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Based on record review and interview the facility failed to:

A. Obtain consent for treatment in 1 of 30 patient Medical Records (MR) reviewed. (#1 of 1-30)

Refer to A 0117

B. Document an evaluation for the need of restraints on 1 of 1 patient record reviewed.

Refer to A 0154

C. Provide a policy for restraint use which addressed, what constituted a restraint, the need for assessment of the patient prior to restraint application, least restrictive restraint use and physician assessment of patients in restraints.

Refer to A 0159

D. Update the patient's care plan to reflect the use of restraints in 2 of 30 (#1 and #7 of 1-30) patient records reviewed.

Refer to A 0166

E. Acquire a physician's order for restraint use in 1 of 1 patient reviewed.

Refer to A 0168

Based on record review and interview the facility failed to obtain consent for treatment in 1 of 30 patient Medical Records (MR) reviewed. (#1 of 1-30)

On 8/20/2014 at 10:00 AM in the conference room, the MR for pt #1 was reviewed and revealed he had been admitted to the hospital via the Emergency Department (ED). While in the ED, the patient was verbal but short of breath. His spouse was with him. The consent to treat read as follows: "Unable to sign due to condition," however the patient was able to verbally give the reason for his visit. There was no documented consent to treat or any other admission paper work signed by the patient or his spouse.

These findings were verified by staff #2 duirng the MR review.

Based on record review and interview, the facility failed to document an evaluation for the need of restraints on 1 of 1 patient record reviewed.

On 8/20/2014, review of the facility restraint log occurred at 10:00 AM in the conference room. One patient (#1) was identified on the log for June-July-August of 2014. Patient #1 Medical Record (MR) was reviewed and revealed the following: A physician's telephone order as follows, "Side Rails up X's (times) 4 (all four side rails up) on bed per family's request. R/T (related to) recent falls". No other physician's order for restraint were identified.
Continued review of the pt MR revealed no physician or nursing assessment to evaluate the patient's fall risk before during or after all four bed rails were raised, preventing the patient from leaving the bed.

On 8/20/2014 at 10:15 AM during an interview staff #2 revealed the facility did not have a falls risk assessment program or tool and did not practice assessing patients for falls risk.

Based on document review and interview the facility failed to provide a policy for restraint use which addressed, what constituted a restraint, the need for assessment of the patient prior to restraint application, least restrictive restraint use and physician assessment of patient in restraints.

On 8/20/2014 review of the facility restraint log occurred at 10:00 Am in the conference room. One patient (#1) with one (1) restraint was identified on the restraint log for June-July-August of 2014.

A review of patient (Pt/pt). Pt #1's Medical Record (MR) was reviewed and revealed the following physician's telephone order, "Side Rails up X's (times) 4 (all four side rails up) on bed per family's request. R/T (related to) recent falls". No other physician's order for restraint were identified.
However, further review of Pt #1's MR revealed the following documentation identified in the nurses notes, dated 1/15/2014 at "1730...continue with restraint keeps trying to pull everything off, if loose". Further review identified a nursing entry dated 1/15/2014 at "1930 Pt restless...Pt has restraint to both arms, restraints not to tight...." .This restraint was not captured on the restraint log and there was no physician's order for restraint use to patient #1's bilateral arms. The above findings were confirmed by staff #2.

Review pt #7's MR was reviewed and revealed a physician's order as follows; "Ativan 0.5 mg IV Q (every) 8 hours PRN (as needed)". Pt #7 had ventilator supported respirations. The Ativan was likely given for chemical restraint when the patient was restless. This was confirmed by staff #2, however there was no physician's assessment of the patient's need prior to the physician giving the order for Ativan and no patient assessment by the nursing staff indicating the patient was restless, anxious or in some other way in need of Ativan. Further review of patient #7's MR identified no reason why the Ativan had been ordered at all.

On 8/20/2014 in the conference room at 10:30 AM staff #2 verified the above findings,
and confirmed there was no facility policy that addressed assessment of need, least restrictive choice for restraint, physician's need to evaluate the patient prior to initiation of restraint and/or renewal of restraint or nurses need to assess a patient prior to, during, and after restraint use.

Based on record review and interview the facility failed to update the patient's care plan to reflect the use of restraints in 2 of 30 (#1 and #7 of 1-30) patient records reviewed.

On 8/20/2014 review of the facility restraint log occurred at 10:00 Am in the conference room. One patient (#1) was identified on the log for June-July-August of 2014. A review of patient (Pt/pt). Pt #1 Medical Record (MR) was reviewed and revealed the following: A physician's Telephone order as follows, "Side Rails up X's (times) 4 (all four side rails up) on bed per family's request. R/T (related to) recent falls". No other physician's order for restraint were identified.

Further review of Pt #1's MR revealed the following found in the nurses notes dated 1/15/2014 "1730...continue with restraint keeps trying to pull everything off, if loose". Further review identified a nursing entry dated 1/15/2014 at 1930 "Pt restless...Pt has restraint to both arms restraints not to tight...."

On 8/20/2014 at 11:00 AM in the conference room review pt #7's MR revealed a physician's order as follows; "Ativan 0.5 mg IV Q (every) 8 hours PRN (as needed)". There was no documentation why Ativan was required to treat pt #7 and no documentation an assessment was done by the physician or the nurse to support the order. Review of patient #7 care plan revealed no documentation of use of Ativan or any problem that Ativan might be used for.

On 8/20/2014 in the conference room at 10:30 AM staff #2 verified the above findings.

Further reviewed revealed the pt #1's care plan did not reflect the use of all four bed rails nor did it reflect the initiation and use of arm restraints bilaterally. Pt #7's care plan did not reflect a reason for PRN (as needed) Ativan to be given or when it was used..

This was also confirmed by staff #2.

Based on record review and interview the facility failed to acquire a physician's order for restraint use in 1 of 1 patient reviewed.

On 8/20/2014 review of the facility restraint log occurred at 10:00 Am in the conference room. One patient (#1) was identified on the log for June-July-August of 2014. A review of patient (Pt/pt). Pt #1 Medical Record (MR) was reviewed and revealed the following: A physician's Telephone order as follows, "Side Rails up X's (times) 4 (all four side rails up) on bed per family's request. R/T (related to) recent falls". No other physician's order for restraint were identified.

Further review of Pt #1's MR revealed the following found in the nurses notes dated 1/15/2014 "1730...continue with restraint keeps trying to pull everything off, if loose". Further review identified a nursing entry dated 1/15/2014 at 1930 "Pt restless...Pt has restraint to both arms restraints not to tight...."

On 8/20/2014 in the conference room at 10:30 AM the ED nursing supervisor verified the above findings.

Based on record review and interview, the facility failed to assure all hospital departments and services were participating in the quality assurance program. The Maintenance Department failed to report quality data to the facility's Quality Improvement/Performance (QAPI) Committee. The facility also failed to monitor the quality provided by 37 of its patient care related contracted services.

Refer to Tag A0308

Based on record review and interview, the facility failed to assure all hospital departments and services were participating in the quality assurance program. The Maintenance Department failed to report quality data to the facility's Quality Improvement/Performance (QAPI) Committee. The facility also failed to monitor the quality provided by 37 of its patient care related contracted services.

Findings include:
Review of the facility document, "Quality Assurance Plan," revealed the following under the section titled, "Goals,": "To establish participation by all departments and services."

Review of the facility's QAPI Committee minutes from April 2013 to April 2014 revealed no reported quality data from the Maintenance Department.

Review of the facility's Board of Managers' Meeting minutes from May 2013 to June 2014 revealed no reported quality data from the Maintenance Department.

Review of the facility document, "Quality Assurance Plan," further revealed the following: "Quality Assurance activities employed at the facility will include assessment of services furnished by contract related to patient care."

Staff #1 provided a list of contracted services used by the hospital. The patient care related contracted services were indicated by being highlighted. Thirty-seven (37) contracted services were indicated to be patient care related.

Review of the facility's QAPI Committee minutes from April 2013 to April 2014 revealed no reported quality data from the 37 patient care related contracted services.

Review of the facility's Board of Managers' Meeting minutes from May 2013 to June 2014 revealed no reported quality data from the 37 patient care related contracted services.

During an interview on 8/21/14 at 8:30am in the conference room, staff #1 confirmed the following:
-the 37 highlighted contracted services were patient care related,
-there was no reported quality data from these services in the QAPI or the Board of Managers' Meeting minutes,
-there was no reported quality data from the Maintenance Department in the QAPI or the Board of Managers' Meeting minutes.

Based on record review and interview, the facility failed to ensure progress notes were timed in 5 (#17, 18, 20, 21, and 22) of 30 charts reviewed. The facility also failed to ensure skin assessments were completed on the initial registered nurse (RN) evaluation for 3 (#27, 29, and 30) of 30 patients.

Findings include:

Review of patient charts revealed the following with progress notes with no time noted (patient # x number of missing times):
-#17 x 6
-#18 x 2
-#20 x 7
-#21 x 4
-#22 x 3

Review of patient charts revealed three (#27, 29, and 30) with no documented skin assessment on the initial RN assessment. The skin assessment section was left blank on these charts.

During an interview on 8/21/14 at 10:10am in the conference room, staff #2 confirmed these findings.

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

A. Show evidence of an infection control plan for the facility.

Refer to A0749

B. Insure the Infection Control program was incorporated into the Quality Assessment Process Improvement (QAPI) program for the facility for 4 consecutive quarters.

Refer to A0756

Based on observation, interview and record review, the facility failed to show evidence of an infection control plan for the facility.

On 8/19/2014 at 2:00 PM, during the initial tour of the building, the following was observed:

In the outpatient radiology building: Broken and missing floor tiles, Personal Protective Equipment (PPE) (masks, eye shield/goggles, biohazard bags, protective aprons) was found missing from the PPE box that was mounted to the wall. A lower level cabinet was observed with both opened and unopened bottles of Rapicide (a cold use disinfectant) stored on the same shelf with pillows and pillow cases. Having linen for patient use and opened chemicals stored side by side would place the patient use items at risk for direct cross contamination with a highly toxic disinfectant. The cabinets below the sink held stock supplies and patient use items.

Continuing with the tour, the hallway in the radiology department was observed with no cove base and visible damage to the baseboard and wall, the length of the hallway. On 8/19/2014 in the morning, an interview with staff #2 and staff #22 revealed a water pipe had broken and damaged the walls. The cove base had been removed and the walls were drying. Upon further investigation staff #4 confirmed no written plan or estimated date of completed repair was available. Staff #22 confirmed patients were transported via this hallway from the ED to the outside radiology building for services. The visible damage to the hallway walls provided opportunity for bacteria and debris to become airborne during transport of patients. This could likely place the patent at risk for respiratory irritation and or infection.

During the tour of the laundry building two openings in the wall were observed without filter or screen covers to collect dust, lint or debris in the wall. Cold air was felt forcefully coming from these openings. No visible air duct could be seen. Interview with staff #20 confirmed this was the cold air ventilation that came out of the wall. Both of these openings were directly above the folding table for clean patient linen. Staff #20 was asked how long had the openings been without covers. She replied for quite some time. This placed the clean patient linen at risk for cross contamination.

During the tour of the hospital laboratory, the cabinet below the sink in the entrance room was observed full of lab stock supplies and patient use items, such as specimen bags and urine cups. The portable blood draw tray, carried by lab techs for blood draws, was observed with patient use tape stuck to the top of the bio-hazard receptacle. A smaller box, inside the tray which held alcohol swabs, was observed made of card board and was stained with ink, brown discoloration and dusty. The card board was unable to be sanitized. This portable tray placed patients at risk for cross contamination of potential blood born substances.

During a tour of the kitchen, the floor surfaces were observed to be dull and no longer able to hold a wax or sealant. Multiple ceramic floor tiles were found to be chipped and broken. Also the dish machine was observed with a heavy hard water build up on the outside parts that involved the floor beneath the dish washer. The condition of the floor tiles and the hard water buildup on the dishwasher presented an avenue to hold bacteria and potential cross contamination.

At the exit of the dietary department in the main corridor was small room which contained a large ice machine. Upon investigation of the inside compartment of the ice machine, black mold was observed suspended from the top panel over the ice. Rust was visible also along the ceiling and joint spaces where the sides met. This was confirmed by staff #2 who also confirmed this ice machine was primarily used for maintenance but occasionally patent family's or staff might get ice from the machine. The black mold and rust presented an actual risk for illness.

During a tour of the ED department multiple cabinets below sinks were observed with stock supplies, patent use items, and general storage of supplies. The isolation room, identified by staff #2 as the negative air flow room used for air borne isolation, was found to have positive pressure after a small piece of tissue was observed to blow away from the door. This was confirmed by staff #2 and staff #4. This was the single airborne isolation room available for patient use. Staff #4 confirmed the negative pressure had not been checked.

Continuing with the tour of the nursing unit, heavy dust was observed in multiple rooms on the high touch surfaces above the patient beds. Multiple ceiling tiles were also observed with large chips and two were observed with holes cut into the tile. Expired patient use items found in a stock closet on the medical surgical unit were identified as follows: pediatric urine collection kits dated 20010, 1 box, B-D brand spinal needles dated 2008 1 box, Ultracell sterile surgical sponges dated 2004 1 box. These findings were confirmed by staff #2. The porcelain sink found in the last patient room on the left was observed to have a chipped surface at the front of the sink. All these findings represent a risk for cross contamination for the compromised patient.

The above environmental findings were reviewed and staff #4, #2 and #1 confirmed no environmental rounds were conducted. Each department was simply supposed to turn in what they recognized as an infection control problem.

On 8/20/2014 at 9:00 AM in the conference room, the infection control program was requested for review. Although staff #1 voiced that each department was involved in the infection control program and no plan was was presented for review. A review of the Governing Body and Medical Executive meeting minutes for 6 months found no mention of discussion, review or acceptance of the hospital's infection control program or plan. The hospital had a Quality review committee meeting every quarter. For each quarter an Infection Control Quality Improvement topic was reviewed but the overall assessment of the program and plan was not documented. For 4 quarters (12 months) there was no review of the Infection Control Plan evidenced by meeting minutes.

Based on interview and document review, the facility failed to insure the Infection Control program was incorporated into the Quality Assessment Process Improvement (QAPI) program for the facility for 4 consecutive quarters.

On 8/20/2014 at 3:00 PM in the conference room, a discussion was held regarding the Infection Control (IC) program and the evidence of involvement with the QAPI program. In the absence of the Chief Nursing Officer, the Chief Executive Officer testified the IC was active within the hospital; however, review of 4 quarterly QAPI meeting minutes revealed the following statement: The following quarterly reports were presented:

Fourth Quarter February 4th
Subject Risk report
Transfer report
Patient Satisfaction report
Outpatient Chart Audit
Pain Management
Restraint Audit
24/48 hour returns
Blood Transfusion
First Quarter April 30th
Subject: Risk Report
Transfer Report
Patient satisfaction survey
Outpatient chart audit
Pain management
Restraint Audit
24/48 hour returns
Blood Transfusion report
Second and third quarter October 30th
Subject Risk report
Transfer report
Patient Satisfaction survey
Outpatient chart audit
Pain management
Restraint audit
24/48 hour returns
Blood Transfusion report

For each quarter an Infection Control Quality Improvement topic was reviewed but the overall assessment of the program and plan was not documented.

The above findings were confirmed by staff #1 and #2.