HospitalInspections.org

Based on medical record review and staff interview the facility failed to ensure a physician assessment was conducted for a patient placed in Seclusion. This was evident in one (1) of two (2) medical records reviewed. (Patient #5).


Findings:

Review of the Medical Record for Patient #5 noted documentation that the patient was placed in Seclusion on 10/14/16 at 10:45 AM until 12:45 PM.

There is no documented evidence on the "Restraint/Seclusion Assessment and Physicians Order" form that the required face-to-face medical evaluation was performed.

Review of the facility's policy, " Patient Restraints and Seclusion," last reviewed 10/2016, documented: "When restraint and seclusion are deemed appropriate for patient safety, the Licensed Independent Practitioner (Physician) shall be summoned within thirty (30) minutes. The Licensed Independent Practitioner is required to conduct a personal examination of the patient when determining the need for restraint and/or seclusion use. Physician assessment will be communicated (documented) on the "Restraint/Seclusion Assessment and Physicians Order" form and in the Electronic Medical Record."

There was no documented physician assessment for this patient who was in seclusion. On 10/17/16 at 12:47 PM, approximately three (3) days after the seclusion episode, a physician's addendum noted, "Patient in locked seclusion on 10/14/16."

During interview on 12/07/16 at 11:45 AM, Staff E stated, "The face to face assessment was not done."

Based on observation, and staff interview, the hospital did not ensure that the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

During a tour of the facility on 12/7/2016 between 10:30 AM and 12:30 PM, the following were identified:

Psychiatric Unit:

1. All the faucets of the hand wash-sinks of the psychiatric unit are potential for looping risk. The faucets of the hand-wash sinks of all patients' bathrooms are from the regular type of faucets (goose neck faucets) and not the safety type of faucets. Examples included but are not limited to: Faucets of Room 113, Room 107, Room 103 and Room 106.

2. Room 113 has two (2) medical beds with multiple looping risk and two (2) movable bed side stands and 2 walkers, which also present potential looping hazard.

3. Room 111 and Room 106 have medical beds with multiple looping risk, and movable bed side stands which present potential looping hazard.

4. Room 103 and Room 107 have captain beds with side holes that are used for patient restraint and present a looping risk. There are movable night stands and desks in these rooms, which also present a looping risk.

The door handles of the patients' rooms are from the safety type, with the upward levers of the handles facing the corridor. The doors are located within deep alcoves (> 3 feet deep) and are not visible to the staff, and this presents a looping hazard.
There are alcoves between every two patient rooms. (Examples are: an alcove between Room 104 and Room 106, and alcove between Room 107 and Room 109).

5. The three (3) door handles for three doors that open to the day room are with handles from the regular type, which present a looping risk.

6. The door handles of the clean supply room, lavatory room and janitor's closet are located within a deep alcove and present a looping risk.

7. The TV cables of the lounge/group room, the wirings of video and speakers on that room, and the space between the TV and TV mounted brackets, present looping hazards.

8. The faucet of the snack (kitchenette area) has a goose neck and present a looping risk.


The above findings were identified in the presence of the Director of Facilities Management and the Senior Administrative Director, and was brought to the attention of the Hospital's leaders during the exit conference.

Based on document review, observation, and interview, the hospital did not: (1) maintain a sanitary physical environment to avoid sources of infection, (2) ensure that staff implements the facility's policy and procedure on hand hygiene to mitigate risks contributing to infection.

Findings include:

1. During tours of the hospital on 12/8 and 12/9/2016, the following were identified:


The ceiling tiles of the ICU Rooms and the Isolation Rooms (560 and 561) are of the regular type and not the washable type that can be washed and or disinfected easily as per AIA requirements.

The walls of the old operating rooms (OR) were found to have ceramic tiles with grout in between them that make these walls difficult to clean or disinfect and is a potential for the transmission of infection. Some of the ceramic tiles were observed to be damaged, broken, or chipped, which has a potential to harbor dirt and promote microbial growth. Examples included but were not limited to OR #1 and OR #2.

The Epoxy Floors of some of the old ORs were chipped and not smooth, which makes the floors difficult to clean and disinfect, and is a potential for the spread of infection.

The metal wheels of two (2) soiled hampers on OR#2 had rusted wheels, which is an infection control concern.

The clean utility room of the Wound Healing Institute was found to have a negative airflow instead of the required positive airflow for this type of room.

These findings were identified in the presence of the Director of Facilities Management who acknowledged the findings.

In OR #5, on 12/8/16 at approximately 2:30 PM, it was observed that a leg rest with torn upholstery was used to support a patient's left leg during a procedure. The rips in the upholstery prevents proper disinfection between patients.

This observation was made in the presence of Staff #K who acknowledged the findings.


2. Observation of blood drawing procedure on 12/9/2016, at approximately 11:19 AM, noted that Staff Y, Laboratory Technician, after blood drawing proceeded to type on a computer keyboard, opened and closed closet doors and drawers with a soiled glove prior to handwashing.

On 12/9/2016 at approximately 1:58 PM, Staff V, Laboratory Technician, did not wash her hands or use an alcohol hand rub after blood drawing on a patient.

The facility policy and procedure titled "Hand Hygiene: Handwashing & Alcohol Hand Rub," last revised 06/2016 stated the following: "hand hygiene should be done (even when gloves are used) ... Before and after contact with each patient ... "

These findings were confirmed by Staff Z, who was present during the observations.



26259