HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each order of restraint for the management of violent or self-destructive behavior was renewed every 4 hours for an adult older than 18 years of age for 1 (#2) of 1 patient records reviewed with the use of restraints in a total sample of 5 patients.

Findings:

The hospital policy titled Restraint Application and Monitoring states:
5. Each order for restraint for the management of violent of self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others must be renewed in accordance with the following limits for up to 24 hours.
A. Every four hours for patients 18 or older. At the end of the above time frames, if the continued use of restraint or seclusion to manage violent or self-destructive behavior is necessary, based on patient assessment, another order is required.
B. Every 2 hours for patients 9 -17.
C. Every 1 hour for patients under the age of 9.
6. After 24 hours, before writing a new order for the use of restraint for the management of violent or self-destructive behavior, a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint by hospital policy must see and conduct a face-to-face evaluation before writing a new order to continue the restraint.

Review of Patient #2's medical record revealed he was in restraints per the physician's note on 1/30/2021, 1/31/2021, 2/01/2021 and 2/02/2021. Orders for restraints could not be found in the medical record for those days. This was verified on 03/24/2021 at 12:30p.m. by S2Reg. S2Reg also verified that hospital policy is a new restraint order every 24 hours with renewal every 4 hours for a patient 18 years of age or older.

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Based on record review and interview, the hospital failed to develop and implement infection control practices for highly infectious diseases during a Covid-19 pandemic. This failure increases the risk of life threatening hospital acquired infections for all patients. This was evidenced by the hospital:

1. failing to establish specific plans of action for prevention and surveillance for highly infectious respiratory diseases; and

2. failing to ensure staff followed hospital guidance and CDC recommendations for glove usage and hand hygiene; and

3. failing to ensure staff performed hand hygiene between clean and dirty activities for 1 (S10RN) of 1 staff member observed administering dialysis.

Findings:

1. Failing to establish specific plans of action for prevention and surveillance for highly infectious respiratory diseases.

Review of COVID-19 Preparedness Plan indicates the Infection Prevention and Control department is responsible for review of all positive COVID-19 results and would "monitor for healthcare-associated transmission among patients and staff. Results will be utilized ... to develop, implement, and / or change/ update infection prevention interventions."

Review of the hospital's infection control plan and risk assessment indicated high priority risk for highly infectious diseases in 2020 and 2021. The document also indicated "action plan required."

In an interview on 3/23/2021 at 1:00 p.m. with S6Dir, she verified that the hospital had no written standards, policies, or procedures for undiagnosed respiratory illness and COVID-19. She also verified that there were no policies or protocols for identifying, tracking or reporting fever, respiratory illness or other sign/symptoms of COVID-19. S6Dir stated that identification and testing of potentially infected patients after admission was the responsibility of the attending physician.


2. Failing to ensure staff followed hospital guidance and CDC recommendations for hand hygiene and glove usage.

Review of the hospital's COVID-19 PPE Guidance revealed the following:
Doffing:
1. Inside of room: Remove contaminated gloves and perform hand hygiene.
2. Inside of room: Don clean gloves and use a paper towel to open door to exit room.
3. (You are now outside of room) Remove face shield, sanitize and place on clean surface or hang on IV pole.
4. Use hand sanitizer to sanitize gloves.
5. Sanitize gown using PDI wipes. Untie gown and remove. Hang up on IV pole to dry.
6. Remove gloves and sanitize hands.
7. Apply new gloves, remove N95 and place in paper bag.
8. Remove gloves and sanitize hands.
9. Shoe covers are removed upon exiting unit.

Review of the CDC document titled Personal Protective Equipment: Questions and Answers revealed the following in part:
Is double gloving necessary when caring for suspected or confirmed COVID-19 patients in healthcare settings? CDC guidance does not recommend double gloves when providing care to suspected or confirmed 2019-Covid patients.

In observations on 03/23/2021 beginning at 10:00 a.m. on 4 Tower and 7 Tower COVID units, multiple staff members were observed wearing 2 pairs of gloves into patient rooms. Upon leaving the rooms, the staff would remove 1 pair. Then they were observed using hand sanitizer on the gloves and then touching clean items and removing PPE.

In an interview on 03/23/2021 at 10:30 a.m. with S4Dir, he said when the nurses go into the patient rooms, they don two pairs of gloves, a gown, shoe covers and a N95 mask. He said when they exit, they remove their outer gloves, sanitize the gloves that remain and then remove their PPE.

In an interview on 03/23/2021 at 12:28 p.m. with S6Dir, she said the hospital uses CDC recommendations for their guidelines. She said wearing two pair of gloves is not recommended for nurse's taking care of Covid-19 patients. She also said she was not aware that was the practice on the Cocid-19 units.

In an interview on 03/23/2021 at 2:43 p.m. with S2Reg, she verified staff should be wearing 1 pair of gloves and sanitizing their hands after removal.

3. Failing to ensure staff performed hand hygiene between clean and dirty activities for 1 (S10RN) of 1 staff member observed administering dialysis.

Review of the hospital's contracted dialysis service policy titled Hand Hygiene revealed in part:
The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination.
Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap before and after direct contact with patients, entering and leaving the treatment area, after contact with inanimate objects near the patient.

In an observation on 03/23/2021 at 1:05 p.m., S10RN was performing dialysis on Patient #5 who was a Covid-19 patient in the hospital's Covid-19 unit. S10RN was observed touching multiple "dirty" items in Patient #5's room with her gloved hands while performing Patient #5's dialysis treatment. She then picked up a cell phone off of a desk with her contaminated gloves and placed it into a clean supply box. She then touched the door handle with the contaminated gloves. After exiting Patient #5's room, S10RN then removed her gloves and sanitized her hands. She then pushed the dirty dialysis machine down the hall with her bare hands. She removed her hair covering and mask with her contaminated hands and then sanitized. She then touched the dirty machine again with her bare hands. When asked to open the clean supply box to view its contents, S10RN picked up a glove off of the top of the dirty dialysis machine and donned it. S10RN then opened the clean supply box with the contaminated glove and touched the contents of the interior of the box.

In an interview on 03/23/2021 at 1:30 p.m. with S6Dir she verified hand hygiene should be performed between clean and dirty activities and after removing gloves. She also verified S10RN contaminated the contents of the clean supply box by touching items with her contaminated gloves and by placing the dirty cell phone into the supply box.