HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to ensure that staff were trained on a periodic basis in first aid related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for five staff (M, BB, DD, YY and RRR) of five staff, whose personnel files were reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. The hospital census was 208.

Findings included:

Review of the hospital's policy titled, "Restraint Policy (Medical, Behavioral-Chemical, Seclusion [the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving])," reviewed 11/2022, showed all staff members involved in the assessment, application of restraints, or care of patients requiring restraint or seclusion must be trained as part of orientation to the unit or hospital, and at minimum, on an annual basis. Training must include first aid techniques and cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped).

Review of the hospital's restraint log showed that violent and/or non-violent restraints were utilized on patients 968 times for the previous six months.

Review of the hospital's education titled, "2022 Registered Nurse (RN)/Licensed Practical Nurse (LPN) Competency Day Restraints and Seclusion," completed yearly prior to October by nursing staff, showed no training specific to first aid techniques.

Review of five personnel files showed no periodic restraint first aid training for the following staff:
- Staff M, Director of Nursing (DON), Emergency Department (ED), no restraint first aid training;
- Staff BB, RN, Vascular Access Team, no restraint first aid training;
- Staff DD, RN, Cardiac/Medical Unit, no restraint first aid training;
- Staff YY, RN, ED, no restraint first aid training; and
- Staff RRR, RN, ED, no restraint first aid training.

During an interview on 02/16/23 at 9:10 AM, Staff T, Chief Nursing Officer (CNO), stated that nursing staff were required to review the education, "2022 RN/LPN Competency Day Restraints and Seclusion," complete a computer test, and perform an in person skills verification check off, on a yearly basis. Staff should have CPR, but there was not a specific class or specific education related to restraint first aid.

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection prevention policies for:
- Maintaining cleanliness in seven operating rooms (ORs) (#1, #2, #3, #4, #5, #6, and #7) of nine ORs observed whose floors had gouges and tears;
- Two areas of the Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacteria], store and track reusable medical and surgical instruments or equipment) floors that were flaking and rough;
- Proper OR attire; and
- Maintaining clean equipment used during patient care for three patients (#40, #41, and #42) of four patients observed.

These failures had the potential to expose all patients to the risk of transmission of blood-borne pathogens. The hospital census was 208.

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection prevention policies for:
- Maintaining cleanliness in seven operating rooms (ORs) (#1, #2, #3, #4, #5, #6, and #7) of nine ORs observed whose floors had gouges and tears;
- Two areas of the Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacteria], store and track reusable medical and surgical instruments or equipment) floors that were flaking and rough;
- Proper OR attire; and
- Maintaining clean equipment used during patient care for three patients (#40, #41, and #42) of four patients observed.

Findings included:

1. Although requested, the hospital failed to provide a policy that specifically addressed the cleaning and integrity of the OR and SPD floors.

Observation on 02/15/23 at 9:25 AM, showed ORs #1, #2, #3, #4, #5, #6, and #7, with multiples gouges and tears present throughout each of the floors.

During an interview on 02/15/23 at 9:25 AM, Staff GG, Registered Nurse (RN), OR Assistant Director, stated that the OR floors should be smooth and free of gouges and tears in order for the floors to be properly cleaned.

During an interview on 02/16/23 at 9:45 AM, Staff FF, Infection Prevention Officer (IPO), stated that the OR floors should have a smooth surface and be easy to clean.

During an interview on 02/16/23 at 9:40 AM, Staff A, System Quality and Infection Prevention Director, stated that her expectation was that all OR floors would have a smooth non-porous surface to allow for adequate cleaning.

2. Observation on 02/15/23 at 8:50 AM, showed two areas of the SPD floor that were flaking and rough.

During an interview on 02/15/23 at 8:50 AM, Staff EE, SPD Coordinator, stated that the floors should be smooth but that they had been that way for over 15 years.

During an interview on 02/16/23 at 9:45 AM, Staff FF, IPO, stated that the SPD floor should have a smooth surface and be easy to clean.

During an interview on 02/16/23 at 9:40 AM, Staff A, System Quality and Infection Prevention Director, stated that her expectation was that all SPD floors would be have a smooth non-porous surface to allow for adequate cleaning.

3. Review of the hospital's policy titled, "Dress Code Patient Services," dated 01/2023, directed staff to:
- Remove or confine all jewelry. Earrings may be worn if confined within the cap or head covering.
- All possible facial hair, including sideburns and neckline, shall be covered with a clean disposable cap or hood.
- During surgical procedures, all personnel will wear protective eyewear with side shields.
- Surgical attire should be facility approved and clean, having been laundered in a healthcare accredited laundry facility.

Observation on 02/15/23 at 9:25 AM, showed Staff HH, Certified Registered Nurse Anesthetist (CRNA), wearing earrings that were not contained within her head covering while working in the OR.

Observation on 02/15/23 at 9:37 AM, showed Staff JJ, OR RN, wearing earrings that were not contained within her head covering while working in the OR.

Observation on 02/15/23 at 9:40 AM, showed Staff KK, Nursing Student, wearing earrings that were not contained within her head covering while working in the OR.

During an interview on 02/15/23 at 9:25 AM, Staff GG, RN OR Assistant Director, stated that earrings should be closed inside the hat or not worn in the OR.

During an interview on 02/16/23 at 9:45 AM, Staff FF, IPO, stated that earrings worn in the OR should be concealed in the hat.

Observation on 02/15/23 at 9:30 AM, showed Staff PPP, Anesthesiologist, without a cap or hood that covered his facial hair while working in the OR.

Observation on 02/15/23 at 9:45 AM, showed Staff OOO, Technician, without a cap or hood that covered his facial hair while working in the OR.

During an interview on 02/15/23 at 9:45 AM, Staff GG, RN OR Assistant Director, stated that the expectation was that all facial hair should be contained with a disposable covering while working in the OR.

During an interview on 02/16/23 at 9:45 AM, Staff FF, IPO, stated that facial hair should be contained in a covering when in an OR.

Observation on 02/15/23 at 9:30 AM, showed Staff II, CRNA, without eye protection and wearing a personal jacket.

During an interview on 02/15/23 at 9:37 AM, Staff GG, RN OR Assistant Director, stated that eye protection should be worn while working with patients in the OR and personal jackets were not allowed in the OR. She also stated that Staff II, CRNA, laundered his jacket at home.

During an interview on 02/16/23 at 9:45 AM, Staff FF, IPO, stated that her expectation was that all staff in the OR wear eye protection while providing patient care. She also stated that outside jackets were not allowed in the OR.

4. Review of the hospital's policy titled, "Nova Statstrip Whole Blood Bedside Glucose," dated 02/2023, directed staff to clean and disinfect the glucose monitor after each patient use to minimize the risk of transmission of blood-borne pathogens.

Observation on 02/15/23 at 11:15 AM, showed Staff SS, Nurse Technician (NT), performed a blood sugar check on Patient #40 and failed to clean the glucose monitor after using it on the patient.
Observation on 02/15/23 at 11:22 AM, showed Staff SS, NT, performed a blood sugar check on Patient #41 and failed to clean the glucose monitor after using it on the patient.

Observation on 02/15/23 at 11:28 AM, showed Staff SS, NT, performed a blood sugar check on Patient #42 and failed to clean the glucose monitor after using it on the patient.

During an interview on 02/16/23 at 9:25 AM, Staff QQQ, RN Cardiology Director, stated that she expected staff to clean the glucose monitor after every patient use.

During an interview on 02/16/23 at 9:45 AM, Staff FF, IPO, stated that her expectation was that all staff cleaned the glucose monitor after every patient use.

During an interview on 02/16/23 at 9:40 AM, Staff A, System Quality and Infection Prevention Director, stated that her expectation was that all staff should clean the glucose monitor between patient use.