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Based on record review, the facility failed to provide documentation to justify the application of restraints for 1 (#12) of 5 medical records reviewed for the use of restraints. Findings include:

1. Patient #12 was admitted to the facility on 7/14/10, diagnoses included insulin dependent diabetes mellitus, coma, hypotension, hyperkalemia, hypothermia, acute renal failure, pseudo hypernatremia, and diabetic ketoacidosis.

During the review of patient #12's medical record, it was noted that on 7/14/10 at 4:00 p.m., upon arrival to the Intensive Care Unit (ICU) the patient was placed in bilateral wrist restraints. The medical record lacked an assessment and a medical justification for the restraints to be applied to resident #12.


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2. Medical Immobilization (no physician order is required) - Devices employed during medical, dental, diagnostic or surgical procedures that are normally part of such procedures; . . PROCEDURE: A. Assessment/Nursing Diagnosis - The primary tool(s) which assist in formulating the decision regarding the patient's need for a restraint device should be the comprehensive nursing assessment and diagnosis . . . Patient's behaviors, which may indicate need for the restraints include, but are not limited to:
1. Alternatives attempted, documented unsuccessful.
2. Patient unable to comprehend seriousness of condition/need for treatment.
3. Patient unable to benefit from patient education and/or follow instructions.
4. Harm to self or others.
5. Combativeness.
6. Unsteadiness.
7. Impulsivity.
8. Disorientation/Confusion.
9. Hallucination.
10. Removing medical devices.
11. Other."

Based on record reviews, and staff interview, the facility failed to assess 1 (#12) of 5 sampled restraint records to determine if less restrictive interventions were sufficient to protect the patient prior to restraint use. Findings include:

Patient #12 was admitted to the facility on 7/14/10, diagnoses included insulin dependent diabetes mellitus, coma, hypotension, hyperkalemia, hypothermia, acute renal failure, pseudo hypernatremia, and diabetic ketoacidosis.

During the medical record review on 7/20/10 at 8:00 a.m., the following information was noted:

Patient #12 was placed in bilateral wrist restraints on 7/14/10 at 4:00 p.m. The active medical record lacked an assessment for less restrictive interventions prior to the initiation of the restraints.

On 7/20/10 at 8:00 a.m., during an interview with a staff member, the surveyor requested the assessment. The staff member stated the record did not contain an assessment for less restrictive interventions.

On 7/20/10 at 8:30 a.m., the nurse who applied the restraints stated she did not obtain a physician order prior to placing the restraints.


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Based on record review and staff interview, the facility failed to document 1 (#12) of 5 sampled restraint records, if less restrictive interventions were tried, and if those interventions were ineffective. Findings include:

1. Patient #12 was admitted to the facility on 7/14/10, diagnoses included insulin dependent diabetes mellitus, coma, hypotension, hyperkalemia, hypothermia, acute renal failure, pseudo hypernatremia, and diabetic ketoacidosis.

During record review on 7/20/10 at 8:00 a.m., patient #12's record lacked documentation of less restrictive interventions attempted prior to applying the bilateral wrist restraints on 7/14/10.

2. A staff member was interviewed on 7/20/10 at 8:30 a.m. The staff member stated there was no documentation of less restrictive interventions attempted prior to the initiation of restraints for patient #12.


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Based on record review and staff interview, the facility did not obtain an order prior to the use of a restraint by a physician or other licensed independent practitioner for 1 (#12) of 5 restraint records reviewed. Findings include:

1. Patient #12 was admitted to the facility on 7/14/10, diagnoses included insulin dependent diabetes mellitus, coma, hypotension, hyperkalemia, hypothermia, acute renal failure, pseudo hypernatremia, and diabetic ketoacidosis.

During the review of patient #12's record, it was noted that on 7/14/10 at 4:00 p.m., the patient was placed in bilateral wrist restraints, before a physician's order was received. The physician's order was received on 7/14/10 at 5:48 p.m.


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During staff interview, on 7/21/10 at 10:30 a.m., the RN stated that the wrist restraints were "medical immobilization" on patients who were intubated. She further stated that all patients on a ventilator were in wrist restraints to keep the patient from pulling out the "tubing."

Based on observation, staff interview, and record review, the facility failed to administer three medications in a safe manner for 1 of 4 observations. Findings include:

On 7/20/10 at 10:00 a.m., the initial observation of the Medical/Surgical floor on the main floor of the hospital occurred. At 10:15 a.m., a medication cup was observed on top of the chart box outside room 169. The medication cup contained three medications: Metformin 500 milligrams (mg), Diltiazem 240 mg, and Lisinopril 10 mg. During this observation there were no nursing staff in the immediate vicinity of the medication cup. At 10:30 a.m., the medication cup was not on the chart box.

On 7/20/10 at 1:40 p.m., an interview was conducted with the director of the Medical/Surgical floor. She stated that the incident had been investigated, and it was not common practice to leave medications unattended. She also stated that the patient was going to have a stress test, so the doctor wrote to hold the medications because two of them were beta-blockers. The manager stated the nurse had made an error in judgement by leaving the medications on top of the chart box instead of taking them back and returning them to the pyxis (medication delivery system), which is what she should have done.

Review of the medication administration record (MAR) and physician's orders occurred on 7/20/10 at 2:30 p.m. The physician's orders written on 7/19/10, indicated the patient was to have nothing by mouth (NPO) in the morning. However, the MAR indicated the patient received Aspirin 325 mg at 9:30 a.m. on 7/20/10.

Based on record reviews, the facility failed to ensure that all clinical record entries were completed for 19 (#s 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 20, 28, 31, 33, 34, 36, 37, and 38) of 64 patient clinical records reviewed. Findings include:

1. Resident #2's physician progress notes dated 7/13, 7/14, 7/15, and 7/17/2010, lacked the time when written.

2. Patient #6's physician order dated 5/17/10, was not timed as to when written. Patient #6's physician progress record dated 5/17/10, lacked the time when written.

3. Patients #'s 7 and 8 out patient physical therapy progress notes lacked the time when written.

4. Patient #9's out patient occupational therapy progress notes lacked the time when written.


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5. During review of the clinical record of patient #20 on 7/19/10 beginning at 1:15 p.m., the surveyor noted the following:
- the admission medicine service note dated 7/12/10 did not include documentation of the time when the note was written.
- the physician order for transfer following transfusion dated 7/15/10, did not include documentation of the time when the order was written.
- the physician order for Januvia written on 7/16/10, did not include documentation of the time when the order was written.
- the physician order for Lovenox written on 7/16/10, did not include documentation of the time when the order was written.
- the physician order for lab tests and an ultrasound of the abdomen written on 7/17/10, did not include documentation of the time when the order was written.
- the physician order for urinalysis and lab tests on the page for 7/17/10, did not include the date, or the time when the order was written.
- the physician order for a bone scan, medication changes, and lab tests dated 7/19/10, did not include documentation of the time when the order was written.
- the physician order for an echocardiogram and electrocardiogram dated 7/19/10, did not include documentation of the time when the order was written.


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6. Patient #3's Mechanical Ventilation Order of 5/5/10, lacked the time when written.
Patient #3's Restraint Orders for 5/5/10, 5/6/10, 5/7/10, and 5/8/10, lacked the date and time when written.


7. Patient #10's Mechanical Ventilation Order of 5/11/10, lacked the time when written.
The Restraint Order for Patient #10 lacked the date and time when written.

8. Patient #11"s Restraint Orders of 5/27/10, 5/29/10, and 5/30/10 lacked the dates and times when written. The Restraint Order of 5/28/10 was missing.

9. Patient #36's Psychiatric Admission Orders of 7/16/10, lacked the time when written.

10. Patient #37's Psychiatric Admission Orders of 7/12/10, lacked the time when written.


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11. Patient #34's OB (Obstetric)/Nursery Discharge Instruction Sheet lacked a date or time of when it was signed.

12. Patient #33's Informed Consent for Labor Pain Reduction by Intrathecal and/or Epidural Drug Administration lacked the time that the form was signed.

13. Patient #31's Informed Consent/Refusal for primary cesarean section urgent, with possible infusion of blood products lacked a physician signature. The document also lacked a date and time for the patient, witness, and physician as to when it was signed.

14. Patient #28's Informed Consent/Refusal for Lumbar Puncture, lacked the time that the form was signed.

15. Patient #12's record contained two Informed Consent/Refusal forms for Esophago-Gastro-Duodenoscopy, that lacked a physician signature, date and time.

16. Patient #13's record contained two Mechanical Ventilation Orders, which lacked a date and time from the physician.

17. Patient #14's Informed Consent/Refusal for right knee incision lacked a physician signature, date and time.

18. Patient #38's Neuroleptic Medication Protocol Orders lacked a physician signature. The Release of Information lacked a time of when the document was signed.

In an interview with the Intensive Care Unit manager on 7/19/10 at approximately 3:30 p.m., the manager stated that there were still some physicians that did not document the time when orders were written.

Based on document review and staff interview, the facility failed to ensure that restraint and physician orders for 7 (#s 3, 6, 10, 11, 20, 36, and 37) of 63 sampled records were dated, timed, and authenticated promptly by the ordering practitioner. Findings include:

1. During the review of the clinical record of patient #20 on 7/19/10 beginning at 1:15 p.m., the surveyor noted the following:
- the physician order for transfer following transfusion dated 7/15/10, did not include documentation of the time when the order was written.
- the physician order for Januvia written on 7/16/10, did not include documentation of the time when the order was written.
- the physician order for Lovenox written on 7/16/10, did not include documentation of the time when the order was written.
- the physician order for lab tests and an ultrasound of the abdomen written on 7/17/10, did not include documentation of the time when the order was written.
- the physician order for urinalysis and lab tests on the page between 2 other orders dated 7/17/10, did not include the date, or the time when the order was written.
- the physician order for a bone scan, medication changes, and lab tests dated 7/19/10, did not include documentation of the time when the order was written.
- the physician order for an echocardiogram and electrocardiogram dated 7/19/10, did not include documentation of the time when the order was written.

In an interview with the Intensive Care Unit manager on 7/19/10 at approximately 3:30 p.m., the manager stated that there were still some physicians that did not time when orders were written.


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2. Patient #6's physician order dated 5/17/10, lacked the time that the order was written.


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3. Patient #3's Mechanical Ventilation Order of 5/5/10, lacked the time when written.
Patient #3's Restraint Orders for 5/5/10, 5/6/10, 5/7/10, and 5/8/10, lacked the time and date when written.

4. Patient #10's Mechanical Ventilation Order of 5/11/10, lacked the time when written.
The Restraint Order for Patient #10 lacked the date and time when written.

5. Patient #11"s Restraint Orders of 5/27/10, 5/29/10, and 5/30/10, lacked the dates and times when written. The Restraint Order of 5/28/10 was missing.

6. Patient #36's Psychiatric Admission Orders of 7/16/10, lacked the time when written.

7. Patient #37's Psychiatric Admission Orders of 7/12/10, lacked the time when written.

Based on observations, staff interview, and record review, the facility failed to:
- prepare food in a clean environment,
- ensure that the reach in freezer was clean and free of ice buildup,
- ensure that non-food contact surfaces of equipment was cleaned,
- ensure that all food preparation equipment was cleaned thoroughly,
- ensure that the maintenance of the dish machine was completed,
- properly clean and store kitchen equipment and utensils,
- properly mark open dates on food containers,
- discard expired food items, and
- discard open, undated, unsealed food items in the freezers and coolers.
(Refer to A-0619 and A-0701 for further illustration of the listed violations.)

Based on staff interviews, policy reviews, and observations, the facility failed to ensure that food was stored, prepared and served under safe and sanitary conditions. Findings included:

1. On 7/20/10 at 9:00 a.m., the ice machine room in the rehabilitation unit contained 1 case of Glucerna Select with a manufacturer's expiration date of 10/10/09, 3 containers of Jevity 1500 ml [milliliters] (1.2 calories/ml) with a manufacturer's expiration date of 5/1/10, and 3 containers of Jevity 1500 ml (1.0 calorie/ml) with a manufacturer's expiration date of 10/10/09.

The rehabilitation manager stated that the Jevity and Glucerna were not frequently used.


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2. On 7/20/10 starting at 7:10 a.m. the following concerns were observed in the main kitchen:
-- The ice scoop was not covered when it was stored to prevent dust and other substance contamination. The scoop storage cover was missing.
-- The vent cover in the mop closet had a heavy accumulation of dust.

3. On 7/20/10 at 1:45 p.m., the effectiveness of the heat booster was observed in the kitchen of Pathways Treatment Center. The booster registered several temperature readings during the rinse cycle testing, and stopped at 123 degrees Fahrenheit, 138 degrees Fahrenheit and at 177 degrees Fahrenheit on three consecutive occasions. The cook stated that he was not sure how long the problem with the booster sensor had existed. When the surveyor requested to review the rinse temperature logs, the cook stated he did not keep logs of the rinse temperatures. The duration of the sensor problem existence could not be determined.

During an interview on 7/21/10 at 3:30 p.m., the chief clinical dietary manager and registered dietitian stated that the kitchen staff were supposed to monitor and keep a log of the rinse temperatures to ensure that the dishes were sanitized properly.

4. During the tour of the kitchen at the Pathways Treatment Center on 7/20/10 starting at 1:50 p.m., the following concerns along with expired, unsealed, opened and undated food items were observed in the freezers and coolers:

-- Dried crusted food and dough splatters were observed on the surface of the Hobart mixer where the attachments were connected.

-- A partially consumed frozen angel food cake was not dated as to when it was placed in the freezer.

-- A Ziploc bag of cut up frozen cornbread was not dated as to when it was placed in the freezer.

-- A frozen flank steak wrapped in Saran wrap was not dated as to when it was placed in the freezer.

-- A frozen partially consumed bag of raw chicken pieces was not dated as to when it was placed in the freezer.

-- A Ziploc bag of frozen vegetarian chicken nuggets (as stated by the cook) was not labeled or dated as to when it was placed in the freezer.

-- A partially consumed bag of frozen french fries was not labeled or dated as to when it was placed in the freezer.

-- A Ziploc bag of frozen raw hamburger patties was not dated as to when it was placed in the freezer.

-- A partially consumed bag of pan fried frozen fish sticks was not dated as to when it was placed in the freezer.

-- A partially consumed bag of cooked frozen fajita chicken strips was not dated as to when it was placed in the freezer.

-- There was a layer of frozen ice completely covering the bottom shelf of the reach-in freezer. The cook stated that he was aware of the plugged drain that needed to be opened. The bottom shelf as well as other interior surfaces of the freezer needed to be wiped and cleaned.

-- A plastic container of frozen pesto sauce was not dated as to when it was placed in the freezer. The cook stated this was an unopened container of pesto, but he was not sure when it was removed from its original cardboard box packaging.

-- A bag of mostly consumed liquid eggs in the reach-in cooler was not dated as to when it was opened and placed in the cooler.

-- A Ziploc bag of individual sized left over pizzas was not dated in the reach-in cooler.

-- An open tube of non-dairy whipped cream that was not dated, in the reach-in cooler.

-- The handles and the surfaces around the handles of the reach-in freezer and the cooler were covered with sticky finger prints that could be felt and observed..

-- The tops of the flour and the sugar bins had dried food and beverage splatter on the lids and were sticky to the touch.

-- The shelf above the flour and sugar bins that housed the spices and the food thermometers were covered with a greasy film that was sticky to the touch. One thermometer did not have a probe cover.

The kitchen manager, building supervisor and the supervisor of plant operations were with the surveyor during the kitchen survey.

5. During an interview on 7/21/10 at 7:45 a.m., the interim nutrition services supervisor stated that it was her understanding that the kitchen in Pathways Treatment Center operated independently and was not supervised by the main nutrition services staff. However, the main kitchen transported foods and groceries to Pathways on a regular basis. She stated she would make sure that the same hospital nutrition services' policy and procedures were followed in this satellite facility as well. The supervisor also stated that once it was brought to her attention on 7/20/10, she requested that the service contractor fix the dishwashing machine's heat booster in Pathways Treatment Center.

Based on observations and staff interviews, the facility failed to ensure the environment was clean and sanitary in the main kitchen and in Pathways Treatment Center kitchen. Findings included:

1. On 7/20/10 starting at 7:10 a.m., the following concerns were observed in the main hospital kitchen:

-- The floor and the cove base molding under the 3 compartment sink and in the pots and pans area, had black colored build up on the grout between several tiles. The interim nutrition services supervisor acknowledged the concern.

-- The floor under the convection stack ovens showed signs of debris and grease accumulation over time, especially in the area between the ovens and the grill. The interim nutrition services supervisor acknowledged the concern.

-- The floor under the tilt fryer had a heavy accumulation of crumbs, debris and food matter, including two dirty kitchen towels. This area also showed signs of long term accumulation. The interim nutrition services supervisor acknowledged the concern.

2. On 7/20/10 at 1:45 p.m., the following concerns were observed in the Pathways Treatment Center kitchen with the building supervisor/director, the cook, and the supervisor of plant operations:

During these observations there was no food production in process in the kitchen.

-- The floor in the dry food storage area had an accumulation of crumbs, debris and food matter, especially against the base boards and under/behind the storage shelves. A package of pudding, a potato, an onion, and two cans of food that had rolled under the shelving near the base boards.

-- The floor under the dishwashing machine had a heavy accumulation of food stuff, debris, and dried water stains.

--There were three trash cans in the kitchen, none of the cans were covered. When the surveyor asked the cook about the lids, he stated they did not have lids for them. All three trash cans contained garbage at the time of the observation.

-- The threshold between dishwashing area and the area of the broken convection oven had black colored substance build-up.

3. During an interview on 7/21/10 at 7:45 a.m., the interim nutrition services supervisor stated that it was her understanding that the kitchen in Pathways operated independently and was not supervised by the main nutrition services staff. However, the main kitchen transported foods and groceries to Pathways regularly. She stated she would make sure that the same hospital nutrition services' policy and procedures were followed in this satellite facility.

Based on observations and staff interviews, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. During the survey of the Intensive Care Unit on 7/19/10 beginning at 1:30 p.m., the surveyor observed the following;
-one Cook Pneumothorax kit with the manufacturer's expiration date of 6/2009.
-two Normal Saline 250 milliliter (ml) bags with the manufacturer's expiration date of 4/2009.
-one Edwards Labs percutaneous sheath introducer kit with the manufacturer's expiration date of 6/2009.
-four PDI benzoin swabsticks with the manufacturer's expiration dates of 7/2008 (1) and 12/2008 (3).
-one Aplicare Povidone-Iodine swabstick 3-pack with the manufacturer's expiration date of 3/2008.
-three Becton-Dickinson 2.7 ml blue top Vacutainers with the manufacturer's expiration date of 2/2010.
-three Becton-Dickinson 2.7 ml green top Vacutainers with the manufacturer's expiration dates of 4/2010 (1) and 5/2010 (2).
-one Ethilon 3-0 suture packet with the manufacturer's expiration date of 1/2008.
-one Jackson-Pratt bulb reservoir with the manufacturer's expiration date of 10/31/2009.
- approximately 150 Povidone-Iodine ointment foil packets with the manufacturer's expiration date of 6/2009.
-ninety eight Becton-Dickinson 3.4 ml lavender top Vacutainers with the manufacturer's expiration date of 11/2009.
-sixty Becton-Dickinson 2.7 ml blue top Vacutainers with the manufacturer's expiration date of 1/2010.

In an interview on 7/19/10 at approximately 3:00 p.m., the intensive care manager stated that staff were responsible for checking the dates of supplies in the unit on a monthly basis.

2. During the survey of the Emergency Department on 7/20/10 beginning at 7:30 a.m., the surveyor observed the following:
-one 18 gauge arterial line kit with the manufacturer's expiration date of 4/2010.
-one Kendall sterile plain packing strip, 1/2 inch by 5 yards, with the manufacturer's expiration date of 12/2006.
-one pair Size 8 1/2 sterile powder free gloves with the manufacturer's expiration date of 12/31/2004.
-five pair Biogel sterile gloves, size 6 and 6 1/2, with the manufacturer's expiration dates of 12/2005 (1), 4/2008 (1), 6/2008 (2), and 9/2008 (1).

In an interview on 7/20/10 at approximately 8:15 a.m., the emergency department manager stated that the department staff were assigned the task of checking for outdated supplies in the department.

3. During the survey of the Rocky Mountain Heart and Lung clinic on 7/21/10, beginning at 1:10 p.m., the surveyor observed the following:
-one Becton-Dickinson 6.0 ml pink top Vacutainer with the manufacturer's expiration date of 3/2010.
-six Becton-Dickinson 3.0 ml pink top Vacutainers with the manufacturer's expiration dates of 2/2010 (5) and 6/2010 (1).
-one Becton-Dickinson 5.0 ml yellow top Vacutainer with the manufacturer's expiration date of 2/2010.
-four Becton-Dickinson 4.5 ml blue top Vacutainers with the manufacturer's expiration date of 3/2010.
-eleven Becton-Dickinson 4.5 ml blue top Vacutainers with the manufacturer's expiration date of 5/2010.
-three Becton-Dickinson 3.0 ml red top Vacutainers with the manufacturer's expiration date of 6/2010.
-five sterile Thoracentesis kits with the manufacturer's expiration dates of 12/2008 (2) and 8/2009 (3)

In an interview on 7/21/10 at 1:45 p.m., the clinic manager stated that only one physician performed the thoracentesis procedure at the clinic and very infrequently. Staff were responsible for checking for expired supplies every month.