HospitalInspections.org

This condition level deficiency was cited based on review of facility policies, medical records and interviews with staff, it was determined the facility failed to ensure:

1. Physician orders were obtained for restraints and/or seclusion for 3 of 3 patients with violent behavior, who were placed in restraints and/or seclusion.

2. Facility staff failed to assess and monitor patients' conditions to determine whether restraint or seclusion could be safely discontinued for 3 of 3 medical records reviewed of patients with restraints or seclusion.

3. Facility staff failed to follow their policy for attempting alternatives or other less restrictive interventions prior to placing 1 of 2 patients in seclusion.

4. Facility staff failed to conduct a debriefing conference with 2 of 2 patients after having been released from seclusion.

These deficient practices affected 3 of 3 medical records (MR), including MR # 5, MR # 6, MR # 8 and had the potential to negatively affect all patients admitted to this facility and experience violent or self-destructive behaviors.

Findings include:

Refer to A171, A174, A186 and A188 for findings.

Based on review of facility policies, medical records and interviews with staff, it was determined the facility failed to ensure physician orders were obtained for restraints and/or seclusion for 3 of 3 patients with violent behavior, who were placed in restraints and/or seclusion. This affected Medical Record (MR) # 5, MR # 6 and MR # 8 and had the potential to negatively affect all patients with violent or self-destructive behavior.

Findings include:

Facility Policy

Facility Policy: Restraints
Department: Nursing Services/Hospital-Wide
Effective Date: December 2009

Policy: All patients have the right to be free from restraints or seclusion of any form that are not medically necessary... Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

Definitions:

Restraint as follows:
Physical Restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement, immobilizes, or reduces the ability of a patient to move his or her arms, legs, body, or head freely or have normal access to one's body...

Seclusion: the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

Scope: This policy applies wherever and whenever restraints are used within the Dale Medical Center organization regardless of age or location of patient. It applies to all uses of restraint/seclusion in all hospital care settings.

Purpose: To establish guidelines and procedures for the use of restraints, seclusion,or protective devices with the goal of protecting the patient from harm and/or danger and provide care in a safe setting...

A restraint can only be used if needed to improve the patient's well-being and less restrictive alternative interventions have been determined to be ineffective to protect the patient or others from harm...

Orders for Restraint:
Written or verbal orders for initial and continuing use of restraint are time limited...

Type of Restraint

There are two fundamental types of restraints:
A restraint is either a Medical/Surgical Restraint (non-violent, Non-self destructive) or Emergency/Violent/Self-Destructive Behavior restraint. Seclusion falls under the Violent/Self Destructive category. It is important to note that the requirements for each type of restraint is not specific to any treatment setting, but to the situation why the restraint is being used... Violent/Self-Destructive/Behavioral reasons for the use of restraint are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder with violent or self-destructive behavior...

Emergency Restraint Physician Order:
Each written order for an emergency physical restraint/seclusion maximum time limit is:
4 hours for adults, 18 years of age or older...

The nurse will access the patient at these specified time periods and call the physician with his/her results, and request that orders be renewed for another period of time, not to exceed time limits as stated above... Twenty four hours of restrain or seclusion for the management of violent or self-destructive behavior is an extreme measure with the potential for serious harm to the patient....

Facility Policy: Seclusion
Department: Behavioral Health
Policy #: 3041
Revision Date: 9/12/2010

Purpose:

To ensure that seclusion is used only as an appropriate treatment intervention when a patient is exhibiting behaviors that could physically harm him/herself, staff or others and less restrictive alternatives have failed.

Definitions:

"Seclusion" is defined as the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

"Emergency" (as it relates to seclusion and/or restraints) is an instance, in which there is an imminent risk of a patient harming him/herself or others, including staff, when non-physical interventions are not viable and safety issues an immediate physical response.

Policy:

It is the policy of New Day Behavioral that all patients have the right to be free from seclusion of any form...

Physician Orders for Seclusion:

The use of seclusion must be in accordance with the order of a physician or other licensed independent practitioner.

Orders for the use of seclusion must never be written as a standing order...

Each written order for the use of seclusion is time limited to:

a) Four (4) hours for adults, eighteen (18) years of age or old...

The written order for seclusion should designate the specific intervention authorized, specify the date, time of day, and the maximum length of time for which the intervention may be used, which shall not exceed the time limits above...

The original order may only be renewed in accordance with these limits for up to a period of twenty four (24) hours...

Medical Record review:

1. MR # 5 was admitted to the behavioral unit of the facility on 4/14/16 with psychiatric disorder.

Review of the Physician orders dated 4/14/16 at 7:00 PM and 4/15/16 at 3:00 AM revealed orders for restraints "Other". Review of the Physician orders dated 4/15/16 at 7:00 AM revealed a "stamped" order that included, "Type of Restraint..." There was no documentation on the orders dated 4/14/16 at 7:00 PM, 4/15/16 at 3:00 AM and 4/15/16 at 7:00 AM of the type of restraint ordered.

An interview was conducted on 5/26/16 at 10:52 AM with Employee Identifier (EI) # 2, Director of New Day (Behavioral unit), who verified the above.

2. MR # 6 was admitted to the behavioral unit of the facility on 3/4/16 with diagnoses including Bipolar disorder, Depressive type and Poly-substance abuse.

Review of the Physician orders revealed an order for seclusion for 4 hours was written. There was no documentation of the date or time the order was written.

Review of the Seclusion Observation Flowsheet revealed the patient was placed in seclusion on 3/4/16 at 1:30 PM. There was no documentation of the physician's name who was notified or the date and time of this notification.

An interview was conducted on 5/26/16 at 10:20 AM with EI # 3, Infection Control Nurse, who verified the above.

3. MR # 8 was admitted to the facility on 4/26/16 with diagnosis of Possible Overdose.

Review of the Emergency Department (ED) record revealed the patient was brought to the ED on 4/26/16 via ambulance at 7:25 PM. The nurse documented the patient was combative, security was at the bedside, soft wrist restraints were placed on patient's arms and feet and the physician was notified.

A medical screening examination was completed by the physician at 7:30 PM on 4/26/16. The patient remained restrained in the ED until admission to the Intensive Care Unit (ICU) on 4/26/16 at 10:10 PM. There was no documentation of a physician's order for restraints for this combative patient

Review of the Initial Physical Assessment dated 4/26/16 at 10:10 PM revealed the nurse documented the patient arrived in the ICU via stretcher, accompanied by hospital staff and local law enforcement. The patient was placed in 4 point soft restraints and security was at the bedside. The nurse documented the patient was alert, intoxicated, hostile, uncooperative and combative.

Review of the Physician Orders dated 4/26/16 at 10.10 PM and 4/27/16 at 7:00 AM revealed orders for soft wrist restraints with a 24 hour time limit. There was no documentation of a physician's order for the use of 4 point restraints, only for soft wrist restraints.

The physician orders for restraints were related to combative behavior and should have been written for a time limit of 4 hours, not 24 hour time limit.

An interview was conducted on 5/26/16 at 9:50 AM with EI # 1, Nursing Supervisor, who verified the above findings.

Based on review of facility policies, medical records (MR) and interviews with staff, it was determined the staff failed to assess and monitor patients' conditions to determine whether restraint or seclusion could be safely discontinued for 3 of 3 medical records reviewed of patient with restraints or seclusion. This affected Medical Record (MR) # 5, MR # 6 and MR # 8 and had the potential to negatively affect all patients with violent or self-destructive behavior.

Findings include:

Facility Policy

Facility Policy: Restraints
Department: Nursing Services/Hospital-Wide
Effective Date: December 2009

Policy: All patients have the right to be free from restraints or seclusion of any form that are not medically necessary... Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

Definitions:

Restraint as follows:
Physical Restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom or movement immobilizes, or reduces the ability of a patient to move his or her arms, legs, body, or head freely or have normal access to one's body.

Seclusion: the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

Scope: This policy applies wherever and whenever restraints are used within the Dale Medical Center organization regardless of age or location of patient. It applies to all uses of restraint/seclusion in all hospital care settings.

Purpose: To establish guidelines and procedures for the use of restraints, seclusion,or protective devices with the goal of protecting the patient from harm and/or danger and provide care in a safe setting...

Orders for Restraint:
Written or verbal orders for initial and continuing use of restraint are time limited...

Type of Restraint

There are two fundamental types of restraints:
A restraint is either a Medical/Surgical Restraint (non-violent, Non-self destructive) or Emergency/Violent/Self-Destructive Behavior restraint. Seclusion falls under the Violent/Self Destructive category...

Emergency Restraint
Seclusion
Management of violent or self-destructive behavior

Seclusion/Restraint is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

The use of restraint or seclusion must be selected only when less restrictive measures have been found to be ineffective to protect the patient, a staff member or others from harm, in accordance with the order of a physician or other licensed independent practitioner.

Restraints may be applied by a nurse in emergency or crisis situations if a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to his/her safety or that of others. Less restrictive interventions should have been attempted and deemed ineffective at this point. Patient's with emergency restraints shall be assessed every 15 minutes and documented...

Emergency Restraint Physician Order:
Each written order for an emergency physical restraint/seclusion maximum time limit is:
4 hours for adults, 18 years of age or older...

The nurse will access the patient at these specified time periods and call the physician with his/her results, and request that orders be renewed for another period of time, not to exceed time limits as stated above... Twenty four hours of restraint or seclusion for the management of violent or self-destructive behavior is an extreme measure with the potential for serious harm to the patient....

Discontinuation of Restraints: The use of restraints should be frequently evaluated and ended at the earliest possible time based on the assessment and reevaluation of the patient's condition. The nurse may discontinue a restraint when it has been deemed appropriate, i.e., patient no longer poses danger to self or others...
Restraint Documentation:
Dale Medical Center utilizes two types of documentation for restraints: paper and electronic. Nurses are responsible for the comprehensive assessment and / reassessment of patients in restraints. Whether the paper restraint special observation checklist, flow-sheet, or electronic documentation is used for restraint documentation, each episode of restraint is documented in the patient's medical record, consistent with policies and procedures:

The medical record may include:

Reason used for continuation and discontinuation of restraint device....
All assessments and monitoring of the patient.

Document the time the restraint is released and response of patient to release of restraint and any action taken.

Assessment of patient regarding clinical condition may include, level of distress and agitation, mental status, circulation, condition and release of limbs, skin, attention to hydration, elimination and nutrition at least every 2 hours, or more often if deemed appropriate...

Facility Policy: Seclusion
Department: Behavioral Health
Policy #: 3041
Revision Date: 9/12/2010

Purpose: To ensure that seclusion is used only as an appropriate treatment intervention when a patient is exhibiting behaviors that could physically harm him/herself, staff or others and less restrictive alternatives have failed.

Definitions:

"Seclusion" is defined as the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

"Emergency" (as it relates to seclusion and/or restraints) is an instance, in which there is an imminent risk of a patient harming him/herself or others, including staff, when non-physical interventions are not viable and safety issues an immediate physical response.

Policy:

It is the policy of New Day Behavioral that all patients have the right to be free from seclusion of any form...

Seclusion maybe used only in a emergent situation in which a patient is exhibiting behaviors or verbalizations that indicate they are at high and imminent risk of physical or emotional harm to others because of threats, attempts or other acts the patient overtly or continually makes or commits.

Seclusion may be used only as an intervention of last resort following attempts to intervene in a less restrictive, less invasive manner...

Seclusion should be used for the shortest period of time necessary to enable the individual to regain internal control...

Each written order for the use of seclusion is time limited to:

a) Four (4) hours for adults, eighteen (18) years of age or old...

If the patient remains in seclusion at the end of the maximum time frame, the nurse will assess the patient and notify the physician with his/her results and request that the order be renewed (if indicated) for another period not to exceed time limits stated above.

Care for the Patient in Seclusion:

... A patient placed in seclusion must be monitored every fifteen (15) minutes, or more ...

A patient placed in seclusion shall be assessed at a minimum of every fifteen (15) minutes for physical and psychological status and comfort, cognitive functioning, readiness for release...

Discontinuation of Seclusion:

The use of seclusion should be frequently evaluated and ended at the earliest time possible based on the assessment and reevaluation of the patient's condition.

When a patient in seclusion exhibits release behaviors for at least fifteen (15) minutes, the patient may be released from seclusion and monitored one to one (1:1) by a staff member for at least thirty (30) minutes prior to being allowed to return to the milieu.

When a patient in seclusion falls asleep, the door must be unlocked and/or opened as soon as possible and the seclusion intervention ended at that time. The patient who falls asleep in the seclusion room must continue to be monitored every fifteen (15) minutes by the staff and reevaluated by the RN upon awakening for continued release...

Documentation:

Each episode of seclusion requires documented information in the patient's medical record. This includes but not limited to:

Patient response to the seclusion intervention

Behavior criteria for release..

Every fifteen (15) minute observation or continuous observation

Every two (2) hour assessment by the RN to include the patient's condition, behaviors, interventions and continued need for seclusion..

Medical Record review:

1. MR # 5 was admitted to the behavioral unit of the facility on 4/14/16 with psychiatric disorder.

Review of the Patient Progress Notes dated 4/14/16 at 7:23 PM revealed the nurse documented the patient was combative and aggressive, threatening staff and other patients, not redirectable and was placed in seclusion at that time and prn (as needed) medications were administered intramuscularly (IM).

Review of the Patient Progress Notes dated 4/14/16 at 9:23 PM revealed the nurse documented the patient was in seclusion, resting with eyes closed with no distress noted.

Review of the Patient Progress Notes dated 4/15/16 revealed the nurse documented the following:
1:32 AM - patient remains in seclusion, resting well with eyes closed
5:54 AM - patient is alert and cooperative with morning vital signs, patient is calm, no distress noted. Attempted to assess patient for discontinuation of seclusion. Pt does not exhibit behavior to removal. Patient continues to be irritable but states (he/she) wants to come out... just don't like for people to argue and fuss with (him/her).
7:47 AM - patient currently asleep in seclusion room due to aggressive behavior toward staff and other patients.
8:19 AM - Unit Manager and security staff member went to seclusion to talk with the patient. The patient was alert and oriented at that time, answered all questions asked by the unit director. Patient released from seclusion at that time and allowed to return to (his/her) room...

Review of the Seclusion Observation Flowsheet (undated) revealed at 8:00 PM, the patient was asleep and remained asleep until 9:45 PM.

Review of the Seclusion Observation Flowsheet (undated) revealed at 10:00 PM, the patient was calm and then at 10:45 PM the patient was asleep and remained asleep until 12:45 AM.

Review of the Seclusion Observation Flowsheet (undated) revealed at 1:00 AM, the patient was calm and remained calm until 3:45 AM.

Review of the Seclusion Observation Flowsheet (undated) revealed the patient was calm from 4:00 AM to 6:45 AM. Review of the Seclusion Observation Flowsheet (undated) revealed the patient was calm, alert and oriented from 7:00 AM to 8:15 AM.

All of the above Seclusion Observation Flowsheets were undated.

There was no documentation the seclusion door was opened once the patient fell asleep, nor was there documentation the patient was allowed to return to his/her room with 1:1 observation on 4/15/16 at 5:54 AM, even though the patient was alert and cooperative with morning vital signs, patient is calm, no distress noted.

An interview was conducted on 5/26/16 at 10:52 AM with Employee Identifier (EI) # 2, Director of New Day (Behavioral unit), who verified the above.

2. MR # 6 was admitted to the behavioral unit of the facility on 3/4/16 with diagnoses including Bipolar disorder, Depressive type and Poly-substance abuse.

Review of the Patient Progress Notes dated 3/4/16 at 1:25 PM revealed the nurse documented the patient entered the hallway, started beating his/her hands on the wall and screaming. The patient entered the open seclusion room and began kicking the door repeatedly while screaming.

Review of the Patient Progress Notes dated 3/4/16 at 1:38 PM revealed the nurse documented the patient was medicated for anxiety and agitation, continued to threaten staff was beating his/her head against the wall and the seclusion door was closed at that time.

Review of the Patient Progress Notes revealed the patient was in seclusion from 3/4/16 at 1:38 PM to 3/9/16 at 1:21 PM. From 3/4/16 at 1:38 PM to 3/9/16 at 12:07 AM, the patient exhibited aggressive, threatening, destructive behaviors, including yelling, banging on the walls and door of the seclusion room, removal of clothing, masturbation, defecation and urination on the floor of the seclusion room, destructive behavior of the walls, door and mattress in the seclusion room.

The patient was medicated multiple times with prn anti-anxiety and anti-psychotic medications. There were multiple changes in the regular dosage of the patient's anti-psychotic medications.

Review of the Patient Progress Notes dated 3/9/16 at 12:24 AM revealed, "... Thorazine 100 milligrams (mg) was administered IM..." and the nurse encouraged the patient to lie down and get some rest.

Review of the Patient Progress Notes dated 3/9/16 revealed the following:
12:45 AM - Patient resting with eyes closed, respirations with ease...
1:30 AM - Called patient by name, patient did not respond. Allowed patient to continue to rest. Patient observed respirations with ease...
2:15 AM - Patient awake up out of bed for toileting needs. Respirations with ease...
2:45 AM - Resting in bed with eyes closed. Respirations with ease.
3:30 AM - Called patient by name, patient did not respond. Allowed patient to continue to rest. Patient observed respirations with ease.
4:00 AM - Allowing patient to rest. Respirations with ease. Resting with eyes closed...
5:27 AM - Called patient by name, patient did not respond. Allowed patient to continue to rest...
5:45 AM - Patient aroused, toileting offered. Patient refused... Patient compliant with getting vital signs taken. No complaints voiced. No yelling or screaming out. No name calling. Patient returned to sleep after vital signs taken.
7:00 AM - Called patient, patient did not arouse. Asked patient if needed toileting, Patient did not respond. Allowed patient to rest with eyes closed. Respirations with ease.
8:00 AM - Patient alert, oriented. Requesting to call mother. Explained to the patient conditions of getting out of seclusion. Patient states, "Just Knock me out"...
10:25 AM - Patient remains in seclusion. Beating on the wall. Spoke with patient about behavior and what it would take to come out of seclusion... Laying on mat at this time
10:34 AM - Patient standing at door in the seclusion room. Yelling at the Mental Health Technician. States "Y'all will get what's coming to you". Discussed what it would take for release from seclusion. Patient laying on mat at this time.
10:50 AM - "... Patient in seclusion at window, tearful. Opened door and talked with patient. Explained that we need (him/her) to work with us to be able to release from seclusion and for this to happen, needs not to demonstrate aggressive or threatening behaviors and follow instructions... Discussed placing hospital gown on patient and leaving seclusion door open for now and that if patient is without behaviors for 1 hour will reassess about releasing from seclusion... Patient agreeable at present..."

1:21 PM - "... Patient is calm and requesting to go to (his/her) room... Patient released from seclusion and assisted to room... without incident..."

Review of the 16 of 40 Seclusion Observation Flowsheets revealed no documentation of dates.

There was no documentation the seclusion door was opened once the patient was resting on 3/9/16 at 12:45 AM to 5:45 AM, was cooperative without yelling or screaming during vital signs assessment at 5:45 AM, then continued to rest until 7:00 AM. There was no documentation the patient was allowed to return to his/her room with 1:1 observation on 3/9/16 until 1:21 PM.

An interview was conducted on 5/26/16 at 10:20 AM with EI # 3, Infection Control Nurse, who verified the above.

3. MR # 8 was admitted to the facility on 4/26/16 with diagnosis of Possible Overdose.

Review of the Emergency Department (ED) record revealed the patient was brought to the ED on 4/26/16 via ambulance at 7:25 PM. The nurse documented the patient was combative, security was at bedside, soft wrist restraints were placed on patient's arms and feet and the physician was notified.

Review of the Initial Physical Assessment dated 4/26/16 at 10:10 PM revealed the patient arrived in the Intensive Care Unit (ICU) via stretcher, accompanied by hospital staff and local law enforcement. The patient was placed in 4 point soft restraints and security was at the bedside. The nurse documented the patient was alert, intoxicated, hostile, uncooperative and combative.

Review of the Patient Progress Notes dated 4/26/16 to 4/27/16 revealed no documentation the patient was assessed every 15 minutes for continued combative and uncooperative behavior according to the facility's policy.

Based on review of facility policies, medical records and interview with staff, it was determined the facility staff failed to follow their policy for attempting alternatives or other less restrictive interventions prior to placing 1 of 2 patients in seclusion. This deficient practice affected Medical Record (MR) # 5 and had the potential to negatively affect all patients admitted to this facility and experience violent or self-destructive behavior.

Findings include:

Facility Policy

Facility Policy: Restraints
Department: Nursing Services/Hospital-Wide
Effective Date: December 2009

Policy: All patients have the right to be free from restraints or seclusion of any form that are not medically necessary...

Definitions:

Restraint as follows:

Seclusion: the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

Philosophy:

... A restraint can only be used if needed to improve the patient's well-being and less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. These alternatives may include having the family, significant other or volunteer remain at the patient's bedside, placing the patients at the nursing station in clear view of nursing staff, or other creative, preventive, des-escalation, verbal intervention solutions to avoid using restraints.

Type of Restraint

There are two fundamental types of restraints:
A restraint is either a Medical/Surgical Restraint (non-violent, Non-self destructive) or Emergency/Violent/Self-Destructive Behavior restraint. Seclusion falls under the Violent/Self Destructive category...

Emergency Restraint
Seclusion
Management of violent or self-destructive behavior

Limiting the use of Restraint
Alternative Methods

Our organization believes nonphysical techniques are the preferred intervention in the management of behavior.

Attempts should be made to evaluate and use alternative interventions such as the following when possible:

Monitoring
Companionship; staff or family to stay with patient
Room near to or visible from the nursing station
Close, frequent observation, one-to-one when necessary

Environmental Measures
Decrease stimulation - quiet surroundings, appropriate lighting, relaxing music...
Orientation/reorientation of patient to surrounding...

Comfort Measures

Interpersonal Skills
... Actively listening to patient; calm reassurance...
Consistency in staffing, i.e., assigning staff familiar to patient as often as possible...

Regular toileting

Education
Diversion Activities
Medication/Nutrition
Reality Orientation and Psychological Intervention
Involve the patient in conversation...
Provide reality links when appropriate...
Attempt to verbally redirect behavior

Interdepartmental Communication/Consultation...

Facility Policy: Seclusion
Department: Behavioral Health
Policy #: 3041
Revision Date: 9/12/2010

Purpose:

To ensure that seclusion is used only as an appropriate treatment intervention when a patient is exhibiting behaviors that could physically harm him/herself, staff or others and less restrictive alternatives have failed.

Definitions:

"Seclusion" is defined as the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

Policy:

It is the policy of New Day Behavioral that all patients have the right to be free from seclusion of any form...

... Seclusion may be used only as an intervention of last resort following attempts to intervene in a less restrictive, less invasive manner after preventive de-escalation or verbal techniques have proven ineffective at diffusing the potential for injury.

Documentation:

Each episode of seclusion requires documented information in the patient's medical record. This include but not limited to:

Clear description of the patient's behavior that warranted seclusion

Alternative strategies, including preventive de-escalation, and verbal intervention techniques attempted prior to use of seclusion.

Medical Record review:

1. MR # 5 was admitted to the behavioral unit of the facility on 4/14/16 with psychiatric disorder.

Review of the Seclusion Observation Flowsheet dated 4/14/16 revealed the patient was placed in seclusion at 7:00 PM for aggressive and combative behavior with staff and another patient.

Review of the Alternative attempted Checklist for Emergency Restraints, which was signed by the Registered Nurse (RN) on 4/14/16 revealed no documentation of a description of the alternatives attempted prior to the patient being placed in seclusion.

An interview was conducted on 5/26/16 at 10:52 AM with Employee Identifier # 2, Director of New Day (Behavioral Unit), who verified the above findings.

Based on review of facility policies, medical records (MR) and interviews with facility staff, it was determined the facility staff failed to conduct a debriefing with 2 of 2 patients after having been released from seclusion. This affected MR # 5 and MR # 6 and had the potential to negatively affect all patients admitted to facility and exhibit aggressive, destructive behavior requiring seclusion.

Findings include

Facility Policy: Seclusion
Department: Behavioral Health
Policy #: 3041
Revision Date: 9/12/2010

Purpose:

To ensure that seclusion is used only as an appropriate treatment intervention when a patient is exhibiting behaviors that could physically harm him/herself, staff or others and less restrictive alternatives have failed.

Definitions:

"Seclusion" is defined as the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.

Policy:

It is the policy of New Day Behavioral that all patients have the right to be free from seclusion of any form...

Seclusion should be used for the shortest period of time necessary to enable the individual to regain internal control...

Care for the Patient in Seclusion:

As soon as feasible after seclusion has been implemented, the RN should discuss with the individual the specific behaviors that necessitated seclusion, how the individual's behavior continues to meet the criteria, the behaviors that must be demonstrated to be released from seclusion, and the individuals suggestions about what staff can do to assist the individual in gaining release from seclusion.

Discontinuation of Seclusion:

The use of seclusion should be frequently evaluated and ended at the earliest time possible based on the assessment and reevaluation of the patient's condition.

When a patient in seclusion exhibits release behaviors for at least fifteen (15) minutes, the patient may be released from seclusion and monitored one to one (1:1) by a staff member for at least thirty (30) minutes prior to being allowed to return to the milieu.

When a patient in seclusion falls asleep, the door must be unlocked and/or opened as soon as possible and the seclusion intervention ended at that time. The a patient who falls asleep in the seclusion room must continue to be monitored every fifteen (15) minutes by the staff and reevaluated by the RN upon awakening for continued release.

Staff must provide the individual a debriefing opportunity to discuss the experience within twenty four (24) hours.

Documentation:

Each episode of seclusion requires documented information in the patient's medical record. This include but not limited to:

Date and time seclusion was implemented

Patient response to the seclusion intervention

Behavior criteria for release..

Written order for seclusion

Every two (2) hour assessment by the RN to include the patient's condition, behaviors, interventions and continued need for seclusion

Debriefing of the patient.

Medical Record review:

1. MR # 5 was admitted to the behavioral unit of the facility on 4/14/16 with psychiatric disorder.

Review of the Patient Progress Notes dated 4/14/16 at 7:23 PM revealed the nurse documented the patient was combative and aggressive, threatening staff and other patients, not redirectable and was placed in seclusion at that time and prn (as needed) medications were administered intramuscularly (IM).

Review of the Patient Progress Notes dated 4/14/16 at 9:23 PM revealed the nurse documented the patient was in seclusion, resting with eyes closed with no distress noted.

Review of the Patient Progress Notes dated 4/15/16 at 5:54 AM, revealed the nurse documented the patient is alert and cooperative with morning vital signs, patient is calm, no distress noted. Attempted to assess patient for discontinuation of seclusion. Pt does not exhibit behavior for removal. Patient continues to be irritable but states (he/she) wants to come out... just don't like for people to argue and fuss with (him/her).

There was no documentation of the behavior the patient exhibited to indicate the patient was not ready for release from seclusion or the rationale for the patient to remain in seclusion.

The patient remained in seclusion until 4/15/16 at 8:19 AM.

Review of the Patient Progress Notes dated 4/15/16 at 8:19 AM, revealed the nurse documented the Unit Manager and security staff member went to seclusion to talk with the patient. The patient was alert and oriented at that time, answered all questions asked by the unit director. Patient released from seclusion at that time and allowed to return to (his/her) room...

There was no documentation a debriefing conference was conducted with the patient once he/she was released from seclusion.

An interview was conducted on 5/26/16 at 10:52 AM with Employee Identifier (EI) # 2, Director of New Day (Behavioral unit), who verified the above.

2. MR # 6 was admitted to the behavioral unit of the facility on 3/4/16 with diagnoses including Bipolar disorder, Depressive type and Poly-substance abuse.

Review of the Patient Progress Notes dated 3/4/16 at 1:25 PM revealed the nurse documented the patient entered the hallway, started beating his/her hands on the wall and screaming. The patient entered the open seclusion room and began kicking the door repeatedly while screaming.

Review of the Patient Progress Notes dated 3/4/16 at 1:38 PM revealed the nurse documented the patient was medicated for anxiety and agitation, continued to threaten staff was beating his/her head against the wall and the seclusion door was closed at that time.

Review of the Patient Progress Notes revealed the patient was in seclusion from 3/4/16 at 1:38 PM to 3/9/16 at 1:21 PM. From 3/4/16 at 1:38 PM to 3/9/16 at 12:07 AM, the patient exhibited aggressive, threatening, destructive behaviors, including yelling, banging on the walls and door of the seclusion room, removal of clothing, masturbation, defecation and urination on the floor of the seclusion room, destructive behavior of the walls, door and mattress in the seclusion room.

The patient was medicated multiple times with prn (as needed) anti-anxiety and anti-psychotic medications. There were multiple changes in the regular dosage of the patient's anti-psychotic medications.

Review of the Patient Progress Notes dated 3/9/16 @ 12:24 AM revealed, "... Thorazine 100 milligrams (mg) was administered intramuscularly (IM)..." and the nurse encouraged the patient to lie down and get some rest.

Review of the Patient Progress Notes dated 3/9/16 revealed the following:
12:45 AM - Patient resting with eyes closed, respirations with ease...
1:30 AM - Called patient by name, patient did not respond. Allowed patient to continue to rest. Patient observed respirations with ease...
2:15 AM - Patient awake up out of bed for toileting needs. Respirations with ease...
2:45 AM - Resting in bed with eyes closed. Respirations with ease.
3:30 AM - Called patient by name, patient did not respond. Allowed patient to continue to rest. Patient observed respirations with ease.
4:00 AM - Allowing patient to rest. Respirations with ease. Resting with eyes closed...
5:27 AM - Called patient by name, patient did not respond. Allowed patient to continue to rest...
5:45 AM - Patient aroused, toileting offered. Patient refused... Patient compliant with getting vital signs taken. No complaints voiced. No yelling or screaming out. No name calling. Patient returned to sleep after vital signs taken.
7:00 AM - Called patient, patient did not arouse. Asked patient if needed toileting, Patient did not respond. Allowed patient to rest with eyes closed. Respirations with ease.
8:00 AM - Patient alert, oriented. Requesting to call mother. Explained to the patient conditions of getting out of seclusion. Patient states, "Just Knock me out"...
10:25 AM - Patient remains in seclusion. Beating on the wall. Spoke with patient about behavior and what it would take to come out of seclusion... Laying on mat at this time
10:34 AM - Patient standing at door in the seclusion room. Yelling at the Mental Health Technician. States "Y'all will get what's coming to you". Discussed what it would take for release from seclusion. Patient laying on mat at this time.
10:50 AM - "...Patient in seclusion at window, tearful. Opened door and talked with patient. Explained that we need (him/her) to work with us to be able to release from seclusion and for this to happen, needs not to demonstrate aggressive or threatening behaviors and follow instructions... Discussed placing hospital gown on patient and leaving seclusion door open for now and that if patient is without behaviors for 1 hour will reassess about releasing from seclusion... Patient agreeable at present..."

Review of the Patient Progress Notes dated 3/9/16 at 1:21 PM - "... Patient is calm and requesting to go to (his/her) room... Patient released from seclusion and assisted to room... without incident..."

There was no documentation a debriefing conference was conducted with the patient once he/she was released from seclusion.

An interview was conducted on 5/26/16 at 10:20 AM with EI # 3, Infection Control Nurse, who verified the above.

This condition level deficiency was cited based on review of medical records (MR), facility policies and interviews with the staff, it was determined the facility failed to ensure:

1. Initial nursing assessments and reassessments were completed on each patient.

2. All physician orders were written for care and treatment.

3. All patient deaths contained a death note, release of body and the OPO (Organ Procurement Organization) form.

4. Nursing staff followed the policy for central line and peripheral intravenous (IV) dressing changes.

5. The Registered Nurse (RN) initiated and updated a Plan of Care for each patient admitted to the facility.

6. The nursing staff evaluated the patient's need for blood pressure (BP) medication and administered BP medications as ordered and as needed (prn).

7. Nursing staff documented accurate assessments of Dopamine infusion dosage/rates, verified and followed physician orders for administration of Dopamine infusions.

These deficient practices affected 2 of 32 MR reviewed including, MR # 32 and MR # 29 and had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A395, A396 and A405 for findings.

Based on review of medical records (MR), facility policies and interviews with the staff it was determined the facility failed to ensure:

1. Initial nursing assessments were completed on each admission.
2. All physician orders are written for care and treatment
3. All nursing reassessments by nursing staff are complete and accurate.
4. All deaths contain a death note, release of body and the OPO (Organ Procurement Organization) form is in the medical record (MR).
5. The policy for central line dressing changes was followed.
6. The policy for peripheral intravenous (IV) dressing changes was followed.

This affected 2 of 32 medical records reviewed including, MR # 32 and MR # 29 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Nursing Admission-Assessment/Reassessment
Policy Revision Date: April 2003

Policy:

It is the policy of Dale Medical Center that each patient admitted will have an admission assessment completed by a Registered Nurse (RN).The admission assessment for pediatric, medical and surgical patients should be completed within four (4) hours of admission...

5. The physical assessment is to be done by the Registered Nurse only.

10. Reassessment of patients needs are contingent upon the complexity and dynamics of the patient's condition, and/or physician's orders.

Policy: Admission/Registration of Patient
Policy Date: September 2, 2014

Purpose:
To initiate treatment for the patient which may be upon admission/registration to Dale Medical Center...

Procedure:
The patient must have a physician order to receive services

Policies and Procedures
Subject: Central Line Care
Effective Date: April, 2008

Central Line Insertion
10. Dress site with sterile dressing per physician preference.
Key Points
10. Sterile gauze and tape or transparent dressing may be used.

11. Gauze dressing is to be changed at least three times per week. Transparent dressing is to be changed at least every 7 days. Either type dressing is to be changed immediately if wet, soiled, or loose, or when inspection of the site is necessary...
Key Points
11. Infection control. Cleanse insertion site with antiseptic and redress. Chlorhexidine is recommended by the CDC (Centers for Disease Control). Document dressing change and site appearance.

Policy and Procedure
Subject: Peripheral Intravenous (IV) Therapy

7. IV sites will be changed every 72 hours and PRN (as needed) for pain or signs of phlebitis...

8. Hands should be washed before changing IV dressing. The IV site dressing will be changed every 24 hours if gauze, every 72 hours if transparent, or as needed.


1. MR # 32 was admitted to hospice/palliative care on 4/14/16 with an admitting diagnosis of Severe Sepsis and Left Lower Lobe Pneumonia.

Review of the MR from 4/14/16 to 4/16/16 revealed no admission orders for hospice/palliative care, no initial RN assessment and incomplete documentation of all nursing assessments.

Review of the nurse note dated 4/14/16 beginning at 12:00 PM the Licensed Practical Nurse (LPN) failed to document a complete physical assessment. Under the systems area of the note the LPN documented "No change from previous assessment".

Review of the wound section of the note revealed the LPN documented "dry dressing, Aquacel foam".

Review of the 4/14/16 note at 11:40 PM revealed the RN documented under the Gastrointestinal Assessment Tube Feeding: PEG (Percutaneous Endoscopic Gastrostomy) tube: "tube flushed per protocol,Clamped".

Review of the hospice/palliative section of the chart provided to the surveyor revealed no physician orders for the specific wound care or for the peg tube flushes.

When the surveyor asked Employee Identifier (EI) # 7, Director of Medical Records if there was an initial RN assessment, careplans, new orders to admit to hospice/palliative care, a death note by the nurse and the OPO form, the response by EI # 7 was "no".

An interview was conducted on 5/26/16 at 10:00 AM with EI # 7, who confirmed the above mentioned records.



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2. MR # 29 was admitted to the facility on 4/5/16 with diagnoses including Pneumonia with Sepsis and Depakote Toxicity.

Review of the Operative Report dated 4/6/16 for the insertion of a central line revealed a sterile bandage was applied to the access site. There was no documentation whether the sterile bandage was gauze or a transparent dressing.

Review of the 24 hour nursing notes from 4/6/16 to 4/14/16 revealed no documentation the central line dressing was changed.

Further review of the 24 hour nursing notes from 4/6/16 to 4/14/16 revealed no documentation the peripheral IV site dressing was changed.

An interview was conducted on 5/26/16 at 1:00 PM with EI # 1, Nursing Supervisor, who confirmed there was no documentation of the type of dressing nor that the policy for central line and peripheral line dressing change was followed.

Based on review of the medical records (MR), facility policy and interviews with the staff, it was determined the facility failed to ensure the Registered Nurse (RN) initiated and updated a Plan of Care for each patient admitted to the facility. This affected 1 of 32 medical records reviewed including, MR # 32 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Nursing Admission-Assessment/Reassessment
Policy Revised Date: 4/2003

Policy:
It is the policy of Dale Medical Center that each patient admitted will have an admission assessment completed by a Registered Nurse (RN)...

7. It is the RN responsibility to initiate discharge planning, insure signing of the consent for treatment form, and to initiate the care plan at the time of admission...

1. MR # 32 was admitted to hospice/palliative care on 4/14/16 with an admitting diagnosis of Severe Sepsis and Left Lower Lobe Pneumonia.

Review of the entire MR for hospice/palliative care revealed no documentation the Plan of Care was initiated or updated after a level of care change in status had been made from inpatient to hospice/palliative care.

An interview was conducted on 5/26/16 at 10:00 AM with Employee Identifier # 7, Director of Medical Records, who confirmed the above mentioned findings.

Based on review of medical records (MR) and interview with staff it was determined the hospital failed to ensure the nursing staff:

1. Evaluated the patient's need for blood pressure (BP) medication.

2. Administered BP medications as ordered and as needed (prn).

3. Documented accurate assessments of Dopamine infusion dosage and rates.

4. Followed physician orders for administration of Dopamine infusions.

5. Verified physician's orders were written for changes in Dopamine infusion rates.

This deficient practice affected 2 of 32 records reviewed which included, MR # 22, MR # 29 and had the potential to affect all patients.

Findings include:

1. MR # 22 was admitted to the facility on 5/23/16 with diagnoses including nausea and abdominal pain.

Review of the physician's orders revealed an order for Apresoline (Hydralazine) Inj (injection): 20 mg (milligrams) / ml (milliliter) 10 mg IVP (intravenous push) PRN (as needed) Q (every) 6 H (hours) for SBP (systolic blood pressure) > (greater than) 160 or DBP (diastolic blood pressure) > 105.

Review of the vital sign graphic sheet record dated 5/23/16 through 5/25/16 revealed the following BP recordings: 185/87; 163/81; 162/87; 180/74; 178/76; and 184/81. Review of the Medication Administration Record revealed the Apresoline was not administered as ordered.

Review of the MR revealed no documentation the physician was notified of the elevated blood pressure readings nor that the ordered medication was not administered.

An interview was conducted on 5/25/16 10:30 AM with Employee Identifier (EI) # 1, Nursing Supervisor, who confirmed the order and that the Apresoline was not administered as ordered.

2. MR # 29 was admitted to the facility on 4/5/16 with diagnoses including Pneumonia with Sepsis and Depakote Toxicity.

Review of the physician's orders revealed an order dated 4/5/16 for Dopamine 400 MG (milligrams) / 250 ML (milliliters) continuous IV (intravenous) at 20 ML/HR.

Review of the nursing documentation dated 4/5/16 at 12:38 PM revealed the following Miscellaneous note: "... Dopamine 2.5 mcg (micrograms) per IV drip administered per Dr. ordered, increased to 5 mcg. Increased to 7.5 mcg, increased and stayed at 15 mcg.." There was no order for the changed drip rate.

Review of the nursing documentation dated 4/5/16 at 11:00 PM revealed the following Intravenous Assessment, "... Dopamine decreased to 10 mcg/kg/min (minute) (25.7 ml/hr)..." There was no documentation of an order on 4/5/16 to decrease the Dopamine.

Review of the nursing documentation dated 4/6/16 at 3:00 AM revealed the following Intravenous Assessment, "... Dopamine 400 mg in 250 D5W (5% dextrose/water) rate changed to 25.7 ml/hr (10 mcg/kg/min) due to wt. (weight) change..." According to the nursing entry on 4/5/16 the drip was decreased to 10 mcg/kg/min at 11:00 PM.

Review of the nursing documentation dated 4/6/16 at 4:00 AM revealed the following Intravenous Assessment, "... Dopamine 400 mg in 250 D5W decreased to 5 mcg/kg/min (12.8 ml/hr) at this time..." There was no documentation of an order to decrease the Dopamine to 5 mcg/kg/min.

Review of the nursing documentation dated 4/7/16 at 12:08 AM revealed the following Intravenous Assessment, "...Dopamine decreased to 2.5 MG (milligrams)/kg/min (6.4 ml/hr) at this time..." There was no documentation of an order to decrease the Dopamine.

Further review of the nursing documentation dated 4/7/16 revealed the Dopamine was stopped at 9:30 AM. There was no documentation of an order to stop the Dopamine.

Further review of the nursing documentation dated 4/7/16 at 11:13 AM revealed the Dopamine was restarted at same rate 2.5 mcg/kg/min d/t (due to) BP 87/50. There was no documentation of an order to restart the Dopamine nor at what rate.

Review of the nursing documentation dated 4/7/16 at 2:40 PM revealed the following: "... IV rate change: Dopamine decreased to 2 mc/kg..." There was no documentation of an order to decrease the Dopamine.

Review of the nursing documentation dated 4/8/16 at 6:35 AM revealed the following Miscellaneous note: "... Order received to D/C (discontinue) Dopamine and give NACL (sodium chloride) 500 ml bolus per..." There was no documentation of an order to D/C the Dopamine.

Review of the nursing documentation dated 4/9/16 at 10:07 AM revealed the following Miscellaneous note: "... Reported BP, HR (heart rate), and mean to (physician), administer Dopamine per protocol..." There was no documentation of the strength or rate of the Dopamine infusion.

Review of the physician's order dated 4/9/16 at 10:26 AM revealed Dopamine 400 mg/250 ml continuous IV at 6.6 ml/hr.

Review of the nursing documentation dated 4/9/16 at 2:44 PM revealed the following Miscellaneous note: "... Dopamine increased to 7.5 ML/HR per..." There was no documentation of an order to increase the Dopamine.

Review of the nursing documentation dated 4/9/16 at 7:00 PM revealed the following Intravenous Assessment, "...Dopamine 400 mg in 250 ml D5W (5% Dextrose in Water) at 7.5 mg/kg/min (9.8 ml/hr)..." The documentation was unclear as to the dose of Dopamine being administered 7.5 ML per hour or 7.5 MG/kg/minute or 7.5 MCG/kg/minute.

Review of the nursing documentation dated 4/10/16 at 7:57 PM revealed the following, "... Dopamine 400 mg in 250 at 10 mg/kg/min (13.1 ml/hr)..." There was no documentation of an order for Dopamine at 10 mg/kg/min.

Review of the nursing documentation dated 4/11/16 at 1:00 AM revealed the following Intravenous Intervention: "... Dopamine decreased to 7.5 mg/kg/minute (9.8 ml/hr)..." There was no documentation of an order to decrease the Dopamine.

Review of the nursing documentation dated 4/11/16 at 7:00 AM revealed the following Intravenous Assessment, "... Dopamine drip at 5 mcg/kg/min..."

Further review of the nursing documentation dated 4/11/16 revealed the following at 7:30 AM: "... Dopamine infusion rate adjusted in infusion pump to correlate with correct concentration (400 mg in 250 ml's)..." Therefore, 5 mcg/kg/min was previously infusing at 6.6 ml/hr, now found to be 14.1 ml/hr. Rate changed to 3 mcg/kg/min (8.4 ml/hr). There was no documentation of an order to decrease the rate of the Dopamine.

Further review of the nursing documentation dated 4/11/16 at 8:00 AM revealed the following: "... IV rate change: Dopamine drip decreased to 2 mcg/kg/min (5.6 ml/hr)..." and at 08:15 the Dopamine drip was discontinued. There was no documentation of an order to decrease or discontinue the Dopamine.

The surveyor requested documentation of the medication error for 4/11/16 at 730 AM and was informed there was no documentation of follow up.

An interview was conducted on 5/26/16 at 1:00 PM with EI # 1 and the surveyor requested any additional documentation regarding the Dopamine infusion. No additional documentation or orders were submitted to the surveyor.

Based on observation and interview with the staff, it was determined the facility failed to ensure the Anesthesia cart in the Operating Room (OR) # 3 was locked while unattended.

Findings include:

A tour of the surgical area was conducted on 5/25/16 at 3:20 PM with Employee Identifier (EI) # 5, Surgical Registered Nurse (RN). During the tour, the surveyor entered OR # 3 through the opened unlocked door. The surveyor observed the Anesthesia cart in the room unattended and the OR door open.

Further observation of the cart, revealed the cart was unlocked. The surveyor opened each drawer to find medications in the cart. When the surveyor asked EI # 5, if it was policy to leave the OR door open and the anesthesia cart unlocked, the RN replied " no the cart is to remain locked when not in use".

An interview was conducted on 5/25/16 at 3:45 PM with EI # 5 who confirmed the above mentioned findings.

Based on review of Centers for Disease Control (CDC) and Prevention guidelines, observations and interview, it was determined the facility failed to ensure:

a) all medications in patient treatment areas were not expired.

b) all medications in use were correctly labeled.

This had the potential to negatively affect patients receiving care at this facility.

Findings include:

Centers for Disease Control and Prevention

4. "When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.
In addition, the United States Pharmacopoeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals:
If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."

An initial tour of the facility was conducted on 5/24/16 at 9:35 AM in the presence of Employee Identifier (EI) # 1, Nursing Supervisor. During this tour, the surveyors observed the following expired medications and/or medications which were open and unlabeled:

30 milliliters (ml) 0.9% Sodium Chloride (NaCl)- open/unlabeled
1% Lidocaine - open/unlabeled
1% Lidocaine - open with date of 4/5/16 (5/3/16 would have been 28 days later)
Lidocaine/Epinephrine 1:100,000 - expiration 2/16
(2) bottles 0.9% NaCl - expiration 11/1/15
2 Cases of Sterile Water - expiration 3/16
(2) bottles Lidocaine/ Epinephrine 1:100,000 - expiration 2/16
(2) bottles - Sterile Water - open/unlabeled

An interview was conducted on 5/24/16 at 9:35 AM with EI # 1, who verified the above findings.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...


A tour of the Dietary department was conducted on 5/24/16 1:30 PM with Employee Identifier (EI) # 8, Dietary Manager revealed the following open food items in the dry storage area with no label to indicate the date opened:

1 bag of confectioner's sugar wrapped with plastic wrap
1 bag of white gravy mix wrapped with plastic wrap
1 pack of Butter Buds
3 bottles of Lite Syrup
1 bag of crushed cracker crumbs in a zip lock bag inside a plastic bin with cracker crumbs in the bottom of the plastic bin
1 box of Cream of Wheat in a zip lock bag - the bag was unsealed with the cream of wheat loose in the bottom of the zip lock bag
1 bag of grits - unsealed
1 jug of Worcestershire sauce
1 jug of Liquid Butter Alternative.

Located in the produce cooler revealed:

1 open jug of yellow mustard with an expiration date of 10/15/2015
1 open jug of mayonnaise with no label to indicate the open or discard date
1 open jug of BBQ sauce with no label to indicate the open or discard date
3 large Kraft Mayonnaise containers filled with a mixture resembling ranch dip with no label to identify the mixture, the date prepared nor when to discard.

Located in the chest freezer of the kitchen area contained the following food items with no label to indicate the open or discard date:

1 bag of sliced squash in a zip lock bag
1 bag of green beans in a zip lock bag
1 bag of chicken breasts in a clear plastic bag with a twist tie closure

During observation of plating for lunch on 5/25/16 at 11:30 AM, the surveyor observed a dietary worker without a hair net preparing and cooking chicken in the deep fryer.

An interview with EI # 8 was conducted on 5/25/16 at 1:30 PM, who confirmed the above mentioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

2. During observation of medication administration, the surveyor observed the Registered Nurse (RN) administer an oral medication, an intramuscular injection and an intravenous push medication to a single patient. The RN was observed donning gloves, removing gloves and donning new gloves between each medication administration without performing hand hygiene between glove changes.

An interview was conducted on 5/25/16 at 9:20 AM with EI # 4 who confirmed the above mentioned findings.



32470

Based on review of Medical Records (MR), facility policy, observations and interviews with the staff, it was determined the facility failed to ensure the staff followed their policy for hand hygiene. This affected MR # 30 and observations of medication administration to an unsampled patient with multiple medications with various routes of administration and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Hand Hygiene - CDC Guidelines
Policy Number: 4008
Date of Revision: 9/2014

Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.

Policy:

All staff should use the hand-hygiene techniques, as set forth in the following procedure...

After coming in contact with patient's intact skin...
Always after removing gloves or facemask

If hands are not visibly soiled, hands may be disinfected with either an alcohol-based hand rub (ABHR) or soap and water...

Recommendations for Hand Hygiene

Indications for Handwashing and Hand Antisepsis:

... Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

Decontaminate hands after removing gloves...

1. An observation of a foley catheter was conducted on the Medical Surgical floor on 5/25/16 at 8:25 AM with Employee Identifier (EI) # 6, Registered Nurse (RN), to observe the insertion of a foley catheter and surgical preparation of the skin for MR # 30.

EI # 6 washed hands and performed foley catheter insertion per sterile technique. After completion, EI # 6 removed all used supplies and disposed of properly and removed gloves. EI # 6 then sanitized hands, explained preparation of the skin for surgery and touched the patient's skin with bare hands to instruct where the patient would be shaved. EI # 6 donned gloves to begin the shaving process and failed to sanitize hands prior to donning the gloves.

An interview was conducted on 5/25/16 at 9:20 AM with EI # 4, Quality Director, who confirmed the above mentioned findings.