 2015 revealed:
*The medical director had never been in attendance.
*The DON was not in attendance for December and February.
*Old business had been discussed.
*Admission/Discharge/Transfer had been discussed.
*Medication errors were reported.
*Patient satisfaction surveys were discussed.
*The ECT program had been discussed.
*There were no action plans discussed regarding on-going findings, conclusions, recommendations, or assessments for all hospital departments involved in the Quality Council for performance improvement.

Interview on 5/21/15 at 8:50 a.m. with the ECT nurse coordinator and the director of health information regarding the Quality Council revealed:
*The director of health information had only been in her position for seven weeks.
*The ECT nurse coordinator was a part of the Quality Council but had been more involved since the extended leave of the DON. She did not have access to all the information and data for the Quality Council.
*They both agreed all departments of the hospital needed to be incorporated into the Quality Council. The Quality Council should have been facility wide.

Review of the provider's undated Performance/Quality Improvement Plan revealed:
*"The scope of the Performance Improvement Program [Quality Council] includes an overall assessment of the efficacy of performance improvement activities with a focus on continually improving outcomes throughout the hospital. The assessment consists of three focus components; performance improvement, quality assessment, and quality control activities.
*Collaborative and specific indicators of both key processes and outcomes of care are designed, measure and assessed by all appropriate departments, services and disciplines of the facility in an effort to improve organizational performance. These indicator are objective, measurable, based on current knowledge and experience and are instructed to produce statistically valid performance measures. This method provides for ongoing evaluation of improvement activities.
*Continuous quality improvement strives for every higher levels of meeting and exceeding customer expectations through clear defined goals, strategic planning, data-driven information, a systematic approach to planning, execution, evaluation, and feedback; and a focus of processes.
*The Quality Council consist of staff representing Director of Operations, Medical Director, Director of Clinical Services, Director of Nursing, Chief Executive Officer, and Quality Management Director. The council has the authority to direct departments/programs to conduct quality improvement and process focused studies, investigate problems, implement action, or direct the implantation of action that involves committees.
*Ongoing measurement; The Quality management program through the Quality Council oversees ongoing measure which may include but not be limited to the following:
-High volume, high risk, problems prone processes associated scope functions.
-Expectation of patients, families, staff, regulatory agencies and community.
-Perception of staff on current performance and opportunities to improve.
-Processes related to the use of anesthesia and invasive procedures.
-Processes related to determining appropriateness of admission (utilization).
-Risk management activities.
-Processes related to nutritional services.
-Review timeliness and adequacy of documentation.
-Quality control activities in at least laboratory, radiology, and dietary.
-Mortality [death] and morbidity [incidence of disease] findings.
*The findings, conclusions, recommendations, actions taken, and results of performance improvement activities shall be documented and reported to the quality management director quarterly. The quality management director shall prepare and present a quarterly report on all performance improvement, quality, and risk management activities to the Quality Council and Governing body."

Based on observation, interview, and policy review, the provider failed to ensure controlled medications used for sedation during electronic convulsive therapy (ECT [electroshock therapy]) in one of one procedure room in the specialty clinic were securely stored and not accessible to unauthorized personnel. Findings include:

1. Observation and interview on 5/20/15 at 8:10 a.m. with the ECT nurse coordinator of the specialty clinic ECT procedure room revealed:
*ECTs were performed on Monday, Wednesday, and Friday of each week.
*There was a black refrigerator stored by the anesthesia machine.
*There was a padlock placed on the refrigerator. The keys to the refrigerator padlock were in a magnetic container placed on the side of the anesthesia machine.
*The ECT nurse coordinator opened the refrigerator, and the following medications were in the refrigerator:
-Ketamine (for sedation) fourteen milliliters.
-Brevital three vials (produces lack of sensation).
-Multiple vials of succycholine (muscle relaxant, paralyzing agent).
*The Ketamine and Brevital drug count was correct. The succycholine was not counted.

Further interview during the above observation with the ECT nurse coordinator revealed multiple employees had the key to the specialty clinic and the procedure room including:
*Maintenance.
*Certified Registered Nurse Anesthetist (CRNA).
*Approximately five security staff.
*House supervisors.
*All the staff in the specialty clinic.

Interview on 5/20/15 at 10:00 a.m. with the interim administrator regarding the security of the above medications revealed:
*She felt as though the keys that the above staff had to the ECT room were not multiple considering the number of staff that were employed.
*Security had keys to the ECT room in case of an emergency.
*She felt as though the CRNA would be aware if any of those medications were missing.
*She was not aware of any policies regarding medication security.

Interview on 5/21/15 at 9:00 a.m. with the ECT nurse coordinator regarding the security of the medication used for ECT procedures revealed she agreed the medications were not secured from unauthorized personnel.

Review of the provider's 8/4/14 Drug Diversion Prevention policy revealed:
*"It shall be the responsibility of the Director of Pharmacy to institute measures that will deter and prevent and or detect any drug diversion that may occur in this institution.
*All controlled medications shall be monitored in the Omnicell system by the Director of Pharmacy with the help of staff pharmacists."

Based on interview, record review, and policy review, the provider failed to ensure the consultant registered dietitian (RD) provided continuity of care for one of one sampled patient (33) who was at nutritional risk. Findings include:

1. Review of patient 33's medical record revealed:
*He had been admitted on 4/13/15.
*He had been discharged on 5/19/15.
*A history and physical report dated 4/13/15 listed:
-Past medical illnesses of hypoglycemia (low blood sugar) and uncontrolled diabetes.
-Past mental illness of an eating disorder.
-Percutaneous endoscopic gastrostomy (PEG) tube (tube inserted in abdomen used to provide nutrition) in place.
*A psychiatric evaluation dated 4/16/15 noted:
-Prior to his admission he had been found to be hypoglycemic and been hospitalized at a different hospital.
-At the other hospital he had not been eating, and the PEG tube had been placed.
-He had a history of eating disorder possibly with binging (over eating) and purging (throwing up) symptoms.
-He had diabetes and had been insulin-dependent since a young man.
*Continual changes to his insulin doses based on his blood sugar readings.
*Activities of daily living snack intake documentation from 4/13/15 through 5/18/15 noted snacks had been consumed at two bed times.

Interview on 5/19/15 at 1:15 p.m. with charge nurse C revealed patient 33 was a brittle diabetic (wide unpredictable swings in blood sugar). The amount of insulin he received had varied continually.

Review of the RD's dietary referral/evaluation form dated 4/17/15 regarding patient 33 revealed:
*He had been referred to her for:
-Poor intake of food and fluids.
-Type I diabetes (insulin dependent).
-Hypoglycemia.
-Did not like snacks.
-Several medical conditions.
*Recommendations included:
-Morning, afternoon, and bedtime snacks.
-RD to follow as needed or per patient or staff request.
No further documentation was found related to patient 33's nutritional risk.

Interview on 5/21/15 at 11:00 a.m. with the RD revealed she:
*Had not been aware patient 33 had a history of an eating disorder.
*Had relied on the staff informing her how patient 33 was doing.
*Had not had any other interactions with patient 33.
*Could have been more actively involved with patient 33's nutritional care needs.
*Worked for the contracted food service company.
*Along with two other temporary RDs had been providing the clinical dietitian services. Two new permanent full time RDs would be starting on 6/1/15.

Review of the provider's 11/1/14 Dietitian Services policy revealed:
*At least two qualified RDs would be consistently retained by the food service company on a full-time basis.
*Designated responsibilities would be developed specifically for the provider to ensure all nutritional aspects of care were met.

Review of the contracted food service company's 11/20/03 Clinical Dietitian-LTC/Acute Care job description revealed the RD worked with medical and nursing staff to promote optimal patient care and make regular rounds to all patient care units.

Based on interview, document review, and policy review, the provider failed to ensure the utilization review committee had two doctors of medicine or osteopathy (natural and holistic medicine) as committee members. Findings include:

1. Interview on 5/20/15 at 1:00 p.m. with the utilization review committee coordinator revealed committee membership included one physician and one psychologist. The psychologist did not have a degree in medicine or osteopathy. He stated he thought only one physician was needed on the committee.

Review of the provider's utilization committee meeting minutes from January 2014 to the present confirmed there had only been one physician on the committee.

Review of the provider's 4/28/15 utilization review committee policy revealed:
*The appointed committee membership should have consisted of at least two medical staff members.
*One of the goals was to be in compliance with existing regulatory standards.

Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene and glove use was maintained by two of two nurses (A and B) during observed care for one of one patient (27). Findings include:

1. Observation on 5/20/15 beginning at 9:20 a.m. revealed registered nurses (RN) A and B entered patient 27's room to provide care for him. Patient 27 had a known infection by a multiple drug resistant organism (contagious germ that is not easily removed by most antibiotics) in his urine. The infection required staff to follow contact precautions when providing his care. Both RNs were gowned and gloved upon entering the room. With those gloved hands RN A:
*Assisted patient 27 to turn on his side.
*Removed the dressing from an open sore on his buttocks.
*Took off the patient's soiled brief.
*Cleaned the patient's bottom of bowel movement.
*Rolled the soiled Chux (disposable incontinence pad) underneath him.
*Obtained a new Chux and placed that under the patient.
*Adjusted the Foley catheter tubing (tube used to drain urine from the bladder).
*Assisted the patient to turn to his other side by holding onto his hand and buttocks.
*Adjusted the blankets and pulled the patient's shirt down.
*At that point RN A removed her soiled gloves and applied a new pair of gloves. No hand hygiene was done prior to putting on the new pair of gloves.

RN A continued to provide care for patient 27. She changed her gloves multiple times, but at no time had she used hand sanitizer between glove changes. At times she touched the patient's side rails, blankets, and other personal items with contaminated gloves.

Observation of RN B at the above time revealed with gloved hands he:
*Removed the old dressing from another wound on patient 27's buttocks.
*Smoothed out the new Chux under the patient.
*Obtained another Chux from the clean supplies.
*At that point he removed his gloves. No hand hygiene was done after removal of those gloves.

Continued observation of RN B at the above time revealed:
*He obtained supplies for irrigation of the catheter.
*He applied sterile gloves. No hand hygiene was done prior to putting on the sterile gloves or after removing them.
*After attempting to irrigate the catheter he removed his gown and gloves and left the room.
*He re-entered the room with both a gown and gloves on. With those gloved hands he:
-Emptied the catheter bag of urine.
-Adjusted the patient's blankets.
-Obtained a syringe and deflated the balloon that held the catheter in the bladder.
-Removed the catheter tubing and bag and placed those in a basin with urine.
-Again adjusted the patient's blankets.
*He removed his gloves but had not used hand sanitizer after they were removed.

Interview on 5/20/15 at 10:15 a.m. with RN A revealed there was no sink in the patient's room. She stated hand sanitizer could not be kept in the patient rooms. She had hand sanitizer in her pocket but could not reach under her protective gown to use it. She could not leave the room each time she removed her gloves to wash her hands since the patient was on contact precautions.

Interview on 5/20/15 at 2:00 p.m. with the infection control coordinator revealed:
*All staff had been educated on proper hand hygiene.
*It was her expectation hand sanitizer should be available for all staff to use.
*She confirmed hand sanitizer could not be kept in patient rooms, but staff should have brought sanitizer with them when providing care.
*She expected all staff to use hand sanitizer in between glove use.
*It was never proper to move from a dirty to a clean site without changing gloves and doing hand hygiene.

Review of the provider's 7/8/14 Infection Control Standard Precautions policy revealed:
*Employees should wash hands after touching body fluids whether or not gloves had been worn.
*Gloves should have been changed between tasks and procedures on the same patient after contact with material that might contain a high concentration of micro-organisms (germs).
*Hands were to have been washed immediately after removing gloves.

Review of the provider's 7/8/14 Multi-drug Resistant Organisms policy revealed staff were to always wash hands after removing or when changing contaminated gloves.