HospitalInspections.org

Based on medical record review, review of the facility's policies and procedures observation and interview, it was determined the facility failed to ensure:

a.) The patients on the Senior Care Unit (Geropsych Unit) were in a safe environment. Refer to A 144

b.) The staff documented the less restrictive interventions were attempted prior to the use of a restraint/seclusion. Refer to A 164

c.) Physician's orders for restraint and seclusion were completed immediately and were accurate. Refer to A 168

d.) The hospital monitored patients while placed in Restraints/Seclusion. Refer to A 175

e.) The contracted rehabilitation services were included in QAPI. Refer to A 308

f.) The staff reported insomnia episodes of patient in the Senior Care Unit (Geropsych Unit). Refer to A 386

g.) The staff followed their own standards of practice for wound assessment, care and documentation. Refer to A 392

h.) All documentation in the medical records were complete and factual. Refer to A 449

i.) Psychiatric consults and follow up care for mental health services was documented in the medical record. Refer to A 450

j.) The staff documented full assessments related to skin abrasions. Refer to A 450

k.) The staff documented the patients' condition on discharge. Refer to A 450

l.) The staff documented the location of where topical ointments were applied. Refer to A 450

m.) The staff notified the physician of changes in a patient's condition. Refer to A 450

n.) A patient's home medications being administered in the hospital were verified by the pharmacist/physician. Refer to A 501

o.) Outdated medications and supplies were not available for patient use. Refer to 505

p.) Pots and pans in the dietary department were properly cleaned and stored, food items stored in the dietary department were labeled and dated to assure they were safe for patient use, solutions for the cleaning buckets contained the proper amount of chemicals for sanitizing, expired supplies were not available for patient use and sharps containers were not allowed to be overfilled. Refer to A 724


q.) The staff performed hand hygiene per standards of practice. Refer to A 748

r.) The staff performed wound care using aseptic technique. Refer to A 748

s.) The staff labeled multi-dose when opened. Refer to A 748

t.) The staff used wound care medications and and supplies on one designated patient. Refer to A 748

u.) Assure overbed tables were properly cleaned after placing dirty linen on them. Refer to A 748

This had the potential to affect all patients served by this facility.

Based on medical record review, review of the facility's policies and procedures observation and interview, it was determined the facility failed to ensure:

a.) The patients on the Senior Care Unit (Geropsych Unit) were in a safe environment. Refer to A 144

b.) The staff documented the less restrictive interventions were attempted prior to the use of a restraint/seclusion. Refer to A 164

c.) Physician's orders for restraint and seclusion were completed immediately and were accurate. Refer to A 168

d.) The hospital monitored patients while placed in Restraints/Seclusion. Refer to A 175

e.) The contracted rehabilitation services were included in QAPI. Refer to A 308

f.) The staff reported insomnia episodes of patient in the Senior Care Unit (Geropsych Unit). Refer to A 386

g.) The staff followed their own standards of practice for wound assessment, care and documentation. Refer to A 392

h.) All documentation in the medical records were complete and factual. Refer to A 449

i.) Psychiatric consults and follow up care for mental health services was documented in the medical record. Refer to A 450

j.) The staff documented full assessments related to skin abrasions. Refer to A 450

k.) The staff documented the patients' condition on discharge. Refer to A 450

l.) The staff documented the location of where topical ointments were applied. Refer to A 450

m.) The staff notified the physician of changes in a patient's condition. Refer to A 450

n.) A patient's home medications being administered in the hospital were verified by the pharmacist/physician. Refer to A 501

o.) Outdated medications and supplies were not available for patient use. Refer to 505

p.) Pots and pans in the dietary department were properly cleaned and stored, food items stored in the dietary department were labeled and dated to assure they were safe for patient use, solutions for the cleaning buckets contained the proper amount of chemicals for sanitizing, expired supplies were not available for patient use and sharps containers were not allowed to be overfilled. Refer to A 724


q.) The staff performed hand hygiene per standards of practice. Refer to A 748

r.) The staff performed wound care using aseptic technique. Refer to A 748

s.) The staff labeled multi-dose when opened. Refer to A 748

t.) The staff used wound care medications and and supplies on one designated patient. Refer to A 748

u.) Assure overbed tables were properly cleaned after placing dirty linen on them. Refer to A 748

This had the potential to affect all patients served by this facility.

Based on medical record review, review of the facility's policies and procedures observation and interview, it was determined the facility failed to ensure:

a.) The patients on the Senior Care Unit (Geropsych Unit) were in a safe environment. Refer to A 144

b.) The staff documented the less restrictive interventions were attempted prior to the use of a restraint/seclusion. Refer to A 164

c.) Physician's orders for restraint and seclusion were completed immediately and were accurate. Refer to A 168

d.) The hospital monitored patients while placed in Restraints/Seclusion. Refer to A 175

This had the potential to affect all patients served by this facility.

Based on medical record review, observation and interview, it was determined the facility failed to ensure the patients on the Senior Care Unit (Geropsych Unit) were in a safe environment. This had the potential to affect all patients served by this facility.

Findings include:

A tour of the 8 Senior Care Unit (SCU) room #s 401, 402, 403, 404, 405, 406, 407 and 408 was conducted on 7/7/15 at 11:00 AM. The following items were found in the rooms:

401 - call light cords approximately 6 feet long at both A and B beds. A bed with an electric plug in cord approximately 5 feet long.

402 and 406 - call light cords approximately 6 feet long at both A and B beds.

403 and 408 - call light cords approximately 6 feet long at both A and B beds. A 41/2 foot telephone cord was connected to the A bed. This was for the patient's bed alarm.

404 and 405 - call light cords approximately 6 feet long at both A and B beds. A 41/2 foot telephone cord was connected to the B bed. This was for the patient's bed alarm.


A tour of the SCU was conducted on 7/10/15 at 12:15 PM with Employee Identifier (EI) # 1, Director of Nursing. During the tour the surveyor observed the following:

The Nurses' Station was easily accessible to patients being able to enter without any barrier.

There was mold and mildew on the ceiling tiles in the Seclusion Room and Ante Room, Group Room, Activity Room and bathroom, and Quiet Room.

Water was pooled in the light fixtures in the Quiet Room and Activity Room.

Plastic picture frames were in the Dining Hall and Group Room that were not secured to the wall.

Push pins and thumb tack were in the wall and bulletin board easily accessible to patients in the Activity Room.

An interview was conducted on 7/10/15 at 12:30 PM with EI # 1 who verified the above findings.



21056

1. Medical Record (MR) # 31 was admitted to the hospital psychiatric unit on 1/07/15 with diagnosis to include Schizophrenia and Schizoaffective Disorder. A review of the medical record revealed the following:

1/09/15 at 7:50 PM, MR # 31 was at the nursing desk charging behind the desk and yelling at staff. MR # 31 went to the refrigerator in the nursing station and began throwing soda cans out of it at the staff. MR # 31 placed himself in the bathroom holding the door shut. The physician was notified, Haldol 5 milligrams (mg) and Ativan 2 mg injection was given. An order was written to start MR # 31 on Haldol 5 mg by mouth twice a day.

There was no documentation of attempts by staff to re-direct MR # 31.

1/11/15 at:
8:46 AM, MR # 31 was in the dinning room, easily agitated, refused breakfast tray and wanted to go outside and smoke. MR # 31 wheeled self to bathroom and obtained a urinal. MR # 31 filled the urinal with toilet water and threw if all over the dinning room and other residents. Staff documented MR # 31's smoking privileges were revoked.

There was no documentation of interventions attempted by staff to de-esclate or re-direct MR # 31.
9:43 AM, MR # 31 was given Haldol 5 mg and Ativan 2 mg, an hour after his behaviors were out of control.

There was no documentation of the location the medication was administered or response to the medications given.

7:21 PM, MR # 31 was in front of the day room, agitated and irritable. MR # 31 went into the bathroom and shut the door and starting kicking the bathroom door.

There was no documentation of failed attempts by staff to re-direct or de-esclate MR # 31. There was no documentation the physician was notified and no update or changes to the care plan.

On 1/13/15 at:
3:46 AM, MR # 31 was at nursing station yelling and threatening staff because he wanted to go smoke. Staff documented MR # 31 was difficult to re-direct and they would monitor him close.

There was no documentation of what types of re-direction failed to work or alternatives to going outside to smoke were offered to MR # 31.
10:00 AM, MR # 31 was paranoid and delusional about another patient taking his money, his food stamps and other items belonging to him. Staff documented they would monitor every 15 minutes.
11:52 AM, MR # 31 thought another patient had a gun and wanted to kill him.

There was no documentation of an intervention attempted by staff.

On 1/14/15 at 2:30 PM, MR # 31 was in the dining room and struck another patient in the face (right eye area). Physician was called and MR # 31 was placed on one to one status.

A review of the medical record failed to have an order for the change in observation status and there was no change to the care plan.

On 1/15/15 at:
6:18 AM, another patient in the unit reported MR # 31 hit him on his left ear with a closed fist. Staff documented they would continue to monitor.

The surveyor requested a copy of the hospital incident report and was told one was not available. The surveyor asked if the physician or family were notified about the incident and stated there was no documentation in the record to show this was done.
11:18 AM, MR # 31 participated in discussion about causes of stress and effective ways to reduce it.
3:30 PM, MR # 31 became irritable and staff documented MR # 31 can be "hostile" at times; MR # 31 roommate was moved to another room due to MR # 31 aggressive towards him.
7:06 PM, MR # 31 was angry, refused vital signs to be taken, wanted to go outside to smoke. MR # 31 went into dry room and slammed door, cursing at staff as he went by them.
9:30 PM, MR # 31 was acting out and argumentative with physician. MR # 31 was given Haldol 5 milligrams (mg) and Ativan 2 mg injection.

There was no documentation in the medical record how MR # 31 tolerated the injection and if the medication was effective.
On 1/15/15 at 10:30 PM, a physician order was written, " May use seclusion room until pt (patient) calms down " A review of the restraint flowsheet documents MR # 31 was placed in the seclusion room at 10:30 PM and released at 11:30 PM.
There was no documentation in the medical record to show interventions attempted by staff to de-escalate MR # 31, notification of the physician about his/her behaviors throughout the day, attempts to re-direct or changes to the care plan.

On 7/10/15 at 11:15 AM, EI # 2, Senior Care Unit Interim Director Of Nursing, was interviewed about MR # 31. EI # 2 was asked how MR # 31 managed to get behind the nursing station, open the refrigerator and remove drinks to throw at staff. EI # 2 stated MR # 31 was strong and pushed through staff and got behind the nursing desk that is unsecured. EI # 2 stated that all psychiatric unit staff are now trained according to the Crisis Prevention Institute (CPI). EI # 2 was asked what was done to make sure MR # 31 was safe when he went into the bathroom and held the door. EI # 2 stated staff were able to open the door. EI # 2 confirmed there was no documentation the nursing care plan was updated or changed with MR # 31's behaviors or episode of seclusion.

Based on the review of medical records and hospital policies and procedures and an interview the hospital failed to document less restrictive interventions were attempted prior to the use of a restraint/seclusion for Medical Record (MR) #s 30 and MR # 31. This affected 2 of 3 medical records reviewed for restraints/seclusion and had the potential to affect all patients served by this facility who required restraints/seclusion.

Findings include:

Facility Policy: Restraints and Seclusions
Date Issued: 9/06

I. Purpose:

"To describe guidelines for assessment and appropriate use of restraint in patient care areas.

To prevent and minimize the incidence of potentially violent and dangerous behavior that threatens injury to staff, the patient him/herself, and/or other patients, and to establish safe guidelines for clinical interventions with patients exhibiting such behavior..."

V. Definitions:

"Seclusion refers to the confinement of a person alone in a room where the person is physically prevented from leaving. (An individual in "seclusion" will be continuously monitored (1:1) at Wiregrass Medical Center Senior Care Unit)."

Facility Policy: Safety Policy - Restraints
Revised: 8/30/00

Statement of Purpose:

"To provide guidelines for the therapeutic interventions necessary to protect a patient from physically injuring self or others and/or prevent the disruption of a therapeutic environment. Interventions will be limited to clinically justified situations employing the least-restrictive safe and effective restraint method..."

Text:
Definitions:
Restraints:

"II. Other less restrictive interventions than restraints will be used and documented before using restraints."

1. MR # 30 was admitted to the Senior Care Unit (Geropsych Unit) on 1/14/15 with diagnoses including Persistent Alcoholic Dementia and Increased Aggression.

Review of the physician's order dated 1/15/15 revealed orders for restraints:

Clinical Justification: Patient/Others Safety

Type of Restraint: Soft Limb Holders (quick release) Wrist and Ankles

Time Limitation: 24 hours

Review of the Patient Progress Notes dated 1/15/15 at 10:40 AM revealed a late entry dated 1/16/15 at 11:34 AM stating the patient became argumentative, yelling at the staff, and ended by saying, "continued on new note".

Review of the Patient Progress Note dated 1/15/15 at 10:45 AM revealed the following documentation, " ' If you want me down there come on and drag me' At that time (name of 2 Registered Nurses) attempted to scoot pt (patient) down to seclusion room at which time pt became physically aggressive hitting staff with closed fists and kicking them with his legs and feet. Staff members were struck multiple times before they were able to restrain pt on floor by having to physically lay on (patient) at which time other staff members came and were able to subdue (patient's) arms and legs and the LPN (Licensed Practical Nurse) was able to administer injection...Soft velcro restraints were obtained and placed on pt BUE (bilateral upper extremities) and BLE (bilateral lower extremities) and escorted to seclusion room... "

Review of the Restraint Flowsheet dated 1/15/15 at 10: 42 AM revealed the following:

1. Other methods attempted:

2. Justification for Decision:

3. Explanation given to patient:

1, 2 and 3 all documented, "pt (patient) in seclusion at my arrival". There was no documentation of a less restrictive intervention attempted before the restraint and seclusion. There was no documentation of the staff attempting a less restrictive method to deescalate the patients behavior before placing the patient in seclusion and restraints.

Review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed the patient was in restraints and seclusion between 10:45 AM and 9:00 PM. Further review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed no documentation of the patients behavior between 6:00 and 9:00 PM.

Review of the Patient Progress Notes dated 1/21/15 at 7:15 AM revealed the following, "the pt has been up all shif (shift), sitting at the nurses station talking and cursing at staff and making threatening statements to staff, verbally abusive. He had verbal comfrontation (confrontation) with MHT (Mental Health Technician) that resulted with staff being wrestled to floor, hitting her in her back and pulling out a handful of her hair. The patient was put in seclusion."

Review of the physician's order dated 1/21/15 at 10:35 AM revealed a late entry dated 1/21/15 at 6:20 AM ordering the patient be placed in seclusion with 1:1 observation. There was no documentation the staff attempted a less restrictive intervention prior to the patient being placed in seclusion.

The surveyor requested a policy for Seclusion which included the staff attempting a lesser restrictive intervention prior to seclusion and none could be provided.

An interview was conducted with Employee Identifier (EI) # 2, Interim Director of Nurses for the Senior Care unit on 7/10/15 at 12:00 PM, who verified the above findings.



21056

2.MR # 31 was admitted to the hospital psychiatric unit on 1/07/15 with diagnosis to include Schizophrenia and Schizoaffective Disorder. A review of the medical record revealed the following:

1/09/15 at 7:50 PM, MR # 31 was at the nursing desk charging behind the desk and yelling at staff. MR # 31 went to the refrigerator in the nursing station and began throwing soda cans out of it at the staff. MR # 31 placed himself in the bathroom holding the door shut. The physician was notified, Haldol 5 milligrams (mg) and Ativan 2 mg injection was given. An order was written to start MR # 31 on Haldol 5 mg by mouth twice a day.
There was no documentation of attempts by staff to re-direct MR # 31.

On 1/15/15 at:
6:18 AM, another patient in the unit reported MR # 31 hit him on his left ear with a closed fist. Staff documented they would continue to monitor.

The surveyor requested a copy of the hospital incident report and was told one was not available. The surveyor asked if the physician or family were notified about the incident and stated there was no documentation in the record to show this was done.
11:18 AM, MR # 31 participated in discussion about causes of stress and effective ways to reduce it.
3:30 PM, MR # 31 became irritable and staff documented MR # 31 can be "hostile" at times; MR # 31 roommate was moved to another room due to MR # 31 aggressive towards him.
7:06 PM, MR # 31 was angry, refused vital signs to be taken, wanted to go outside to smoke. MR # 31 went into dry room and slammed door, cursing at staff as he went by them.
9:30 PM, MR # 31 was acting out and argumentative with physician. MR # 31 was given Haldol 5 milligrams (mg) and Ativan 2 mg injection.

There was no documentation in the medical record how MR # 31 tolerated the injection and if the medication was effective.
On 1/15/15 at 10:30 PM, a physician order was written, " May use seclusion room until pt (patient) calms down " A review of the restraint flowsheet documents MR # 31 was placed in the seclusion room at 10:30 PM and released at 11:30 PM.
There was no documentation in the medical record to show interventions attempted by staff to de-escalate MR # 31, notification of the physician about his/her behaviors throughout the day, attempts to re-direct or changes to the care plan.

On 7/10/15 at 11:15 AM, EI # 2, Senior Care Unit Interim Director Of Nursing, was interviewed about MR # 31 and confirmed the above findings.

Based on review of medical records and the facility's policy and procedure and interview, it was determined the facility failed to ensure physician orders for restraint and seclusion were completed immediately and were accurate.

This includes Medical Record (MR) #s 30 and 18 (2 of 3 records reviewed with restraints and/or seclusion) and had the potential to affect all patients served by this facility who required restraints and/or seclusion.

Findings include:

Facility Policy: Safety Policy - Restraints
Revised: 8/30/00

Statement of Purpose:

"To provide guidelines for the therapeutic interventions necessary to protect a patient from physically injuring self or others and/or prevent the disruption of a therapeutic environment. Interventions will be limited to clinically justified situations employing the least-restrictive safe and effective restraint method. Protection and preservation of patient's rights, dignity, and well-being are ensured by maintaining a safe environment, assuring the patient's ability to care for him/herself not compromised, and to assure that the patient maintains a comfortable body temperature, modesty, and visibility to others..."

Text:
Definitions:
Restraints:

"I. Restraints including limb holders, restraining jacket, and body restraints are used for:..."

"8. The order includes clinical justification, time limit not to exceed 24-hours and type of restraint."

1. MR # 30 was admitted to the Geriatric Psychiatric Unit on 1/14/15 with diagnoses including Persistent Alcoholic Dementia and Increased Aggression.

Review of the physician's order dated 1/15/15 revealed orders for restraints:

Clinical Justification: Patient/Others Safety

Type of Restraint: Soft Limb Holders (quick release) Wrist and Ankles

Time Limitation: 24 hours

Review of the Patient Progress Notes dated 1/15/15 at 10:40 AM revealed a late entry dated 1/16/15 at 11:34 AM stating the patient became argumentative, yelling at the staff, and ended by saying, "continued on new note".

Review of the Restraint Flowsheet dated 1/15/15 which began at 6:00 PM revealed the following:

1. Other methods attempted:

2. Justification for Decision:

3. Explanation given to patient:

1, 2 and 3 all documented, "pt (patient) in seclusion at my arrival". There was no documentation of a less restrictive intervention had been attempted before the restraint and seclusion.

Review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed the patient was in restraints and seclusion between 10:45 AM and 9:00 PM. Further review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed no documentation of the patients behavior between 6:00 and 9:00 PM.

There was no documentation of a physician's order for seclusion on 1/15/15.

Review of the Patient Progress Notes dated 1/21/15 at 7:15 AM revealed the following, "the pt has been up all shif (shift), sitting at the nurses station talking and cursing at staff and making threatening statements to staff, verbally abusive. He had verbal comfrontation (confrontation) with MHT (mental Health Technician) that resulted with staff being wrestled to floor, hitting her in her back and pulling out a handful of her hair. The patient was put in seclusion."

Review of the physician's order dated 1/21/15 at 10:35 AM revealed a late entry dated 1/21/15 for 6:20 AM ordering the patient be placed in seclusion with 1:1 observation. Therefore the physician's order was not completed immediately after the episode.

An interview was conducted with Employee Identifier (EI) # 2, Interim Director of Nurses for the Senior Care unit on 7/10/15 at 12:00 PM who verified the above findings.







21056

Medical Record (MR) # 18 was admitted to the hospital on 6/05/15 and transferred to a Long Term Care Hospital on 6/08/15. A review of the restraint orders revealed MR # 18 was ordered bilateral wrist restraints on 6/05/15 at 10:00 AM. The 10:00 AM, 6/05/15 and 6/06/15 restraint orders failed to document the type of restraint that was to be used on MR # 18.

In an interview on 7/10/15 at 11:00 AM, EI # 1 confirmed the restraint order for 6/05/15 and 6/06/15 was not complete, but stated wrist restraints were used.

Based on the review of medical records and the facility's policies and procedures and interview the hospital failed to monitor Medical Record (MR) # 30 and 18 while placed in Restraints/Seclusion. This affected 2 of 3 records reviewed for restraints and had the potential to affect all patients served.

Findings include:

Facility Policy: Safety Policy - Restraints
Revised: 8/30/00

Statement of Purpose:

"To provide guidelines for the therapeutic interventions necessary to protect a patient from physically injuring self or others and/or prevent the disruption of a therapeutic environment. Interventions will be limited to clinically justified situations employing the least-restrictive safe and effective restraint method. Protection and preservation of patient's rights, dignity, and well-being are ensured by maintaining a safe environment, assuring the patient's ability to care for him/herself not compromised, and to assure that the patient maintains a comfortable body temperature, modesty, and visibility to others..."

Procedure:

"5. The maximum length of time between observing the patient in restraints is every 2 hours. Due to the patients physical condition, emotional condition and absence of family members or significant others, the patient will be observed more often then every 2 hours as needed. Documentation will be made on the patients circulation, condition of the skin and limbs, attention to hydration, feeding, toilet, range of motion, and general condition as resting, still agitated, etc. the patient will be offered personal hygiene needs, nutritional needs as well as emotional and comfort needs. The restraint flow sheet will be used to document. Numbers 1, 2, and 3 must be filled out completely on the flow sheet."

1. MR # 30 was admitted to the Senior Care Unit (Geropsych Unit) on 1/14/15 with diagnoses including Persistent Alcoholic Dementia and Increased Aggression.

Review of the physician's order dated 1/15/15 revealed orders for restraints:

Clinical Justification: Patient/Others Safety

Type of Restraint: Soft Limb Holders (quick release) Wrist and Ankles

Time Limitation: 24 hours


Review of the Restraint Flowsheet dated 1/15/15 at 10: 42 AM revealed the following:

1. Other methods attempted:

2. Justification for Decision:

3. Explanation given to patient:

1, 2 and 3 all documented, "pt (patient) in seclusion at my arrival". There was no documentation of the staff attempting a less restrictive method to deescalate the patients behavior before placing the patient in seclusion and restraints.

Further review of the Restraint Flowsheet dated 1/15/15 revealed the following:

6:00 PM (Start time) - no documentation the patient was offered fluids, bathroom break, personal hygiene or alternate restraints. The staff did document checking the circulation.

8:00 PM - no documentation the patient was offered personal hygiene or alternate restraints.

9:00 PM. Restraints were off and the seclusion door was opened.

There was no documentation of Restraint Flowsheet dated 1/15/15 between 10:42 AM and 6:00 PM.

There was no documentation the patient received:
Fluids offered every 2 hours
Mental Status check every 2 hours
Bathroom offered every 2 hours
Meals Snacks Supplement at all.
Personal hygiene every 8 hours
Alternate restraints every 2 hours.

Review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed the patient was in restraints and seclusion between 10:45 AM and 9:00 PM. Further review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed no documentation of the patients behavior between 6:00 and 9:00 PM.

Review of the Patient Progress Notes dated 1/15/15 at 10:40 AM revealed a late entry dated 1/16/15 at 11:34 AM stating the patient became argumentative, yelling at the staff, and ended by saying, "continued on new note". There was no documentation of a new note nor was there documentation of the incident that lead the patient to be placed in seclusion and restraints.

Review of the Patient Progress Notes dated 1/21/15 at 7:15 AM revealed the following, "the pt has been up all shif (shift), sitting at the nurses station talking and cursing at staff and making threatening statements to staff, verbally abusive. He had verbal comfrontation (confrontation) with MHT (Mental Health Technician) that resulted with staff being wrestled to floor, hitting her in her back and pulling out a handful of her hair. The patient was put in seclusion."

Review of the physician's order dated 1/21/15 at 10:35 AM revealed a late entry dated 1/21/15 for 6:20 AM ordering the patient be placed in seclusion with 1:1 observation. There was no documentation of a Restraint Seclusion Flow Sheet for 1/21/15 to include every 2 hours.

An interview was conducted with Employee Identifier (EI) # 2, Interim Director of Nurses for the Senior Care unit on 4/10/15 at 12:00 PM who verified the above findings.



21056

2. MR # 18 was admitted to the hospital on 6/05/15 and placed in bilateral wrist restraints on 6/05/15 at 10:00 AM. A review of the nursing notes and restraint monitoring flowsheets revealed MR # 18 was not monitored every two hours per hospital policy on 6/05/15, 6/06/15 and 6/07/15.

The nursing notes documented on 6/07/15 at 12:05 AM, MR # 18 was unresponsive to any stimuli and the restraints were removed at 6:30 AM.

In an interview on 7/10/15 at 11:00 AM, EI # 1 confirmed staff failed to document the restraint monitoring every two hours per hospital policy.

Based on interview and review of the hospital's Quality Assurance Performance Improvement (QAPI) program, the hospital failed to assure the contracted rehabilitation services were included in QAPI. This had the potential to affect all patients served.Findings include:On 7/08/15 at 8:08 AM, the surveyor interviewed Employee Identifier (EI) # 11, Physical Therapy Office Manager. During the interview EI # 11 was asked for the rehabilitation departments QAPI information. EI # 11 stated they would have to ask the Physical Therapist what information was submitted, but did not think there was any information to show the surveyor. On 7/10/15 at 7:40 AM, the surveyor interviewed Employee Identifier (EI) # 3, Clinical Resource Manager/Infection Control/Employee Health Director, and EI # 10, QAPI Director. During the interview staff were asked if all hospital departments submitted data related to QAPI and stated all, except therapy. During a review of the hospital's QAPI program there was no information the rehabilitation services were included in the hospital's QAPI.

Based on medical record review, review of the facility's policies and procedures and interview with the staff, it was determined the facility failed to ensure the staff:

a.) Reported insomnia episodes of patient in the Senior Care Unit (Geropsych Unit). Refer to A 386

b.) Followed their own standards of practice for wound assessment, care and documentation. Refer to A 392

This had the potential to affect all patients served by this facility.

Based on medical record review and interview with the staff, it was determined the facility failed to ensure the staff reported insomnia episodes of patient in the Senior Care Unit (Geropsych Unit). This affect 1 of 1 patients in the Senior Care unit with insomnia episodes. This include Medical Record (MR) # 30 and had the potential to affect all patients served by this facility.

Findings include:

1. MR # 30 was admitted to the Senior Care Unit (Geropsych Unit) on 1/14/15 with diagnoses including Persistent Alcoholic Dementia and Increased Aggression.

Review of the Patient Progress Note dated 1/19/15 at 1:43 AM revealed the patient was at the nurses station yelling and threatening staff. The patient difficult to redirect.

Review of the Patient Progress Note dated 1/19/15 at 3:51 AM revealed the patient was sitting at the nurse station.

Review of the Patient Progress Note dated 1/20/15 at 12:48 AM revealed the patient was sitting in front of the nurse station being argumentative with the staff and being verbally aggressive. It was difficult to redirect the patient.

Review of the Patient Progress Note dated 1/21/15 at 3:03 AM revealed the patient continued to be awake sitting at the nurse station talking non stop, cursing at staff and name calling.

Review of the Patient Progress Note dated 1/21/15 at 7:15 AM revealed the patient had been up all shift sitting at the nurses station talking and cursing at the staff and making threatening statement to staff. He had a verbal confrontation with the Mental Health Technician that resulted with the staff being wrestled to floor, hitting her in her back and pulling a handful of her hair. The patient was put in seclusion.

Review of the physician's order dated 1/22/15 at 2:25 PM revealed an order to discontinue the Ambien and start Restoril 30 mg (milligrams) every night.

An interview was conducted with Employee Indentifer (EI) # 2, Interim Director of Nurse for Senior Care Unit, who stated the staff should have discussed the insomnia with the physician before 1/22/15.

Based on the review of the facility's policies and procedures and medical records and interview, it was determined the facility failed to ensure the staff followed their own standards of practice for wound assessment, care and documentation. This affect Medical Record (MR) # 32, and #19 (2 of 3 records reviewed with wounds) and had the potential to affect all patient served by this facility.

Findings include:

Infection Control
Policy & Procedures:
Subject: Wound Care/ Treatment Guidelines
Revised 8/2009
Statement of Purpose: To provide excellent wound care to promote healing
Guidelines:
" 1. A daily assessment should be done on all wounds requiring treatment. This should include measurement and a description...
7. Medications and supplies shall be for one designated patient...
10. Documentation of treatment and how the patient tolerated the procedure shall be done immediately after the treatment."


Administration
Policy & Procedures:
Subject: Wound Care
Date issued: 12/13
Statement of Purpose: To provide wound care assessment and obtain orders for wound care.
Text:" A. Skin assessment and obtain orders for wound care.
1. All skin irregularities noted in chart and photographed.
2. Medical Doctor (MD) contacted immediately for wound care orders if appropriate.

B. Wounds must be assessed, measured, and characteristic (drainage, smell) documented daily.

1. Wound care and dressing change per MD orders.
2. Any significant changes on wound size or characteristic, the charge nurse will be notified immediately.
3. Regardless of scheduled time regarding wound care, wound care will be performed immediately prior to discharge. Wound will be photographed and documented on at this time."

1. MR # 32 was admitted to the Senior Care Unit (Geropsych Unit) on 7/2/15 for Aggressive Behaviors and Skin Tears.

Review of the physician's orders dated 7/2/15 revealed the following:

a.) Cleanse skin tears with NS (normal saline), apply TAO (triple antibiotic ointment), cover with non adherent dressing and Kerlix and secure with tape every day.

b.) Cleanse wound to back of LLE (left lower extremity) with NS, pat dry, apply TAO, cover with non adherent dressing and Kerlix with tape twice a day.

Review of the Patient Progress Notes dated:

7/3/15 at 12:52 = "Bruising left side lower back and extending to center of back near coccyx. skin tear back of left thigh, skin tear right elbow".

7/4/15 at 6:49 PM = "Bruising left side lower back and extending to center of back near coccyx. Bruising bil. (bilateral) arms. Skin tear back of left calf, right forearm, and bil. legs. Dressing intact..."

7/5/15 at 7:43 PM = "Bruising left side lower back and extending to center of back near coccyx. Bruising bil. arms. Skin tear back of left calf, right forearm, and bil. legs. Dressing intact..."

7/6/15 at 12:30 and 7:51 PM = "Bruising left side lower back and extending to center of back near coccyx. Bruising bil. (bilateral) arms. Skin tear back of left calf, right forearm, and bil. legs. Dressing intact..."

7/7/15 at 10:36 AM and 10:10 PM = "Bruising left side lower back and extending to center of back near coccyx. Bruising bil. (bilateral) arms. Skin tear back of left calf, right forearm, and bil. legs. Dressing intact..."

There was no documentation of a wound assessment to include measurements and description or wound care of the skin tear to the back of the left calf, right forearm or bilateral legs since admission 7/2/15 to 7/8/15 when the medical record was reviewed.

An interview was conducted on 7/8/15 at 2:15 PM with Employee Indentifer (EI) # 2, Interim Director of Nurses for the Senior Care unit.



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2. Medical Record (MR) # 19 was admitted to the hospital on 3/14/15 with intractable pain, multiple decubiti and skin breakdown. Nursing staff documented on admission a foul smell from multiple unstageable decubiti to the right and left hip, left below the knee amputation (BKA) stump, left elbow and underside of the penis. On admission wound cultures were obtained and on 3/15/15 the physician performed debridement of the right hip pressure ulcer. Pictures of the wounds were taken, but there were no measurements of any of the wounds or descriptions of the wounds other than their locations.

The medical record documented a Physical Therapy (PT) consult was placed on 3/15/15 for evaluation and treatment of the wounds. There was no documentation in the medical record of where the PT consult was completed, recommendations made or treatment of the wounds provided.

A review of the nursing notes revealed:

3/15/15 at 2:45 PM, wet to dry dressing was applied to bilateral hip wounds and kerlex wrap applied to the left stump. There was no physician order for the care provided and no documentation about the other wounds MR # 19 was admitted with.

3/16/15 at 1:02 AM, staff documented dressing was changed. There was no documentation of what type of dressing change was provided, assessment of the wounds or location of wounds that received a dressing change.

3/17/15 at 9:05 AM, staff documented MR # 19 was taken to surgery for debridement of hip wound and PEG (Percutaneous Endoscopic Gastrostomy) tube placement. There was no description of any dressings, wounds or wound care treatments provided to the other wounds that were not debrided.

3/19/15 at 7:39 AM, physician documented daily surgical debridement was performed. There was no assessment of any of the wounds MR # 19 was admitted with and no documentation of wound care provided to wounds that were not debrided.

3/21/15 at 6:30 AM, staff documented necrosis observed to all wounds. There was no other documentation about an assessment of the wounds. At 3:10 PM, staff documented wet to dry dressing changes, but did not document which wounds the dressing changes were provided to. There were no physician orders for the wet to dry dressing changes.

3/22/15 staff did not document an assessment of the wounds MR #19 was admitted with.

3/23/15 at 6:55 AM, staff documented surgical incision to bilateral hip pressure ulcers and two right leg wounds. There was no documentation to show if there was a new wound to the right leg since only one was documented on admission. At 6:25 PM, staff documented dressing dry and intact. There was no documentation of which wound dressing the staff were describing.

3/24/15 MR # 19 was transferred to a Long Term Care Hospital.

In an interview on 7/10/15 at 10:12 AM, EMployee Identifier (EI) # 1, Director of Nurses, confirmed the above findings. EI # 1 stated staff should measure wounds on the initial assessment and at least every seven days, or more if needed. At 10:43 AM, EI # 13, nurse ED, confirmed there were no PT notes found in the electronic medical record.

Based on the review of the medical records and interview with the staff, it was determined the facility failed to ensure all documentation were complete and factual. This affected 1 of 3 records reviewed from the Senior Care Unit (Geropsych Unit) and had the potential to affect all patients served by this facility.

Findings include:

1. MR (Medical Record) # 30 was admitted to the Senior Care Unit on 1/14/15 with diagnoses including Persistent Alcoholic Dementia and Increased Aggression.

Review of the Patient Progress Notes dated 1/15/15 at 10:40 AM revealed a late entry dated 1/16/15 at 11:34 AM stating the patient became argumentative, yelling at the staff, and ended by saying, "continued on new note". There was no documentation of a new note.

Review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed the patient was in restraints and seclusion between 10:45 AM and 9:00 PM. Further review of the Restraint Seclusion Flow Sheet dated 1/15/15 revealed no documentation of the patients behavior between 6:00 and 9:00 PM.

Review of the Patient Progress Note dated 1/15/15 at 11:27 AM revealed a Therapy Chart Note which documented, "pt (patient) refused group actually became aggressive with staff in hallway while lbsw (Licensed Bachelor Social Worker) was conducting group". This was at a time documentation revealed the patient was in seclusion and restraints.

Review of the Patient Progress Note dated 1/21/15 at 7:15 AM revealed the patient had been up all shift sitting at the nurses station talking and cursing at the staff and making making threatening statement to staff. He/she had a verbal confrontation with the Mental Health Technician that resulted with the staff being wrestled to floor, hitting her in her back and pulling a handful of her hair. The patient was put in seclusion.

Review of the Physician's Order dated 1/21/15 at 10:35 AM indicated an late entry for 6:20 AM which ordered to place the patient in seclusion with 1:1 observation.

Review of the medical record revealed no documentation of a Restraint Seclusion Flow Sheet of Care and Observations for 1/21/15. There was a Restraint Seclusion Flow Sheet of Care and Observations with no documentation of a date which documented the patient was in seclusion from 6:45 AM to 10:15 AM.

An interview was conducted on 7/8/15 at 2:15 PM with Employee Indentifer (EI) # 2, Interim Director of Nurse for Senior Care Unit (Geriatric Psychiatric Unit), who verified the above findings.

Based on medical record reviews and interviews the hospital failed to document:
a. Psychiatric consults and follow up care for mental health services
b. Full assessments related to skin abrasions
c. Condition of patient on discharge
d. Location of where topical ointments were applied
e. Physician notification of changes in a patient's condition.

This affected Medical Records (MR) # 9, 4, 7, 20, and 29 and had the potential to affect all patients served.

Findings include:

1. Medical Record (MR) # 9 presented to the Emergency Department (ED) on 4/13/15 with suicide thoughts after a fight with his/her mother. A review of the ED visit note documented MR # 9 had a past history of cutting herself. There was no documentation in the ED record to indicate MR # 9 was given a psychiatric consult or follow up appointment with a mental health provider. MR # 9 was discharged home.

In an interview on 7/10/15 at 10:08 AM, Employee Identifier (EI) # 1, Director of Nursing and # 13, ED nurse, confirmed a psychiatric consult and referral should have been done, but was not because MR # 9 was currently on psychiatric medications for past issues. EI # 13 confirmed the hospital will put in place a new process for better documentation related to mental health issues.

2. MR # 4, a two year old male, presented to the ED on 4/08/15 with redness/abrasion in the groin area. A review of the nursing and physician assessment failed to document what caused a skin abrasion on the genitals. MR # 4 was discharged home.

In an interview on 7/10/15 at 10:07 AM, EI # 1 confirmed there was no documentation by the nurse or physician to explain the skin abrasion to the genitals.

3. MR # 7 presented to the ED on 4/11/15 with right side pain, headache and cuts on the hand after reporting he/she was knocked into a table by an uncle. A review of the ED medical record did not document the condition of MR # 7 when discharged.

In an interview on 7/10/15 at 10:00 AM, EI # 1 was asked if the alleged assault was reported. EI # 1 stated MR # 7 was asked if he/she felt safe and no report was made.

4. MR # 20 was admitted to the hospital on 5/10/15 with failure to thrive, anemia, dehydration and Gastrointestinal Stromal Tumor (GIST). A review of the medical record revealed the following wound care was ordered: clean forearm (right or left was not included in order) with water and apply Neosporin twice a day.

A review of the nursing notes and Medication Administration Record (MAR) revealed nursing staff failed to document the location of the Neosporin on the following dates: 5/13/15, 5/14/15, 5/15/15, and 5/16/15. There was no documentation the twice a day wound care was provided on 5/15/15.

On admission an Ensure supplement was ordered for every night.

On 5/17/15 at 1:34 PM, nursing staff documented MR # 20 was having trouble swallowing and the lunch tray was held. At 5:31 PM, nursing staff documented MR # 20 refused meal tray. There was no documentation the physician was notified of MR # 20's difficulty swallowing and no documentation of where MR # 20 was given a supplement or nutritional consult ordered to address swallowing issues.

On 5/18/15 the only meal documentated for MR # 20 was breakfast. There was no documentation MR # 20 was given the ordered Ensure or notification to the physician of a need for a dietary consult.

In an interview on 7/10/15 at 10:55 AM, Employee Identifier (EI) # 1 confirmed the above findings.



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5. MR # 30 was admitted to the Senior Care Unit (Geropsych Unit) on 1/14/15 with diagnoses including Persistent Alcoholic Dementia and Increased Aggression.

Behavioral Observation Forms:

Review of the Behavioral Observation Forms dated 1/20/15, 1/21/15, 1/23/15, and 1/26/15 revealed difficulty identifying the location of the patient due to illegibility.

An interview was conducted on 7/8/15 at 2:15 PM with Employee Indentifer (EI) # 2, Interim Director of Nurse for Senior Care Unit (Geriatric Psychiatric Unit), who verified the above findings.

6. MR # 29 was admitted to the Senior Care Unit on 6/24/15 with diagnoses including Schizoaffective Disorder.

Review of the Behavioral Observation Forms dated 6/28/15, 6/29/15, 7/5/15, 7/6/15, and 7/7/15 revealed difficulty identifying the location of the patient due to illegibility.

An interview was conducted on 7/9/15 at 8:45 AM with EI # 2, who verified the above findings.

Based on review of the Medical Records (MR) and interviews with the staff it was determined the facility failed to ensure all physician verbal orders were authenticated by the physician's signature,date and time. This had the potential to negatively affect all patients served by the facility and did affect MR #s 32, 16, 23, 24, 25, 26, and 27.

Findings include:

An interview was conducted on 7/7/15 at 2:05 PM with EI # 9, Medical Records Supervisor. Employee Indentifer (EI) # 9 stated the standard required time frame for physician authentication for verbal orders was 24 hours.

1. MR # 32 was admitted to the Senior Care Unit (Geropsych Unit) on 7/2/15 for Aggressive Behaviors and Skin Tears.

Review of the medical record on 7/8/15 at 2:05 PM revealed the physician's verbal orders dated:

7/2/15 between 6:02 PM and 11:59 PM were authenticated on 7/8/15 at 12:18 PM, 6 days later.

7/3/15 between 12:02 and 3:51 AM were authenticated was dated 7/8/15 at 12:18 PM, 5 days later.

An interview was conducted on 7/8/15 at 2:15 PM with Employee Indentifer (EI) # 2, Interim Director of Nurses for the Senior Care Unit. EI # 2 verified the physician's verbal orders were not authenticated with in the required 24 hours.

2. MR # 16 was admitted to the facility on 1/21/15 with diagnoses including Small Bowel Obstruction.

Review of the medical record on 7/9/15 revealed the physician's verbal orders dated:

1/21/15, 1/22/15, 1/23/15, and 1/24/15 were authenticated on 2/16/15 at 8:59 AM, which was 26, 25 and 24 days later.

1/27/15, 1/28/15, 1/29/15, and 1/31/15 were authenticated on 2/16/15 at 10:22 AM, which was 20, 19, 18 and 17 days later.

1/26/15, 1/30/15, 2/2/15, 2/4/15 and 2/5/15 were authenticated on 2/19/15 at 11:15 AM, which was 24, 20, 17, 15 and 14 days later.

3. MR # 23 was an outpatient on 4/2/15 for a Cholelithiasis.

Review of the Anesthesia Record dated 4/2/15 revealed the patient received Zofran 4 mg (milligrams) at 7:30 AM. There was no documentation of a physician's order for the Zofran.

Review of the verbal orders dated 4/1/15 and 4/2/15 revealed the Physican authenticated on 4/13/15, which was 11 and 12 days later.

An interview was conducted on 7/9/15 at 11:30 AM with EI # 3, Clinical Resource Manager who verified the above findings.

4. MR # 24 was an outpatient on 3/5/15 for a Colonoscopy .

Review of the verbal orders dated 3/5/15 and 3/9/15 revealed the Physican authenticated on 3/31/15, which was 26 and 22 days later.

An interview was conducted on 7/9/15 at 11:30 AM with EI # 3, who verified the above findings.

5. MR # 25 was admitted to the hospital on 5/8/15 for a Colonoscopy follow up.

Review of the medical record on 7/9/15 revealed the physician's verbal orders dated:

Four verbal orders dated 5/7/15 were authenticated on 5/19/15, which was 12 days later.

Twenty-three verbal orders dated 5/7/15 were authenticated on 5/13/15, which was 6 days later.

Three verbal orders dated 5/8/15 were authenticated on 5/14/15, which was 6 days later.

Six verbal orders dated 5/8/15 were authenticated on 5/19/15, which was 11 days later.

An interview was conducted on 7/9/15 at 11:30 AM with EI # 3, who verified the above findings.

6. MR # 26 was an outpatient on 6/23/15 for a Removal of a Cysts on the Scalp .

Review of the verbal orders dated 6/22/15 revealed the Physican authenticated on 6/24/15, which was 2 days later.

An interview was conducted on 7/9/15 at 11:30 AM with EI # 3, who verified the above findings.

7. MR # 27 was an outpatient on 3/5/15 for a Removal of a Cysts on the Head.

Review of the verbal orders dated 5/12/15 revealed the Physican authenticated on 5/19/15, which was 7 days later.

An interview was conducted on 7/9/15 at 11:30 AM with EI # 3, who verified the above findings.

The surveyor request a policy which include a 24 hour time frame for authentication of physician's verbal orders on 7/9/15 at 2:00 PM from EI # 1, Director of Nurse and none could be provided.

An interview was conducted on 7/10/15 at 11:15 AM with EI # 1, Director of Nurses, who verified the physician's verbal orders were not authenticated with in the required 24 hours.

Based on interview, review of the facility's policies and procedures and observations, it was determined the facility failed to ensure a patient's home medication being administered in the hospital were verified by the pharmacist/physician. This had the potential to affect all patients served by this facility.

Findings include:

Pharmacy
Policy & Procedures:
Subject: Disposition of Patient Personal Medication
Revised 3/01
Statement of Purpose: To standardize a process for receiving, recording, verifying and returning patient personal medications.
Text: " II. A home medication may be used during a hospital stay with a physician's written order. These would include but not limited to: drugs not available on the Formulary, inhalers, sprays, birth control pills or any medications that the physician may order to be left at bedside for self administration by patient or by a responsible family member."

A tour of the Senior Care Unit was conducted on 7/7/15 at 11:15 AM. In the medication room the surveyor observed in the drawer labeled for an unsampled patient were the following home medications being administered to the patient:

Tacrolimus (prevent transplant organ rejection)

Mycophenolate (prevent transplant organ rejection)

SMZ-TMP DS (antibiotic)

An interview was conducted on 7/7/15 at 11:30 AM with Employee Indentifer (EI) # 6, Licensed Practical Nurse. The surveyor asked EI # 6 how the staff knew what was in the home medication bottles was what the label read. EI # 6 replied, "I don't."

Based on observations, interview and review of the policies and procedures the hospital failed to assure outdated medications and supplies were not available for patient use. This affected the Surgery Suite, Senior Care Unit, and Pharmacy and had the potential to affect all patients.

Findings include:

Pharmacy
Policy & Procedures:
Subject: Destruction of out-of-date medications Non-Narcotic and Narcotic Drugs
Revised 11/20/01
Statement of Purpose: To establish a policy for disposing of out-of-date medications (Non-Narcotic)
" Out-of-date medications will be pulled from stock and stored in an area separated from other medications..."

Central Sterile
Policy & Procedures:
Subject: Expiration date / shelf life
Revised 1/09/03
Statement of Purpose: To assure all supplies have been sterilized and used before pre-established expiration date.
Policy: " Expiration dates are checked weekly, supplies are rotated so older ones are used first...check for expiration date and damage to packages weekly"

A tour of the Senior Care Unit was conducted on 7/7/15 at 11:15 AM with Employee Identifier (EI) # 4, Director of Nursing (DON) Long Term Care. The surveyor observed:

One 4 ounce (oz.) bottle of Hydrogen Peroxide, expired 6/14
One 3 oz. Safe Gel, expired 5/15

An interview was conducted with EI # 4 on 7/7/15 at 11:30 AM who verified the above findings.

A tour of the Surgery Suite was conducted on 7/7/15 at 1:40 PM with EI # 5, Manager-Surgery. The surveyor observed:

Endoscopy Room # 1:
1 - Metoclopramide 10 mg(milligrams)/2 ml (milliliters) vial expired 5/15

Endoscopy # 2:
1 - Amidate 20 mg/10 ml expired 3/1/15
2 - Metoclopramide 10 mg/2 ml vial expired 3/15

Operating Room (OR) # 2:
2 - Furosemide 10 mg/ml 2 ml vials expired 3/15
1 - Promethazine 25 mg/ml expired 5/14

Outpatient:
Refrigerator:
5 - Tuberculin 5 ml expired 5/14

Medication Room:
7 - Benzonatate 100 mg expired 6/15
5 - Meclizine HCL (Hydrogen Chloride) 12.5 mg expired 12/17/14

An interview was conducted with EI # 5 on 7/7/15 at 2:30 PM who verified the above findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

In addition, the hospital failed to assure pots and pans in the dietary department were properly cleaned and stored, food items stored in the dietary department were labeled and dated to assure they were safe for patient use, solutions for the cleaning buckets contained the proper amount of chemicals for sanitizing, expired supplies were not available for patient use and sharps containers were not allowed to be overfilled. This had the potential to affect all patients served

Findings include:

Refer to A - 724 and the Life Safety Code survey report for violations.

Based on observations, facility policies and interviews the hospital failed to assure pots and pans in the dietary department were properly cleaned and stored, food items stored in the dietary department were labeled and dated to assure they were safe for patient use, solutions for the cleaning buckets contained the proper amount of chemicals for sanitizing, expired supplies were not available for patient use and sharps containers were not allowed to be overfilled. This had the potential to affect all patients served.

Findings include:

During a tour of the dietary department on 7/07/15 at 10:50 AM, the surveyor observed the following pots and pans stored wet and/or with food debris inside:
4 quart pans - 4 wet nested stack together and 1 of the 4 with food debris inside the pan
4.3 quart pans - 7 wet nested stacked together and 2 of the 7 had dried crusted food debris inside the pan
6.7 quart pans - 4 wet nested stacked together and 3 of the 4 with a clear greasy substance to touch noted on the outside of the pans.
2 quart pans - 2 wet nested

Hospital Policy:
Pot and Pan Washing
Text: Pots and pans should be allowed to air dry. A clean large utility cart may be used for this due to lack of drain board space.

During the tour on 7/07/15 at 10:50 AM the surveyor observed the following food items in the refrigerator that were not dated or labeled:
one bag of mixed vegetables
one zip lock bag containing round cooked meat patties

Hospital Policy:
How to label food
Text: Any left over or prepared food prepared must have a label containing, what the item is, date prepared, and when to use by date.

During the tour on 7/07/15 at 11:15 AM the surveyor observed a red bucket with white cloths inside and asked Employee Identifier (EI) # 14, Dietary Manager, if this was for sanitizing solutions. The test strip showed the parts per million (PPM) of chemical solution was between zero and 150 PPM. EI # 14 stated the chemical solutions should be between 200 and 400 PPM.
On 07/07/15 at 11:15 AM, in an interview with EI # 14, Dietary Manager, she stated the cleaning buckets should be checked and changed every two hours.

Hospital Policy:
Cleaning solutions (81A)
Purpose: To establish proper mixture for cleaning solutions.
Text: Solutions for cleaning buckets should be checked and changed every two hours.

During a tour of the rehabilitation department on 7/07/15 at 1:05 PM, the surveyor observed the following expired supplies:Kendall curity plain packing strips, expired 3/2015Open bottle of rubbing alcohol, expired 2/2015During this tour the surveyor observed the following equipment in the rehabilitation department without a preventative maintenance label:HydrocollatorMagic Chef Microwave

During a tour of the Radiology Department on 7/07/15 at 1:12 PM, the surveyor observed the following:
Nuclear room: Sharps container in room on wall was full.

Mammo Room: Opened bottle of rubbing alcohol with no date the bottle was opened.

CT Room: MedRad CT track packs expired greater than one year - 9 total packs.
Storage Room: Eclipse Needle 25 gauge 1 1/2 expired 5/2015 - 30 each

During a tour of the Emergency Department on 7/07/15 at 1:33 PM the surveyor observed the following expired supplies:
Two Lumbar trays expired 11/2014
Two Multi Luman catheter kits expired 10/2014
Three Evacuated containers expired 6/2015
One Bone marrow biopsy kit expired 3/2015
During a tour of the Intensive Care Unit (ICU) on 7/07/15 at 1:55 PM, the surveyor observed two bottles of rubbing alcohol that were expired. One expired 12/2014 and the other 3/2015. The ICU medication room refrigerator, which contained medication vials, log had no temperatures documented for the month of July. The sharps container located inside the ICU nursing station was full and the medication refrigerator in the nursing station, that contained medications, had no temperatures documented on the log for 7/2/15, 7/3/15, 7/4/15 or 7/5/15.

Based on the review of CDC Guidelines and policies and procedures, observation and interviews, it was determined the facility failed to ensure the staff preformed:

a.) Hand hygiene per standards of practice

b.) Wound care in an aseptic technique.

c.) Labeled multi-dose when opened

d.) Used wound care medications and and supplies on one designated patient.

e.) Assure overbed tables were properly cleaned after placing dirty linen on them.


This had the potential to negatively affect all patient served by this facility and the staff who cared for them.


Findings Include:

Infection Control
Policy & Procedures:
Subject: Wound Care/ Treatment Guidelines
Revised 8/2009
Statement of Purpose: To provide excellent wound care to promote healing
Guidelines:
" 1. A daily assessment should be done on all wounds requiring treatment. This should include measurement and a description...
7. Medications and supplies shall be for one designated patient...
10. Documentation of treatment and how the patient tolerated the procedure shall be done immediately after the treatment."

************

Infection Control
Policy & Procedures:
Subject: Wound Care Procedure
Revised 8/2009

Statement of Purpose: Scrupulous aseptic technique must be used in doing wound care...Care must be taken to prevent contamination of the supplies and surfaces used in wound care.

Procedure:
1. Set up the supplies on a clean surface at the bedside (cover the surface with a clean impervious barrier before putting the supplies out.
12. Clean the wound according to the order. Clean from the center outward.
14. Remove gloves and place in bag.
15. Put on new gloves.
16. Apply clean dressing as ordered.

************

Infection Control
Policy & Procedures:
Subject: Handwashing
Revised 8/2009
Statement of Purpose: To decrease the risk of transmission of infection by appropriate handwashing.
Policy: " Handwashing is generally considered the most single procedure of preventing nosocomial infections..."

************

CDC (Center for Disease Control) MMWR ( Morbidity and Mortality Weekly Report) 2002 Guidelines for Hand Hygiene in Health-care Settings:

Specific Indications for Hand Hygiene

Before:
Patient contact

After:
Contact with a patient's skin
Removing gloves

************

CDC - Injection Safety - Multi-dose Vials
Last Updated February 9, 2011

If a multi-dose has been opened or accessed (e.g. needle-punctured) the vial should be dated and discarded within 28 days unless the manufactured specifies a different (shorter or longer) date for that opened vial.

A tour of the Medication Room in the Senior Care Unit was conducted on 7/7/15 at 11:15 AM with Employee Identifier (EI) # 6, Licensed Practical Nurse. The surveyor observed an open 10 ml (milliliter) vial of Lantus insulin, 30 ml vial of Lidocaine 2% and a 500 ml bottle of Normal Saline without a date opened label.

Observation of medication passes was conducted on 7/8/15 from 7:45 to 8:30 AM with EI # 6 on the Senior Care Unit. Medications were passed to 3 patients in the Activity Room and 2 patients in the Dining Hall, EI # 6 did not perform hand hygiene between patients or areas.

Observations of EI # 7, Mental Health Technician (MHT) taking 5 patients' vital signs was conducted on 7/8/15 between 7:45 and 8:30 AM. EI # 7 did perform hand hygiene between patients.

On 7/8/15 at 11:00 AM the surveyor was in a Medical Surgical room to observe a respiratory treatment. EI # 8, Phlebotomist entered the patient's room, donned gloves, performed a venipuncture to obtain blood, removed gloves and exited the patient's room all without performing hand hygiene.

Observation of wound care on Medical Record # 32 was conducted on 7/8/15 at 1:25 PM with EI # 6 and EI # 2, Interim Director of Nurse for the Senior Care Unit. EI # 6 was in the medication room and obtained gauze, 250 ml (milliliter) of Normal Saline (NS), non stick dressings, tongue blade, spray can of Granulex, triple antibiotic ointment in a tube and tape. EI # 6 performed the following steps for wound care:

A.) placed all the supplies on the patient counter top without a barrier.
B.) placed a barrier on the bedside table and opened all the supplies.
C.) Performed hand hygiene and donned gloves
D.) Removed dressing for 2 open areas (1 with yellow drainage and 1 bleeding) and gloves, performed hand hygiene and donned gloves
E.) Poured NS onto gauze and cleaned both wounds with the same gauze.
F.) Applied triple antibiotic ointment to a tongue blade and applied the ointment to the bleeding wound then to the wound with yellow drainage.
G.) Removed gloves and donned gloves without hand hygiene.
H.) Applied Granulex to the right heel.
I.) Removed gloves and picked up the remaining supplies which included NS bottle, Granulex, and triple antibiotic ointment and returned to the general use in the medication room.

EI # 2 donned gloves when entering the patient's room to assist EI # 6. EI # 2 removed the gloves after EI # 6 performed the wound care. EI # 2 did not perform hand hygiene.

EI # 6 failed to perform wound care with an aseptic technique.

An interview was conducted with EI # 3, Infection Control Director on 7/8/15 at 2:00 P.M. EI # 3 verified the staff did not perform hand hygiene as per policy.




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On 7/09/15 at 11:40 AM, the surveyor observed Employee Identifier (EI) # 12, Medical/Surgical Registered Nurse, provide Foley catheter care for an unsampled patient. After providing the Foley catheter care EI # 12 placed the dirty linens in the dirty linen bag, then, placed the dirty linen bag on the patients over bed table. After removing the dirty linen bag from the patients over bed table EI # 12 wet a clean wash cloth and wiped the over bed table. There was no sanitizing solution used to the the patients over bed table.