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Based on record review and interview, the facility failed to provide a timed and dated one hour face-to-face assessment of a restrained patient for 1 of 2 patients reviewed for behavioral restraints resulting in the potential for unrecognized and unmet patient needs. Findings include:

The review of Patient #31's medical record on 9/12/2018 at 1454 revealed that the patient was placed in 4-point leather restraints for violent behavior. Review of the restraint documentation revealed no face-to-face assessment sheet; however, the physician's progress note stated that a face-to-face had been done.

During an interview with Staff S on 9/12/2018 at 1520, Staff S stated that the expectation would be to have a one hour face-to-face completed by the physician that was dated and timed and that it should be with all of the other restraint documentation.

Policy regarding the one hour face-to-face was requested but not provided prior to exit of survey.

Based on record review and interview, the facility failed to have verbal orders authenticated in a timely fashion for 1 (#31) of 3 patients reviewed for restraint orders resulting in the potential for miscommunication for patient care and the potential for loss of patient's rights. Findings include:

Review of Patient #31's medical record on 9/12/2018 at 1454 revealed that a telephone order for behavioral restraints was obtained on 4/3/2018 at 0240. The order was electronically authenticated by the physician on 4/6/2018 at 2003.

On 9/12/2018 at 1520, Staff S was queried as to what time-frame was acceptable for a physician to authenticate a verbal order to which she stated, "24-hours."

Policy regarding authentication was requested regarding physician authentication of orders and a page from the bylaws, approved by the Board of Directors 6/6/2017, was provided indicating section 2.2.3 H which states, "All admission orders shall be completed and promptly signed by the admitting physician. If a verbal order is used to admit any patient, the order shall be authenticated promptly and within 24 hours of admission. All admission orders must be authenticated prior to discharge." It was brought to Staff S's attention that this referred to admission to which she stated, "It would be the same for any order. It should be authenticated within 24 hours."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated September 11, 2018.
K-0132
K-0211
K-0363
K-0372
K-0712

Based upon observation, interview, and document review the facility failed to ensure the facility maintained an environment devoid of high dust, failed to ensure anesthesia supplies were stored off of the surgical suite floor, and failed to ensure staff donned personal protection equipment in the surgical suite resulting in the potential for the spread of infectious disease to all patients. Findings include:

On 9/11/18 at 1120 during the tour of the Critical Care Unit in room #1, a patient ready room, high dust was found on the overhead lighting above the head of the patient's bed. Staff A confirmed the finding. On 9/11/18 at 1125 high dust was found on the overhead lighting above the head of the patient's bed in room # 4, a patient ready room. Staff A confirmed the finding.

On 9/12/18 at 1220 during observation in the restricted surgical suite supplies for gas anesthesia / oxygen delivery were observed in a uncovered plastic bin sitting next to a trash receptacle at the head of the surgical table. On 9/12/18 at 1225 staff HH and staff MM were queried if the supplies for gas anesthesia/oxygen deliver were to be stored on the floor of the surgical suite. Staff MM stated, "they are in a plastic container and not in direct contact with the floor, but no I was not aware that the supplies were not to be stored there..."

On 09/12/18 at 1215 during observation of the Surgical Services/Operating room area, in the restricted surgical suite area, staff GG (surgeon), staff HH (certified registered nurse anesthesiologist - CRNA), and staff MM (anesthesiologist) were observed wearing skull caps in the restricted surgical area without bouffant coverings.

On 9/12/18 at 1230 an interview occurred with staff . Staff II was queried if staff were required to have full coverings of hair. Staff II replied, "yes...we have some staff, including physicians who refuse to wear bouffant."

On 09/12/18 at 1300 Staff KK, the regional manager for surgical services confirmed that entering a restricted area without head covering is against policy. Staff KK stated, "it (wearing bouffants in the restricted surgical suite) is a topic of discussion we are currently having with all staff including physicians.

On 9/12/18 at 1530 a document review of the policy titled "Surgical Attire", policy # 9903, dated 4/14/16 states, "disposable bouffant full-style skull hat or hood style hats are strongly encouraged. Disposable OR hats/hoods must be clean, low-linting, and completely confine all hair of face and head. Hats that fail to cover the side hair and hair at the nape of the neck should not be worn in the surgical suite. Single use headgear should be removed and discarded in a designated receptacle as soon possible after daily use. The use of reusable cloth hats/hoods is strongly discouraged; cloth hats must be removed and laundered after daily use or immediately when they become wet, soiled, or visibly contaminated. A disposable hat or headgear must be worn over a reusable cloth surgical hat in the restricted areas of the OR (operating room) environment..."




36887

On 9/11/2018 at 1130, emergency department (ED) rapid access room #1 was enetered and found to have dust on the light over the head of the bed. This finding was confirmed by Staff C at the time of discovery.

On 9/11/2018 at 1137, ED trauma room #14 was entered and found to have heavy dust on the boom (a mechanical arm containing equipment) as well as dust on the television. These findings were confirmed by Staff C at the time of discovery.

Based on observation, interview, and record review the facility failed to maintain four of five (Cardiac care unit, medical surgical, intermediate care nursery, and Computerized tomography) emergency crash carts in prepared for immediate use condition. This results in the potential inability for staff to respond to care-related medical emergencies for patients in the four areas. Findings include:

On 09/11/2018 at 02:00 PM during the tour of the radiology department the emergency crash cart was opened and the equipment was examined. In the box labeled rapid air access, the carbon dioxide detector was dated as expired 06/2018. Staff OO was shown the expired device and he stated "I will have it replaced immediately."

On 09/12/2018 at 09:00 AM during tour of the intermediate care nursery the emergency crash cart was opened and the equipment was examined. In the third drawer, two disposable Pediatric lumbar Puncture trays were dated expired 06/2018. Staff U was shown the expired equipment, she stated "That confirms the need for a check sheet to be filled out when checking the crash carts readiness."


29955

On 9/11/2018 at 1120 during the initial tour of the facility on the medical surgical unit it was revealed the facility failed to check the emergency crash cart on a daily basis. A review of the daily check log for the emergency crash cart indicated fifteen daily checks were not performed on 4/8/2018, 4/10/2018, 4/23/2018, 4/27/2018, 5/1/2018, 5/2/2018, 5/28/2018, 5/29/2018, 6/4/2018, 6/15/2018, 6/21/2018, 7/1/2018, 7/3/2018, 8/27/2018, and 8/31/2018. Staff A was queried about the missing daily checks on the emergency crash cart for the medical surgical unit. Staff A stated,"daily checks on the crash carts are to be performed by the charge nurse on duty during day shift."

On 9/11/2018 at 1140 during the initial tour of the facility on the critical care unit it was revealed the facility failed to check the emergency crash cart on a daily basis. A review of the daily check log for the emergency crash cart indicated the daily check was not performed on 8/27/2018. Staff A confirmed the crash cart is to be checked on a daily basis by a registered nurse daily in the critical care unit.

A document review of the policy titled "Crash Cart Control", policy number 19078, version 2, dated 07/07/2018, states "1. The CCU (critical care unit) cart is checked daily and documented on the daily sheet. 2. The Medical-Surgical cart is checked on day shift by the R.N. (registered nurse) and documented on the daily sheet. 7. The Nursery cart is checked at least every 24 hours and this is documented on the Nursery Unit Readiness Checklist form."