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Based on staff interview and review of policy, procedure, and clinical records it was determined that the facility failed to ensure physicians did not order the use of restraints on an as needed basis (PRN) for one (#27) of thirty records reviewed. This practice does not ensure patients are free from unnecessary restraints.

Findings include:

Patient #27's physician telephone order dated 3/14/11 at 1:30 p.m. and noted by
the nurse, instructed to "place in restraints if needed". Review of the Medication Administration Record for treatments revealed to "restrain if needed"

Review of policy and procedure "Behavorial Health Restraint for Emergency Use" #120.8 last revised 9/10 revealed PRN and standing physician orders are not acceptable.

Interview and review of the clinical record with the Clinical Standards Manager on 4/1/11 at approximately 3:00 p.m. confirmed the findings.

Based on staff interview and review of clinical records it was determined that the registered nurse failed to supervise and evaluate care for five (#5, #4, #9, #26, #27) of thirty records reviewed. This practice does not ensure patient goals are met and may cause a delay in discharge.

Findings include:

1. Patient #5 was admitted to the facility on 3/28/11. Review of the graphic record on 3/31/11 revealed nursing staff had not recorded vital signs from 12:00 noon on 3/29/11 until 8:00 a.m. on 3/30/11.

Interview with the nursing manager for 2 North on 3/31/11 at approximately 11:45 p.m. confirmed the lack of documentation. She stated that vital signs are to be measured and recorded at least every 8 hours.

2. Patient #4 was admitted to the facility on 3/25/11. On 3/28/11 the physician wrote and order for sequential compression devices (SCD) to be placed on both lower extremities. Review of nursing documentation revealed no evidence that the SCDs had been applied.

The nursing manager of 2 North confirmed the findings on 3/31/11 at approximately 12:30 p.m.


3. Patient #26's post operative spine surgery physician orders dated 3/14/11 at 7:00 a.m. instructed for neuro vascular checks every two hours, incentive inspirometer every 1-2 hours while awake, remove the urinary catheter the next day, and the patient may be straight catheterized as needed if unable to void. Review of nursing documentation from 3/14/11 post operatively to 3/15/11, the day of discharge, revealed no evidence of the urinary catheter being removed, the patient voiding after the catheter was removed, neuro vascular checks being performed every two hours or the incentive inspirometer being used every 1-2 hours while awake.

4. Patient #27's physician orders dated 3/14/11 instructed for the patient to be weighed daily. Review of the record did not reveal evidence of the patient being weighed as ordered.

Interview and review of the clinical record for patient #26 and #27 with the Clinical Standards Manager on 4/1/11 at approximately 3:00 p.m. confirmed the findings.

5. Patient #9 was admitted to the 2 south surgical unit on 3/28/11 following a cervical discectomy. A review of the admission physician orders dated 3/28/11 revealed neuro vascular checks were to be done every 2 hours. A review of the clinical flow sheets revealed the neuro vascular checks were completed on 3/28/11 at 1:00 p.m., 3:00 p.m. and 5:00 p.m. The checks were completed on 3/29/11 at 8:05 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. The checks were completed on 3/30/11 at 9:00 a.m. Review of the electronic and paper chart with the manager of the Progressive Care Unit confirmed no further order to cancel the checks or the neuro vascular checks being completed every 2 hours as ordered.

Based on record review and staff interview it was determined that the facility failed to ensure medications were administered according to physician orders for 2 (#4, #27) of 30 sampled patients. This practice does not ensure achievement of desired therapeutic action of the medication.

Findings include:

1. Patient #4 was admitted to the facility on 3/25/11. On 3/26/11 the physician wrote an order for Zosyn 3.375 grams intravenously every 6 hours. Review of the medication administration records revealed that the medication was administered at 6:00 p.m. on 3/26/11. There was no documentation of it being administered until 9:00 a.m. on 3/27/11. That was a total of 15 hours between doses. The next dose was given at 2:00 p.m. on 3/27/11, which was 5 hours later. The next dose documented was at 12 noon on 3/28/11, which was 22 hours later.

The nursing director of 2 North was present during the record review on 3/28/11 at approximately 12: 30 p.m. She stated that a nurse had removed the medication from the Pyxis machine on 3/27/11, however she confirmed there was no evidence it had been administered. She confirmed the findings.

2. Patient #27's physician order dated 3/14/11 at 11:00 a.m. instructed for Glucerna one can three times a day with meals. Review of the Medication Administration Record revealed the entry for Glucerna. There was no evidence of the patient receiving the supplement.

Based on staff interview and clinical record reviews it was determined that the facility failed to ensure the medical record contained consent for transfer to higher level of care for one (#24) of thirty records reviewed. This does not ensure a complete medical record is maintained.

Findings include:

1. Patient #24 present to the Emergency Department on 3/1/11 with a chief complaint of attempted suicided. Review of physician orders revealed the patient was admitted. Review of physician orders dated 3/2/11 instructed to transfer the patient to an acute care facility with a psychiatric unit. Review of the clinical record did not reveal evidence of the Certification for Transfer being completed.

Interview and review of the clinical record with the Clinical Standards Manager on 3/31/11 at approximately 2:00 p.m. confirmed the findings.

Based on staff interview and clinical record review it was determined that the nursing staff failed to ensure that nursing care was documented in the appropriate clinical record for one (#21) of thirty records reviewed. This practice does not ensure the accuracy of the information in the medical records.

Findings include:

Patient #21 present to the Emergency Department (ED) on 1/1/11 with vaginal bleeding. Review of the ED record revealed no other complaints or concerns. Review of nursing documentation on 1/1/11 at 1:15 p.m. revealed the patient was identified. The note indicated wound care was provided to the right thumb following a burn.

Interview and review of the clinical record with the Clinical Standards Manager on 3/31/11 at approximately 3:00 p.m. revealed the entry was made in the wrong medical record.

Based on observation and interview with the dietary manager, the facility failed to ensure that dietary workers did not contaminate their hands with the lid to the trash can while preparing salads and sandwiches, failed to maintain an effective pest control program, and failed to ensure that ceilings and floors were maintained intact and in a clean manner. This practice does not ensure safe handling of food.

Findings include:

On 04/01/11 beginning at 11:20 a.m. the following concerns were noted in the main kitchen:

1. Two dietary workers were noted to be preparing salads and sandwiches while wearing gloves. A large trash can covered with the lid was observed next to their work table. When they had refuse from their prep work, they had to touch the lid's handle to open the trash can to dispose of their trash. Neither were observed to change their gloves or wash their hands after touching the handle of the trash lid. They were observed to return to preparing the ready to eat foods .

2. While observing the two dietary workers a fly was observed in the area. The dietary manager reported, during the observation, that there was a pest management program but since the dumpster area was close to the kitchen doors, there often were flies observed in the kitchen.

3. A ceiling tile was noted to have a surface that was not intact as there was an approximately two inch hole in the tile which was above the steam table. Also, extending from the ceiling tile was a 2 to 3 inch long fluttering strand of dust, which was also above the steam table.

4. The floor under the steam table was noted to be soiled. The dietary manager reported, during the observation, that dietary staff wash the floor daily, but the soiling that was observed required intensive scrubbing, which wasn't frequently performed.

Based on observation of meal delivery and review of the policy related to meal tray delivery, the facility failed to follow their policy and ensure that dietary staff performed hand hygiene before and after leaving a patients' room, and before and after donning gloves. This practice does not ensure safe handling of food.

Findings include:

Observation of a dietary staff member on 04/01/11 beginning at 12:15 p.m., while delivering meal trays, revealed she was not performing hand hygiene before entering and after leaving each patient's room. The dietary staff member was observed to wear gloves in and out of patient's rooms, sometimes taking them off prior to leaving the room, but not observed to either sanitize or wash her hands. When the dietary staff member removed her gloves, she was observed to put on another pair of gloves, without either using a sanitizer or washing her hands.
Per the facility policy, (PCS - 8 - 003a Patient Meal Service, page 7), "All FNS (Food and Nutrition Services) employees will wash hands or use hand sanitizer before entering and after leaving each patient room. If gloves are used, they must be discarded upon leaving each room and a new pair replaced before entering the next patient room."

Based on clinical and policy review and staff interview it was determined that the facility failed to perform Pre-Admission Screening and Resident Review for one (#27) of one patient transferred to a Skilled Nursing Facility or provide documentation of how the patient was transported. This practice does not ensure patients are appropriately screened for placement or discharged in a safe manner.

Findings include:

42 CFR 483.100 requires that the facility transferring a patient to a Skilled Nursing Facility (SNF) ensures that a Pre-Admission Screening and Resident Review (PASSR) be completed prior to the patient's being transferred to the SNF to ensure appropriate placement.

Patient #27's admission assessment noted the patient lived at home with a family member. Physician order dated 3/15/11 instructed to discharge the patient to a skilled nursing facility. Review of the record revealed no evidence that the PASSR was completed prior to the transfer.

Review of nursing documentation dated 3/15/11 did no show evidence of the time and mode of transportation involved in the patient's discharge.

Review of policy and procedure "Skilled Nursing Facilities Discharges" #2-044 last revised 2/10 revealed on page 6, #13 to complete and send the PASSR form if the patient had not been in a SNF.