HospitalInspections.org

Based on observation and interview, it was determined the Hospital failed to ensure patient rooms were free of fire hazards. This has the potential to affect all patients serviced by the Hospital.

Findings include:

1. During a tour of 6-West (Adult Behavioral Health unit), conducted on 5/14/19 at approximately 3:40 PM with the Director of Behavioral Health (E#11), the Manager of 6-West (E#5), and the Manager Accreditation (E#1), in Room #636, pieces of paper towel were occluding the ceiling fire sprinkler head.

2. During the tour of 6-West (Adult Behavioral Health unit), E#11 and E#5 both stated that they were uncertain how the paper towel pieces could have gotten there, when it occurred, and/or who could have done it. Both verbally agreed it was a safety hazard.

A. Based on document review and interview, it was determined for 1 of 1 (Pt #12) patient reviewed for non-violent restraint usage, the Hospital failed to ensure non-violent restraints were ordered, in accordance with its policy. This has the potential to affect all patients who require the use of restraints.

Findings include:

1. Policy ID#: BB-12, Restraints (last revised by the Hospital on 3/13/19) was reviewed on 5/14/19 at approximately 10:45 AM. On page 4, the policy noted, "V. Procedure: A. Non-Violent/Non Self-Destructive Behavior Restraints... 2. Ensure Appropriate Order for Restraint for Non-Violent/ Non Self-Destructive Behavior is obtained. a. Restraint shall be used only upon written order of a physician or other licensed independent practitioner, unless an emergency situation occurs... b. In an emergency situation, when no LIP (licensed independent practitioner) is available, the Lead RN (Registered Nurse) may apply the restraint for a period not to exceed one hour. The LIP must be contacted within that hour."

2. Pt #12 Admission Date: 5/9/19 Diagnosis: Seizure-like Activity.
Pt #12's record was reviewed on 5/15/19 at approximately 10:55 AM with the Nurse Educator (E#14) and the Manager Accreditation (E#1). On 5/11/19 at 7:36 AM, there was a physician order for a jacket/vest restraint. Nursing documentation stated the jacket/vest was discontinued at 8:50 AM. On 5/11/19 at 8:50 AM, nursing documentation stated, "Discontinuation criteria met... Other... adding additional restraints under a new order." At 9:00 AM, nursing documentation stated that a jacket/vest, soft right wrist, and soft left wrist restraints were applied.
There was no order written for this "new order" until 5/11/19 at 2:00 PM. There was no documentation of any communication with the physician and/or LIP related to the addition of soft right and left wrist restraints or of a "new order".

3. During an interview conducted during the record review, E #1 and E #14 verbally agreed there was no documentation of communication with the physician and/or LIP as to the addition of the bilateral soft wrist restraints within one hour of applying them and the order was not written until approximately three hours later, both of which should have been done, in accordance with Hospital policy.


B. Based on document review and interview, it was determined for 1 of 2 (Pt #13) patients, reviewed for violent restraint usage, the Hospital failed to ensure violent restraints were ordered, in accordance with its policy. This has the potential to affect all patients who require the use of violent restraints.

Findings include:

1. Policy ID#: BB-12, Restraints (last revised by the Hospital on 3/13/19) was reviewed on 5/14/19 at approximately 10:45 AM. On pages 6 to 7, the policy noted, " B. Restraints/Seclusions for Violent/Self-Destructive Behavior... 2. Ensure Appropriate Restraints/Seclusion for Violent/Self-Destructive Behavior Order is obtained..."

2. Pt #13 Admission Date: 5/4/19 Chief Complaint: Hallucinations and Alcohol/Drug Assessment.
Pt #13's record was reviewed on 5/14/19 at approximately 11:05 AM with the Intake Manager (E#15). Emergency Department nursing documentation noted on 5/4/19 Pt #13 required the use of four-point locked restraints from 3:55 PM until admitted to inpatient unit at 9:55 PM. On 5/4/19 at 3:54 PM, there was a physician order for 4 point, locked restraint continuously for four hours. There was no order for the continuation of restraints, beyond 7:55 PM.

3. During an interview conducted during the record review, E#15 stated, "I don't see another order (for 4-point, locked restraint continuation) and there should be (an order)."

Based on document review and interview, it was determined for 1 of 2 (Pt #13) patients, reviewed for violent restraint monitoring, the Hospital failed to ensure patient monitoring, in accordance with its policy. This has the potential to affect all patients who require the use of violent restraints.

Findings include:

1. Policy ID#: BB-12, Restraints (last revised by the Hospital on 3/13/19) was reviewed on 5/14/19 at approximately 10:45 AM. On page 8, the policy noted, "6. Ensure the Patient is Monitored Appropriately. a. 3) Staff assigned will check every 15 minutes... "

2. Pt #13 Admission Date: 5/4/19 Chief Complaint: Hallucinations and Alcohol/Drug Assessment.
Pt #13's record was reviewed on 5/14/19 at approximately 11:05 AM with the Intake Manager (E#15). Emergency Department nursing documentation noted on 5/4/19 Pt #13 required the use of four-point locked restraints from 3:55 PM until admitted to the inpatient unit at 9:55 PM. The "BH Restraint & Seclusion Progress Note", dated 5/4/19, indicated patient monitoring hourly between 5:00 PM and 7:00 PM, instead of every 15 minutes and lacked patient monitoring between 7:00 PM and 9:55 PM.

3. During an interview conducted during the record review, E#15 stated, "No, the monitoring (every 15 minutes) was not done."

Based on observation, document review, and interview, it was determined the Hospital failed to ensure outdated medications stored in the Pharmacy, were not available for patient use. This has the potential to affect all patients serviced by the Hospital.

Findings include:

1. An observational tour of the Pharmacy was conducted on 5/13/19, at approximately 1:45 PM, with the Regional Director of Pharmacy (E#8), the Hospital Pharmacy Operations Manager (E#9), and the Regional Pharmacy Clinical Manager (E#10). Approximately six blue, unlabeled storage totes were observed under the counters in the Pharmacy medication area, with various medications present.

2. Policy #: S-21, Medication Storage and Security (last revised by the Hospital 1/9/19) was reviewed on 5/13/19 at approximately 4:15 PM. The policy noted, "3. M. All expired, damaged and/or contaminated medications are segregated until they are removed from the clinic or hospital..."

3. During the tour of the Pharmacy, E#8, E#9, and E#10, verbally agreed the totes were not labeled as expired and/or unavailable for patient use and should have been.