HospitalInspections.org

Based on a review of facility documentation, medical records (MR) and staff interview (EMP), it was determined that the facility failed to document the time when the physician reassessed the patient condition and renewed restraint orders for 10 of 15 medical records reviewed (MR2, MR3, MR5, MR8, MR9, MR31, MR32, MR33, MR34, and MR37).

Findings include:

Review of facility policy "Use of Restraints/Standard of Care" effective date August 2014 revealed " ...VIII. Physician Care of Patients In Restraint/Seclusion ...A. General Physician Responsibilities The physician is responsible for overseeing how the patient's assessed needs are being met. This accomplished through: A time limited written order for restraint or seclusion. This order will include: 1. Date of Order 2. Time of Order ..."

Review of MR2 revealed that on October 5, 2016 a physician reassessed MR2's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

Review of MR3 revealed that on October 5, 2016 a physician reassessed MR3's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

Review of MR5 revealed that on October 2, 4, 5, 6, and 7, 2016 a physician reassessed MR5's condition and renewed orders for restraints, signed the orders but failed to document the times the orders were renewed.

Review of MR8 revealed that on October 18, 2016 a physician reassessed MR8's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

Review of MR9 revealed that on October 25, 26, and 27, 2016 a physician reassessed MR9's condition and renewed orders for restraints, signed the orders but failed to document the times the orders were renewed.

Review of MR31 revealed that on October 28, 2016 a physician reassessed MR31's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed. Also, a registered nurse failed to sign off the order.

Review of MR32 revealed that on October 26, 2016 a physician reassessed MR32's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

Review of MR33 revealed that on October 25, 26 and 27, 2016 a physician reassessed MR33's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

Review of MR34 revealed that on October 26, 2016 a physician reassessed MR34's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

Review of MR37 revealed that on October 21, 2016 a physician reassessed MR37's condition and renewed an order for restraints, signed the order but failed to document the time the order was renewed.

During interview on November 16, 2016 at approximately 2:00PM EMP1 confirmed the above and revealed "they were not signed but ... "


During interview on November 16, 2016 at approximately 2:00PM EMP1 confirmed the above and revealed, "They were not signed but ..."

Based on a tour of the facility, review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure staff followed the contact isolation process.
Findings include:
Review of facility documentation "Jefferson Hospital Infection Control Plan 2015-2016 " revealed " Airborne or Airborne Contact Isolation ... 3. Smoke testing must be performed by the Maintenance Department prior to admitting the patient to the room and daily thereafter while the room is being utilized for isolation. Maintenance Dept. documents results of daily testing. ... G. Droplet Precautions is designed to prevent inhalation of infectious agents. ... Diseases Requiring Droplet Precautions ... Influenza, Type A or Type B ... Specifications for Droplet Precautions ... 2. Post " Droplet Precautions " (Blue) sign at the door."
Interview with EMP2 on November 15, 2016, at approximately 9:55 AM when asked if any patients were in droplet or airborne precautions revealed, " Yes, the patient in 5119 is in droplet precautions ... has to stay in it for the entire admission. I've told them (staff) that and 5216 is in air born isolation. "
During a tour of the facility on November 15, 2016, at approximately 10:05 AM the surveyor observed EMP4 hanging up a Droplet Precaution sign in front of room 5119.
During the tour EMP1 confirmed the above findings when asked are they just hanging up that sign revealed, " Yes.
Interview with EMP4 at the time of the tour when asked if he/she was just hanging up the sign revealed," Yes, I wasn't aware ... was in droplet precautions, I had ... yesterday. ... was admitted on the 11th."
Review of facility documentation " JRMC Maintenance Dept. Request Work Order " revealed "Smoke Test Rm[room]. 5216 ... Completed ... 11/11/16 ... Tested Neg[negative] - Good. Further review revealed the smoke test was not completed as per facility policy.
Interview with EMP1 on November 18, 2016, at approximately 12:15 PM confirmed the above findings and revealed, "They [the smoke tests] were not done."