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Based on observations and staff interviews, the facility failed to protect patients' right to privacy by publically displaying private information regarding 42 of 58 patients on monitors at the nursing stations and displaying private information of all 58 of 58 patients on the back of their medical records. The facility's census was 253 patients (208 patients on the West campus and 45 patients on the East campus).
Findings Included:
1. During tours of the Orthopedic Unit on 01/03/11 at 2:45 PM, and the Cardiology (Medical-1) Unit on 01/05/11 at 11:05 AM, observations showed two large monitors hanging from the wall and in clear view to the public on each Unit. The monitors included private information regarding all 33 patients monitored on the Orthopedic and Cardiology Units. The monitors on the Orthopedic Unit contained the patients' room numbers and their last names. The monitors on the Cardiology Unit contained the patients' room numbers, and their first and last names. The monitors were secured on a wall located at each units' nursing station. Each monitor faced a hallway in which the general public could view them.
During an interview with the Director of Cardiology, RN Staff A on 01/03/11 at 2:45 PM, and the Director of Orthopedics, RN Staff B on 01/05/11 at 11:05 AM, Staff A and Staff B stated they used the monitors so that staff caring for the patients could easily view and monitor them.
2. During tours of both the Orthopedic Unit and Cardiology Unit on 01/03/11 at 2:45 PM, and on 01/05/11 at 11:05 AM, observations showed the back of the patients' medical records displayed personal information. The records on the Orthopedic Unit showed their room numbers and their last names. The records on the Cardiology Unit showed their room numbers and their first and last names.



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3. Observation and interview on 01/05/11 at 11:10 AM, showed a cardiac monitor at the end of the hallway, in the Intensive Care Unit (ICU). This monitor was clearly visible to the public and showed the first four letters of the patients first name, and the first initial of the patients last names, and the patient's diagnosis for all nine patients on the ICU. The Director of the ICU, RN Staff A, stated staff always used the first four letters of the patients' first names for the monitor, even if their first names consisted of only three or four letters (revealing the entire first name). Staff A confirmed visitors could pass this area, and all patient private information could be viewed by the general public.

Based on observation, interview, and record review the facility:
- failed to provide a safe environment in 14 of 14 patient bathrooms on the Adult Psychiatric Unit by not covering or shielding the hinge to prevent an open gap above the top hinge of the bathroom door.
The configuration of the bathroom doors with conventional hinges create a looping hazard (material or a device could be knotted and passed through the crack above the top hinge for strangulation or choking) for all patients in the facility.
- failed to provide a safe environment for two of 14 patient bathrooms by using non-suicide-resistant shower water control knobs.
The configuration of the shower water control knobs creates a looping hazard (material or a device could be looped around the knob to be used for choking and strangulation) for all patients in the facility.
-failed to protect patients by having an accessible telephone cord on a public telephone located in a corridor alcove, and an exposed television cord, and electrical cables in one of three common areas on the adult unit.
The configuration of the electrical cords creates a potential hanging or strangulation hazard for all patients in the facility.
- failed to secure furnishings and heavy furniture in one patient common area which could cause potential harm if pulled or tipped over by patients or staff.
- failed to follow infection control guidelines for hand hygiene for medication administration and after Glucometer use (test of blood for glucose level) for three (patient #4, #5 and #6) of three patients observed during care procedures.
- failed to follow isolation precautions for patient #22 in the out-patient dialysis (circulating the patient's blood through an artificial kidney to filter patient blood) department.
- failed to follow policy for drug replacement for crash cart (emergency supply cart) for out-patient dialysis department.

The facility admitted patients with diagnoses of suicidal ideation, history of suicidal ideations, attempts at self harm, seizure precautions, assault precautions and fall precautions. These deficient practices potentially affected 22 of 22 inpatients at the East Hospital Campus.

- The facility also failed to implement interventions to prevent a fall for one patient (#4) reviewed with falls, even though this patient was identified as a high fall risk. Staff also failed to document physical assessment and/or investigate the reason for the fall per facility protocol, in the West Hospital Campus. The facility had a combined census of 253 at the start of the survey.

Findings included:

1. Observation of the East Hospital Campus, Adult Psychiatric unit on 01/4/11 from 2:30 PM through 4:00 PM, accompanied by the Director of Facilities and Facility/Grounds Supervisor, showed doors to 14 patient bathrooms (315, 317, 318, 319, 320, 321, 322, 323, 324, 325, 326, 327, 328, and 329) with standard three-hinge configuration. No covers or shields were affixed/attached to the doors to prevent material or a other devices being passed through the crack above the top hinge.

Two of the 14 patient rooms, (319 and 328) had single water control knobs that protruded from the wall three and one half inches, approximately four feet above the floor.

Exposed plumbing behind bathroom toilets in 12 of the 14 patient rooms, (318, 319, 320, 321, 322, 323, 324, 325, 326, 327, 328, and 329) created a strangulation or choking hazard. A rectangular metal box attached to the wall enclosed and protected the valve and flush lever of each toilet, but exposed the remainder of the water service pipe with a three inch gap between the wall and the pipe, The square edged metal boxes and openings between the wall and water pipe varied from eight to 24 inches high and created several attachment points for material to be looped over the valve cover, or passed through the crack between the wall and the water pipe.

2. Observation of the East Hospital Campus Adult Psychiatric unit on 01/4/11 from 2:30 PM through 4:00 PM, showed a public telephone in a corridor alcove with a flexible cord that measured 31 inches long, a potential looping hazard for choking and strangulation.

In a common room area used by patients and staff showed electrical cables from a 30 inch television and video equipment that exceeded 18 inches in length. No safety devices were affixed/attached to the cables to prevent them from a potential hazard for choking or strangulation. Additionally, the television and video equipment, as well as the wood entertainment center were not secured to the wall or floor, and posed potential harm to all patients if pulled or tipped over.

The control arm of an automatic door closer (pneumatic device to keep the door closed), between the laundry area and the common room area presented an attachment point and provided a looping hazard for choking or strangulation for all patients in the facility.




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3. Observation on 1/4/11 at 11:05 AM, showed Registered Nurse (RN) Staff II administered two medications to Patient #4. Staff II failed to wash his/her hands before and after medication administration.

During an interview on 1/4/11 following medication administration Staff II stated, "I should have washed my hands, and I did not".

4. Observation on 1/4/11 at 11:30 AM, showed patient care technician (PCT), Staff JJ putting on gloves. Staff JJ then did a finger-stick blood sample on Patient #5 for a Glucometer reading. Staff JJ then went to Patient #6 and obtained a finger-stick blood sample for a Glucometer reading. Staff JJ failed to change gloves between patients and failed to wash his/her hands between patients.

During an interview on 1/4/11 following finger-stick procedure Staff JJ stated, "I did not wash my hands and I should have".

Review of the facility policy titled "Hand Hygiene", reviewed on 09/2010, showed in part the following:
2. Health Care Workers (HCW) shall decontaminate hands using either soap and water or alcohol based hand hygiene products:
A. Before having direct contact with patients.
C. After contact with a patient's intact skin, non-intact skin, body fluids, or excretions, mucous membranes and wound dressings if hands are not visibly soiled.
D. After removing sterile or nonsterile gloves.
6. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves.

5. Observation on 1/3/11 at 3:15 PM, showed Staff BB (PCT), wearing an isolation gown opened and unsnapped, while disconnecting dialysis blood lines from Patient #22. Staff BB failed to have the front of the isolation gown closed, thereby protecting his/her uniform, and the patient during care.

During an interview on 1/3/11 at 3:30 PM, RN, Staff AA confirmed that the isolation gown was not properly closed.

During an interview on 1/3/11 at 3:40 PM, Staff BB said, "I forgot to button it up, the purpose of the isolation gown is to keep blood off our clothes".

Review of the facility policy titled "Infection Control", reviewed on 09/2009, showed (in part) the follwoing:
3. Staff members, including physicians, advanced practice registered nurses, physician assistants, social workers, dieticians and biomedical personnel, will wear appropriate personal protective equipment (PPE) to include gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood).





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6. Review of patient #4 ' s History and Physical (H & P) dated 12/2/10, showed the patient was admitted to the Intensive Care Unit (ICU) on 12/28/10 with diagnoses of shortness of breath, a cough and chronic obstructive pulmonary disease (lung problem).
Review of a Nurses Note dated 12/28/10, timed 11:00 PM, showed the patient fell trying to walk out of his room.
Review of facility policy entitled, "Fall Prevention," reviewed 05/09, showed patients identified as high fall risk will be started on the following interventions to minimize fall risk:
a) Offer frequent toileting-every two hours during the day and every four hours at night.
b) Evaluate for and provide a low bed, if appropriate.
c) Use a bed/chair alarm as needed.
During interviews on 01/05/11 at 11:59 AM, and 2:45 PM, the Director of the medical unit, Registered Nurse (RN), Staff G, (Note: patient #4 was on the medical unit at the time of hi/her fall), stated the following:
a) On 12/28/10, at 8:30 PM, the patient ' s fall risk score was "6" (a score of 5 or above indicates high risk).
b) On 12/28/10, at 7:45 PM, the patient was confused.
c) On 12/28/10, at 8:40 PM, the patient locked him/herself in the bathroom. The door had to be unlocked. The patient continued to be agitated.
d) On 12/28/10, at 9:00 PM, a sitter was ordered by the physician.
e) On 12/28/10, at 10:00 PM, the patient fell (same fall as above, documented at 11:00 PM). The sitter had not arrived yet. Staff failed to monitor the patient for one hour, allowing the patient to fall.
f) Staff G stated he/she could not find any evidence in the record of assessment related to the fall, or documentation regarding circumstances surrounding the fall. There was no evidence of alarm use or a low bed to prevent falls, suggested fall prevention interventions.
g) Staff G stated the patient was transferred to the Intensive Care Unit later that night (12/28/10).
Review of a facility-provided list of all patient falls, for the prior three months, dated 01/04/11, the list failed to include the above fall.
Review of a facility policy entitled, "Customer Safety Reporting," (CSR) revised 04/09, showed the following:
a) The purpose of the CSR is to promptly document information relative to any potential or actual compromise of customer saftey or desired outcome.
b) It is the responsibility of each and every employee to report safety concerns.
c) Events requiring immediate notification (in addition to completion of the CSR) include falls.
During an interview on 01/05/11 at 9:38 AM, the Director of Risk Management, Staff D, stated no CSR form had been completed on the above fall, and should have been. Staff D stated the CSR tool is utilized to develop interventions regarding trends of falls via the quality department.
Review of the patient's fall care plan on 01/05/11, initiated 12/29/10 (after the fall), showed the patient was a fall risk related to activity and confusion, and had universal fall precautions (including frequent toileting, low bed and alarm use).
Review of an hourly rounding form for the patient dated 12/28/10, showed staff toileted the patient one time, at 5:00 PM, from 7:00 AM through 6:00 PM.
Review of an Activity Report log for the patient dated 12/28/10, showed staff toileted the patient at 7:27 PM and 8:40 PM. However, staff still failed to toilet per policy and care plan (which could have contributed to the patient's attempts to get out of bed).
Review of the patient's record (by facility staff) confirmed staff failed to document the circumstances surrounding the fall, including specific assessment regarding the fall and if there was an injury.

Based on facility policy review, observation and interview, facility staff failed to ensure patients' medical information was secured to prevent unauthorized access for patients in the Out-patient Dialysis (circulating the patient's blood through an artificial kidney to filter the patient's blood) department for 70 of 70 dialysis patients. The facility census was 253 patients; the Out-patient Dialysis census was 70.

Findings included:

1. Review of the facility's policy titled, "Medical Records", reviewed 9/09, showed in part the following:
PURPOSE: To maintain complete and accurate records and to protect them against loss and unauthorized use. The requirements apply to both hard copy and electronic health records.
POLICY:
The dialysis facility will:
A. Safeguard patient records against loss, destruction, or unauthorized use.
B. Keep confidential all information contained in the patient's record

2. Observation on 1/3/11 at 4:00 PM, showed all Out-patient Dialysis medical records in open-faced chart racks. These racks had no method of securement or locking. The unsecured and unlocked records showed patient name, age, date of birth, address, social security number, insurance information, physical health history and other confidential information.

During an interview on 1/3/11 at 4:15 PM, Staff CC, Director of Out-patient Dialysis confirmed that the facility kept patients medical records in open chart racks. Observations showed the facility did not lock or secure the patients' medical records. Staff CC stated a contract service cleaned the Out-patient Dialysis Unit after-hours, and could view the confidential information of all dialysis patients.





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3. Observation of West Hospital Campus Orthopedic ICU Unit on 1/31/11 at 9:45 AM, showed a 20 inch monitor screen mounted on the wall inside a glass-enclosed nurses station. This monitor was directly across from the elevator vestibule, which is the routine point of entry for the general public. The screen showed patients vital signs, last names and room numbers. Behind the glass enclosed nurses station patient charts were lying on the desk or placed in an open chart rack, these charts included the patient's last names in bold print and could be seen clearly by the general public.

4. Observation of the same unit at 9:50 AM, showed a flat screen monitor in a hallway with a technician entering data on a patient's automated chart. The patient's name and other personal information were visible on the monitor, by looking over the shoulder of the technician. The monitor was located directly outside of room 475, where a visitor stood leaning against a room door drinking his/her coffee. No security screens (for direct viewing by sole operator, blocks casual viewers and affords a measure of privacy in a public setting) were affixed/mounted on the frames of the flat-screen monitors in the hallway, or at any of the work stations.

Based on observation, interview and record review the facility failed to modify three of three patients' care plans (with restraints) reviewed (patients # 4, #10, and #9) to identify restraint use and the goals pertaining to the use of those restraints.
Findings Included:
1. Review of a facility policy entitled, "Restraint and Seclusion", revised 07/09, showed the following:
a) The patient's plan of care shall be modified to indicate the type of restraint and the goals of the restraint episode.
Review of another facility policy entitled, "Patient Care Planning Nursing Process", revised 04/05, showed the following:
a) An individualized, goal-directed patient care plan will be established for all hospitalized patients.
b) The care plan shall address the physical, functional, emotional, social, educational, environmental, equipment, communication, spiritual, safety, infection control, and discharge needs of the patient.
c) The care plan will be pertinent, concise and reflect the patient's current status.
Review of the Medical Staff Rules and Regulations dated 09/30/10, showed an order for a restraint must be in accordance with a written modification to the patient's plan of care.
Review of a facility-provided list of patients with restraints dated 01/03/11, showed patients #4, #9 and #10 had restraints.
Review of patient #4 ' s History and Physical (H & P) dated 12/2/10, showed the patient was admitted to the Intensive Care Unit (ICU) on 12/27/10 with diagnoses of shortness of breath, a cough and chronic obstructive pulmonary disease (lung problem).
Observation on 01/03/11 at 3:17 PM, showed patient #4 in bed with bilateral wrist restraints on.

Review of nurses notes from 12/28-01/03/11, showed the following:
a) On 12/29/10 at 11:48 PM, the patient was restrained with bilateral wrist restraints for patient and staff safety. The patient remained in restraints until a 16-hour trial removal on 12/30/10 at 6:10 AM.
g) On 12/30/10 at 10:30 PM, the patient was placed back in the bilateral wrist restraints.
h) The patient remained in restraints until 01/04/11 at 4:30 AM, when the bilateral wrist restraints were discontinued.
Review of restraint orders from 12/29/10 through 01/03/11, showed the patient had signed physician orders for bilateral wrist restraints, continually, from 12/29/10 at 11:48 PM, through 01/04/11 at 8:00 AM. The reasons for the restraints included: behaviors of agitation, prevent accidental injury to self, pulling at medical lines, and wandering.
Review of the patient's plan of care (on 01/03/11), initiated on 12/27/10, showed staff failed to identify the type of restraint used, or place any goals and specific interventions regarding the restraint use in the care plan. The only entry regarding restraints in the care plan was an intervention, "Restraints Flowsheet," initiated on 01/01/11.
2. Review of patient #9's H & P, dated 12/23/10, showed the patient was admitted to ICU with a diagnosis of intentional drug overdose.
Observation on 01/04/11 at 1:30 PM, showed the patient had bilateral wrist restraints on.
Review of signed physician's orders showed restraint orders beginning on 12/27/10 at 12:40 PM, and continuing through 01/04/11.
Review of the patient's care plan, initiated on 12/23/10, showed staff failed to identify the type of restraint used, or place any goals and specific interventions regarding the restraint use in the care plan. The only entry regarding restraints in the care plan was an intervention, "Restraints Flowsheet," initiated on 12/28/10.
3. Review of patient #10's H & P, dated 12/28/10, showed the patient was admitted to the ICU with a diagnosis of respiratory failure.
Observation on 01/04/11 at approximately 1:40 PM, showed the patient had bilateral wrist restraints on.
Review of signed physician's orders showed restraint orders beginning on 12/28/10 at 3:30 AM, and continuing through 01/04/11.
Review of the patient's care plan, initiated on 12/28/10, showed staff failed to identify the type of restraint used, or place any goals and specific interventions regarding the restraint use in the care plan. The only entry regarding restraints in the care plan was an intervention, "Restraints Flowsheet," initiated on 12/29/10.

1. Review of a facility policy entitled, "Restraint and Seclusion", revised 07/09, showed the following:
a) The attending physician shall be contacted immediately for an order after the application of a restraint.
b) Restraint orders are written on a time-limited bases, not to exceed 24-hours.
Review of patient #9's H & P, dated 12/23/10, showed the patient was admitted to the ICU with a diagnosis of intentional drug overdose.
Observation on 01/04/11 at 1:30 PM, showed the patient had bilateral wrist restraints on.
Review of signed physician's orders showed restraint orders beginning on 12/27/10 at 12:40 PM, and continuing through 01/04/11. However, the orders dated 01/02, 01/03, and 01/04/11 failed to show the reason for the restraint.
2. Review of patient #10's H & P, dated 12/28/10, showed the patient was admitted to the ICU with a diagnosis of respiratory failure.
Observation on 01/04/11 at approximately 1:40 PM, showed the patient had bilateral wrist restraints on.
Review of signed physician's orders showed restraint orders beginning on 12/28/10 at 3:30 AM, and continuing through 01/04/11. However, an order dated 12/28/10 failed to show the reason for the restraint.

Based on observation, interview and record review the facility failed to conduct a one-hour face-to-face assessment on one of one patients reviewed (patient # 4) with behavioral restraints. The facility census was 253.
Findings Included:
1. Review of a facility policy entitled, "Restraint and Seclusion," revised 07/09, showed the following:
a) For behavioral restraints-As soon as possible, but no longer than one hour after the initiation of restraint, the trained registered nurse shall perform a face-to-face assessment to include documentation of the patient ' s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint.
Review of restraint training documentation, dated June, 2010, showed behavioral restraints as needed for the management of behaviors that jeopardizes the safety of the patient or others. The behavioral restraint is time limited to four hours for the adult.
Review of a facility-provided list of patients with restraints dated 01/03/11 showed patient #4 with restraints. During an interview with the Director of the Intensive Care Unit (ICU), Registered Nurse (RN), Staff A, confirmed Patient #4 was restrained.
Review of patient #4's History and Physical (H & P) dated 12/2/10, showed the patient was admitted to the ICU on 12/27/10 with diagnoses of shortness of breath, a cough and chronic obstructive pulmonary disease (lung problem).
Observation on 01/03/11 at 3:17 PM, showed patient #4 in bed with bilateral wrist restraints on.
During interviews on 01/03/11 at 3:43 PM, RN Staff C stated the patient tried to get out of bed, and attempted to hit staff. Staff C stated the patient was unsafe and impulsive. Staff A stated the wrist restraints prevented the patient from hitting the sitter and other staff. Staff A confirmed, after chart review, no one-hour face-to-face assessment had been completed on patient #4.
Review of nurses notes from 12/28-01/03/11, showed the following:
a) On 12/28/10 at 7:45 PM, the patient was agitated and refused redirection.
b) On 12/29/10 at 10:35 PM, pt had increased agitation and anxiety.
c) On 12/29/10 at 11:29 PM, pt was swinging arms about impulsively.
d) On 12/29/10 at 11:48 PM, the patient was restrained with bilateral wrist restraints for patient and staff safety (behavioral, so a one-hour face-to-face assessment required).
e) On 12/30/10 at 6:10 AM, the wrist restraints were removed for a trial.
f) On 12/30/10 at 3:29 PM, the patient was agitated.
g) On 12/30/10 at 9:20 PM, the patient was very agitated.
h) On 12/30/10 at 10:30 PM, the patient was grabbing at the sitter and intermittently hostile. The patient was placed back in bilateral wrist restraint (behavioral, so requires another 1-hour face-to-face assessment).
i) On 01/02/11 at 1:48 AM, the patient was agitated and attempting to hit the nurses.
j) On 01/03/11 at 10:00 AM, the patient threatened to hit the sitter and the nurse.
Review of restraint orders from 12/29/10 through 01/03/11, showed signed physician orders for bilateral wrist restraints, continually, from 12/29/10 at 11:48 PM, through 01/04/11 at 8:00 AM. The reasons for the restraints included behaviors of agitation, prevent accidental injury to self, and wandering.
Review of the patient's record (confirmed by Staff A) showed staff failed to address the wrist restraints as behavioral, and failed to do a one-hour face-to-face for two separate incidences of restraint initiation (12/29/10 and 12/30/10).