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Based on review of personnel files, patient record review, hospital policy, and staff interview, it was determined the hospital failed to ensure staff were properly trained in restraint techniques before restraining a patient for 1 of 2 patients (Patient #2) who were restrained and whose records were reviewed. It was determined the hospital also failed to ensure treatment override orders were properly signed off by the attending physician for 2 of 2 patients (Patients #2 and #9) who were restrained and whose records were reviewed. This failure had the potential for patients to be restrained in a manner that was unsafe. Findings include:

A hospital policy titled "Nursing Services / Restraint Use / Staff Training Requirements," reviewed by the hospital on 7/12/20, stated, "Only licensed nursing and clinical staff that have successfully completed MANDT training [restraint technique training] are authorized engage [sic] in the emergency use of physical restraint."

A hospital policy titled "Nursing Services / Treatment Override," reviewed by the hospital on 7/12/20, stated, "All override orders shall be regularly reviewed and rewritten by the treating physician."

These policies were not followed. Examples include:

1. The hospital failed to ensure staff who restrained patients were properly trained.

Patient #2 was a 35 year old male admitted to the hospital on 12/08/21 with an admitting diagnosis of acute psychosis. He was discharged from the hospital on 12/23/21. His record was reviewed.

An occurrence report, dated 12/08/21, regarding Patient #2 was reviewed. The occurrence report stated Patient #2 was held in a two person MANDT restraint using a side body hug for 10-15 seconds. The occurrence report indicated the two person MANDT hold was completed by a social worker and PT B.

PT B's personnel file was reviewed and her MANDT restraint training was requested. PT B's MANDT restraint training was completed on 10/07/2020, and expired on 10/31/21. When PT B restrained Patient #2 on 12/08/21, PT B's restraint training was expired, indicating she was not authorized to engage in the emergency use of physical restraint.

The DNS was interviewed on 1/21/22 at 9:26 AM. She confirmed there was no current restraint training for PT B, and confirmed PT B restrained Patient #2 on 12/08/21. She confirmed without current restraint training, staff were not authorized to use physical restraint on a patient.

2. The hospital failed to ensure emergency treatment override orders for restraints were later signed off by the physician.

a. Patient #2's record was reviewed. His record included a restraint packet that showed Patient #2 was placed in a 2 person restraint on 12/08/21. The restraint packet included an emergency treatment override order for the physical restraint. The emergency treatment override order for the physical restraint was signed by the DNS and indicated a telephone order for the restraint was received from the physician. However, the restraint order was not later physically signed off by the physician. Without the physical signature of the physician, there was no documentation that the emergency treatment override order for the restraint for Patient #2 was reviewed by the physician.

b. Patient #9 was a 46 year old female admitted to the hospital on 10/18/21 with an admitting diagnosis of acute psychosis. She was discharged from the hospital on 10/28/21. Her record was reviewed.

Patient #9's record included a restraint packet that showed she was placed in a 2 person restraint on 10/22/21. The restraint packet included an emergency treatment override order for the physical restraint. The emergency treatment override order for the physical restraint was signed by the RN and indicated a telephone order for the restraint was received from the physician. However, the restraint order was not later physically signed off by the physician. Without the physical signature of the physician, there was no documentation that the emergency treatment override order for the restraint for Patient #9 was reviewed by the physician.

The DNS was interviewed on 1/21/22 at 9:36 AM. She confirmed the emergency treatment override orders for restraints for Patients #2 and #9 were not physically signed off by the physician. She confirmed all emergency treatment orders for restraint should be reviewed and physically signed off by the physician.

The hospital failed to ensure restraints were implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy.

Based on review of hospital policy, review of patient records, and staff interview, it was determined the hospital failed to ensure patients were seen face-to-face by a trained practitioner within 1 hour after the initiation of a restraint for 1 of 2 patients (Patient #2) who were restrained and whose records were reviewed. This caused the potential for negative outcomes after restraint initiation to go unnoticed by clinical staff. Findings include:

A hospital policy titled "Nursing Services / Restraint Use," reviewed by the hospital on 7/12/20, stated, "An RN who has been trained to evaluate patients in restraint is immediately notified to perform an in-person, face-to-face evaluation of the patient within one hour of the initiation of restraint." This policy was not followed. An example includes:

Patient #2 was a 35 year old male admitted to the hospital on 12/08/21 with an admitting diagnosis of acute psychosis. He was discharged from the hospital on 12/23/21. His record was reviewed.

A restraint packet and occurrence report for Patient #2 was provided. It stated Patient #2 was placed in a physical restraint for violent/self-destructive behaviors to others and to himself on 12/08/21. There was no documentation of a 1 hour face-to-face assessment by a trained practitioner after the initiation of the restraint for Patient #2.

The DNS was interviewed on 1/21/22 at 9:26 AM. She reviewed Patient #2's record. She confirmed there was no documentation of the 1 hour face-to-face assessment after initiation of the restraint for Patient #2.

The hospital failed to ensure a patient was seen and evaluated by a trained practitioner after initiation of a restraint.

Based on review of personnel records and staff interview, it was determined the hospital failed to ensure all appropriate staff were certified in the use of CPR. This resulted in an unsafe environment for all patients. Findings include:

The personnel records of 8 direct care employees were reviewed, including 2 RN, 1 LPN, 4 PT and 1 Administrative Assistant. The record of PT A contained an expired CPR certificate.

During an interview on 1/20/22 at 1:30 PM, the Administrator confirmed all direct care staff were required to have current CPR certification. He reviewed PT A's personnel record and confirmed it did not include documentation of current CPR certification.

Appropriate hospital personnel were not certified in cardiopulmonary resuscitation.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure orders for the administration of medications contained clear instructions for administration for 1 of 10 patients (Patient #10) whose records were reviewed. This created unclear instructions for nursing staff administering medications. Findings include:

Patient #10 was a 63 year old female admitted to the hospital on 11/28/21 with an admitting diagnosis of acute psychosis. She was discharged from the hospital on 12/01/21. Her record was reviewed.

Patient #10's record included the following medication orders, dated 11/28/21:

- Ativan 2 mg PO or IM once for anxiety
- Ativan 1 mg PO or IM every 6 hours as needed for anxiety
- Haldol 10 mg PO or IM every 6 hours as needed for agitation
- Benadryl 50 mg PO or IM every 6 hours as needed for extrapyramidal symptoms

The orders for Patient #10's medications did not indicate when or why the nurse should give the medications PO versus IM. It was unclear how nursing staff would decide to give medications PO or IM.

The Director of Pharmacy was interviewed on 1/20/22 at 10:43 AM and Patient #10's medication orders were reviewed in his presence. When asked how the RN would decide what route to give a medication when the order was written IM or PO, he stated orders were written this way "when a prescriber doesn't want to get called multiple times in a night," and the nurse would use their own judgement to decide which route to give a medication. The Pharmacist stated, regarding the medication orders, "it would help if it was written more clearly."

The hospital failed to ensure orders for the administration of medications contained clear instructions.

Based on observation and staff interview, it was determined the hospital failed to ensure only authorized personnel had access to locked areas where drugs and biologicals were stored. This created the ability for unauthorized staff to enter the medication room. Findings include:

A tour of the hospital with the Administrator and the DNS was conducted on 1/18/22 beginning at 12:30 PM. There was a medication room behind the nursing station. The door to the medication room was held open with a trash can. The door had a sign on it which stated, "door to be kept closed at all times." With the door being held open and not locked, any staff member could gain entry to the medication room.

The Administrator was interviewed at the time of the observations on 1/18/22 beginning at 12:30 PM. When asked who was authorized to enter the medication room, he stated the door was locked and only RNs and LPNs had access to the medication room. He confirmed the door to the medication room should not have been held open.

The hospital failed to ensure only authorized personnel had access to locked areas where drugs and biologicals were stored.

Based on observation and staff interview, it was determined the facility failed to ensure all drugs and biologicals used for patients were not expired and readily available for all patients receiving care in the facility. This had the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

A tour of the hospital and observation of the hospital's medication room was conducted in the presence of the DON on 1/17/22 beginning at 12:25 PM.

a. The following medications were expired in the hospital's medication room:

- 18 single dose packages of Aripiprazole 5 mg, expired 12/2021

- 1 vial of Thorazine 50 mg / 2 mL, expired 11/2021

- 7 single dose packages of Quetiapine 50-100 mg, expired 12/2021

- 4 single dose packages of Folic Acid 400 mg, expired 12/2021

- 2 bottles of magnesium citrate, one expired 10/2021, the other expired 11/2021

- "Magic Mouthwash," a mixture of viscous lidocaine and other medications used to treat sores in the mouth. It had no expiration date and no preparation date.

- 1 vial of Levemir insulin, expired 11/2021

2. The following multidose multi-patient use medications were opened with no open date:

- Docusate sodium 100 mg

- Guaifenesin 400 mg

- Vitamin D3 25 mcg

- Tylenol 650 mg tablet

- 1 vial of Humalog insulin

- "Magic Mouthwash," a mixture of viscous lidocaine and other medications used to treat sores in the mouth. It had no expiration date and no preparation date.

3. There was 1 vial of Lantus insulin, with an open date of 11/29/21, indicating it should have been discarded 12/27/21.

The DNS was interviewed during the observations and tour of the medication room on 1/17/22 beginning at 12:25 PM, and she confirmed the medications were expired.

The Director of Pharmacy was interviewed on 1/20/22, beginning at 10:41 AM. When the above expired medications were reviewed, he stated he had oversight over the expired medications and had fallen behind last month due to a new medication tracking system. He confirmed the above expired medications should not have been available for patient use. Additionally, he stated multi dose injectable medications should be discarded after 28 days. When asked for the hospital policy on labeling of OTC multidose oral medications he stated he was not aware of a policy.

The hospital failed ensure all drugs and biologicals used by patients were not expired and readily available for all patients receiving care in the facility.



42316

Based on observations, instructions for use review, and staff interview, it was determined the hospital failed to ensure supplies and equipment were maintained at an acceptable level of safety and quality. The failure to maintain supplies and equipment had the potential to directly affect all patients. The findings include:

Bio-medical safety and quality testing of patient medical equipment was not done. Without current inspections of medical equipment, the hospital would not be able to ensure safe operation as follows:

A tour of the hospital with the DNS was conducted on 1/19/22 beginning at 2:45 PM. The hospital had several pieces of equipment used on patients including:

- 2 wrist blood pressure cuffs.
- 1 vital signs cart which included a blood pressure cuff, pulse oximeter, and thermometer.
- 1 blood glucose meter.
- 1 pulse oximeter.
- 1 infrared thermometer.

1. The vital signs cart had a last biomedical service sticker of 4/23/20, the sticker stated it was due for its next service 4/23/21. There was no documentation it had been checked for functionality or maintenance performed since 4/23/20.

The DNS was interviewed during the observation on 1/19/22 and she confirmed there was no documentation the vital signs cart had been checked since 4/23/2020.

2. The blood glucose meter instructions for use included:

"We recommend performing Control Tests for practice before using your meter for the first time to test your blood. Control Tests should be performed:

- For practice to ensure your testing technique is good,
- Occasionally as you use a vial of test strips,
- When opening a new vial of test strips,
- If results seem unusually high or low,
- If a vial has been left opened or exposed to extreme heat or cold, or humidity,
- Whenever a check on performance of the system is needed,
- If meter damage is suspected"

There was no documentation a control test was performed for the blood glucose meter.

The DNS was interviewed at the time of the observation on 1/19/22. She stated there was no documentation of a log of maintenance or control tests for the blood glucose meter.

3. The hospital did not have maintenance records or functionality checks for the wrist blood pressure cuffs, infrared thermometer and pulse oximeter.

The DNS was interviewed at the time of the observations on 1/19/22. She confirmed there was no log of maintenance or functionality checks for the above equipment. Additionally, she stated she was unsure of the maintenance requirements for the above equipment.

The Administrator was interviewed on 1/19/22 beginning at 3:00 PM. He stated the biomedical service they were using had canceled their contract approximately 5 months before the survey and they had been unable to find another service. He confirmed there had been no biomedical checks on the above equipment.

The hospital failed to maintain patient equipment.



42316

Based on observation, review of CDC guidelines, facility document review, and staff interview, it was determined the facility failed to maintain a functional and sanitary environment for patients receiving care at the facility. This had the potential to impact all patients receiving services at the facility and placed patients at an increased risk for infections to occur.

1. The facility failed to follow CDC guidance related to laundry.

The CDC website, accessed on 1/20/22, stated "A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot-water washing."

During a tour of the facility on 1/17/22, beginning at 12:25 PM, the DON and Administrator were asked about the facility's Infection Control program as it related to laundering of the facility linens. The laundry room was observed during the tour. The Administrator stated linens and patient's clothes were laundered by the facility. He stated the housekeeper performed laundry duties. When asked if a log was maintained which included temperature monitoring of the water for the washing machine, he said there was no log.

The Housekeeper was interviewed on 1/20/22 beginning at 2:00 PM. When asked what nationally recognized guidelines for Infection Control the facility followed, the Housekeeper stated "CDC." When asked if she kept a log of water temperatures, she said no.

The facility failed to follow CDC guidelines related to laundry services.

2. The Facility failed to maintain a sanitary environment

a. A tour of the hospital and observation of the hospital's biohazard room was conducted in the presence of the DNS on 1/19/22 beginning at 3:00 PM. The room consisted of the facilities water softener and hot water heaters. The two biohazard trash cans were directly adjacent to the facilities water softener. The lid to one of the biohazard trash cans was sitting on top of the water softener potentially contaminating the clean water. The DON confirmed the biohazard trash can lid should not be sitting on the water softener.

b. A tour of the hospital and observation of the hospital's nurses station was conducted in the presence of the DNS and Administrator on 1/17/22 beginning at 12:25 PM. When asked what is used to clean the counter tops of the nurse's station, the Administrator provided "ZEHN-X" 180 count extra strength disinfectant wipes.

The "ZEHN-X" disinfectant wipes website was accessed 1/17/22. It stated under the FAQ section:

"Is Zehn-X EPA registered? Our 180 ct [count] EXTRA strength formula is going through the EPA registration process and will be soon."

The CDC website (https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html#rec5n) accessed 1/17/22 stated:

"Use a one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes in patient care areas where uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or uncertainty exists about the presence of multidrug resistant organisms on such surfaces."

The Administrator was interviewed 1/17/22 beginning at 2:45 PM. He confirmed the wipes were not EPA registered and approved for hospital use per the CDC.

c. A tour of the facility was conducted with the DNS and Administrator on 1/17/22 beginning at 12:25 PM. The following issues were noted:

- The facility's main nursing station had a handwashing sink used by the nursing staff. The sink had a layer of dirt and grime and build up in the sink and the surrounding countertop. The wall directly behind the sink had broken paint exposing the drywall.

- The floor behind the nurse's station had a thick layer of dust and debris and was stained.

- The counter top at the nurse's station was broken and cracked in several areas exposing the porous material underneath.

The DNS was interviewed at the time of the tour and confirmed the above observations.

The Housekeeper was interviewed on 1/20/22 beginning at 2:00 PM. When the above observations were reviewed with her, she stated they have had recent turnover and was doing as much as she could per day. She confirmed the above observations.

d. The facility had a Blood glucose meter used to check multiple patients' blood sugar levels.

The blood glucose meter instructions for use included. "The TRUE METRIX Self Monitoring Blood Glucose System is for one person use ONLY. DO NOT share your meter or lancing device with anyone, including family members. Do not use on multiple patients!! ALL parts of your blood glucose monitoring system could carry blood-borne pathogens after use, even after cleaning and disinfecting." These instructions were not followed.

The DNS was interviewed on 1/19/22 beginning at 3:00 PM. When shown the blood glucose meter's instructions for use, she confirmed the meter was used on multiple patients and it should not have been. When asked if the meter was disinfected between patients she said "yes," however confirmed there was no log.

The facility failed to maintain a sanitary environment.