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Based on observation, interview, and record review, the facility failed to ensure, for two incapacitated patients (a person with an underlying medical condition or disability which affects thinking, reasoning and/or memory) (Patients 33 and 39), the Conditions of Admission (COA - admission and medical services agreement, which included notice of patient rights when admitted to the facility) were provided to Patients 33 and 39's responsible party (RP).

This failure resulted in Patients 33 and 39's RPs not receiving the COA information when they were admitted to the facility and had the potential for the RPs to not be aware of the patients' rights.

Findings:

a. During an observation on February 2, 2021, at 9:50 a.m., conducted with Nurse Manager (NM) 1, Patient 33 was observed lying in bed, awake, and with bilateral soft wrist restraints (any manual method that would immobilize or reduce the ability of a patient to move freely). Patient 33 was observed to mumble when asked a question.

During a concurrent interview and record review, on February 2, 2020, at 2:05 p.m., conducted with the Associate Director of Patient Access (ADPA), Patient 33's record was reviewed. The "History and Physical (H&P)," indicated Patient 33 was admitted to the facility on January 19, 2021, with a chief complaint of altered mental status (AMS).

The COA form indicated, "...The undersigned certifies that he/she has read the foregoing, received a copy thereof, and is the patient, the patient's legal representative, or is duly authorized by the patient as the patient's general agent to execute the above, and accept its terms, and agree that they are irrevocable... Date: 1-19-21...Signature: Verbal due (sic: to) Covid...If signed by other than patient, indicate relationship (patient's legal representative) (no written response)...Witness (signature of the facility staff)..."

The ADPA stated when a patient in the Emergency Department (ED) would be admitted, the Patient Access Representative (PAR) would give the COA information and would obtain a verbal consent from the patient. The ADPA stated the PAR should review the patient's record from the physician's assessment of the patient's mental capacity or ask the Registered Nurse (RN) if the patient was capable of consenting to the COA.

The ADPA stated Patient 33 had AMS and would not be able to give a verbal consent for COA. The ADPA stated the PAR should have written "patient not able to sign" on Patient 33's COA form.

During an interview on February 2, 2021, at 1:45 p.m., conducted with the Director of Care Coordination (DCC), the DCC stated a social worker (SW) consult would be initiated when a patient was not able to sign the COA. The DCC stated the role of the SW would be to assist in finding the patient's RP who would receive the information for the COA and give verbal consent on behalf of the patient when the patient was incapacitated.

The DCC stated the SW would not be aware of Patient 33's need to contact the patient's RP because the COA was verbally consented by Patient 33.

b. During an observation on February 3, 2020, at 9:20 a.m., conducted with RN 3, Patient 39 was observed lying in bed, awake, with bilateral soft wrist restraints and a lap belt restraint. Patient 39 was observed to have a blank stare when asked a question.

During a concurrent interview and record review, conducted with Clinical Nurse Specialist (CNS) 1, Patient 39's record was reviewed. The H&P indicated Patient 39 was admitted to the facility on February 2, 2021, with diagnoses that included Alzheimer's disease (a progressive disease that could result in loss of memory and other mental functions).

Patient 39's "ED Note - Nursing," dated February 2, 2021, indicated, "...Confused at baseline. Hx (history) Dementia (memory loss)..."

The COA form indicated, "...The undersigned certifies that he/she has read the foregoing, received a copy thereof, and is the patient, the patient's legal representative, or is duly authorized by the patient as the patient's general agent to execute the above, and accept its terms, and agree that they are irrevocable... Date: 2/2/21...Signature: pt (patient) unable due to Covid restrictions...If signed by other than patient, indicate relationship (patient's legal representative) (no written response)...Witness (signature of the facility staff)..."

CNS 1 stated the COA form should indicate Patient 39 was not able to sign because of mental condition and not because of COVID-19 restrictions. CNS 1 stated when a patient was not able to sign the COA, the SW would assist in finding the patient's RP who would receive information for COA and give verbal consent on behalf of the patient, when the patient was incapacitated.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent," dated September 2018, the P&P indicated, "...Conditions of Admission...

Upon admission or as soon thereafter as reasonably possible...the patient or an incompetent (sic - a competent) patient's surrogate decision-maker will be asked to give consent to the general medical care and the general terms and conditions for receiving care from the Hospital. This will be presented in the form of the "Conditions of Admission..."

During a review of the facility's P&P titled, "Patient Rights and Responsibilities," dated September 2018, the P&P indicated, "...The hospital assists the patient in the exercise of his/her rights and informs the patient of any responsibilities he/she has in the exercising of these rights. All these rights apply to the patient's legally-recognized decision-maker...

The patient is offered the statement of patient rights and responsibilities upon registration or admission..."

Based on observation, interview, and record review, the facility failed to ensure care was provided in a safe setting for one patient (Patient 28), when Patient 28 was attached to multiple medical lines, including intravenous (IV - administration of medications through a vein) tubing strung across the room, and was not provided assistance with transferring (moving from one surface to another) and ambulation (walking or moving from place to place).

This failure resulted in an unsafe setting, placed Patient 28 at a higher risk for falls, and resulted in Patient 28 stumbling when trying to transfer from his bed to his chair.

Findings:

During a concurrent observation and interview, on February 4, 2021, at 12:30 p.m., conducted with Patient 28, Patient 28 was observed in his room alone, sitting at the edge of the bed with multiple medical lines attached to him. Patient 28's IV tubing was observed trailing from the patient, extended over the bed and across the room to the wall closest to the door, and then connected to the IV pump located outside of Patient 28's room.

Patient 28 was observed with a nasal cannula (device used to deliver oxygen with two prongs placed in the nostrils) connected to a tubing attached to the oxygen outlet at the head of the bed. Patient 28 was also observed to be connected to a pulse oximeter (a device that measures oxygen levels in the blood) located on a bedside table by a cord trailing from one of Patient 28's fingers.

Patient 28 was then observed to stand up, step on and stumble over the entangled lines, then he proceeded to untangle the lines and tubing, and sat in a chair by the window.

Patient 28 stated he would independently walk around the room and to the bathroom without assistance from the nurses while attached to the lines and tubing.

On February 5, 2021, Patient 28's record was reviewed. Patient 28 was admitted to the facility on February 1, 2021, with diagnoses that included acute hypoxic respiratory failure (not enough oxygen circulating in the blood), pneumonia (infection in the lungs), and COVID-19 (a highly contagious respiratory disease caused by a new coronavirus) infection.

During an interview on February 4, 2021, at 10 a.m., conducted with the Director of Quality, Safety, and Infection Control (QSIC), the QSIC stated the nursing practice of placing IV pumps outside the room with long tubing extending to the patient was a safety risk for both patients and staff.

During an interview on February 4, 2021, at 12:35 p.m., conducted with Registered Nurse (RN) 1, RN 1 stated she was the primary nurse caring for Patient 28. RN 1 stated it was a safety concern when a patient had medical lines or tubings attached. RN 1 further stated Patient 28 was independently ambulating in the room and to the bathroom without assistance from nursing staff.

During an interview on February 5, 2021, at 1:27 p.m., conducted with Clinical Nurse Specialist (CNS) 1, CNS 1 stated when patients had tubings attached to medical equipment, patients were at a higher risk of falling. CNS 1 stated patients at a higher risk of falling should not be getting out of bed or ambulating by themselves. CNS 1 continued to state nurses should be instructing patients with attached medical device lines and tubing to call for assistance to get out of bed.

During a review of Patient 28's nursing notes titled, "Fall Risk Assessment and Interventions," dated February 4, 2021, at 8:15 a.m., the nursing notes did not indicate Patient 28's mobility interventions included assistance with transfer and ambulation.

During a review of the facility's policy and procedure (P&P) titled, "Falls Prevention Protocol," dated April, 2020, the P&P indicated, "...Prevention interventions are implemented in an attempt to prevent the patient from falling and decrease the risk of injury from a fall...Patient specific fall prevention interventions are selected based on the risk factors identified during assessment (Addendum A)...Addendum A: Adult Inpatient Fall Risk Assessment Tool...Mobility Interventions...Transfer/amb (ambulation) assistance..."

Based on observation, interview, and record review, the facility failed to ensure for one patient (Patient 33), there was a physician's order for the use of bilateral soft wrist restraints (any manual method that could immobilize or reduce the ability of a patient to move his or her arms freely).

This failure had the potential to result in an inappropriate, unnecessary, and/or prolonged use of restraints, and failure to promote and protect the rights of the patient.

Findings:

During an observation on February 2, 2021, at 9:50 a.m., conducted with Nurse Manager (NM) 1, Patient 33 was observed lying in bed, awake, with bilateral soft wrist restraints. Patient 33 was observed to mumble when asked a question.

In a concurrent interview, NM 1 stated Patient 33 had bilateral soft wrist restraints because she was pulling out her intravenous tubing (IV - administration of medication or fluids through a vein).

During a concurrent interview and record review, on February 2, 2021, at 1:55 p.m., conducted with Nursing Informatics Specialist (NIS) 1, Patient 33's record was reviewed. The "History and Physical," indicated Patient 33 was admitted to the facility on January 19, 2021, with a chief complaint of altered mental status.

Patient 33's "Nursing Note," dated January 23, 2021, indicated, "...Anti anxiety med (medication) was given to pt (patient) who also was able to remove her soft restraints (sic - soft wrist restraints) twice..."

The flowsheet record indicated Patient 33 had bilateral soft wrist restraints on January 30, 2021.

NIS 1 stated there was no documentation Patient 33's bilateral soft wrist restraints were discontinued on January 23 and 30, 2021.

NIS 1 stated there was no documentation a physician's order was obtained for Patient 33's bilateral soft wrist restraints on January 23 and 30, 2021.

NIS 1 stated for patients who continue to require the use of restraints, a new physician's order for the use of the restraints for each calendar day should be obtained.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Seclusion," dated September 2020, the P&P indicated, "...Each calendar day, a new order is required for patients who continue to require Non-Violent Restraints..."

Based on observation, interview, and record review, the facility failed to ensure monitoring and reassessment of two patients (Patients 33 and 34), who had restraints was conducted in accordance with the facility's policy and procedure (P&P).

This failure had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints.

Findings:

a. During an observation on February 2, 2021, at 9:50 a.m., conducted with Nurse Manager (NM) 1, Patient 33 was observed lying in bed, awake, with bilateral soft wrist restraints. Patient 33 was observed to mumble when asked a question.

In a concurrent interview, NM 1 stated Patient 33 had bilateral soft wrist restraints because she was pulling out her intravenous tubing (IV - administration of medication or fluids through a vein).

During a concurrent interview and record review, on February 2, 2021, at 1:55 p.m., conducted with Nursing Informatics Specialist (NIS) 1, Patient 33's record was reviewed. The "History and Physical," indicated Patient 33 was admitted to the facility on January 19, 2021, with a chief complaint of altered mental status.

The restraint flowsheet record indicated Patient 33's restraints were last assessed and monitored on January 22, 2021, at 6 p.m. Patient 33's restraints were next assessed and monitored on January 23, 2021, at 10 a.m. (16 hours later).

NIS 1 stated there was no documentation Patient 33's bilateral soft wrist restraints were discontinued on January 22 and 23, 2021.

NIS 1 stated Patient 33 should have been assessed and monitored every two hours to ensure patient safety and to evaluate if the patient was still in need of the restraints.

b. During an observation on February 2, 2021, at 10:50 a.m., conducted with Registered Nurse (RN) 5, Patient 34 was observed lying in bed, with eyes closed, and was intubated (a tube inserted through the mouth into the lungs to help a person breath). Patient 34 was observe to have bilateral soft wrist restraints.

In a concurrent interview, RN 5 stated Patient 34 had restraints because the patient was agitated and tried to pull out his tube when awake.

During a concurrent interview and record review, on February 2, 2021, at 2:20 p.m., conducted with NIS 1, Patient 34's record was reviewed. The "History and Physical," dated January 31, 2021, indicated Patient 34 was brought in to the Emergency Department for a fall.

The restraint flowsheet record indicated Patient 34's restraints were last assessed and monitored on February 1, 2021, at 12 a.m. Patient 34's restraints were next assessed and monitored on February 1, 2021, at 8 a.m. (8 hours later).

NIS 1 stated there was no documentation Patient 34's bilateral soft wrist restraints were discontinued on February 1, 2021.

NIS 1 stated Patient 34 should have been assessed and monitored every two hours to ensure patient safety and to evaluate if the patient was still in need of the restraints.

During a review of the facility's P&P titled, "Restraint and Seclusion," dated September 2020, the P&P indicated, "...Reassessment and Monitoring...

Monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff...

Monitor and document the following at least every 2 hours as appropriate...

Restraint Status/Evaluation of continued need
Restraint site assessment
Orientation/LOC (level of consciousness)
Behavior Status...
Respiratory rate
Nutrition/hydration
Activity/position
Toileting
ROM (range of motion) (to restrained limbs)..."

Based on observation, interview, and record review, the facility failed to ensure;

1. Staff was trained to identify the risk of tripping or entanglement when intravenous (IV) lines were secured to the floor which could lead to an inadvertent breach of the IV lines, potential disconnection of those lines, and an increased risk for patient injury and infections ( IV lines - can be either a short catheter inserted into a peripheral vein or a central line inserted into a large vein leading to the heart; both lines deliver fluids and medication directly into the vein); and

2. EVS (environmental services) staff 1 utilized appropriate infection control techniques when transporting contaminated personal protective equipment (PPE).

The cumulative effect of these systemic problems resulted in an increased risk for the spread of infection throughout the facility.


FINDINGS:

1a. During an observation on February 4, 2021, at 12:30 p.m., Patient 28 was observed in his room alone and sitting at the edge of the bed with multiple medical lines attached. Patient 28's IV tubing was observed to trail from the patient, over the bed, across the room to the wall closest to the door, and then connected to the IV pump located outside of Patient 28's room.

Patient 28 was observed with a nasal cannula (device used to deliver oxygen with two prongs placed in the nostrils) connected to tubing attached to the oxygen outlet at the head of the bed. Patient 28 was also observed to be connected to a pulse oximeter (a device that measures oxygen levels in the blood) located on a bedside table by a cord trailing from one of Patient 28's fingers.

Patient 28 was then observed to stand up, step on, and stumble over the entangled lines, then he proceeded to untangle the lines and tubing, and sat in a chair by the window.

On February 5, 2021, Patient 28's record was reviewed. Patient 28 was admitted to the facility on February 1, 2021, with diagnoses that included acute hypoxic respiratory failure (not enough oxygen circulating in the blood), pneumonia (infection of the lungs), and COVID-19 (a highly contagious respiratory disease caused by a new coronavirus) infection.

b. During an observation on February 4, 2021, at 12:20 p.m., Patient 26 was observed from the hallway in her room, lying in bed, with IV tubing attached. Patient 28's IV tubing was observed to dangle off of her bed to the floor. The IV tubing trailed along the floor from the bed, under a trash can, and to the doorway (entrance to patient room). Patient 28's IV tubing was observed attached to the door frame with a taped clip and connected to an IV pump outside the patient's room.

c. During an observation on February 4, 2021, at 12:25 p.m., Patient 27 was observed in her room and was lying in bed with IV tubing attached. Patient 27's IV tubing was observed to dangle off of her bed to the floor, then trailed along the floor from her bed to the wall closest to the entry door to her room. The IV tubing was observed taped to the wall with red tape, trailed along the wall to the door, and attached to the door frame with a taped clip, and connected to the IV pump outside the patient's room.

During an interview on February 4, 2021, at 10 a.m., with the Director of Quality, Safety, and Infection Control (QSIC), the QSIC stated having IV pumps located outside the patient's room with the IV tubing trailing across the room to the patient was against infection control and safety guidelines.

The QSIC stated he was concerned about increased CLABSI rates (central line-associated bloodstream infections: a serious infection caused by bacteria or other germs that enter the patient's bloodstream through a central IV line) with this nursing practice. The QSIC further stated to decrease infection and safety risks, the IV tubing should not be touching the floor.

d. During an observation on February 4, 2021, at 11:58 a.m., conducted with Registered Nurse (RN) 2, Patient 48 was observed lying in bed, with IV tubing attached. Patient 48's IV tubing trailed from the patient's right arm, to the floor next to the patient's bed, to the doorway, and to the IV pump located outside the door of Patient 48's room.

In a concurrent interview, RN 2 stated the IV tubing should not be touching the hospital floor as it had the risk for contamination and may cause infection to the patient.

During a record review on February 5, 2021, the "History and Physical," dated January 29, 2021, indicated Patient 48's chief complaint was possible infection with COVID-19.

e. During an observation on February 4, 2021, at 12:05 p.m., conducted with Charge Nurse (CN) 1, Patient 47 was observed lying in bed, with IV tubing attached. Patient 47's IV tubing was observed to trail from the patient, to the floor next to the patient's bed, to the doorway, and to the IV pump located outside the door of Patient 47's room.

In a concurrent interview, CN 1 stated the nurses were aware of the need to keep the IV tubing off the floor to decrease the risk of infection it may bring to the patient.

During a record review on February 5, 2021, the "History and Physical," dated January 30, 2021, indicated Patient 47 tested positive for COVID-19.

f. On February 3, 2021, at 9:30 a.m., a tour and observation of the 4-East unit, consisting of patients with COVID-19 was conducted. Patient 8 was observed seated in a chair being assisted with her meal by a Patient Care Attendant.

A review of Patient 8's record on February 3, 2021, reflected the patient was admitted on January 11, 2021, with a diagnosis of COVID-19 pneumonia.

Patient 8's room consisted of one room with an anteroom (a small outer room). An intravenous (IV) pump was observed in the anteroom. The IV tubing was observed to go through the closed door jamb, over a glove box on the wall, then was taped directly to the floor, then went across the patient's bed to the patient who was seated on a chair. The patient was receiving IV fluids

An interview was conducted with the QSIC on February 4, 2021, at 1 p.m. The QSIC stated the IV tubing should not be on the floor. The QSIC further stated there had been no formal nursing staff education regarding placing the IV tubing on the floor, it was a safety issue with the potential of staff and patient falls and pulling of IV lines.

g. On February 4, 2021, at 3 p.m., a tour and observation of the 2-West unit, a COVID-19 unit was conducted. An observation of Patient 12 was conducted. A mobile IV pump was observed outside of Patient 12's room. The IV tubing was observed to go through the closed door jamb then was affixed to the floor by a couple pieces of clear tape. Patient 12 was receiving IV fluids to keep the tubing line open (TKO).

A concurrent interview was conducted the RN 4, caring for Patient 12 on February 4, 2021. RN 4 stated, "We should keep the IV tubing off of the floor."

h. On February 4, 2021, at 3:10 p.m., a tour and observation of the 2-West unit, a COVID-19 unit, was conducted with Lead Registered Nurse (LRN) 1. An observation of Patient 13 was conducted.

Outside of Patient 13's room was a mobile IV pump. The IV tubing was observed to go through the closed door jamb and then was affixed to the floor by a couple pieces of white tape. Patient 13 was receiving IV fluids TKO and also received Rocephin 1 gram and Azithromycin 500 milligrams (antibiotics) during the day.

An concurrent interview was conducted with LRN 1 who stated she did not receive formal education regarding IV tubing placement and the tubing should probably be affixed to the wall for safety.

i. On February 4, 2021, at 3:20 p.m., a tour and observation of the 2-West unit, a COVID-19 unit was conducted with LRN 1.

An observation of Patient 54 was conducted. Outside of Patient 54's door was an IV pump. The IV pump was running at TKO rate. The IV tubing was observed to go through the closed door jamb and was affixed to the floor by a couple pieces of tape.

A concurrent interview was conducted with LRN 1 who stated the IV tubing on the floor could be a tripping hazard for staff and ambulatory patients (patients who can walk). LRN 1 further stated occasionally the IV tubing is pinched by the door jamb.

j. On February 4, 2021, at 3:30 p.m., a tour and observation of the 2-West unit, a COVID-19 unit, was conducted with LRN 2.

An observation of Patient 55 was conducted. Outside of Patient 55's door was a IV pump with fluids running. The IV tubing was observed to go through the closed door jamb and then was affixed to the floor by a couple pieces of tape.

During a concurrent interview with LRN 2, she stated the staff tried to keep the IV tubing off of the floor.

According to the Society of Critical Care Medicine, Critical Care Exploration, July 30, 2020, "...Infection risk may be increased if tubing rests on the floor or an extension set disconnects and is exposed to air..."

2. On February 3, 2021, at 9:30 a.m., a tour and observation of the 2-East unit, a COVID-19 unit, was conducted. Environmental Services Staff (EVS) 1, was observed as she was cleaning Patient 8's room.

EVS 1 was observed as she removed her gown and proceeded to push a barrel which contained two bags of soiled personal protective equipment (PPE) linen. A large top bag was balanced on top of the full barrel of contaminated PPE. The top bag was observed to have multiple tears with PPE observed emerging from the torn areas of the bag.

EVS 1 then pushed the barrel down the hallway to the dirty storage room. EVS 1 then lifted the torn bag, and holding it against her ungowned uniform, tossed the bag into the cart.

An interview was conducted with EVS 1 on February 3, 2021, at 10:15 a.m. EVS 1 stated there was too much soiled PPE with all the COVID patients. EVS 1 stated the EVS staff needed to have two barrels in the patient's rooms to contain all of the soiled PPE. EVS 1 further stated the plastic bags were thin and they broke. EVS 1 stated she did not wear a gown when she was outside of a patients room.

An interview was conducted with the Manager of EVS (MEVS), on February 3, 2021, at 2 p.m. The MEVS stated EVS 1 should have put on a clean gown and double bagged the torn bag. The MEVS further stated staff are not to overfill the bags or hold contaminated PPE against their clothing as the soiled PPE could carry disease.

An interview was conducted with the QSIC on February 3, 2021, at 2 p.m. The QSIC stated EVS1 should have gotten another bag and double bagged it. The QSIC further stated staff should never hug a bag to their body, it was an infection control and safety issue as staff could also be accidentally be stuck by a needle caught in the PPE.