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Based on medical record review, staff interview, and policy review the hospital failed to obtain physician orders for the use of restraints on two of six patients (Patient #19 and #25) reviewed with restraint use. The hospital census was 478.

Findings include:


1. On 06/10/15 the medical record for Patient #19 was reviewed including the nursing restraint flow sheet and physician orders from 06/01/15 through 06/07/15.


The nursing restraint flow sheet documented bilateral mitten restraints were started on 06/07/15. The nursing restraint flow sheet documented mitten use on 06/07/15 at 7:00 AM, 9:00 AM, and 11:00 AM. The restraint flow sheet lacked documentation after the 11:00 AM entry and lacked documentation the restraints were removed.


The physician orders reviewed from 06/01/15 through 06/10/15 lacked documentation of an order for bilateral mitten restraint use on 06/07/15.


2. On 06/10/15 the medical record for Patient #25 was reviewed including the nursing restraint flow sheet and physician orders from 06/02/15 through 06/10/15.


The nursing restraint flow sheet documented bilateral soft wrist restraints utilized daily from 06/02/15 through 06/10/15 (nine days).


The physician orders reviewed from 06/02/15 through 06/10/15 lacked documentation of orders for bilateral soft wrist restraints on 06/02/15, 06/04/15, 06/05/15, 06/06/15, 06/08/15, and 06/10/15 (six of the nine days).


3. On 06/10/15 hospital policy #1C-106, Restraints, Care of the Adult Patient (Non-Psychiatric Setting), dated 05/2015 was reviewed. The policy documented orders for restraints was needed prior to the application except in an emergency situation and non-violent restraints orders were renewed by the physician following a face-to-face assessment each calendar day.


On 06/10/15 at 3:06 PM, Staff C confirmed the lack of restraint orders per hospital restraint policy for Patient #19 and Patient #25.

Based on medical record review, review of policy and procedure and staff interview the facility failed to develop or update plans of care for two (#11 and #34) of 33 patients reviewed for patient plans of care. The agency census was 478.


Findings include:


Review of the agency policy and procedure entitled Documentation by Nursing within ProMedica, Acute Care with an Approval date of 01/2011 directed nursing staff that individualized nursing plans of care will serve as the documentation for nursing interventions related to recurring care based on the patient's assessed needs and alteration of care adjusted on the plan as appropriate.


1) Review of the medical record on 06/10/15 for Patient #11 revealed the patient was admitted to the facility 06/04/15 with diagnoses which included rule osteomylitis of the spine versus hematoma of the spine. The medical record revealed the patient had a needle biopsy (needle puncture to spine) of the vertebral disc procedure on 06/09/15. Review of the patient's plan of care for the dates of 06/09 and 06/10/15 revealed the nursing plan of care used to direct Patient's #11's care needs failed to initiate a plan to address the patient's new care needs following the needle biopsy related to the patient's risk of infection.


This deficient practice was verified on 06/10/15 at 2:12 PM by nursing Staff B.


2) Review of the medical record on 06/10/15 for Patient #34 revealed the patient was admitted to the facility 06/05/15 with diagnoses which included congestive heart failure. The medical record revealed the patient had a cardiac catheterization procedure (flexible tube inserted into the heart via blood vessels in the groin) on 06/09/15. Review of the patient's plan of care for the dates of 06/09 and 06/10/15 revealed the nursing plan of care used to direct Patient's #34's care needs failed to initiate a plan to address the patient's new care needs following the heart catheterization related to the patient's risk of infection and risk for bleeding following the heart catheterization.


This deficient practice was verified on 06/10/15 at 2:12 PM by nursing Staff B.

Based on medical record review, policy review, and staff interview the facility failed to ensure consent forms were properly signed, dated, witnessed, and/or contained the decription of the procedure to be performed. This affected six of 33 medical records reviewed including Patients (#5, #11, #16, #21, #24, and #33). The hospital census was 478.


Findings include:


On 06/11/15 the hospital policy #1A-102, Informed Consent For Hospitalization and Operative/Invasive Procedures, dated 07/2013 was reviewed. The policy documented an informed consent form, in order to be properly executed, must be consistent with hospital policies including the physician performing the procedure would need to inform the patient and/or the legal representative of the specific procedure including the risks, benefits, and alternatives of the procedure and complete a consent form with signatures, dates and time. Other healthcare professionals may educate and witness the patient's or legal representative's signature. In situations where verbal or telephone consent is obtained from the patient's legal representative, two witnesses to the consent are required.


1. Review of the medical record for Patient #21 included seven consent forms that lacked requirements for proper execution.


Consent for a percutaneous needle biopsy dated 05/21/15 lacked documentation of who gave verbal consent, the relationship to the patient, and the two witnesses' signatures. The consent also lacked information related to the biopsy including what organ was to be affected by the biopsy.


Consent for a fistulagram/venoplasty dated 05/21/15 lacked documentation of who gave verbal consent, the relationship to the patient, and the two witnesses' signatures.


Consent for a fistulagram/venoplasty dated 05/28/15 lacked documentation of who gave verbal consent and the relationship to the patient.


Consent for a bronchoscopy dated 06/02/15 documented telephone consent by the patient's spouse but lacked the two witnesses' signatures.


Consent for a central line procedure dated 06/02/15 documented telephone consent by the patient's spouse but lacked the two witnesses' signatures.


Consent for a bronchoscopy dated 06/04/15 documented telephone consent by the patient's spouse but lacked the two witnesses' signatures.


Consent for a blood transfusion dated 06/07/15 documented telephone consent by the patient's spouse but lacked the two witnesses' signatures.


2. Patient #5's medical chart was reviewed and included two consent forms that lacked requirements for proper execution.


Consent for a biopsy and aspiration dated 06/04/15 lacked a witness signature.


Consent for a percutaneous needle biopsy dated 06/09/15 documented verbal consent given by the patient but lacked the two witnesses' signatures. The consent also lacked information related to the biopsy including what organ was to be affected by the biopsy.


3. Patient #16's medical chart was reviewed and included two consent forms that lacked requirements for proper execution.


Consent for a cystoscopy dated 05/28/15 documented a signature by the patient but lacked a witness signature.


Consent for a peripherally inserted central catheter dated 06/01/15 documented a verbal consent by the patient but lacked a date or time for the consent and lacked the two witnesses' signatures.


4. Patient #24's medical record was reviewed and included one consent form that lacked requirements for proper execution.


Consent for general hospital treatment dated 05/30/15 was signed by the patient's mother but lacked a witness signature.


5. Review of the medical record on 06/10/15 for Patient #11 revealed the patient was admitted to the facility 06/04/15 with diagnoses which included rule osteomylitis of the spine versus hematoma of the spine. The medical record revealed the patient under went a needle biopsy (needle puncture to spine) of the vertebral disc on 06/09/15. The medical record revealed Patient #11 was presented a consent form for percutaneous needle biopsy which was incomplete with regard to the organ being biopsied or the reason for the biopsy. This incomplete consent form further failed to document the anatomical areas of potential injury related to this procedure.


This deficient practice was verified on 06/10/15 at 2:12 PM by nursing Staff B.


6. Review of the medical record for Patient #33 revealed the patient was admitted to the facility on 06/06/15 with diagnoses which included chest pain. The medical record revealed the patient signed the facility's General Consent for Treatment on 06/06/15 which lacked any date or time the consent was signed as well as any facility witness signatures or dates and times. Interview of Staff Z on 06/10/15 at 3:03 PM verified that all hospital patient consent forms were to be signed with date and time per hospital policy and procedure.

Based on observation, interview, and record review, the facility failed to maintain two hour barrier between nonconforming buildings, to ensure its corridor doors with gaps had astragals, rabbets, or bevels, to maintain the rating of the barriers protecting vertical openings, to ensure access to exits were marked with approved readily visible signs, to have at least two smoke compartments on every patient sleeping floor, to maintain the rating of its smoke barriers, to ensure each door in its smoke barrier closed completely, to ensue each hazardous area had a self closing door, to maintain the rating on its barriers protecting stairways and other exit components, to comply with National Fire Protection Association 101, 2000 edition, 7.2.1.6, to ensure emergency lighting was provided in accordance with National Fire Protection Association 101, 7.9, to have adequate lighting on each path of egress, to include all personnel in participating in fire drills, to ensure its fire alarm system complied with National Fire Protection Association 72, 1999 edition, to maintain its automatic sprinkler system in accordance with National Fire Protection Association 13 and 25, to ensure space heaters were appropriately used and not in patient care areas, to have an intervening wall between medical gas zone shut off valves and the outlets they serve, to ensure medical gas shut off valves were arranged to that shutting off one anesthetizing location would not affect others, to maintain ratings of smoke barriers penetrated by ducts, to ensure each anesthetizing location had emergency battery powered lighting in accordance with National Fire Protection Association 99, 1999 edition, to maintain one hour rating on wall between itself and other building occupants, to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101 and to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101, and to use power strips in accordance with National Fire Protection Association 70, 1999 edition.

Findings include:

See A709






32059

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients.

Findings include:

K11 Failed to maintain two hour barrier between nonconforming buildings
K18 Failed to ensure its corridor doors with gaps had astragals, rabbets, or bevels
K20 Failed to maintain the rating of the barriers protecting vertical openings
K22 Failed to ensure access to exits were marked with approved readily visible signs
K23 Failed to have at least two smoke compartments on every patient sleeping floor
K25 Failed to maintain the rating of its smoke barriers
K27 Failed to ensure each door in its smoke barrier closed completely
K29 Failed to ensue each hazardous area had a self closing door
K33 Failed to maintain the rating on its barriers protecting stairways and other exit components
K38 Failed to comply with National Fire Protection Association 101, 2000 edition, 7.2.1.6
K46 Failed to ensure emergency lighting was provided in accordance with National Fire Protection Association 101, 7.9.
K47 Failed to have adequate lighting on each path of egress
K50 Failed to include all personnel in participating in fire drills
K52 Failed to ensure its fire alarm system complied with National Fire Protection Association 72, 1999 edition
K62 Failed to maintain its automatic sprinkler system in accordance with National Fire Protection Association 13 and 25
K70 Failed to ensure space heaters were appropriately used and not in patient care areas
K77 Failed to have an intervening wall between medical gas zone shut off valves and the outlets they serve
K78 Failed to ensure medical gas shut off valves were arranged to that shutting off one anesthetizing location would not affect others
K104 Failed to maintain ratings of smoke barriers penetrated by ducts
K106 Failed to ensure each anesthetizing location had emergency battery powered lighting in accordance with National Fire Protection Association 99, 1999 edition
K114 Failed to maintain one hour rating on wall between itself and other building occupants
K130 Failed to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101 and failed to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101
K147 Failed to use power strips in accordance with National Fire Protection Association 70, 1999 edition