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Based on interview and record review, the facility failed to comply with Texas Dog Laws when the facility failed to inform local authorities when two patients presented to the Emergency Room with dog bites. (Patients #G8 and G9)

Findings Include:

Review of the facility's medical records logs reflected:
On 2/28/2017, Patient #G9, a 13 year old female presented to the Emergency room with a complaint of a dog bite."Pt [patient] was walking home, and 'she saw the dog running towards her after the dog was playing with its owners' ...puncture wound noted to right calf. Minor bleeding note..."
On 12/24/16, Patient #G8, a 17 year old male presented to the Emergency room with a complaint of a dog bite. "Bit [sic] to left forearm by pts dog... two puncture wounds noted to left forearms..."

During an interview on 4/19/17, in the facility conference room, Staff #G17, the Quality Director, stated, "We don't have to report the dog bites."

Review of the El Paso Texas Dog Law www.texasdogbiteinjurylaw.com/texas-cities-animal-ordinances.php reflected "...Anyone who suffers an animal bite or scratch that breaks the skin should contact El Paso animal Services and state authorities within 24 hours of the incident..."

Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights. As evidence by:

1. Failing to provide an emotionally safe environment. Cross refer to A0144.

2. Failing to ensure the patient right to be free from the inappropriate use of restraint, by allowing hospital employed/contracted staff to utilize handcuffs as restraints in the Emergency Department. Cross refer to A0154.

3. Failing to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. Cross refer to A0168.

4. Failing to ensure the use of restraint included written modification to the patient's plan of care. Cross refer to A0166

5. Failing to ensure that unless superseded by State law that is more restrictive--
(i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older. Cross refer to A0171.

6. Failing to ensure that restraint incidents had documented face-to face evaluations within 1 hour after the initiation of the restraint to evaluate:
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.
Cross refer to A0179

7. Failing to ensure that for restraint episodes, the patient medical record includes a description of the patient's behavior and the intervention used. Cross refer to A0185.

8. Failing to ensure that for restraint episodes, the patient medical record included, alternatives or other less restrictive interventions attempted (as applicable). Cross refer to A0186.

9. Failing to ensure that for restraint episodes, the patient medical record included, the patient's condition or symptom(s) that warranted the use of the restraint or seclusion. Cross refer to A0187.

10. Failing to ensure that for restraint episodes, the patient medical record included. the patient's response to the intervention(s) used, including the rationale for continued use of the intervention. Cross refer to A0188.

11. Failing to ensure that patients had the right to safe implementation of restraint or seclusion by trained staff. Cross refer to A0194.



33326

Based on observation, interview and record review the facility failed to protect and promote each patient's rights when a patient was not given a bath for four days, restraints were not care planned and a patient was restrained for nine days without alternative interventions being attempted and the facility was using a medical restraint for a patient being restrained for behavioral issues.

Cross Refer to A144, A154 and 166

Based on observation, interview and record review the facility failed to provide an emotionally safe environment when a patient requested a shower and was not provided access to a shower for four days. (Patient G#16)

Findings include:

An observation on the morning of 4/19/17 in the facility Emergency room revealed Patient #G16 was under a protective order of custody, a security guard was standing outside the patient's door.

During an interview on the morning of 4/19/17 in the facility Emergency room, Patient #G16 when asked if he had been offered a shower or had asked for a shower stated, "I asked for one but wasn't given one ....I need a shower ...I smelt myself and nearly knocked myself over ..."

The facility was informed Patient #G16 was requesting a shower on the morning of 4/19/17.

During an interview on the morning of 4/20/17 in the facility Emergency room, Staff #G16, Emergency Room Director when asked if Patient #G16 had received a shower stated,"...he went to court today ...he got a shower at around 7:00 this morning ....I asked for him to get a shower yesterday too..." When asked if he had gotten one yesterday, Staff #G16 stated, "I don't know."

Review of Patient #G16 medical records reflected a 26 year old male admitted on 4/16/17 at 11:40 a.m. was given a shower on 4/20/17 at 7:15 a.m. There was no further documentation to reflect he was offered or given a shower.

The facility did not provide a policy for the hygiene of patients held in the Emergency room over 24 hours.

Based on a review of documentation and interview, the facility failed to ensure the patient right to be free from the inappropriate use of restraint. According to the Centers for Medicare Interpretive Guidance: The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such 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.

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,

"Exceptions to the Definition of Restraints:
3) Use of Handcuffs:
The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However the use of such 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."

Based on interview and review of documentation, the facility was inappropriately utilizing handcuffs as a method of restraint, often applied by off duty police officers who were contracted employees of the facility. This use of handcuffs as a restraint is not considered a safe, appropriate health care restraint interventions for use by hospital staff to restrain patients and is not permitted per facility policy and CMS regulations.

In an interview on 04/20/17, staff member #A42 stated that the few restraints they had observed in Del Sol Emergency Department occurred during Code Strongs when all free staff including nurses, security, and the off duty police officers responded. This staff member was asked about the use of handcuffs during Code Strongs in the Emergency Department at the Del Sol campus. The staff member replied that the off duty police officers at the facility apply handcuffs in a code strong scenario. They added once the patient is in handcuffed, security personnel will stand to the side to monitor the patient. "Usually the off duty police officer takes over".

Staff member #A23 stated that patients are sometimes brought to the facility Emergency Department in handcuffs while in police custody. This staff member stated that police officer will at times hand the care of the handcuffed patient off to the off duty police officer employed by the facility. This staff member was asked when the patient's handcuffs would be removed. They replied, "We assess them every 15 minutes, the nurse and security talk and determine when they can be released". This staff member also confirmed that at times when a Code Strong is called for an aggressive patient, the patient will be handcuffed by the off duty police officer at the facility until calm.

Review of sample of Code Strongs recorded for the Del Sol Emergency Department for the month of March and April 2017 revealed one documented restraint involving the handcuffing of a patient which was not documented in medical records.
* A "Daily Security Supervisor Pass Down" report on 03/18/17 included the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."

It is unknown if facility security or contracted off duty police officers applied this handcuff restraint. Per facility based policy and CMS guidance, this type of employee is not permitted to apply handcuffs as a restraint.

Review of "[Security Company Name] Security-Patient Restraint" forms revealed 2 of 4 documented restraint incidents involving the use of handcuffs and/or shackles:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]"
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

Documentation indicates that Patient #A14 was restrained using a handcuff by a facility contracted off duty police officer, which is against facility based policy and CMS guidance. Based on documentation it is unknown who applied the shackles to Patient #A14. It is unknown if facility security or contracted off duty police officers applied the handcuff restraint on Patient #A17.

Based on interviews and documentation review, the facility utilized handcuffs to restrain patients. At times, these handcuffs were applied by hospital contracted employees, which is not allowed. Handcuffs should only be utilized by non-hospital employees or non-contracted law enforcement officials for custody, detention, and public safety reasons. In such a scenario, the non-hospital employed or contracted law enforcement officials should maintain custody and direct supervision of their prisoner.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.


33326

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Based on record review and interview the facility used a restraint inappropriately when an assessment for Risk for Restraint and less restrictive alternatives were not attempted prior to placing a patient in a restraint. (Patient #G21)

Findings Include:

Review of Patient #G21's medical records revealed on 3/12/17 Patient #G21 experienced a fall. Review of physician's orders for "Restraint device: Enclosure...Unsafe mobile attempts..." with daily orders written from 3/12/17 through 3/22/17. Review of the facility's available interventions included 'Sitter'.

During an interview on 4/20/17 in the facility conference room, Staff #G18, Director of Advance Clinical, when asked if the facility had attempted to use a sitter, staff #G18 stated, "No." While reviewing the electronic assessment for Risk for Restraint Staff #G18 confirmed the assessment form did not include all the questions to review as the facility's Restraint policy required.

Review of the facility provided document PC 210 Restraints (dated 6/30/15) reflected "...Purpose: 1. to protect the dignity and safety of inpatients...through safe restraint processes. 2. To identify patients at risk for restraint and provide alternatives to restraint use. 3. To provide guidelines for use of least restrictive interventions to avoid restraint use....The Registered Nurse performs an assessment for risk for restraint when a patient exhibits behavior that may place the patient at risk for restraint....4. Second Tier of Review....a. Alternatives attempted."

Based on interview and record review the facility failed to develop and keep current, a nursing care plan for each patient when interventions and reassessments were not care planned on (3) out of (3) patients reviewed for restraint care plans. (Patients #G23, G21 and G22)

Findings Include:

Review of Patient #G23's medical records revealed a 42 year old female admitted on 3/9/17 and placed on restraints on 3/10/17. The patient's care plan was not updated to reflect the implementation of the restraint.

Review of Patient #G21's medical records revealed a 71 year old male admitted on 3/9/17 and placed on restraints on 3/12/17. The patient's care plan was not updated to reflect the implementation of the restraint.

Review of Patient #G22's medical records revealed a 32 year old male admitted on 1/11/17 and placed on restraints on 1/12/17. The patient's care plan was not updated to reflect the implementation of the restraint.

During an interview on 4/20/17 in the facility conference room, Staff # 18, Director of Advance Clinical, confirmed the care plans did not include the implementation of the restraints.

Review of the facility provided document "PC 210 Restraints" (dated 6/30/15) reflected, "...Purpose: 1. to protect the dignity and safety of inpatients ...through safe restraint processes. 2. To identify patients at risk for restraint and provide alternatives to restraint use... 10. Care of the Patient/Plan of Care...a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint..."

Based on a review of documentation and interview, the facility failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,
"POLICY:

HCA is dedicated to fostering a culture that supports a patient's right to be free from restraint or seclusion. Restraint use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints. The facility Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness and necessity of restraint use.

Las Palmas Del Sol Healthcare does not provide for psychiatric/substance abuse patients and limits the use of restraints to situations where appropriate clinical justification is appropriate. At all times we strive to protect the patient's rights, dignity and safety at Las Palmas Del Sol Healthcare...

5. Order for Restraint
a. An order for restraint must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.
1) An order for restraint may not be written as a standing order, protocol or as a PRN or 'as needed' order.
2) If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required.
b. If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.
c. The treating physician is to be notified as soon as possible if another physician, (e .g. on-call physician) orders the restraint.
d. When a LIP/physician is not available to issue a restraint order, an RN with demonstrated competence may initiate restraint use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint is applied...

5B. Order for Restraint with Violent or Self Destructive Behavior
a. Physician orders for restraint must be time limited, and must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed:
1) 4 hours for adults, aged 18 years and older
2) 2 hours for children and adolescents aged 9 to 17 years, or
3) 1 hour for children under 9 years
i. The time frames specified are maximums. The physician may order a shorter period of time.
ii. Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint or seclusion when criteria for release are met.
b. To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed:
1) 4 hours for adults, aged 18 years or older
2) 2 hours for children and adolescents aged 9 to 17 years, or
3) 1 hour for children under 9 years
c. Orders may be renewed according to time limits above for a maximum of 24 consecutive hours. Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion."

There were multiple documented uses of restraints at the Del Sol campus with no physician order for restraints documented. Review of a sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

The facility was unable to provide documented physician orders for the above episodes of restraint.

An employee with the facility security provided the surveyors copies of the "[Security Company Name] Security-Patient Restraint Form". Staff members # #A35, 36, and 42 confirmed this form was stored in the security office of this facility.

Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

The facility was unable to provide documented physician orders for the above episodes of restraint.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview, the facility failed to ensure that unless superseded by State law that is more restrictive--
(i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:
(A) 4 hours for adults 18 years of age or older

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,
"5B. Order for Restraint with Violent or Self Destructive Behavior
a. Physician orders for restraint must be time limited, and must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed:
1) 4 hours for adults, aged 18 years and older
2) 2 hours for children and adolescents aged 9 to 17 years, or
3) 1 hour for children under 9 years
i. The time frames specified are maximums. The physician may order a shorter period of time.
ii. Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint or seclusion when criteria for release are met.
b. To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed:
1) 4 hours for adults, aged 18 years or older
2) 2 hours for children and adolescents aged 9 to 17 years, or
3) 1 hour for children under 9 years
c. Orders may be renewed according to time limits above for a maximum of 24 consecutive hours. Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion."

There were multiple documented uses of restraints at the Del Sol campus. Review of a sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

Due to lack of documentation in the medical record or elsewhere besides the "Pass Down Reports", it is unknown if the above restraints lasted less than 4 hours. Per policy and regulation any restraint lasting longer than 4 hours, requires an order renewal. These episodes also did not have physician orders present.


Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

Due to lack of documentation in the medical record, it is unknown if the above restraints last less than 4 hours. The restraint of Patients #A 14 and 16 appears to have lasted for over 8 hours with no physician orders or renewal present. Per policy and regulation any restraint lasting longer than 4 hours, requires an order renewal.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.


35725

Based on review of medical records and interviews, the facility failed to comply with patient rights related to the use of restraint or seclusion. The physician ordered a restraint for the management of an agitated patient. The physician order was written to expire 24 hours from the time the restraint was initiated.

Findings were:

In a review of the following record in the conference room at Del Sol Hospital the afternoon of 4/20/17 revealed that physician orders and the restraint of patient #G23 exceeded the four (4) hour limit used for the management of violent or self-destructive behavior of an adult 18 years of age or older.

Patient # G23 with a Date of Birth of 04/12/75
Order for Restraint dated 03/10/17 at 2004.
Order expiration date: 03/11/17 at 2004.
Restraint device: Soft BUE [bilateral upper extremities]

Nurse Notes Entered: March 10, 2017 at 1956, read, "patient continue to be very restless and agitated after Ativan. Haldol 5 mg IM [intramuscular] administered at this time w/security at BS [with security at bedside] holding patient in bed to keep from falling out of bed. Charge nurse calling [doctor's name] for further orders, including possible restraint order."
Nurses Notes Entered: 3/10/17 at 2004, read, "Code Strong called, spoke to [doctor's name] on the phone, states to restraint [sic] patient. Will carry out as ordered."

Another Order for Restraint was dated 03/11/17 at 1913
Order expiration date 03/12/17 at 2359
Restraint device Soft BUE

Nurse Notes dated 3/11/17 at 0145 read, "Woke-up non-restless at this time. 3 staff at BS, and patient became increasingly restless and agitated, fighting wrist restraints and legs up and in down on the air and over the rail."
Nurse Notes dated 3/11/17 at 0201 read, "Zyprexa 5 mg IM administered as ordered, Code Strong called -security officers at BS. Continue to watch effect of Zyprexa."
Nurse Notes dated 3/11/17 at 0239 read, "Continue to be restless & agitated, fighting w/security officer 37 min. after Zyprexa given. Haldol 5 mg IV administered this time as ordered-monitor effect of med prior to Valium for few minutes."
Nurses Note dated 3/12/17 at 0330 read, "Continue to be restless off/on, legs over the rails and pulling against restraints. Precedex drip at 0.8 mcg/kg/hr. at present."
Nurse Note dated 3/12/17 at 0331 read, "Ativan 2 mg administered for persistent & increasing restlessness."

Another Order for Restraint was dated 03/12/17 at 1919
Order expiration date 03/13/07 at 2359
Restraint device Soft BUE
Nurse Notes Entered: March 13, 2017 at 0800 read, "Received Pt. awake A&O x1 [alert and oriented times one]. Pt disoriented, but calm, watching TV, unable to speak or voice any concerns, restraints in place secured and intact. Seizure pads in place for precautions. Pt is now on nasal cannula at 2 LT. SPO2 at 95%, no signs of resp. distress seen at the moment. PEG Tube in place, no residuals seen at the moment. Did notice increased coughing and phlegm with Jevity boluses. El Paso State support center staff at bedside. No signs of distress seen at the moment. Will continue to monitor."

Review of the above patient's medical record, revealed that the patient had a physician's order for Soft BUE restraint. Restraint orders exceeded the 4 hour limit used for the management of violent or self-destructive behavior of an adult 18 years of age or older use. Nurse's notes indicated that the patient exhibited behavior of agitation, restlessness and fighting. No documentation was observed that the use of soft BUE restraints were used as medical restraint.

The above findings were confirmed by the Risk Manager the afternoon of 4/20/17.

Based on a review of documentation the facility failed to ensure that restraint incidents had documented face-to face evaluation within 1 hour after the initiation of the restraint to evaluate:
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,
"9. Face-to-face assessment by a Physician or LIP:
a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will:
1) Work with staff and patient to identify ways to help the patient regain control
2) Evaluate the patient's immediate situation
3) Evaluate the patient's reaction to the intervention
4) Evaluate the patient's medical and behavioral condition
5) Evaluate the need to continue or terminate the restraint or seclusion
6) Revise the plan of care, treatment and services as needed..."

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

Due to lack of documentation in the medical record or elsewhere besides the "Pass Down Reports", there was no documented face-to face evaluation regarding the above restraint episodes within 1 hour after the initiation of the restraint to evaluate:
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.


Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the "[Security Company Name] Security-Patient Restraint" form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documented face-to face evaluation within 1 hour after the initiation of the restraint to evaluate:
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: A description of the patient's behavior and the intervention used.

Findings included:

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the "[Security Company Name] Security-Patient Restraint" form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of patient's behavior and the intervention use in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: Alternatives or other less restrictive interventions attempted (as applicable).

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,
"12. Documentation Requirements:
The medical record contains documentation of:
a. Assessment for risk for restraint
b. Restraint alternatives employed
c. Determination of effectiveness/ineffectiveness of restraint alternatives..."

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the "[Security Company Name] Security-Patient Restraint" form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of alternatives or other less restrictive interventions attempted in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: The patient's condition or symptom(s) that warranted the use of the restraint or seclusion.

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,
"7. Monitoring the Patient in Restraints
a. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint.
b. An RN will assess the patient at least every 2 hours. The assessment will include:
1) Signs of injury associated with restraint, including circulation of affected extremities
2) Respiratory and cardiac status
3) Psychological status including level of distress or agitation, mental status and cognitive functioning
4) Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met
5) Hydration/nutritional needs are being met
6) Hygiene, toileting/elimination needs are being met
7) The patient's rights, dignity, and safety are maintained
8) Patient's understanding of reasons for restraint and criteria for release from restraint
9) Consideration of less restrictive alternatives to restraint
c. More frequent monitoring and notification of the ordering physician or LIP occurs when:
1) Patient's medical and emotional needs and health status change
2) The type and design of the device or intervention poses increased risk
3) The level of patient agitation/distress at being placed in restraint as evidenced by an escalation of behavior
4) Evidence of injury related to use of restraint
d. A trained staff member monitors each patient in restraint at least 3 times an hour for safety, and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift.
e. Monitoring is based on the individual needs of the patient. Variables of the patient's condition, cognitive status, risks associated with the chosen intervention may require more frequent evaluations.
f. For patients under continuous audio, video or in-person observation, care is rendered in real time, but documentation that safety, rights, and dignity were maintained for the defined period of time may be entered at end of the shift.
g. Any change in physical or psychological response will be reported to the RN. The RN will determine if medical intervention is required or if criteria for release have been met..."

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the "[Security Company Name] Security-Patient Restraint" form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of the patient's condition or symptom(s) that warranted the use of the restraint or seclusion in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: The patient's response to the intervention(s) used, including the rationale for continued use of the intervention.

Findings included:

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The "Daily Security Supervisor Pass Down" reports documented the following:
* On 03/18/17 the form documented the following, "ER #36 right handcuff applied @1145 due to punching & throwing food at the wall."
* On 03/23/17 at 7:08 PM the following was documented, "EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department]."
* On 04/12/17 the form documented the following, "1540 Code Strong ER #36 pt became combative while trying to elope and was restrained."

Review of "[Security Company Name] Security-Patient Restraint" forms revealed the following:
* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, "@ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.
04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.
04/15/17 1945 [staff name] checking restraints
04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]."
* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, "At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD."
* Patient #A16 was restrained on 3/31/17 the form stated in part, "Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm." In 15-minute intervals, staff #A39 stated, "4-point restraints checking okay" starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented "4-points restraints Cok [checking okay]" in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.
* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, "Patient who is 17 years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.
04/15/17 pt @ 0100 was placed with one handcuff.
04/15/17 pt @ 0120 was released from other handcuff."

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the "[Security Company Name] Security-Patient Restraint" form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of the patient's response to the intervention(s) used, including the rationale for continued use of the intervention in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview, the facility failed to ensure that patients had the right to safe implementation of restraint or seclusion by trained staff.

Findings included:

Facility based policy entitled, "PC 210 Restraints" stated in part,
"6. Application of Restraints
a. Restraints are applied by staff with demonstrated competence in restraint application.
1) Attachment A: Direct Care Staff (non RN) Monitoring and Providing Care to a Patient Restraint Competency
2) Attachment B: RN Competency: Patient Restraint Competency
3) Attachment C: RN Competency: Patient Restraint for Violent or Self Destructive Behavior...

APPENDIX A: TRAINING REQUIREMENTS (Attachments A, B, & C)

A. Direct Care Staff
Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities, including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion.
Training will occur:
1. Before performing restraint application, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion,
2. As part of orientation, and
3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients.
4. The results of skills and knowledge assessment, new equipment, or QAPI data may indicate a need for targeted training or more frequent or revised training.

B. Staff who conduct the one hour face-to-face evaluation
The purpose of the 1-hour face-to-face evaluation is to complete a comprehensive review of the patient's condition and determine if other factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis etc. are contributing to the patient's violent or self-destructive behavior.
Training for the RN or PA who conduct the 1-hour face-to-face will include:
1. Application of restraints.
2. Implementation of seclusion.
3. Monitoring, assessment and providing care for a patient in restraint or seclusion, including:
a.The patient's immediate situation
b.The patient's reaction to the intervention
c.The patient's medical and behavioral condition
d. The need to continue or terminate the restraint and seclusion...

Training Content

A. Restraint and Seclusion
All staff, including contract or agency personnel designated as having direct patient care responsibilities, will receive training in identifying patient and staff behaviors, events and environmental factors that may trigger circumstances that require the use of restraint or seclusion. Education and training will be based on the specific needs of the patient populations served. For example, staff who routinely provide care for patients who exhibit violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others (such as an emergency department or on a psychiatric unit) may receive more in-depth training than staff routinely providing medical/surgical care....

C. Least Restrictive Interventions
Staff will be trained on choosing the least restrictive intervention based on the individualized assessment of the patient's medical or behavioral status or condition. Safe patient care requires looking at the patient as an individual and assessing the patient's condition, needs, strengths, weaknesses, and preferences and tailoring interventions to individual patient's needs after weighing factors such as the patient's condition, behaviors, history, and environmental factors.

D. Safe Application
Staff will be trained on the safe application of all types of restraint and seclusion used in this facility including training to recognize and respond to signs of physical and psychological distress (e.g., positional asphyxia).

E. Necessity of Restraint
Staff will be trained and able to demonstrate competency in identification of specific behavioral changes that may indicate that restraint or seclusion is no longer necessary and can be safely discontinued.

F. Monitoring
Staff will be trained and demonstrate competency in monitoring the physical and psychological well-being of a patient who is restrained or secluded. This training will include but will not be limited to: respiratory and circulatory status, skin integrity, vital signs, and any special requirements identified by the facility associated with the one-hour face-to-face evaluation..."

Facility based policy entitled, "EC 210 Code Strong" stated in part,
"Security staff is trained in Nonviolent Crisis Intervention, a program that is safe, non-harmful behavior management system designed to help security and staff professionals provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons, even during their most violent moments.

Any physical intervention is potentially dangerous and should be handled by security or trained personnel in Nonviolent Physical Crisis Intervention procedures.

A. Security, Law Enforcement, or CPI certified personnel will respond to any situations involving an actual or potential risk of violent, harmful, or threatening behavior involving patients, employees, physicians or visitors...

D. If seclusion/restraint is the outcome of the Code Strong, the Restraint and Seclusion policy will be utilized...

CPI PROCESS...
1. The Security Coordinator shall be responsible for assuring the development scheduling, implementation and documentation of comprehensive training program (CPI) for staff that work in high security risk areas.
2. In the following list of units, any clinical department Charge Nurse shall be provided with CPI training. Morning and Evening shifts. The charge nurse will respond only in their designated unit in the event of Code Strong. All other non-clinical units on the list will have designated staff member chosen by the units Directors.
A. Security (All Staff)...
D. Emergency Dept."

The Del Sol campus was only able to provide documentation that the Emergency Department nursing staff received training in "De-escalation-A Culture of Safety" which staff member #A34 stated was a 1-2 hour course regarding verbal de-escalation. There was no documented training regarding physical restraints. Per facility policy, the charge nurse for each shift should have received this training. Staff members #A28 confirmed that the nursing staff does not receive training at the Del Sol campus to implement physical restraints.

Review of Del Sol security personnel files revealed that only 1 of 6 employees (#A43) had received comprehensive training program regarding physical interventions. This employee received TRAIN instead of CPI per policy. Staff members #A35 and 36 confirmed that all security personnel did not have documented CPI training. The facility was also not able to provide documentation of training regarding physical/mechanical restraints for the contracted off duty police officers that the facility employs.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34, 35, 36, and A37.

Based on observation and review of records, the facility failed to ensure that nursing care was provided for all patients as a patient's abnormal, elevated blood pressure was not reported to the provider as ordered and per nursing standards. This presents a health risk for a patient.

Findings included:
 
Review of the medical record for Patient #B26 at the Del Sol facility revealed a physician order on 3/25/17 at 1318 which stated, "Notify provider if temperature is >101 F, heart rate <50 or >100, oxygen saturation <92%, systolic blood pressure < 90 or >170, diastolic blood pressure > 100, respiratory rate < 12 or >28."
On 3/30/17 at 6:25 am and again at 6:37 am, Patient #B26 had a documented blood pressure of 182/104. The blood pressure was documented 182/104 again at 0910 on 3/30/17. There was no documented evidence of physician notification of the elevated blood pressure nor was there documentation of any nursing assessment or intervention addressing the elevated blood pressure. The above findings were confirmed in an interview with Staff #B14 the afternoon of 4/18/17 on the patient care unit.

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,
"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;
(B) Implement measures to promote a safe environment for clients and others; ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(vi) contacts with other health care team members concerning significant events regarding client's status;"

Based on record review and staff interview, the facility failed to ensure that properly executed consent forms were completed before patient treatment.

Findings included:

Review of the medical record for Patient #B22 at the Del Sol facility revealed that Patient #B22 presented to the Emergency Department on 4/16/17 and was admitted to the hospital on 4/17/17 between 0200 and 0330 and began receiving inpatient treatment. However the Consent to Treatment was not signed by the patient or other patient representative until 4/18/17 at 1050. The above findings were confirmed in an interview with Staff #B14 the afternoon of 4/18/17 on the patient care unit.

Based on observation, interviews, and tour of the kitchen at Las Palmas, it was determined that the facility failed to ensure that food and dietetic services were organized.

Findings were:

The hospital failed to ensure that food and dietetic services organization requirements were met. Tour of the kitchen the afternoon of 4/17/17 revealed the following findings.

Tour of the kitchen on the afternoon of 04/17/2017 revealed the following:
*In the refrigerator, fish, peas, green beans, onions, carrots cheese oil packages were opened and not labeled.
*In the freezer twelve (12) packages of okra and three (3) packages of peas were not labeled.
*Metal food racks in the freezer were dirty with a white substance.
*Milk from a gallon container with no date, spilled on the bottom floor of the refrigerator.
*Dijon Mustard was opened and not labeled.
*Multiple metal baking pans were stacked while wet. When these pans were separated, water dripped onto the floor. When dishes and pans are not air dried, there is potential for bacterial growth.
*40 metal baking pans contained food debris was observed, this indicating inadequate cleaning.
*Ten (10) muffin pans were observed with food debris.
*One pan with a greasy film was observed.
*Three (3) knives observed with food debris, indicating inadequate cleaning.
*Kitchen utensils handles worn out with food debris.
*Black stains were observed on refrigerator, ceiling and wall indicating improper cleaning and maintenance.
*Kitchen workers were observed using cooking utensils for serving food and not using serving utensil.
*Two (2) large rectangular white cutting boards with black stains and other color stains and multiple knife cuts were dirty, indicating inadequate cleaning and potential for bacterial growth.
At 3:35 pm staff #G 2 was observed using the pans with the food debris.

The above findings were confirmed by Director of Food Services on the afternoon of 04/17/2017.

Based on observation and a review of documentation, the hospital failed to maintain a full-time employee to serve as the director of the food and dietetic services that was responsible for the daily management of the dietary services.

Findings were:

During a tour of the dietary area of the Del Sol campus on 4-19-17, the following observations were made:

*A stack of 4 "half-pans" had been stacked on top of each other while still wet to the touch and with visible water droplets.
*A stack of 3 24-count cupcake pans had been stacked on top of each other while still wet to the touch and with visible water droplets.
*A stack of 5 "full-pan" covers had been stacked on top of each other while still wet to the touch and with visible water droplets.
*A stack of 4 large sheet pans had been stacked on top of each other while still wet to the touch and with visible water droplets.

Stacking dishes, pans or any other dietary ware while wet allows a breeding ground for bacteria, increasing the possibility of illness among patients and staff.

*2 serving dishes of what appeared to be a tomato-based product were sitting uncovered in the walk-in freezer.
*1 large sheet pan filled with what appeared to be meatballs was sitting uncovered in the walk-in freezer.
*1 large pan filled with what appeared to be cooked chicken breasts was sitting uncovered in the walk-in freezer.

Failing to cover food allows dust and debris to enter the dish, increasing the possibility of illness among patients and staff.

None of the food items in the dry goods pantry had been marked with a date indicating when they had been received into the facility. These items included (but were not limited to) the following:

*3 138-ounce bottles of salsa
*4 1-gallon bottles of vegetable oil
*25 1-pound boxes of corn starch
*6 5-pound bottles of teriyaki glaze
*5 2-quart bottles of low-sodium soy sauce
*3 1-gallon bottles of teriyaki sauce
*2 1-gallon bottles of barbeque sauce
*7 4.5-pound bottles of sweet & sour sauce
*1 8lb,10oz bottle of enchilada sauce
*3 64-ounce bottles of szechuan stir-fry sauce
*3 1-gallon bottles of "lite" mayonnaise
*4 1-gallon bottles of ranch dressing
*4 1-gallon bottles of coleslaw dressing
*3 large, metal "can" carts, each containing 30 rows (with each row holding at least 6 #10 cans of soups, vegetables, sauces etc)

Marking food items with the received date allows proper rotation of stock and reduces the possibility of serving stale or unusable food.

*Greater than 30 external shipping boxes were stored in the pantry with the other food items. External shipping boxes carry dirt and other debris (which may contain bacteria and vermin) into the facility.

Facility policy titled "Infection Control" states, in part:
"Policy:
Food & Nutrition Services will prepare and serve wholesome food under sanitary conditions."

Facility policy titled "Storage of Prepared Foods" states, in part:
"Process Standards
...
E. All stored food must be covered, labeled and dated."

Facility policy titled "Handling of Cooked Foods" states, in part:
"2. All food is wrapped or sufficiently covered before placing in refrigerator or warming cabinet."

Facility policy titled "Food Storage" states, in part:
"Policy:
...
B. Stock is rotated so that older items are used first.
1. Products are dated to assure 'First In-First Out' procedure is followed.
...
L. All cooked foods and protein-based salads and desserts are labeled, dated and securely covered.
...
P. All food items stored after opening or preparation should be tightly covered, labeled and dated before storing."

The above was confirmed in an interview with staff #E-40 on the afternoon of 4-19-17.

Based on observation, interview and record review the facility failed to develop a policy and procedures for the use of SwabCaps (disinfecting cap for needle free connectors).

Findings Include:

An observation made on the morning of 4/18/17 in the facility's operating room revealed Staff #G7, RN, administered Versed, a medication for sedation, intravenous (IV) into Patient #G5's IV access port. The access port was covered with a swab cap, a small plastic cap containing a disinfectant. Staff #G7 removed the swab cab but did not wipe the access port with an alcohol wipe. Staff #G5 administered IV medications through Patient #G5's IV access port (4) four additional times without wiping the access port with an alcohol wipe. Staff #G5 replaced the same swab cap each time.
During an interview on 4/18/17 in the facility's operating room, Staff #G3, Surgery Director, stated, "The swab cap takes the place of scrubbing the hub...the swab cap is a single use device."


Review of the facility provided Manufacturer's document Reference Guide for SwabCap reflected "...Single use only..."

During an interview on 4/19/17, in the administrative conference room, with Staff #G9, Infection Control Director, when asked if the facility has developed a policy and procedure for the use of the Swab Caps, Staff #G9 stated, "No....they are single use ...the manufacturer gave an in-service on the use ...we use Lippencott for the procedure...."

Review of the facility provided document "Lippencott Procedure- IV bolus injection" (dated 4/15/17) reflected, " ...For administration through an intermittent vascular access device ...if a disinfectant-containing end cap is on the end of the needleless connector, remove it. Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad...bolus medication...apply a new disinfectant-containing end cap to the needless connector of the venous access device to reduce the risk of vascular catheter-associated infection...."

Based on observation and interview, the facility failed to ensure a sanitary environment and practices to avoid sources and transmission of infections and communicable diseases.

Findings included:

During a tour of the Labor and Delivery unit at the Del Sol facility the morning of 4/19/17, the following was observed:
In LDR room 13, there was a reddish-brown drip approximately 1 inch in length which appeared to be dried blood on the stirrup of the labor and delivery bed, which was available for patient use. There were 2 pieces of plastic tape, approximately 1 inch each in the infant bassinet. The mattress pad in the infant bassinet had tears in the vinyl covering which exposed the porous foam beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens. This was confirmed in an interview with Staff #B14 the morning of 4/19/17 during the tour.
In LDR room 8, there was a paper sticker on the inside of the right and the left stirrup of the labor and delivery bed, which was partially adhered, leaving a sticky substance which could not be properly disinfected. The bed was available for patient use. This presents a risk for cross contamination. This was confirmed in an interview with Staff #B14 the morning of 4/19/17 during the tour.

During a tour of the Newborn Nursery at the Del Sol facility, 6 out of 8 mattress pads in the infant bassinets, available for newborn patient use, had tears, punctures, or worn edges in the vinyl covering which exposed the porous foam beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens. One of the pads had an unknown sticky substance adhered to the pad. This was confirmed in an interview with Staff #B19 the morning of 4/19/17 during the tour.

During a tour of the nursery supply room at the Del Sol facility, there was a water stained ceiling tile observed. At the entrance to the nursery patient supply room, there were lockers which were used by the nursery staff for their personal belongings, including purses and other belongings, which presents a risk for cross contamination. The floor in the supply room was in need of cleaning, as there was debris and dust on the floor. There was a fine layer of dust in the bins containing patient supplies.

During a tour of the Labor & Delivery Recovery Room at the Del Sol facility the afternoon of 4/18/17, there was a 1.5 inch opened tear in the vinyl covering of one of the recovery beds which exposed the porous foam beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens. The right stirrup and foot rest were in need of cleaning as they were covered with a layer of dust. There was dust on horizontal surfaces, including the window sills in the Recovery Room. This was confirmed in an interview with Staff #B14 the morning of 4/19/17 during the tour.

In an interview the morning of 4/19/17, Staff #B20, Environmental Services Director in the facility conference room, stated that the housekeeping staff are support to report any torn mattresses or pads when they are observed.

During a tour of the Labor and Delivery OR at the Del Sol facility the morning of 4/19/17, the following was observed:
The flooring in the corners of OR 1 were in need of cleaning as there was dirt or a dirty appearance in these areas This room was available for patient use. There were tears in the flooring in the edges of the flooring baseboard and there was a 1/2 hole in the flooring in the center of the OR. This presents a risk for cross contamination.
The floor in the corners of OR 3 were in need of cleaning as there was dirt or a dirty appearance in these areas and there were small tears in the flooring in the edging of the flooring baseboard. This OR was available for patient use.
There were 10 sterile instruments in paper/plastic peel-packs in a plastic bin and approximately 6 sterile instruments in a second plastic bin, available for patient use. These paper/plastic peel packs had been folded and placed in a plastic bin in OR 3. Sterilized instruments should be stored in a manner that preserves the integrity of the packaging material. Folding the paper presents a risk that the paper will be torn or be creased and the sterility compromised. There were also 6 sterilized instruments observed in OR 3 which were observed in the closed position or the clamps were closed; therefore not all surfaces were exposed to the sterilizing agent preventing effective sterilization. It could not be determined that the sterilizing agent penetrated all surfaces to ensure complete sterilization of all surfaces of the instruments. The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

This was confirmed in an interview with Staff #B19 the morning of 4/19/17 during the tour at the Del Sol facility.



33326

Based on observation, interview and record review the facility failed to effectively monitor for care in a safe and sanitary environment when,

a.) Patients with intravenous catheters did not have the access hubs cleaned to prevent possible infections for (4) patients. (Patients G5, G7, G18 and D13)

b.) Medications were not administered in the operating room using aseptic techniques.

Findings:

a.) An observation made on the morning of 4/18/17 in the facility's operating room revealed Staff #G7, RN, administered Versed, a medication for sedation, IV into Patient #G5's IV access hub. The access hub was covered with a swab cap, a small plastic cap containing a disinfectant. Staff #G7 removed the swab cab but did not wipe the access port with an alcohol wipe. Staff #G5 administered IV medications through Patient #G5's IV access hub (4) four additional times without wiping the access hub with an alcohol wipe. Staff #G5 replaced the same swab cap each time.

During an interview on 4/18/17 in the facility's operating room, with Staff #G3, the Surgery Director, when asked how the swab cap is to be used, staff #G3 stated, "The swab cap takes the place of scrubbing the hub...the swab cap is a single use device...."

An observation made on the morning of 4/18/17 on the facility's Intensive Care Unit (ICU) revealed Staff #G10, RN, disconnected Patient #G18's IV tubing from the access hub. Staff #G10 looped and connected the exposed end of the IV tubing line into a secondary access hub on the IV line tubing. Staff #G10 did not wipe the access hub with an alcohol wipe.

An observation made in the afternoon of 4/19/17 in the facility's Emergency Room (ER) revealed Staff #G13, RN, administered IV fluids through Patient #G14's peripheral IV catheter access hub. Staff #G13, RN, did not wipe the access hub with an alcohol wipe.

During an interview on 4/18/17 on the facility's ER, Staff #G13, RN, stated, "I'm supposed to wipe with alcohol... I didn't..."
During a tour of the Las Palmas 5 North Unit on 4/19/17 at approximately 11:10 am in the company of Staff # D21, unit director, Staff #D20, RN, was observed hanging an IV piggyback medication for patient #D13. Staff #D20 was about to connect the piggyback tubing to a blue needleless intravenous hub without disinfecting the hub when the surveyor asked Staff #D20 what the procedure was for disinfecting the hub. Staff #D20 stated that the hub should be cleansed with an alcohol wipe. Staff #20 then obtained an alcohol wipe and cleansed the hub before connecting the piggyback tubing. In an interview with Staff #D20 in the hallway outside Patient #D13's room at approximately 11:15 am, Staff #D20 agreed that she was going to connect the piggyback tubing without disinfecting the hub and that the hub should be disinfected before connecting the piggyback tubing.

Review of the facility provided document "Lippencott Procedure- IV bolus injection" (dated 4/15/17) reflected, "...For administration through an intermittent vascular access device...if a disinfectant-containing end cap is on the end of the needleless connector, remove it. Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad...bolus medication ...apply a new disinfectant-containing end cap to the needless connector of the venous access device to reduce the risk of vascular catheter-associated infection ...."

b.) An observation made on the morning of 4/18/17 in the facility's operating room revealed Staff #G7, RN, removed the dust cap from a Midazolam 5mg (milligram)/5 ml (milliliter) vial. Staff #G7 did not wipe the rubber septum with an alcohol wipe prior to withdrawing the solution.

Review of the facility provided document "Multiple Use Vials/Containers" (dated 4/2014) reflected, "Purpose: ...guidelines for the utilization of multiple use containers in all areas of the Hospital ...Strict aseptic technique must be utilized in withdrawing drugs from injectable multi-use vials. 1. Ensure that rubber stopper is appropriately cleaned and allowed to air dry prior to withdrawing solution...."





36594

Based on review of facility documents, observation and interview, the facility failed to provide a safe and sanitary environment as the facility:

A. Failed to ensure staff responsible for the sterilization of supplies had necessary training.
B. Failed to ensure flash sterilizers were used for emergency sterilization only.
C. Failed to maintain a sterilizer log that included contents of each load, biological indicators and chemical indicators.
D. Failed to ensure preventive maintenance of all sterilizers were performed according to policy, using the sterilizer manufacturer's service manual as a reference.

Findings included:

A. Facility based policy entitled, "Sterilization" (reference #5.16) stated in part,
"L. All new staff members will be in-serviced on the proper procedure prior to using the autoclaves."
Facility based policy entitled, "Flash Sterilization: Steam Sterilizer Operation" (reference #6.5) stated in part,
"D. A steam sterilizer indicator strip (or equivalent product) will be placed in each load and verified prior to taking the load into the OR...
P. All Surgical Services personnel responsible for understanding the principles of flash sterilization and the correct method for operating the autoclaves. Documentation of each load must be done by the person actually running the load.
Q. The Surgical Services personnel must verify that all personnel understand the proper method of flash sterilization. All new personnel must be in serviced on the proper [sic] prior to using the autoclaves."
Facility based policy entitled, "IC4.8-Cleaning, Disinfection, and Sterilization" stated in part,
"17. Quality control
a. All staff assigned to reprocess semicritical and critical instruments and equipment will receive comprehensive sterilizer specific training on hire and annually thereafter to ensure that they understand the importance of reprocessing these items..."

Review of the personnel records for staff members in the Surgical Services responsible for immediate use sterilization using sterilizers #1 and 2 revealed that these employees only had a competency on immediate use present in their file. There was no documented training on the specific machines used for this sterilization process. Staff member #A18 confirmed to effectively implement and maintain these sterilizers, staff require training specific to the machine model.

Review of the personnel records for staff members in the Surgical Services responsible for sterilization revealed competencies for "Sterilization, Steam" that were unsigned by an evaluator at the time of the survey on 4/19/17:
*Staff A11, A12, A13, A14, A21, A22, A23, A24 and A25
The above was verified with staff #A18 in an interview on the afternoon of 4/19/17.

B. A statement from the Association for the Advancement of Medical Instrumentation (AAMI), Accreditation Association for Ambulatory Health Care (AAAHC), Association of periOperative Registered Nurses (AORN), Association for Professionals in Infection Control and Epidemiology (APIC), ASC Quality Collaboration, Association of Surgical Technologists (AST), and International Association of Healthcare Central Service Materiel Management (IAHCSMM). Immediate-Use Steam Sterilization. Undated. Found at: , stated in part, "Instrument inventories should be sufficient to meet anticipated surgical volume and permit the time to complete all critical elements of reprocessing."

The Centers for Disease Control and Prevention (CC) website article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: , stated in part, "it [flash sterilization] is not recommended as a routine sterilization method because of the lack of timely biological indicators to monitor performance, absence of protective packaging following sterilization, possibility for contamination of processed items during transportation to the operating rooms, and the sterilization cycle parameters (i.e., time, temperature, pressure) are minimal... Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time."
Facility based policy entitled, "IC4.8-Cleaning, Disinfection, and Sterilization" stated in part,
"11. Flash Sterilization...
b. When necessary, flash sterilization will be used for patient care items that will be used immediately and cannot be packaged, sterilized and stored before use. Category IB. Flash sterilization should never be used for convenience, to save time, or as an alternative to purchasing additional instrument sets..."

Review of Del Sol documentation of Immediate Use Steam Sterilization [IUSS] revealed:
*18 items were sterilized in January with the following reasons:
o "only one of these" - 2 items
o "all like items in use" - 4 items
o Surgeon/Rep brought in - 1 item
o Per request by MD - 1 item
*10 items were sterilized in February with the following reasons:
o "Late arrival by vendor" - 1 item
o "All like items in use" - 2
o Other: "needs in case" - 1 item
o Other: "not enough in reps tray" - 1 item
*33 items were sterilized in March with the following reasons:
o "Missing from tray" - 1 item
o "none available" - 1 item
o "Per request by MD" - 4 items
o "All like items in use" - 9 items
o "Surgeon/rep brought in" - 2 items
o "Late arrival by vendor" - 5 items
o "Not enough drills" - 1 item
o Other with no further explanation - 1 item
o Other: "Not enough" - 1 item
*14 items were sterilized in April with the following reasons:
o "All like items in use" - 6 items
o Surgeon/rep brought in - 2 items
o Per request by Dr. - 1 item

In an interview with staff #A18 on 4/18/17 at 4:00 pm, when asked about IUSS, staff #A18 stated, "They don't have enough supplies."

C. The Association of Perioperative Registered Nurses (AORN) Journal Vol. 86, Issue 1, p58-72 article, "The New Era of Flash Sterilization" (2007) by Arlene Carlo, RN, BSN, CPM, FCSP, found at http://www.aornjournal.org/article/S0001-2092(08)00716-3/pdf, stated in part, "Documenting
Records document that the sterilization process is being monitored as it occurs and provide evidence that cycle parameters have been met. Record-keeping is necessary to document essential information such as the reason for flash sterilization. These might include...
In addition,
* the cycle run (ie, date, time, load number)
* load contents (eg, individual instrument, instrument set);
* CI [chemical indicator] and BI [biological indicator] results;
* patient identification; and
* sterilizer operator identification should be documented. The information typically is recorded in a flash sterilization log (Figure 1).

Flash sterilization records allow for traceability of every load of instruments or set that was used for patients, provide an audit trail, and are necessary if there is a recall of items sterilized or if flash sterilization records are subpoenaed for a lawsuit."

Facility based policy entitled, "Infection Control/Positive Biological Monitor Results" (reference #6.0) stated in part,
"D. Initiate recall of all items from affected loads run in the sterilizer up to present date. Use sterilization logbook to make listings of items run in loads."

Review of IUSS documentation revealed no identification of load contents in:
*3 out of 10 loads in February
*6 out of 33 loads in March
*4 out of 14 loads in April

Review of IUSS documentation revealed no identification of which patient instruments of IUSS were used on in:
*2 out of 33 loads in March
*2 out of 14 loads in April

In an interview with Staff #A18 on 4/18/17 at 4:00 pm, when discussing IUSS logs, staff #A18 stated, "These are incomplete. Some don't even have patient names."

Review of the Del Sol sterilization documentation of sterilizers #1 and #2 revealed no biological indicators retained.

In an interview with Staff A18 on 4/20/17 at 10:25 am when asked about chemical indicators for the IUSS [immediate use steam sterilization], Staff #A18 stated, "These [logs] are incomplete. I don't know why they don't have the indicators there. There's a few where they copy them, they should just attach them here [to the log]."

Review of the IUSS log revealed chemical indicators used:
*2 out of 18 times in January
*2 out of 10 times in February
*4 out of 33 times in March
*2 out of 14 times in April
The above was verified in an interview with Staff #A18 on the morning of 4/20/17.

D. Facility operator manual for the "Amsco Century Medium Steam Sterilizers" stated in part, "7.1 Preventive Maintenance Schedule: Maintenance procedures described in Sections 7 and 9 must be performed regularly at the indicated intervals ...
7.1.1 Clean Chamber Drain Strainer: Important: The chamber drain strainer must be cleaned at least once a day, preferably in the morning before running the first cycle ...
7.1.2 Clean Chamber: Important: The entire chamber should be wiped down and rinsed following any spills or other soiling ...
Important: Chamber must be at room temperature, sterilizer off all night, before washing.
2. Washing the inside of the chamber and shelf assembly (plus any other loading equipment) with a mild detergent solution such as STERIS liquid-Jet or current STERIS equivalent ...
4. Professional cleaning of the chamber on a yearly basis (or as required due to local conditions) is suggested to maintain appearance of the chamber interior. Contact STERIS for information regarding this service."

Facility based policy entitled, "Sterilization" (reference #5.16) stated in part,
"I. Sterilizers are maintained on a quarter basis. Weekly they are also washed with a sterile towel and distilled water..."
Facility based policy entitled, "Sterilizer Maintenance" (reference #6.2) stated in part,
"A. The filter screen in steam sterilizers will be checked at the beginning of each day for lint and debris. Gaskets and outsides are wiped down each day with hospital approved disinfectants..."

During a tour of the Del Sol campus Surgical Services area on 04/19/17, the sterilizers #1 and 2 used for immediate use sterilization were observed to be Amsco Century models.

In an interview on 04/20/17, staff member #A18 was asked about routine maintenance performed on these sterilizers such as cleaning the drain. Initially, the staff member reported the surgical services staff that utilized the sterilizer stated that these models had fixed drains that did not require checking or cleaning that was done during quarterly preventative maintenance of the machines. Staff member #A18 returned shortly and informed this surveyor they had contacted the manufacturer and the drains are not fixed, this staff member was personally able to pop the drain out with minimal effort.
Staff member #A18 confirmed that staff responsible for maintaining the 2 immediate use sterilizers had not been checking or cleaning the drain, per policy and manufacturer recommendations.
This staff member also confirmed there was no evidence of the machines being cleaned weekly, per policy. The Sterile Processing department maintained a logbook related to cleaning their sterilizers, there was no log book documenting the cleaning of the immediate use sterilizers #1 and 2.

Based on observation, interview and record review the facility failed to provide Surgical Services in an organized manner when,

a.) The facility did not implement a procedure to ensure the sterile processing washers and sterilizers were cleaned and maintained according to the manufacturer's instructions.

b.) The operating room had dust on the horizontal surfaces and equipment was rusting and had areas of chipped paint.

c.) (1) Hemostat was sterilized in the closed position, was available for use and surgical staff did not recognize the hemostat should not be used.


Findings Include:

a.) During an interview on 4/18/17 in the facility's Sterile Processing Department (SPD) Staff #G6, SPD Director when asked what routine maintenance the facility provides of the washers stated, "...we check the drains each day and do verification weekly ...." When asked what was done during the weekly verification Staff #G6 stated, "I'm not sure." When asked if the facility documents the cleaning of the washers and sterilizers Staff #G6 stated, "No." When asked for the washer manual the facility was unable to provide them; they needed to be sent by overnight mail.

On 4/19/17, review of the facility provided washer document reflected "...6.2 Daily Cleaning ...Remove sump debris screen from wash chamber and clean...Remove manifold sliding inlet and inspect for debris. 7. Brush off and rinse under tap water...Reinstall manifold sliding inle....Weekly Cleaning...Clean wash chamber rotary spray arm assembly...Remove locking pin securing each spray arm on rotary spray arm hub. Remove spray arms. D. Use a fine wire to clean sediment from spray jet...Rinse spray arms under running water to clean out sediments f. Reinstall spray arm assembly to the ceiling of wash chamber. 4. Remove spray arms from bottom rotary spray arm assembly as follows....Clean spray arms using a fine wire and running water to clear sediments...Clean rotary spray arm...."

b.) Observations made on the morning of 4/18/17 of the facility's operating rooms revealed the following items and conditions that would make the items unable to be thoroughly cleaned:
- Operating Room #9, rust on the metal Stryker cabinet and tape on walls and equipment,
- Operating Room #1, chipped paint and rust on the overhead light and operating bed,
- Operating Room #6, Olympus metal cart with dust on the horizontal surfaces and
- Operating Room storage room, (3) Valley Lab metal carts with chipped paint and rust.

During a tour on 4/18/17, of the facility's operating rooms, Staff #G3, Director of Surgery, confirmed the findings.

c.) An observation made during a tour of the facility's SPD on 4/18/17 revealed a hemostat (a surgical instrument that clamps shut) that had been sterilized in the closed position was available for use.

During an interview on 4/18/17 in the SPD, Staff #G3, Director of Surgery, stated, "They must have closed after processing...but the staff would not use them..." When asked if the surgical staff was aware not to use them, Staff #G3 approached staff members, showed them the hemostat, and asked them if the instrument was able to be used. (4) Four out of (5) surgical staff, when asked if the closed hemostat should be used, were not able to recognize the instrument might not have been thoroughly sterilized and should not be used.

Based on record review and interview the facility failed to ensure the completeness of medical records when a surgeon did not complete a patient's Medical History and Physical prior to the procedure. (Patient #G5)

Findings include:

An observation made on the morning of 4/18/17 in the facility's operating room #9 revealed Patient #G5's medical history and physical had not been completed prior to the surgery. The Patient #G5 had already been sedated and the medical procedure had started.

During an interview on 4/18/17, in the facility's operating room #9, Staff #G3, Director of Surgery, stated, "It should have been filled out prior to the surgery."

Review of the facility provided document Provision of Care (dated 8/09) reflected, "...relevant documents have been assembled prior to the start of the procedure...D. Relevant documents to be reviewed include: 1. H&P that meets the CMS conditions of participation."

An observation on the morning of 4/18/17 in the facility's operating room #8 revealed Staff #G8, MD, completing Patient #G5's history and physical after the completion of the procedure.

Based on record review and interview the facility failed to ensure the completeness of medical records when an abbreviation was used on a Surgical Consent. (Patient G17)

Findings include:

Review of Patient #G5's "Disclosure and Consent" dated 4/19/17 revealed, "...to treat my condition which has been explained to me...Left UPJ stone obstruction..."

During an interview on the morning of 4/20/17, in the Surgical Pre-Operative Unit, Staff #16, Pre-Operative Clinical Coordinator, confirmed UPJ was an abbreviation and stated, "...we don't use abbreviations on consents... that consent was filled out by the floor nurse... we should have caught it..."

Review of the facility provided document "Ethics, Rights & Responsibilities" (dated 7/28/15) reflected, "...All documentation within the consent, both preprinted and handwritten will be completed without the use of abbreviations. All words must be fully written out..."