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Based on medical record review, staff interview, and policy review, the facility failed to ensure staff obtained a physician or other licensed practitioner order for the use of seclusion. This affected one of one patient's reviewed for the use of restraints in a total of 10 patient medical records reviewed. (Patient #3)

Findings include:

The medical record of Patient #3 was reviewed on 02/04/14 at 5:00 PM. A physician's history and physical noted the patient presented to the Emergency Department on 01/01/14 at 4:37 PM feeling increasingly depressed and suicidal. Patient #3 reported spending the night on a bridge deciding whether to jump off the bridge. Patient #3 had a history of a previous suicide attempt in October, 2013 and had three psychiatric admissions since that time. The history and physical also indicated the patient had a history of abuse of heroin, cocaine, and marijuana. Patient #3 complained of bilateral foot pain after a cold wet exposure for three days when the patient was unable to find shelter.

Per the history and physical review Podiatry was consulted and Patient #3 was diagnosed with stage I-II frostbite on both feet. Laboratory reports further indicated the patient was positive for Hepatitis C and had an elevated creatine kinase (CK). The decision was made to admit the patient to a medical floor for treatment due to the patient's medical issues.

An admission psychiatric social worker assessment was conducted on 01/01/14 at 6:41 PM, as required by facility policy. It was documented that the plan of care was once the Patient #3 was medically cleared, the patient would be transferred to Psychiatric Emergency Services for treatment. It was further noted Patient #3 was suicidal "with likely intent."

Patient #3 remained inpatient on a medical floor where the patient was treated for medical issues. During this time, a sitter was noted to remain at Patient #3's bedside documenting every 15 minute checks as required by facility policy when a patient reports suicidal ideations.

Patient #3, having been medically stabilized, was transferred from medical inpatient to psychiatric inpatient on 1/03/14 at 3:05 PM.

A nursing note on 01/04/14 at 8:51 PM reported Patient #3 was visiting with the girlfriend when the girlfriend yelled loudly. It was documented the girlfriend yelled, "Ouch!" and requested the patient to let her go. The patient refused to let go of the girlfriend until she kissed him. When staff intervened, the patient became upset with staff, cursing at them. It was documented the patient was "escorted to seclusion." While in the seclusion room, it was noted the patient was kicking at the door and yelling, eventually punching a window. Although it was documented a psychiatric physician was called, the medical record lacked documentation an order was written for seclusion.

Staff A was interviewed on 02/05/14 at 1:00 PM. Staff A reported an order to put a patient in seclusion, must be obtained.

The facility policy entitled Restraint and/or Seclusion was reviewed on 02/05/14 at approximately 1:15 PM. According to the facility policy, a physician order is required for all Restraints. The order is to include the rationale or current behavior that justifies the Restraint, the type of Restraint, the date of the order, the time of the order, and the duration of the order. These facts were confirmed with Staff A on 02/05/14 at 4:00 PM.

Based on observation, interview, record review and review of policies and procedures, it was determined the hospital failed to maintain the water supply system to ensure a safe physical environment. (A722) The cumulative effect of this systemic practice resulted in the facility's inability to ensure patient safety.

Based on observations, interviews, record reviews, lab reviews, policy and procedure reviews the hospital failed to implement an immediate remediation process to temporarily kill Legionella pneumophila bacteria verified in the facility's water system on 01/17/14. A total of 10 patient medical records were reviewed. This had the potential to affect all patients, staff and visitors to the Surgical Intensive Care Unit and Neonatal Intensive Care Unit.

Findings include:

The facility was made aware of lab verified positive Legionella pneumophila water cultures on 01/17/14. The cultures were collected per facility policy that directed biannual random testing of distal water sites (faucets, showers, etc.). The policy was a precautionary measure implemented in 2011 in response to the facility's addition of an organ transplant unit.

The random water cultures, collected on 01/08/14, identified two of ten distal sites as positive for Legionella pneumophila. The two sites included "HS13-719: 2nd floor Surgical Intensive Care Unit (SICU) Room 7 Sink" and "HS13-720: 3rd floor Neonatal Intensive Care Unit (NICU) Airborne Isolation Room Sink". Contracted safety engineers collected the water samples throughout the facility biannually and a contracted laboratory certified by the Centers for Disease Control and Prevention (CDC) was contracted for the isolation of Legionella from water samples.

The facility's initial action plan in response to the positive water cultures was prepared by the Infection Control Medical Director, Staff #19, on Friday, 01/17/14. The action plan included measures directed to the two units where positive testing was found. The plan included additional confirmation water cultures collected at ten distal sites within the NICU and SICU, installation of a copper silver ionization water system (a long term solution), staff education to avoid using tap water for patient related activity, and monitoring for Legionella in patients with pneumonia.

The facility provided additional laboratory results on 02/04/14 from the ten confirmation water cultures within the NICU and SICU. The samples, collected on 01/21/14, documented six positive Legionella pneumophila cultures. Five positive cultures were identified in SICU and one positive culture was identified in NICU.

The facility provided an invoice by the plumbing contractor dated 01/29/14 that documented the installation of a loop Cooper Silver Ionization System from the fifth floor critical care pavilion to the first floor critical care pavilion, completed on Monday, 01/27/14. On 01/29/14 at 3:00 PM during an Administration interview the facility's Chief Privacy Officer, Staff #12, stated post-ionization installation samples would be collected on Monday 02/03/14 with results expected on or near Monday 02/17/14. The Chief Nursing Officer, Staff #13, verified the facility could not provide documentation of negative cultures of Legionella pneumophila in the water system until at least 02/17/14.

On 01/29/14 from 11:20 AM through 12:40 PM observations and interviews were made during a tour of the SICU and NICU. Observations included 2.5 gallon bottles of water in the pod areas. The water supply system in SICU including sinks, ice machines, and toilets lacked any signage to not use the water. The SICU Manager, Staff #17, identified two patients in the SICU as high risk due to transplant status.

The water supply system in NICU including sinks had signs indicating "Do not use sinks until further notice". Not all sinks in the NICU had signs. At 12:40 PM an interview with the NICU Manager, Staff #8, revealed that some of the sink signs may have come off. Staff #8 also indicated the bottled water was for staff hand washing and patient care.

On 01/29/14 ten patient medical records were reviewed and no issues or concerns were identified related to the potential risk or actual risk of Legionella pneumophila.

On 01/30/14 at 2:45 PM an interview was conducted with the Director of Facilities, Staff #15. Staff #15 stated the water supply system had never been turned off to the two units once the water supply was verified with positive Legionella pneumophila bacteria.

Immediate remediation options identified in the facility's Waterborne Pathogens Policy to temporarily eradicate Legionella bacteria included "superheating and flushing" or "hyper-chlorination and flushing". The facility chose to implement a long term solution to the presence of Legionella in the water system. The long term solution delayed verification of Legionella pneumophila bacteria eradication in the facility's water system for at least 32 days, and maintained an unnecessary potential of harm to patients, staff, and visitors.

Based on observation during of the Surgical Intensive Care Unit (SICU), staff interview, and policy review, the facility failed to follow current facility policy related to the cleaning of lobbies and corridors in patient areas and cleaning of Intensive Care Unit rooms related to dust noted in the area. This had the potential to all affect patients hospitalized in the SICU.

Findings include:

The SICU was toured on 01/29/14 at approximately 10:30 AM with Staff #13. A thick layer of dust was observed falling to the floor from the fire alarm surface in the corridor leading to the SICU. Two empty rooms in the SICU were toured. Dust was noted in SICU Room #31 along the rail where medical gases are attached. The monitor in Room #31 had a thin layer of dust on top of it. SICU Room #32 was also toured. A large clump of dust about the size of a softball was noted on top of the atomic clock on the wall at the head of the bed. There was also dust along the rail in this room. A layer of dust was visible on top of a blanket warmer between Pods 1 and 2. The fire alarm in Pod #3 was also noted to have dust on the surface of it. A red phone on the workstation in Pod #3 was observed coated with a thick layer of dust. During the tour, Staff #13 was observed taking a picture of the dust on the phone with a cell phone. Staff #13 stated, "This is ridiculous." The computer monitors on the workstation were also coated with a thin layer of dust.

The facility policy entitled Environmental Services was reviewed on 01/29/14 at 4:30 PM. According to the policy, environmental services staff are instructed to damp wipe sills, ledges, and other horizontal building and furniture surfaces. These facts were confirmed with Staff #13 on 01/29/14 at 4:45 PM.