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Based on record reviews and interview, the hospital failed to ensure the 1 hour face to face evaluation was documented related to restraint interventions in the closed record of Patient 10 for 1 of 10 closed patient charts reviewed for care and services. (Patient 10)


The findings are:


Review of the closed patient chart for Patient 10 revealed the patient was admitted on 6-9-16 with Spondylosis Lumbar Spinal Stenosis for surgery with a lateral fusion at L3 - L4 and L4 - L5. On 08/11/2016 at 12:50 p.m., review pf Patient 10's chart revealed a nurse note dated 6/10/16 that read, "
confused, anxious, and agitated, pulled at IV(intravenous) tubes. Oxygen saturation 100%(percent) - 90% - on oxygen at 3 liters per nasal cannula with 100% saturation. On 8-11-16 at 2:00 p.m., review of the nurse's note dated 6/11/16 at 5:47 a.m. revealed, "At 5:00 a.m., BP(Blood Pressure) alarming, pump beeping. Walked into room to find that patient had removed his wrist restraints, pulled out his IV(intravenous) and was taking off his SCDs(sequential compression devices). He was confused saying he had to get out of here and to call the police. Help arrived and pt(patient) was restrained again. Two new IVs were started and IVFs/PCA (intravenous fluids/patient controlled analgesic) restarted. Pt oriented to self and year. Stated he was in Michigan, Arkansas. Oriented pt. to time, place, and situation. Pt. is now calm and restrained." Review of the nurse note dated 6-11-16 at 9:52 p.m. revealed, "Pt. without restraints prior to receiving report. Pt. now alert with appropriate behavior." There was no documentation of the 1 hour face to face evaluation.

In an interview with the Director of Intensive Care on 8-11-16 at 12:50 p.m., the Director reported that a physician order was written for soft limb wrist restraints bilateral due to the patient disconnecting and removing therapeutic devices such as intravenous lines and the Bipap mask. The restraints were started on 6-10-16 at 8:00 p.m. and discontinued on 6-11-16 at 6:00 a.m.".

Hospital policy, titled, "Restraint and Seclusion", reads, "It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and re-evaluation."

Based on record review and interview, the hospital failed to ensure less restrictive interventions were attempted before restraining patients for 1 of 1 closed patient records reviewed for care and services related to restraint interventions. (Patient 10)


The findings are:


On 8/11/2016 at 2:00 p.m., review of Patient 10's chart revealed the patient was admitted on 6-9-16 with Spondylosis Lumbar Spinal Stenosis for a lateral lumbar fusion for a severe disk collapse at L3-L4 and L4-L5. Review of the patient's chart showed a physician order dated 6/10/16 for soft limb wrist restraints bilateral due to patient attempting to disconnect the intravenous lines. Review of the nursing notes revealed there was no documentation that least restrictive measures were tried before the application of the bilateral wrist restraints on 6/10/16 at 8:00 p.m., and there was no documentation of restraints on the patient's plan of care. On 8/11/2016 at 2:50 p.m., the Director of Intensive Care reported, "Restraints were started on 6-10-16 at 8:00 p.m. and discontinued on 6-11-16 at 6:00 a.m. (Restraint Monitoring Non Violent) due to the patient disconnecting and removing therapeutic devices."

Hospital policy, titled, "Restraint and Seclusion", reads, "It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and re-evaluation.
Section C, page 3 (b). "relevant orders for use of restraints, including least restrictive intervention, time limit, clinical justification, type of restraint to be used, and criteria for release and (d.) use of restraints must be addressed in the patient's modified plan of care."

Based on review of the hospital's quality data and interview, the hospital failed to ensure its quality program included elements for oversight and monitoring of the hospital's contracted dialysis services.


The findings are:


On 08/11/16 at 12:45 p.m., review of the hospital's Quality Assessment and Performance Improvement data and minutes revealed the hospital's quality program had no documentation of oversight of the hospital's contracted dialysis services. On 08/11/16 at 1:40 p.m., in an interview with Nurse Manager 1 revealed, he/she revealed, "The contracted dialysis staff do their own Performance Improvement metrics. We meet with them quarterly to review their data. The contracted dialysis nurses follow our policies and procedures as far as infection control such as room cleaning." There was no evidence that the hospital's quality program data had indicators for the contracted dialysis service to identify and monitor the effectiveness and safety of renal dialysis services and quality of care in a potential complex problem prone area.

Based on review of the hospital's quality data for adverse medical errors, review of the hospital's patient safety data, and review of the hospital's policies and procedures, the hospital failed to provide evidence that preventive strategies were developed and implemented for medication errors.

The findings are:

On 8/10/2016 at 4:30 p.m., review of the hospital's adverse medication log and review of the hospital's patient safety committee meeting minutes revealed there was no documentation or other evidence that the hospital's patient safety committee developed and implemented strategies to decrease and/or prevent recurrences related to reported medication errors from August 2015 to May 2016.

On 8/11/2016 at 3:00 p.m., in an interview with the Patient Safety Officer, he/she stated "We've implemented actions." No documentation to support this statement was shared with the surveyor.

On 8/10/2016 at 4:00 p.m., review of the hospital's policy, titled, "Patient Safety Plan", reads, "...Goals To provide a systematic, coordinated and continuous approach to the maintenance and improvement of patient safety through this plan, which...Provides an ongoing proactive approach to reduce risk...Important Functions The patient Safety Plan includes important organizational functions as outlined by the standards of the Joint Commission including:...Medication Management...".

Based on record review, interview, and review of the hospital's quality data, the hospital's governance failed to ensure its quality program reflects the complexity of the hospital's services, involves all hospital departments and services including those services furnished under contract or arrangement in that the hospital's quality program revealed there was no documentation of oversight by the hospital's quality program for the hospital's contracted dialysis service.

The findings are:

Cross Reference to A 0283: The hospital failed to ensure its quality program included elements for oversight and monitoring of the hospital's contracted dialysis services.

Cross Reference to A 0286: The hospital failed to provide evidence that preventive strategies were developed and implemented for medication errors.

Based on observations and interview, the hospital failed to ensure expired patient supplies were removed from the patient care areas. (Procedure Room 4, Sub Sterile Supply Area, Anesthesia Supply Room, and Central Sterile Supply Processing area)


The findings are:


On 08/09/16 at 10:40 a.m., random observations in Procedure Room 4 revealed (2) speedband superview super 7 trays expired on 07/31/16. On 08/09/16 at 10:40 a.m., in an interview with Nurse Manager 4, he/she verified the findings.

On 08/09/16 from 2:09 p.m. - 2:32 p.m., random observations in the sub sterile supply area revealed (21) Nurolon 4-0 gastro-intestinal 18 inch (45 centimeter (cm)) black braided nylon surgical sutures expired 07/16. Five (5) nasal raes 7.5 millimeter (mm) expired 10/13 that were located in the anesthesia supply room. On 08/09/16 at 2:2., the findings were verified by the Director of the Operating Room (OR).

On 08/10/16 at 3:04 p.m., random observations in the central sterile processing supply area revealed (4) safesheath 13 cm 9 F (French) expired 06/16, (3) clearview uterine manipulator 7 cm tip expired 07/16, (5) Povidone - Iodine cleansing scrub swabstick 3 pack expired 08/15, (1) Beaverguard guarded 35 mm(millimeter) depth blade expired 02/16, and (1) compound tincture of Benzoin 10% (percent) swabstick expired 01/16. On 08/10/16 at 3:04 p.m., the findings were verified by Nurse Manager 4.

Based on record review and interview, the hospital failed to ensure physician progress notes were dated and timed for 1 of 30 patient medical records reviewed for care and services. (Patient 16)

The findings are:


On 8/9/2016 at 11:45 a.m., review of Patient 16's medical record revealed the progress notes were not dated and timed by the physician for the following dates:
8/6/2016
8/7/2016
8/8/2016
8/9/2016
On 8/9/2016 at 11:50 a.m., the finding was verified by the Director of Intensive Care.

Based on record review and interview, the hospital failed to ensure consent forms were properly executed for admission. (Patient 8)


The findings are:


On 8/9/16 at 11:25 a.m., review of Patient 8's chart revealed the patient was admitted on 8/8/16. Review of the patient's "Consent of Services" form revealed documentation that the patient gave a verbal consent. The hospital failed to ensure the consent form was properly executed. On 8/9/16 at 11:26 a.m., in an interview with Nurse Manager 1, he/she verified the findings, but had no explanation why the consent form noted it was a verbal consent when the patient have the ability to write.

Based on record review and interview, the hospital failed to ensure its staff completed the documentation (physician progress notes, updated nursing care plans, orders for consults, etc.) necessary to monitor the patient's condition for 3 of 28 in-patient charts reviewed for care and services. (Patient 9, 10, and 11)


The findings are:


On 8/9/16 at 1:32 p.m., review of Patient 9's chart revealed the patient was admitted on 8/3/16 with a history and physical dated 8/3/16. There were no physician progress notes for 8/9/16. Review of the patient's "Interdisciplinary Plan of Care" showed there was no documentation within 24 hours by nursing for 8/7/16. On 8/9/16 at 1:50 p.m., Nurse Manager 1 verified the findings.

On 8/9/16 at 2:50 p.m., review of Patient 10's chart revealed the patient was admitted on 7/28/16 with a history and physical dated 7/28/16. There was no physician progress note dated 8/7/16. Review of the patient's "Interdisciplinary Plan of Care" revealed there was no documentation within 24 hours by nursing on 8/8/16. On 8/9/16 at 3:17 p.m., Nurse Manager 1 verified the findings.

On On 8/9/16 at 3:21 p.m., review of Patient 11's chart revealed the patient was admitted on 8/2/16. Review of the patient's "Interdisciplinary Plan of Care" showed there was no documentation by nursing within 24 hours on 8/3/16 or 8/4/16. Review of the patient's frequent vital signs orders post surgery dated 8/8/16, stated, "Continuous, per unit routine". Nurse Manager 1 reported that continuous, per unit routine is vital signs every 15 minutes times 4, every 30 minutes times 2 and every hour times 2. Review of the patient's documented vital signs revealed the patient's vital signs were obtained: 20:00, 20:15, 20:30, 20:45, 21:15, 21:45, 22:45 and 04:16. Nursing failed to obtain vital signs as ordered (within 1 hour from 22:45). On 8/9/16 at 3:35 p.m., Nurse Manager 1 verified the findings.

Based on observations and interview, the hospital failed to ensure that all drugs and biologicals were kept in a secure area.

The findings are:

On 8/9/2016 at 1:25 p.m., random observations Patient Room 505, in the Progressive Care Unit revealed an insulin pen on the patient's bedside counter. On 8/9/2016 at 1:25 p.m., Registered Nurse 6 stated, "No, we don't keep meds(medications) at the bedside. I just gave insulin and had to go pull the patient's Potassium."

Based on review of the dietary data and interview, the hospital failed to designate a full-time employee to serve as the hospital's Dietary Director for the hospital's dietetic services.


The findings are:


On 08/08/16 at 11:55 a.m., in an interview with the Dietary Department Chef, he/she revealed the hospital's Dietary Department does not have a Dietary Manager or an Interim Dietary Manager. The dietary department's Chef reported there is an employee from the food management and facilities management company(contract) serving as the dietary Manager/Director. Review of hospital's dietary data revealed the hospital's Interim Dietary Manager is a contract employee of the food management company.

Based on review of facility governing body minutes and interview, the hospital failed to designate in writing its Infection Control Officer.


The findings are:


On 08/11/16 at 10:15 a.m., review of the hospital's governing body minutes and medical staff data revealed there was no written designation of hospital's infection control officer by the governing body. On 08/11/16 at 10:18 a.m., in an interview with the Director of Risk Management and Accreditation, he/she revealed, "We do not have a governing body appointment for the infection control officer. Medical Bylaws just basically states that he/she is a part of the infection prevention committee."

Based on observations and interview, the hospital failed to ensure staff followed principles for infection control to prevent potential cross contamination of infectious agents in the hospital setting for 4 of 4 Registered Nurses(RN), 1 of 1 Physicial Therapist(PT), and 1 of 1 Registered Respiratory Therapist(RRT) in the provision of care. (RN 1, 2, 3, and 5; PT 1 and RRT 1)

The findings are:

On 8/8/16 at 12:57 p.m., random observations in the outpatient adult physical therapy service area revealed Physical Therapist 1 walked to the waiting area, identified self, and made direct contract with Out-patient #35 via hand shake, proceeded to the treatment area, obtained the patient's history and physical information, then performed the various exercises outlined for the patient. Physical Therapist 1 failed to perform hand hygiene prior to direct contact with the patient. On 8/9/16 at 9:51 a.m., in an interview with Outpatient Manager 1, he/she confirmed hand hygiene should be performed before and after patient care.

On 8/9/16 at 10:12 a.m., random observations on the 4th floor surgical unit during a tour revealed the clean linen cart was not covered. The canvas was flipped back on top of the cart. The hospital failed to ensure clean linens were covered to minimize the potential cross transmission of infectious agents in the surgical setting. On 8/9/16 at 10:12 a.m., the Director of Quality and Nurse Manager 1 verified the findings.

On 8/9/16 at 2:01 p.m., random observations on the 5th floor during a Patient 34's respiratory treatment revealed Respiratory Therapist (RRT) 1 entered Patient 34's room with a computer on wheels, performed hand hygiene, donned gloves, elevated the head of the patient's bed, removed a stethoscope from his/her neck, assessed the patient's lungs and returned the stethoscope to his/her neck. RRT 1 identified the patient, continued the respiratory treatment, removed the gloves, performed hand hygiene, and exited the room, but RRT 1 failed to disinfect the computer on wheels and failed to disinfect the stethoscope.

On 8/9/16 at 2:21 p.m., random observations on the 5th floor during Patient 35's respiratory treatment revealed Respiratory Therapist (RRT 1)entered Patient 35's room with the computer on wheels, performed hand hygiene, and donned gloves. RRT 1 removed the stethoscope from his/her neck, assessed the patient's lungs, returned the stethoscope to his/her neck, identified the patient, continued with the patient's respiratory treatment, removed the gloves, performed hand hygiene, shook hands dry, donned clean gloves, cleansed the patient face mask and medication reservoir, removed gloves, performed hand hygiene, and exited the room. RRT 1 failed to disinfect the computer on wheels, failed to disinfect the stethoscope after use, and failed to rub hands until dry after using hand sanitizer (foam).

On 8/9/16 at 2:38 p.m., in an interview with Respiratory Therapist 1, he/she verified the findings acknowledging that he/she usually wipes the equipment down, but didn't this time.

On 8/9/16 at 4:05 p.m., random observations during a medication pass on the 4th floor surgical unit revealed Registered Nurse (RN 3)entered patient 33's room, donned gloves, identified the patient, administered the medications, removed gloves, documented via the computer, performed hand hygiene, and exited the room. RN 3 failed to perform hand hygiene prior to gloving and failed to perform hand hygiene after removal of the gloves before documenting in the computer. On 8/9/16 at 4:10 p.m., in an interview with Registered Nurse 3, he/she verified the findings.




30011

On 08/08/16 at 12:08 p.m., random observations in the dietary dish room revealed the dish conveyer belt area had a black square container beneath the sink filled with a clear liquid running over and out of the container, and the winsmith speed reducer (purcolator) located next to the rolling conveyer belt had a square container under it with fluid accumulation in the container. On 08/08/16 at 12:08 p.m., the findings were verified by the Dietary Chef.

On 08/08/16 at 2:40 p.m., observations of Patient 2 revealed Registered Nurse (RN) 2 in the intensive care unit transported the computer on wheels into and out of the patient's room during medication administration without disinfecting the computer on wheels after use.

On 08/08/16 from 3:09 p.m. - 3:12 p.m., observations of Patient 2 revealed RN 2 accessed the patient's left upper arm fistula for initiation of the patient's dialysis with the patient's door open. RN 2 donned no personal protective equipment (PPE) during the procedure. Observations revealed RN 5 handed one 5 milliliter syringe to RN 2 for blood collection for laboratory testing. On 08/11/16 at 12:32 p.m., in an interview with the Director of Risk Management and Accreditation, he/she revealed, "The nurses here at the hospital would follow the contracted services policy for PPE use."

Hospital policy, titled, "Hospital Services Policy and Procedure, Standard Precautions, procedure 602", reads, "....2. Personal protective equipment (PPE) will be used at all times when the nature of anticipated patient care or cleaning of environmental surfaces and/or equipment indicates patient treatment stations....1. Gowns: required when there is a likelihood of blood contact, especially when initiating and terminating treatment."

On 08/08/16 at 3:22 p.m., observations of Patient 2 revealed RN 5 attached a syringe of medication in the dialysis tubing line without disinfection of the intravenous line prior to attaching the syringe.

Hospital policy, titled, "Hospital Services Policy and Procedure, Standard precautions, procedure 602", reads,"....All hubs of IV (intravenous) tubing and medication vials will be scrubbed with 70% (percent) alcohol or hospital approved agent and allowed to air dry prior to accessing."

On 08/09/16 from 11:30 a.m. - 11:50 a.m., observations of the dietary serving area revealed a square drain shifted and moved off of its base when stepped upon. On 08/09/16 at 12:00 p.m., in an interview with Dietary Aide 1, he/she revealed, "The drain cover is loose, and you could possibly fall in it."





37024

On 8/8/2016 at 12:40 p.m., random observations in the Emergency Department (ED) revealed RN 1 entered a patient's room with a computer on wheels, removed the top from a medication vial, inserted a needle into the medication vial, and withdrew medication, but RN 1 failed to disinfect the septum of the medication vial. On 8/8/2016 at 12:45 p.m., random observations in the ED revealed RN 1 transferred the computer on wheels from the patient's room and placed it in the hallway, but RN 1 failed to disinfect the computer on wheels after removing the computer on wheels from the patient room.

On 8/9/2016 at 10:30 a.m., review of the hospital's policy, titled, "Hand Hygiene", reads, "Indications for hand washing and hand antisepsis include Just before and immediately after direct contact with patients, blood/body fluids or equipment and environmental items touched by patients...".




37212

On 08/10/16 at 10:00 a.m., observations in the Neonatal Intensive Care Unit (NICU) revealed bottles of breast milk dated 08/08/16 in the refrigerator. On 08/10/16 at 10:05 a.m., RN 4 verified the findings, and stated, " Breast Milk is good for 5 days in the refrigerator and 5 months in the freezer. We go by the 5 and 5 type rule. " Hospital policy ID 2433139, titled, " Breast Milk, storage of , " original date 11/10/1999, reviewed date 6/29/16," reads, "Breast Milk may be stored for up to 24 hours in the appropriate refrigerator. Longer storage of breast milk requires that the milk be frozen and stored in the freezer. "

On 08/09/2016 at 11"50 a.m., observations of the hospital's loading dock revealed a storage container housing used red Sharps biohazard boxes with dated labels of use that were located on right side of the container. The left side of the container contained red clean Sharps biohazard boxes with a clear loose plastic cover over the shelf. On the floor in front of the shelf were two used red Sharps containers with needles inside. One of the Sharps containers had no cap on the top securing the needles inside the container, and the needles in the Sharps container were at the full line. Both (dirty)Sharps containers were touching the plastic that covered the shelf with the clean Sharps containers. On 08/09/16 at 11:55 a.m., Environmental Services Manager 1 stated, "The red biohazard containers on the right are dirty and pick up is on Tuesday so that is today. The containers on the left are clean containers."