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Based on record review and interview, staff failed to follow facility policy for ensuring Physician orders were obtained and the required restraint monitoring was completed for the use of restraints for one patient (Patient #33) of three patients sampled for restraints. The facility census was 296.

Findings included:

1. Review of the facility's policy titled, "Restraints", last revised 04/09 revealed in part the following:
A. Authorization and Ordering of Restraints
-Restraint is initiated only upon the order of a physician. The order is time-limited not to exceed 24 hours and includes the specific reason for the intervention
B. Documentation
Each episode of restraint use shall be documented in the patient's medical record and shall include but not limited to:
-Results of patient monitoring will occur at regular intervals according to the individual's assessed needs but not to exceed two hours between intervals

2. Medical record review on 7/28/10 for Patient #33 revealed the patient was admitted to the facility on 7/13/10.

Patient #33's Acute Care Nursing Flow sheet (night shift) dated 7/26/10 revealed at 10:35 PM assessment completed as noted, patient cooperative, restraints maintained secondary to pulling at tubes.

Review of Patient #33's Physician Orders revealed the last order for restraints obtained on 7/25/10 at 6:00 PM. The medical record contained no physician's order for the continued use of restraints on 7/26/10 after 6:00 PM when the previous order expired.

Patient #33's Nursing Non-Behavioral Restraint Documentation flow sheet dated 7/25/10 documented the patient in restraints at 6:00 PM on 7/26/10. The medical record contained no Nursing Non-Behavioral Restraint Documentation flow sheet documenting the use of restraints on 7/26/10 after 6:00 PM as the Acute Care Nursing Flow sheet indicated.

In an interview on 7/28/10 at 2:45 PM, Staff M, Nurse Manager confirmed Patient #33's medical record did not contain a Physician's order for restraints after 6:00 PM on 7/26/10. Staff M said there was no monitoring flow sheet after 6:00 PM on 7/26/10.

In an interview on 7/28/10 at 3:30 PM, per telephone Staff N, Registered Nurse who cared for Patient #33 on 7/26/10 during the day shift revealed when he/she left at 6:00 PM Patient #33 was still in restraints.



27724

Based on record review, the facility failed to ensure physicians authenticated orders with date and time as per facility policy for four patients (Patients #20, #25, #28 and #33) of 11 patient's sampled for physician's orders. The facility census was 296.
Findings included:
1. Review of the policy titled "Chart Completion" (Hospital), last revised 7/09 revealed in part the following:
B. Hospital Implementation
1. It is the responsibility of any clinicians/staff members/individuals who give a verbal order to authenticate that item within the medical record within a timely manner.
3. Health Information Management department policies must stipulate that the accurate dated (and time when required by law or other regulations) must accompany all physician signatures.

2. Medical record review of Patient #20's Physician Orders revealed the physician wrote an order on 7/22/10 to change free water flushes to 50 milliliters, change flap checks to every four hours and chest physiotherapy three times a day. The physician did not time the order.

3. Patient #25's medical record review revealed the physician wrote Electroconvulsive Therapy Orders on 7/24/10. The physician did not time the orders.

4. Medical record review of Patient #28's Physician Orders revealed the physician wrote an order on 7/24/10 to change normal saline to every 12 hours, to discontinue the 1.8% normal saline, to saline lock the intravenous line and ok for neuro observation floor with sitter. The physician did not time the order.

5. Patient #33's medical record review revealed the physician wrote Trauma Service Intensive Care Unit Admission Orders on 7/15/10. The physician did not time the orders.



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16309

Based on record review the facility failed to ensure telephone and/or verbal orders were signed by a physician with 48 hours for two patients (Patient's #20 and #33) of 11 patients sampled for physician's orders. The facility census was 296.
Findings included:
1. Review of the facility's policy titled "Verbal/telephone Order Read-Back Verification," last revised 11/09 reveled in part the following:
12. The physician/physician assistant/nurse practitioner giving the verbal/telephone orders reviews and countersigns them within 48 hours of giving the orders

2. Medical record review of Patient #20's Physician Orders revealed the following:
-A telephone order dated 7/21/10 at 9:30 PM to hold Toradol (pain medication) tonight, use Tramadol (pain medication) one per mouth every four hours as needed for pain tonight and address need for Toradol and order if necessary in the morning.
-A verbal order dated 7/220/10 at 8:45 AM to discontinue the oral Toradol.

The physician did not date or time his/her signature when signing the verbal/telephone orders to indicate the orders were signed within 48 hours.

3. Medical record review of Patient #33's Physician Orders revealed the following:
-A telephone order dated 7/23/10 at 1:35 PM to deflate Foley balloon, re-insert Foley, inflate balloon with 12 milliliters of normal saline
-A telephone order dated 7/24/10 at 7:00 PM to leave Foley catheter out, discontinue scheduled oxycodone (pain medication), give Percocet (pain medication) one tablet by mouth every four hours as need for pain.

The physician did not date or time his/her signature when signing the telephone orders to indicate the orders were signed within 48 hours.

Based record review the facility failed to ensure physicians and patients dated and timed consents for the administration of blood and blood products as per facility policy for one patient (Patient #20) of three sampled patients for blood administration consents. The facility census was 296.

Findings Included:

1. Review of the facility policy titled "Informed Consent", last revised 7/09, revealed in part the following: The elements a valid informed consent include disclosure of the following information: #9-Date and time of the patient, witness, and physician signature.

2. Medical record review revealed Patient #20 entered the facility on 7/15/10. The Informed Consent for Transfusion of Blood Components was signed and dated 7/2/10 by the patient and physician. The patient did not time his/her signature as per the facility policy.




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16309

Based on policy review, interview and observation, facility staff failed to follow the facility policy for the proper cleaning of vascular access devices to prevent the risk of transmission of organisms for two patients (Patient's #23 and #24) of three patients observed for intravenous medication administration. The facility census was 296.

Findings included:

1. Review of the facility policy titled "Intravenous Therapy: Vascular Access Device Care and Maintenance," last revised 4/10 revealed in part the following:
B. Practice and Procedure
1. f-Follow Scrub the Hub and Save the Line Practice Protocol for all intravenous lines
- Vigorous friction to hub with hospital approved CHG (chlorhexidine) swab for 30 seconds then let dry 30 seconds before accessing the line every time.

2. Observation on 7/28/10 at 9:13 AM, during Patient #23's medication administration, Staff K, Registered Nurse (RN) cleaned the intravenous hub with a swab for 15 seconds.

In an interview after the medication administration, Staff K said the facility policy was to scrub the intravenous catheter hub for 30 seconds. Staff K said he/she thought she had cleaned the hub for the required time.

3. Observation on 7/28/10 at 9:25 AM, during Patient #24's medication administration, Staff L, RN cleaned the intravenous hub with a swab for 12 seconds.

In an interview after the medication administration, Staff L said the policy was to clean the hub for 30 seconds and let dry for 30 seconds. Staff L said he/she counted and it seemed like 30 seconds.

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Based on policy review and record review the facility failed to ensure physicians and patients properly completed and documented informed surgical consent with the date and time for three patients (Patients #20, #27 and #32) of six patients sampled for surgical consents. The facility census was 296.

Findings Included:

1. Review of the facility policy titled, "Informed Consent," last revised 7/10 revealed in part the following:
Elements of Informed Consent for treatment or procedure
#9 Date and time of the patient, witness and physician signature
Procedure
#15 It is the legal responsibility of the physician performing the procedure to make certain the Consent form is accurately completed, signed, dated and timed and initialed by the patient, witness and physician
#3 Members of the Department of Anesthesia are responsible for explaining the risks, benefits, and alternatives for anesthesia any time a member of this department is assigned care of a patient. This is documented on the consent form in the Anesthesia declaration and the patient/patient representative signature, date and time is obtained. The Anesthesia physician then signs, dates and times in acknowledgement

2. Medical record review revealed Patient #20 entered the facility on 7/15/10. Patient #20's Special Informed Consent to Surgery or Other Procedure for neck dissection (disassembly), tongue resection, flap and mandibulectomy (procedure to remove part of the jaw) revealed the patient's signature. The form did not include the date and time of the patient's signature to indicate it was signed prior to the procedure.
The form revealed under the Section to be Completed by Anesthesia, the patient's signature. The form did not include the date and time of the patient's signature.

3. Medical record review revealed Patient #27 entered the facility on 7/22/10. Patient #27's Special Informed Consent to Surgery or Other Procedure- Electroconvulsive Therapy (ECT) (shock treatment) revealed the patient's signature and date. The form did not include the time of the patient's signature. The Physician signature did not include the date or time of his/her signature. The form revealed under the Section to be Completed by Anesthesia, the patient's signature. The form did not include the date and time of the patient's signature.

4. Medical record review revealed Patient #32 entered the facility on 7/21/10. Patient #32's Special Informed Consent to Surgery or Other Procedure for facial surgery revealed under the Section to be Completed by Anesthesia, the patient's signature. The form did not include the date and time of the patient's signature.