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Based on review of documents, medical records and staff interviews it was determined the hospital failed to ensure patients are informed of their rights (see tag 0117), patients are given the mechanism for filing a complaint or grievance (see tag 0118), patients are given the opportunity to sign an informed consent (see tag 0131), care is rendered in a safe setting (see tag 0144), when using restraints less restrictive and alternative measures are tried (see tag 0165), staff implemented restraints safely (see tag 0167), restraints are discontinued at the earliest possible time (see tag 0174) and staff documents monitoring of restraints according to hospital policy (see tag 0175).

Based on observation, document review and staff interviews it was determined the facility failed to inform each patient of the patient's rights, in advance of furnishing care, to all inpatients in the facility. This failure has the potential to negatively impact all patients within the facility.

Findings include:

1. A tour of Unit Eight (8) North East (8NE) was conducted on 03/04/19 at 11:30 a.m. During this tour I asked to see an admission packet given to patients upon admission. The Registered Nurse (RN) stated, "The whole hospital is out of welcome patient booklets."

2. A review of policy Patient Rights & Responsibilities, last review date 02/26/16, states under Procedure section: "A. WVUH's statement on rights and responsibilities of patients is included in the patient information booklet that will be made available to each patient or responsible party upon admission or as soon after admission as feasible."

3. An interview was conducted on 03/05/19 at 10:40 a.m. with the Director of Nursing Services for Seven (7) East, Seven (7) West, Seven (7) Northeast, Ten (10) East and Ten (10) West. She stated regarding the patient welcome handbooks, "Initially Seven (7) East had run out of the books in January so we shared them throughout the other units until they ran out completely at the end of February." When checking on the availability of handbooks, she found they are currently being produced and individual units will have to order them once they become available. The welcome handbooks list the patient's rights and responsibilities and have information on how to file a complaint or grievance with the hospital, State or accrediting organization. This information is only contained in the handbooks and is not posted on the units. When asked about how they are notifying patients of their rights and how to file a grievance she stated, "I don't have an answer for that."

Based on observation, document review and staff interviews it was determined the facility failed to inform each patient, including all inpatients within the facility, of whom to contact to file a grievance. This failure has the potential to negatively impact all patients within the facility.

Findings include:

1. A tour of the Unit Eight (8) North East (8NE) was conducted on 03/04/19 at 11:30 a.m. During this tour I asked to see an admission packet given to the patients upon admission. The Registered Nurse (RN) stated, "The whole hospital is out of welcome patient booklets."

2. A review was conducted of policy Patient and Family Complaint and Grievance Mechanism with a last review date of 03/03/17. It states in part under Procedure section: "Patients and families are informed of their right to present complaints or grievance and are given the opportunity and instructions on the process from the following sources: 1. The Patient Information Guide."

3. An interview was conducted on 03/05/19 at 10:40 a.m. with the Director of Nursing Services for Seven (7) East, Seven (7) West, Seven (7) Northeast, Ten (10) East and Ten (10) West. She stated regarding the patient welcome handbooks, "Initially seven (7) East had run out of the books in January so we shared them throughout the other units until they ran out completely at the end of February." When checking on the availability of handbooks, she found they are currently being produced and individual units will have to order them once they become available. The welcome handbooks list the patient's rights and responsibilities and have information on how to file a complaint or grievance with the hospital, State or accrediting organization. This information is only contained in the handbooks and is not posted on the units. When asked about how they are notifying patients of their rights and how to file a grievance she stated, "I don't have an answer for that."

Based on document review and staff interviews it was determined the facility failed to obtain general consent for treatment for all patients being directly admitted from another facility from 7:00 p.m. until 8:00 a.m. This failure has the potential to negatively impact all patients directly admitted from another facility within those hours.

Findings include:

1. An interview was conducted on 03/05/19 at 12:48 p.m. with the Manager of Financial Counseling and the Director of Patient Access. When a patient is admitted to the hospital, the admissions representatives check for yearly consent and obtain consent if there is none obtained within the last year. The nursing staff cannot obtain this electronic consent as only the admission staff have access to it. During the evening shift the patients check in with the Emergency Department or with the front desk and would sign consent upon arrival. If a patient is transferred from another facility directly to their room, no consent would be obtained after 7:00 p.m. until 8:00 a.m. the next morning. The Director of Patient Access stated, "We would not go up in the middle of the night to get a patient to sign consent."

2. A review of the policy General Consent, last review date 08/01/18, was conducted. Under Section Policy, it states: "A. To maintain Federal and State compliance, upon first contact with West Virginia University Hospitals (WVUH) or Ambulatory Services, and no less then annually thereafter, every WVUH/Ambulatory Services Inpatient and Outpatient, or legally authorized person for the patient, will be asked to sign the WVUH General Consent." Under Procedure it states: "A. Upon arrival into any WVUH/Ambulatory Services facility the registration staff will obtain signature from all new patients, or patient's authorized representative, as verification that the patient or representative is aware of and agrees to the information outlines within the general consent."

3. In an interview with the Regulatory Coordinator on 03/06/19 at 1:00 p.m. we discussed the above findings and he had no additional information.

Based on record review and staff interviews it was determined the facility failed to render care in a safe setting for one (1) out of ten (10) patients (patient #1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. The patient was noted to be pleasantly confused with no other assessment exceptions. At 3:30 a.m. the patient was ordered restraints and additional medication. The patient remained agitated, confused and combative throughout the night. No additional physician orders were obtained. The last documented restraint check was at 10:00 a.m. No additional restraint documentation was present after this time, including when the restraints were removed. The discharge instructions given to the patient listed a new medication to be applied topically. The discharge summary written by the physician states this is to be applied to bilateral hands for contact dermatitis.

2. A telephone interview was conducted on 03/05/19 at 11:00 a.m. with the Registered Nurse (RN) #2 who took care of patient #1 during the night shift 7:00 p.m. until 7:30 a.m. This nurse remembered the patient. The patient continued to pull on the restraints, however during this shift skin assessments were done every two (2) hours and no redness was noted. The patient pulled the restraints so hard she turned her hand blue and they had to release the restraint several times to allow the hand to return to normal color.

3. A telephone interview was conducted with a Clinical Associate (CA) from 8NE on 03/05/19 at 11:25 a.m. This CA remembered patient #1 and was involved in her care on the night of 02/17/19. She stated in part, "By morning the patient wasn't yelling as much and not as agitated but still confused and not following commands. It is both a RN and CA's responsibility to check restraints. I did check her hands and at one time the hand on the right was turning blue so the RN and I released the restraint and it resumed normal color."

4. An interview was conducted on 03/04/19 at 3:15 p.m. with RN #3 in charge of patient #1 on her day of discharge 02/18/19. RN #3 remembered the patient. She was unsure exactly when she removed the restraints as there was no documentation in the chart of the discontinuation of restraints. RN #3 stated, "The patient's wrists were red after I removed the restraints but I had assumed it was due to her pulling on the restraints so I did not document the redness or notify the physician." She did discuss with the daughter about the redness on the wrist and told the daughter the patient was fighting the restraints and this was the cause of the redness. Again, this nurse explained she felt the redness on the wrist was due to the restraints and there was bruising noted on the right hand due to a blood draw and compounded by the restraints. But again, she stated she did not document this in the medical record.

5. An interview conducted with the Director of 8NE at 3:45 p.m. concurred with the above findings that the redness on the wrists was probably caused by the restraints.

Based on record review and interviews it was determined the facility failed to provide the least restrictive intervention for six (6) out of eight (8) patients who had restraints during their hospitalization (patients #1, 2, 3, 7, 8 and 10). This failure has the potential for harm to all restrained patients.

Findings include:

1. A review of clinical records for patients #1, #2, #7 and #8 revealed they were inpatients on Eight (8) Northeast (8NE) in February 2019. During their admission they were restrained in bilateral soft wrist restraints before 1:1 care and observation by a sitter were tried.

2. A review of the clinical record for patient #3 revealed he was an inpatient on 8NE at the time of the survey. During this admission he was restrained in bilateral soft wrist restraints before 1:1 care and observation by a sitter were tried.

3. A review of the clinical record for patient #10 revealed although he was an inpatient on 8NE at the time of the survey, he was initially admitted to the Surgical Intensive Care Unit (SICU) on 3/1/19. During his stay in the SICU he was placed in bilateral soft wrist restraints before 1:1 care and observation by a sitter were tried. He was transferred to eight 8NE on 3/2/19 at 5:53 p.m. where restraints were continued.

4. A phone interview was conducted with Registered Nurse (RN) #2 on 3/5/19 at 11:01 a.m. He revealed he was the nurse assigned to patient #1 on 2/17/19 night shift (7:00 p.m. to 7:00 a.m.). He stated he did not consider a sitter prior to use of restraints when this patient became combative. He stated, "It's often hard to get a sitter."

5. In an interview conducted with the Manager of 8NE on 3/5/19 at 8:07 a.m. she acknowledged, based on documentation, no sitter was used for patient #1 prior to use of restraints.

6. In an interview conducted with Manager of the SICU on 3/6/19 at 8:28 a.m. she acknowledged no sitter was used for patient #3 prior to use of restraints. She revealed sitters are used in SICU as needed. She concurred the presence of IV lines, artificial airways or tubes are not indications by themselves for use of restraints. She concurred documentation did not exist to support use of restraints on this patient.

7. In an interview conducted with the Manager of the Patient Safety Program on 3/5/19 at 11:45 a.m. she revealed the facility has a sitter program. She revealed sitters are clinical assistants who provide patient care and one (1) on one (1) observation on order of a physician. She revealed sitters are provided on a twenty-four hour basis and the positions can be covered by Licensed Practical Nurses (LPN) as needed. She stated, "If there's a need we have to cover it."

8. In an interview with the Manager and Director of 8NE conducted on 3/5/19 at 2:45 p.m. they acknowledged restraints should have been used only after a trial use of a sitter on the patients noted above. They concurred with the above findings.

Based on record review and staff interviews the facility failed to implement restraints safely in one (1) out of eight (8) patients restrained (patient #1). This failure has the potential to negatively impact all patients restrained.

Findings include:

1. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. The patient was noted to be pleasantly confused with no other assessment exceptions. At 3:30 a.m. the patient was ordered restraints and additional medication. The patient remained agitated, confused and combative throughout the night. No additional physician orders were obtained. The last documented restraint check was at 10:00 a.m. No additional restraint documentation was present after this time, including when the restraints were removed. The discharge instructions given to the patient listed a new medication to be applied topically. The discharge summary written by the physician states this is to be applied to bilateral hands for contact dermatitis.

2. A telephone interview was conducted on 03/05/19 at 11:00 a.m. with Registered Nurse (RN) #2 who took care of patient #1 during the night shift 7:00 p.m. until 7:30 a.m. This nurse remembered the patient. The patient continued to pull on the restraints, however during this shift skin assessments were done every two (2) hours and no redness was noted. The patient pulled the restraints so hard she turned her hand blue and they had to release the restraint several times to allow the hand to return to normal color.

3. A telephone interview was conducted with a Clinical Associate (CA) from 8NE on 03/05/19 at 11:25 a.m. This CA remembered patient #1 and was involved in her care on the night of 02/17/19. She stated in part, "By morning the patient wasn't yelling as much and not as agitated but still confused and not following commands. It is both a RN and CA's responsibility to check restraints. I did check her hands and at one time the hand on the right was turning blue so the RN and I released the restraint and it resumed normal color."

4. An interview on 03/04/19 at 3:15 p.m. with RN #3 who was in charge of patient #1 on her day of discharge on 02/18/19. RN #3 remembered the patient. She was unsure exactly when she removed the restraints as there was no documentation in the chart of the discontinuation of restraints. The RN stated, "The patient's wrists were red after I removed the restraints but I had assumed it was due to her pulling on the restraints so I did not document the redness or notify the physician." She did discuss with the daughter about the redness on the wrist and told the daughter the patient was fighting the restraints and this was the cause of the redness. Again this nurse explained she felt the redness on the wrist was due to the restraints. There was bruising noted on the right hand due to a blood draw and compounded by the restraints. But again she stated she did not document this in the medical record.

5. An interview conducted with the Director of 8NE at 3:45 p.m. concurred with the above findings that the redness on the wrists was probably caused by the restraint.

Based on record review, document review and staff interviews it was determined the facility failed to ensure restraints were discontinued at the earliest possible time for three (3) out of eight (8) patients (patients #1, 3 and 8). This failure has the potential to negatively impact all restrained patients.

Findings include:

1. A review was conducted of policy Use of Non-Violent, Non-Self-Destructive Restraints, last review date 07/24/18. It states: "Evaluation of whether restraints can be discontinued must be an ongoing process. Assessment will include ...attempts to eliminate restraints and the alternatives that were tried to manage the behavior."

2. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. At 3:30 a.m. the patient was ordered restraints and additional medication. The last documented restraint check was at 10:00 a.m. No additional restraint documentation was present after this time including when the restraints were removed.

3. An interview on 03/04/19 at 3:15 p.m. with Registered Nurse #3 (RN) in charge of patient #1 on her day of discharge 02/18/19. This RN remembered the patient. She stated she did not remove the restraints sooner because she didn't know if other interventions would work prior to the daughter coming so she waited until just before the daughter was to get there to remove the restraints. She was unsure exactly when she removed the restraints.

4. A review of patient #3's medical record was conducted on 03/04/19. The patient was admitted on 02/27/19 for a bowel obstruction. The patient was confused, intubated and on a ventilator. On 2/27/19 at 8:00 p.m. restraints were initiated after alternative methods failed and to limit the ability to remove the artificial airway. On 2/27/19 at 10:00 p.m. the documentation in patient's response to restraints every two (2) hours stated, lying still until the restraints were discontinued on 03/02/19 at 10:15 a.m. On 03/02/19 patient was noted to be restless and restraints were reapplied. On 03/03/19 at 8:00 a.m. the documentation in patient's response to restraints every two (2) hours stated, lying still until the restraints were discontinued 03/04/19 at 9:00 a.m.

5. An interview was conducted on 03/06/19 at 8:24 a.m. with the Nurse Manager of the Surgery Intensive Care Unit (SICU). She confirmed patient #3's documentation that stated lying still while still in restraints. She stated, "It should be documented if a trial release was performed without restraints and the patient's reaction to the trial." Her expectation would be to reassess the need for restraint every two (2) hours. She stated, "Based on this patient's documentation, restraints were used inappropriately." She agrees the restraints should have been released sooner.

6. A review of patient #8's medical record was completed 03/06/19. The patient was admitted on 02/18/19 at 2:32 p.m. after a fall. His diagnosis was cervical fracture and seizure. On 02/19/19 at 10:40 p.m. the patient was noted to be confused, agitated and pulling at lines. An order for restraints was obtained. The patient remained agitated until 02/21/19 at 2:00 a.m. when the documentation in patient's response to restraints every two (2) hours stated asleep until the restraints were discontinued 02/21/19 at 2:00 p.m.

7. An interview was conducted on 03/06/19 at 11:45 a.m. with the Manager of 8NE and the Director of 8NE. Regarding patient #8 they confirm the patient was charted as being asleep from 02/21/19 at 2:00 a.m. until 02/21/19 at 2:00 p.m. with restraints still on. They both concur the restraints should have been removed according to the documentation.

Based on record review and staff interviews it was determined the facility failed to monitor and document the patient's response to restraints in one (1) out of eight (8) patients (patient #1). This failure has the potential to negatively impact all restrained patients.

Findings include:

1. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. The patient was noted to be pleasantly confused with no other assessment exceptions. At 3:30 a.m. the patient was ordered restraints and additional medication. The patient remained agitated, confused and combative throughout the night. No additional physician orders were obtained. The last documented restraint check was at 10:00 a.m. No additional restraint documentation was present after this time, including when the restraints were removed. The discharge instructions given to the patient lists a new medication to be applied topically. The discharge summary written by the physician states this is to be applied to bilateral hands for contact dermatitis.

2. A telephone interview was conducted on 03/05/19 at 11:00 a.m. with Registered Nurse (RN) #2 who took care of patient #1 during the night shift 7:00 p.m. until 7:30 a.m. RN #2 remembered the patient. The patient continued to pull on the restraints, however during this shift skin assessments were done every two (2) hours and no redness was noted. The patient pulled the restraints so hard she turned her hand blue and they had to release the restraint several times to allow the hand to return to normal color.

3. A telephone interview was conducted with a Clinical Associate (CA) from 8NE on 03/05/19 at 11:25 a.m. This CA remembered patient #1 and was involved in her care on the night of 02/17/19. She stated in part, "By morning the patient wasn't yelling as much and not as agitated but still confused and not following commands. It is both a RN and CA's responsibility to check restraints. I did check her hands and at one time the hand on the right was turning blue so the RN and I released the restraint and it resumed normal color."

4. An interview was conducted on 03/04/19 at 3:15 p.m. with RN #3 who was in charge of patient #1 on her day of discharge on 02/18/19. RN #3 remembered the patient. She was unsure exactly when she removed the restraints as there was no documentation in the chart of the discontinuation of restraints. RN #3 stated, "The patient's wrists were red after I removed the restraints but I had assumed it was due to her pulling on the restraints so I did not document the redness or notify the physician." She did discuss the redness on the wrist with the daughter and told the daughter the patient was fighting the restraints and this was the cause of the redness. Again this nurse explained she felt the redness on the wrist was due to the restraints. There was bruising noted on the right hand due to a blood draw and compounded by the restraints. But again she stated she did not document this in the medical record.

5. An interview was conducted with the Director of 8NE at 3:45 p.m. and she concurred with the above findings that the redness on the wrists was probably caused by the restraint.

Based on document review and staff interviews it was determined the facility failed to track and trend restraint data according to policy. This failure has the potential to negatively impact all patients.

Findings include:

1. A review was conducted of policy Use of Non-Violent, Non-Self-Destructive Restraints, last review date 07/24/18. Under Compliance the policy stated: "In order to monitor Compliance with this policy and restraint usage, data is collected, trended and analyzed. Compliance of restraint documentation is monitored at the unit level. Restraint data trends are reported through the Center of Quality Outcomes."

2. An interview was conducted on 03/06/19 at 3:40 p.m. with the Director of Eight (8) Northeast (8NE) who is also in charge of the restraint committee. She confirmed she has not reported to Quality Assurance in over a year and data on restraints is not tracked or trended.

3. An interview was conducted on 03/06/19 at 3:45 p.m. with the Regulatory Compliance Officer. He confirmed no data on restraint application in use is tracked and trended in the Quality Assurance program.

Based on record review and staff interviews it was determined the facility failed to reassess the patient in response to nursing interventions for one (1) out of ten (10) patients (patient #1). This failure has the potential to negatively impact all patient receiving care.

Findings include:

1. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. At 3:30 a.m. the patient was ordered restraints and additional medication. The patient remained agitated, confused and combative throughout the night. No additional physician orders were obtained. The last documented restraint check was at 10:00 a.m. No additional restraint documentation was present after this time, including when the restraints were removed.

2. An interview was conducted on 03/04/19 at 3:15 p.m. with Registered Nurse (RN) #3 who was in charge of patient #1 on her day of discharge on 02/18/19. RN #3 remembered the patient. RN #3 stated, "the patient's wrists were red after I removed the restraints but I had assumed it was due to her pulling on the restraints so I did not document the redness or notify the physician."

3. An interview was conducted with the Nurse Manager of Eight (8) Northeast on 03/05/19 at 8:00 a.m. Her expectation would be an assessment would be done prior to and after the restraints are removed. If any new skin issues, especially after the removal of the restraints, she would expect the nurse to chart in the medical record, notify the physician and fill out an incident report. She also explained all skin alterations, whether the nurse felt they were caused by restraints or not, should be charted in the electronic medical record. She again stated, "If restraints were removed and reddened areas were underneath where the restraints were located, I would expect an incident report to be filed." Regarding an assessment prior to discharge she stated, "If the patient was to be discharged at 1:00 p.m. I would expect a full head to toe assessment at 12:00 p.m. This patient left at 1:51 p.m. on 02/18/19. Patient #1's last assessment was completed at 8:30 a.m. on 02/18/19." She also concurred there was no charting for the time the restraints were discontinued.

4. An interview was conducted with the Director of Eight (8) Northeast at 03/05/19 at 8:30 a.m. and she concurred with the above findings.

Based on record review and staff interviews it was determined the facility failed to ensure an accurate and complete medical record for one (1) out of ten (10) patients (patient #1). This failure has the potential to negatively impact all patients in the facility.

Findings include:

1. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. At 3:30 a.m. the patient was ordered restraints and additional medication. The patient remained agitated, confused and combative throughout the night. No additional physician orders were obtained. The last documented restraint check was at 10:00 a.m. No additional restraint documentation was present after this time, including when the restraints were removed.

2. An interview was conducted on 03/04/19 at 3:15 p.m. with Registered Nurse (RN) #3 who was in charge of patient #1 on her day of discharge on 02/18/19. RN #3 remembered the patient. RN #3 stated, "The patient's wrists were red after I removed the restraints but I had assumed it was due to her pulling on the restraints so I did not document the redness or notify the physician."

3. An interview was conducted with the Nurse Manager of Eight (8) Northeast on 03/05/19 at 8:00 a.m. Her expectation would be an assessment would be done prior to and after the restraints are removed. If any new skin issues, especially after the removal of the restraints, she would expect the nurse to chart in the medical record, notify the physician and fill out an incident report. She also explained all skin alterations, whether the nurse felt they were caused by restraints or not, should be charted in the electronic medical record. She again stated, "If restraints were removed and reddened areas were underneath where the restraints were located, I would expect an incident report to be filed." Regarding an assessment prior to discharge she stated, "If the patient was to be discharged at 1:00 p.m. I would expect a full head to toe assessment at 12:00 p.m. This patient left at 1:51 p.m. on 02/18/19. Patient #1's last assessment was completed at 8:30 a.m. on 02/18/19." She also concurred there was no charting for the time the restraints were discontinued.

4. An interview was conducted with the Director of Eight (8) Northeast at 03/05/19 at 8:30 a.m. and she concurred with the above findings.

Based on record review, document review and staff interviews it was determined the facility failed to ensure complete discharge instructions for one (1) out of ten (10) patients (patient #1). This failure has the potential to negatively impact all patients discharged from the facility.

Findings include:

1. A review was conducted of patient #1's medical record on 03/04/19. The patient was admitted on 02/17/19 at 5:53 p.m. as a transfer from another facility for observation on Unit Eight (8) Northeast (8NE) after a probable allergic reaction to a new medication. The nurses note on 02/18/19 at 12:56 p.m. states: "Patient being discharged back to her assisted living residence. Will review all discharge instructions with the daughter." The discharge instructions given to the patient lists a new medication to be applied topically. The discharge summary written by the physician states this is to be applied to bilateral hands for contact dermatitis.

2. An interview on 03/04/19 at 3:15 p.m. with Registered Nurse (RN) #3 who was in charge of patient #1 on her day of discharge on 02/18/19. RN #3 remembered the patient. On discharge hydrocortisone cream was ordered and she said, "I did not know where the cream was supposed to go and I did not see any rashes on the patient." RN #3 said she did not check with a doctor or follow up on exactly where the hydrocortisone cream was to be applied. She stated, "I was trying to get her out of there as soon as possible to get her back into familiar surroundings."

3. An interview was conducted on 02/05/19 at 11:18 a.m. with the Internal Medicine hospitalist who discharged patient #1. The physician stated he remembered the patient. He ordered hydrocortisone cream and discussed the order with the RN who was present at the time. The redness was obvious to both of patient #1's hands, however the nurse or family could have called the hospitalist call line if they had any questions about where to apply the cream.

4. An interview was conducted with the Nurse Manager of Eight (8) Northeast on 03/05/19 at 8:00 a.m. Regarding the discharge instructions, if there was a question about any medication including where and how to use the medication, she would expect the nurse would call the physician to clarify.