HospitalInspections.org

Based on review of policies and procedures, medical records, and staff interview it was determined that the facility failed to:

(A0165) ensure that 8 of 8 emergency department patients were not restrained with unauthorized devices (handcuffs, or a surgical mask placed over their face to act as a spit mask and restrain the patient from spitting). This deficient practice poses the potential risk to the health and safety of patients when unauthorized restraint devices are utilized in a healthcare setting by untrained employees. (Patients # 10, 14, 20 and 21- handcuffs; Patients # 23, 13, 15 and 16 -Surgical mask)

(A0171) ensure 11 of 12 patients had valid and complete orders for seclusion and/or restraint documented per facility policy. This deficient practice poses the potential risk to the health and safety of patients when seclusion and/or restraint is utilized without a complete and valid physicians' order; (Patients # 8, 9, 10, 11, 12, 13, 14 16, 17, 18, and 19)

(A0184) ensure that 8 of 12 patients received a one hour face-to-face evaluation per facility policy. This deficient practice poses the potential risk that a change in the medical or psychological condition of the patient will not be identified. (Patients # 10, 13, 14, 15, 16, 20, 21, and 23)

(A0200) ensure that 14 of 14 emergency department employees, and 8 of 9 security staff had current NVCI training (Employees #28, 35, 53-64 & 43, 45-47,49-52). Additionally, 9 of 9 security staff were not in compliance with required annual seclusion and restraint training (employees #43-47, 49-52). This deficient practice poses the potential risk to the health and safety of patients when seclusion and restraint is being practiced by untrained employees.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights; which poses a potential risk to the health and safety of patients if patients are not maintained free from potential harm when they are restrained without a physician orders, assessments completed prior to restraining and the use of less restrictive interventions utilized prior to the initiation of restraints.

Based on review of policies and procedures, medical records, and staff interview it was determined that the facility failed to ensure that 8 of 8 emergency department patients were not restrained with unauthorized devices (handcuffs, or surgical mask place over their face to act as a spit mask and restrain the patient from spitting). This deficient practice poses the potential risk to the health and safety of patients when unauthorized restraint devices are utilized in a healthcare setting by untrained employees. (Patients # 10, 14, 20 and 21- handcuffs; Patients # 23, 13, 15 and 16 -Surgical mask)

Findings Include:

The facility policy titled "Violent or Disruptive Behavior" requires: "...when physical intervention is required as a last resort due to an individual's dangerous behavior, the least amount of force needed to maintain the safety of staff, patients, and visitors is utilized...."

The facility policy titled "Guidelines for the Use of Restraints for Voluntary/Involuntary Immobilization" requires: "...Use only approved restraint devices to restrain patients, following all manufacturers' directions for application ...handcuffs, shackles, and other chain-type restraint devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients...."

Four "Safety and Security Event" reports were provided that revealed the use of handcuffs on patients by security staff. (Patients # 10, 14, 20, and 21)

Four of 12 medical records reviewed contained documentation that a "spit mask" , a sugical mask had been used on a patient to prevent spitting. (Patients # 23, 13, 15 and 16)

Employee #14 confirmed that there are no facility policies or procedures for the use of surgical masks on patients to prevent spitting.

Employee #28 confirmed during an interview conducted on 08/21/19, that handcuffs are used to restrain patients in the emergency department.

Employee #38 revealed during an interview conducted on 08/21/19, that all security staff carry handcuffs on their person. Further, security staff can use handcuffs to restrain a patient until an IM (chemical restraint) is given or the nurses are able to apply restraints. Employee #38 confirmed that there are no facility policies or procedures for the use of handcuffs to restrain patients.

Employee #28 revealed in an interview conducted on 08/21/19, that emergency department staff use surgical masks on patients to prevent spitting.

Based on review of policies and procedures, medical records, and staff interview it was determined the facility failed to ensure 11 of 12 patients had valid and complete orders for seclusion and/or restraint documented per facility policy. This deficient practice poses the potential risk to the health and safety of patients when seclusion and/or restraint is utilized without a complete and valid physicians' order. (Patients # 8, 9, 10, 11, 12, 13, 14 16, 17, 18, and 19)

Findings Include:

The policy titled "Guidelines for the Use of Restraint for Voluntary/Involuntary Immobilization" requires: "...the initial restraint order for crisis restraints is renewed as needed every 4 hours for adults; every 2 hours for ages 9-17; and every 1 hour for ages under 9 after expiration of the original order by reporting to the physician the present condition of the patient and obtaining a verbal/telephone order from the physician...."

Eleven of 12 medical records reviewed failed to reveal a complete and valid physicians' orders for seclusion and/or restraint. There was no renewal order obtained after the initial order had expired, or the order was obtained late, or no order was ever obtained for seclusion and/or restraint as required by facility policy.

Employee #41 confirmed during an interview conducted on 08/22/19, that the medical records were missing complete and valid orders for seclusion and/or restraint.

Based on review of policies and procedures, medical records, and staff interview it was determined that the facility failed to ensure that 8 of 12 patients received a one hour face-to-face evaluation per facility policy. This deficient practice poses the potential risk that a change in the medical or psychological condition of the patient will not be identified. (Patients # 10, 13, 14, 15, 16, 20, 21, and 23)

Findings Include:

The policy titled "Guidelines for the Use of Restraint for Voluntary/Involuntary Immobilization" requires: "...the physician completes a face-to-face assessment of the patient within one hour of the application of restraint...."

Eight of 12 medical records reviewed failed to show evidence of a completed one hour face-to-face evaluation after a seclusion and/or restraint event as required by facility policy.

Employee #1 confirmed in an interview conducted on 08/22/19, that the face-to-face evaluations were not completed per hospital policy.

Based on review of policies and procedures, medical records, and staff interview it was determined that the facility failed to ensure that 14 of 14 emergency department employees, and 8 of 9 security staff had current NVCI training (Employees #28, 35, 53-64 & 43, 45-47,49-52). Additionally, 9 of 9 security staff were not in compliance with required annual seclusion and restraint training (employees #43-47, 49-52). This deficient practice poses the potential risk to the health and safety of patients when seclusion and restraint is being practiced by untrained employees.

Findings Include:

The policy titled "Guidelines for the Use of Restraints for Voluntary/Involuntary Immobilization" requires: "...All staff with direct patient contact must have ongoing education, training, and demonstrated knowledge based on the specific needs of the patient population in the proper and safe use of restraints and seclusion prior to application of restraints. Education is initiated at orientation for new and contract staff, and is ongoing...Documentation of competency in the safe use of restraints and seclusion will be maintained for all staff members involved in restraint use...."

The policy titled "Behavioral Emergency Response Team" requires: "...All staff assigned to the BERT must complete Non-Violent Crisis Intervention(NVCI) Training...Required responders: Social Services, Security, Administrative Shift Coordinator (ASC), Charge Nurse on Unit, direct observer (if one is sitting with the patient), treating physician if present...."

The policy titled "Violent or Disruptive Behavior" requires: "...Staff identified as 'at risk' for encountering patients and/or visitors demonstrating disruptive behaviors are trained in Non-Violent Crisis Intervention and are certified by the Crisis Prevention Institute. Annual competency is required...."

Documentation provided by human resources revealed that 8 of 9 security staff were either overdue for, or had never completed NVCI training. Additionally, no documentation was provided that any security staff had completed seclusion/restraint training.

Fourteen emergency department personnel files reviewed revealed that 14 of 14 employees did not have current NVCI training.

Employee #38 revealed during an interview conducted on 08/21/19, that NVCI is to be completed every 2 years.

Employee #28 revealed that NVCI is required upon hire, but does not need to be repeated.

Employee #1 confirmed that this is the current practice at the facility. Additionally, Employee #1 revealed that restraint and seclusion education is provided upon hire, and a refresher is required yearly

Based on review of policies and procedures, observations, facility documents, and staff interviews, it was determined that the facility failed to ensure staff implemented the process for the inspection and maintenance of supplies and medications in 6 out of 7 emergency code carts per facility policies. Failure to maintain emergency supplies and medications potentially jeopardizes the safety and quality of care provided to patients in emergency and life threatening situations.

Findings include:

The policy titled, "Code Cart/Emergency Medication Availability and Securement" revealed: "...6. Code carts are checked each shift by nursing or designated department staff. 7. Code cart drug drawers are inspected monthly by Nursing and Pharmacy. 8. Supplies in code carts are inspected monthly and are replaced when used or upon expiration by department staff...Nursing/Patient Care Area 1. The Code Cart is checked for readiness each shift by the person in charge or a designated person A. Complete the Code Cart Checklist form 1. Check the proper operation and readiness of the equipment listed....2. Observe...the cart is within the expiration date. 3. Sign the designated areas of the form...C. The Cardiopulmonary Department restocks the used adult cart and makes it available for the next department...G. After entry has been made into the code cart, the Pharmacy Department is notified and is responsible for the replacement of emergency medications...2. Emergency medication drug boxes...RSI kit in ICU...checked monthly...Pharmacy 1. Pharmacy is in charge of the control and distribution of all medications. Pharmacy is responsible for checking the code cart medication for outdated medications. This duty is performed by Pharmacy on a monthly basis...."

The policy titled, "Code Cart Cleaning and Maintenance" revealed: "...It is the responsibility of staff in each department where a code cart is located to follow the check list attached to the code cart to ensure the presence, working condition and outdates of the necessary medications, supplies and equipment. 2. It is the responsibility of staff in each department where a code cart is located to restock supplies as needed after the cart has been opened for use...."

Observations, during a tour of the facility on 08/19/2019, revealed the following:

ICU Code Cart #1:

The monthly "Adult Code Cart Checklist" which contains a list of the supplies and medications contained in each of the 6 code cart drawers, the top of the cart, and the side of the cart revealed no documentation as to when the contents of the code cart was last checked.

The RSI Airway Box associated with Code Cart #1 was last checked for expired supplies and medications on 06/25/2019 at 2245 hours. Taped to the top of the RSI box was a packaged ET tube introducer straight tip with an expiration date of 02/2019.

The shift "Code Cart Checklist" revealed that the lock # on the code cart and the percentage of remaining oxygen in attached O2 Tank was not checked on 08/01/2019, 08/09/2019 night shift, 08/15/2019 - 08/17/2019 night shift. A discharge test was conducted on the defibrillator on 08/05/2019, as indicated by the documentation "Pass".

The shift "ICU Intubation Box Check Sheet" revealed that the lock # was not checked on 08/02/2019 night shift, 08/03/2019 night shift, 08/06/2019 night shift, 08/09/2019 night shift, 08/15/2019 - 08/16/2019 night shift, and 08/27/2019, night shift.

ICU Code Cart #2:

The monthly "Adult Code Cart Checklist" revealed no documentation as to when the contents of the code cart were last checked.

The shift "Code Cart Checklist" revealed that the lock # on the code cart and the percentage of remaining oxygen in attached O2 Tank was not checked on 08/02/2019 day shift, 08/09/2019 night shift, 08/15/2019 - 08/17/2019 night shift. A discharge test was conducted once on the defibrillator on 08/05/2019, as indicated by the documentation "Pass".

The shift "ICU Trach Tray Box Check Sheet" revealed that the lock # was not checked on 08/02/2019 day shift, 08/03/2019 night shift, 08/06/2019 night shift, 08/09/2019 night shift, 08/15/2019 - 08/16/2019 night shift, and 08/27/2019, night shift.

Drawer #4 contained a 60cc Normal Saline syringe which expired 07/2019.

Employee #15 confirmed, in an interview conducted on 08/19/2019 at 1400 hours, the Normal Saline syringe was expired.

Employee #15 identified, in same interview, the nurses only check to see if the locks are intact on the code carts, and that they are not required to check for expiration dates. Additionally, Employee #15 confirmed that a discharge test on the defibrillator had not been done every week as required.

Med/Surg Telemetry Code Cart #3:

The monthly "Adult Code Cart Checklist" revealed 04/09/2019, as the last time the contents of the code cart were checked.

In drawer #2 of the cart there was a 7.5mm hi/lo nasotracheal cuffed tube which expired 02/2019.

Located on the side of the cart was a 15 French adult ET introducer which expired 07/2019.

Employee #16 identified, in an interview conducted on 08/19/2019 at 1430 hours, nurses are not required to check for expiration dates. Employee #16 confirmed, in same interview, the nasotracheal tube and the ET introducer were expired.

Med/Surg Code Cart #4:

Located on the side of the cart was a 15 French adult ET introducer which expired 07/2019.

Employee #17 confirmed, in an interview conducted on 08/19/2019 at 1500, the ET introducer was expired. Additionally, Employee #17 verified that nursing staff is required to open the code cart on a monthly basis to ensure supplies and medications are intact and have not expired.

Post-Partum Code Cart #5:

The monthly "Adult Code Cart Checklist" revealed 06/28/2019, as the last time the contents of the code cart were checked.

The shift "Code Cart Checklist" revealed that the lock # on the code cart and the percentage of remaining oxygen in attached O2 Tank was not checked on 08/01/2019, 08/02/2019 - 08/03/2019 night shift, 08/05/2019 - 08/06/2019 night shift, 08/08/2019 - 08/10/2019 night shift, and 08/12/2019 - 08/16/2019, night shift.

Drawer #1 of code cart is a sealed tray which contains needles, syringes, and IV catheters. The seal on this tray was open and not secured. The yellow sticker on top of the tray revealed: "...First to expire 16 gauge needles on 06/03/2019...." Upon inspection, unable to locate expired 16 gauge needles.

Employee #18 identified, in an interview conducted on 08/19/2019, that h/she could not explain why the seal was broken on the tray located in drawer #1 of the code cart, and that once the seal had been broken the tray should have been restocked and sealed again.

Neonatal Code Cart #6 in Post-Partum Nursery:

Inspection of code cart #6 revealed an infant LMA classic size 1 still in the sealed manufacturer's packing. The packing label revealed: " ...Reusable, Non-sterile, Should be autoclaved prior to use ...."

Employee #18 confirmed, in an interview conducted on 08/19/2019, the LMA had not been sterilized, and that h/she did not know the LMA was in the cart unsterilized.

Employee #1 confirmed, in an interview conducted on 08/19/2019, staff are not inspecting the code carts or maintaining the supplies and medications within the code carts as required by hospital policy.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency, if specific needs of both the patient and staff are not identified as part of the EP plan.

Findings Include:

The community-based risk assessment was requested on August 20, 2019. The facility did not have a documented community-based risk assessment to review. The facility had a documented facility-based risk assessment.

The Chief Operating Officer (COO), Chief Information Officer (CIO), and key hospital staff acknowledged during the exit conference on August 20, 2019, that the facility did not have a documented community-based risk assessment to review.

Based on observation, staff interview and record review, it was determined the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Failure to include a process for cooperation and collaboration could lead to harm to both patients and staff if all collaborating parties are not aware of the specific needs of the facility involved and affected by the emergency.


Findings include:

The facility's Emergency Plan was reviewed on August 20, 2019. The Emergency Plan did not indicate, with supportive documentation, a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

The COO, CIO, and key hospital staff confirmed during their exit conference on August 20, 2019, that the facility emergency plan did not indicate a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop an emergency policy and procedure at alternative care sites may cause harm to the patients during an emergency if the needs of the patients are not met.


Findings Include:

The facility's Emergency Plans policies and procedures was reviewed on August 20, 2019. The facility did not have emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency.

The COO, CIO, and key hospital staff acknowledged during the exit conference on August 20, 2019, that the facility did not have emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency.