HospitalInspections.org

Based on observation, review of manufacturer's statement, and interview, the facility failed to ensure expired sutures were not available for patient use in the Emergency Department (ED) Trauma Room.

The findings included:

Observation with the Infection Control Director of the ED Trauma Room on November 8, 2011, at 2:10 p.m., revealed the following sutures without an expiration date on the box: one box (3 dozen) 2-0 silk; one box of 0 black braid silk; one box 3-0 black braid silk; one box chromic gut; two boxes 3-0 chromic gut; and two boxes 2-0 chromic gut.

Review of the manufacturer's statement, in a letter December 2009, revealed " ...If you have (named manufacturer) sutures in your inventory that do not have an expiration date on the packaging, this product was manufactured prior to 1998 and is considered expired ..."

Interview with the Infection Control Director in the ED Trauma Room on November 8, 2011, at 2:10 p.m., confirmed the sutures were expired and available for patient use.

Based on medical record review, facility policy review, and interview, the facility failed to document the dosage of sliding scale insulin administered for two patients (#13, #16); failed to ensure all elements were included for the use of a physical restraint for one patient (#5); and failed to ensure an order was written for the use of chemical restraints for one patient (#5) of twenty patients reviewed.
.

The findings included:

Medical record review revealed patient #13 was admitted to the facility on December 20, 2010, with diagnoses to include Diabetes Mellitus, Osteoarthritis, Hypertension, Benign Prostatic Hypertrophy, Diverticulitis, and Right Cerebrovascular Accident.

Continued medical record review of physician's orders dated December 20, 2010, revealed an order for sliding scale insulin:
Blood sugar 71 - 150 0 units
Blood sugar 151 - 200 0 units
Blood sugar 201 - 250 2 units
Blood sugar 251 - 300 4 units
Blood sugar 301 - 350 8 units
Blood sugar 351 - 400 10 units
Blood sugar >400 12 units

Further medical record review of the Medication Administration Record (MAR) revealed an entry dated December 20, 2010, at 4:00 p.m., with blood sugar of 261, and documentation insulin was administered but no documentation of the dosage of insulin administered. Continued review of the MAR revealed on December 22, 2010, at 4:00 p.m., with blood sugar of 268 and documentation insulin was administered but no documentation of the dosage of insulin administered. Further review of the MAR revealed an entry dated December 24, 2010, at 11:00 a.m., with blood sugar of 227 and documentation insulin was administered but no documentation of the dosage of insulin administered.

Medical record review revealed patient #16 was admitted to the facility on May 11, 2011, with diagnoses to include Chest Pain with Syncopal Episode, Coronary Artery Disease, Peripheral Artery Disease, Coronary Artery Bypass Graft, Diabetes Mellitus, Hypertension, and Atrial Fibrillation.

Continued medical record review of physician's orders dated May 12, 2011, revealed an order for sliding scale insulin:

Blood sugar 51 - 150 0 units
Blood sugar 151 - 200 3 units
Blood sugar 201 - 250 5 units
Blood sugar 251 - 300 7 units
Blood sugar 301 - 350 10 units
Blood sugar 351 - 400 12 units
Blood sugar >400 14 units

Further medical record review of the MAR revealed an entry dated May 12, 2011, at 11:00 a.m., with blood sugar of 225, and documentation insulin was administered but no documentation of the dosage of insulin administered.

Review of facility policy entitled "Blood Glucose Monitoring and Documentation" revealed "...the following will be documented: insulin given with date and time to include routine insulin doses as well as sliding scale insulin doses...".

During interview on November 8, 2011, at 3:00 p.m., in the conference room, the Case Manager/Utilization Review Nurse/Infection Control Nurse confirmed insulin was administered to patient #13 on three occasions and patient #16 on one occasion but there was no documentation of dosage of insulin administered.

Patient #5 was admitted to the Emergency Department (ED) on May 19, 2011, at 9:15 a.m., with the Chief Complaint of Very Combative and Acting Strange.

Medical record review of the Nurse's Notes, dated May 19, 2011, at 9:15 a.m., revealed the patient was ambulatory upon arrival. Continued review revealed the patient's family reported the patient awoke at 5:00 a.m.; came out of bedroom confused, agitated, going from room to room, and didn't know family members. Continued review revealed the patient's last alcohol intake was four days prior and the family reported the patient does not drink daily. Continued review revealed, at 9:15 a.m., the patient was placed in the Trauma room with the assistance of 5 people, was disoriented, combative, cursing, kicking, and biting. Continued review at 9:19 a.m. the patient was given Ativan (anti-anxiety medication) 2 mg (milligrams) IV (intravenous), and the patient remained agitated and was placed in 4 point restraint; had an indwelling urinary catheter placed; and urine specimen and lab work obtained all while the physician was at the bedside. Continued review revealed the patient's blood pressure was 166/95 and the pulse was 130. Continued review revealed at 9:37 a.m., the patient received Ativan 1 mg IV, although the patient remained agitated; at 10:30 a.m., the patient received Thiamine (vitamin) 100 mg IV; at 10:31 a.m., the patient received Ativan 1 mg IV, although the patient remained agitated; and at 10:18 a.m., the patient received Succinylcholine (muscle relaxant to facilitate intubation) 3mg, which induced sedation. Continued review revealed at 10:30 a.m., the physician was arranging a transfer for higher level of care. Continued review revealed at 10:55 a.m., the patient's blood pressure was 166/88, pulse was 117, respiration was 24, and oxygen saturation was 94%. Continued review revealed at 11:10 a.m., the physician was at the bedside to intubate (placement of a tube in the patient's throat utilized to administering breathing) the patient. Continued review revealed at 11:15 a.m., the patient received Versed (sedative) 3 mg IV, and remained sedated; at 11:24 a.m., the patient remained sedated and received Norcuron (muscle relaxant utilized to assist in facilitating intubation) 10 mg and Versed 2 mg IV. Continued review revealed at 11:24 a.m., the patient was being bagged (use of equipment to mechanical breath for the patient). Continued review revealed at 11:50 a.m., the patient was transported to a higher level care hospital by Emergency Medical Services with a final diagnosis of Altered Mental Status.

Review of the Clinical Justification Protocol, dated May 19, 2011, at 9:30 a.m., revealed " ...combative ...mittens right and left ...tethered restraints BLE (both lower extremities) ..."

Review of the Physician's Order, revealed an order, dated May 19, 2011, at 9:30 a.m., "Behavioral Restraint". Continued review did not reveal an order for Chemical Restraints or the reason, types of Behavior Restraints to be utilized, or the length of time the restraint was to be utilized.

Review of the facility policy Restraints/Protective Devices, number PC.050, dated as revised March 2011, revealed " ...use of medical/surgical, behavioral, chemical and special population' restraints ...should only be utilized when it is clinically justified or when warranted by patient behavior that threatens the immediate physical safety of the patient, staff, or others ...types of restraints include: ...mittens ...wrist ...ankle ...leather ...Order for application of restraint ...must indicate reason for restraint usage and type of restraint used ...Behavioral Restraint reason is driven by the primary behavioral health problem such as acute mania, acute psychosis ...each order is ...time limited ...Chemical Restraint: A drug used as a restraint is a medication used to control behavior or to restrict the patient's freedom of movement, and is not a standard of treatment for the patient's medical or psychiatric condition ...A standard treatment for medication used to address a patient's medical or psychiatric condition would include the following ...used within the pharmaceutical parameters approved ...follows national practice standards ...treat a specific patient's clinical condition based on that patient's targeted symptoms ...enables the patient to more effectively or appropriately function in the world around ...Orders - refer to reason for restraint (same requirements) ..."

Interview with the Utilization Review Director, on November 8, 2011, at 10:20 a.m., in the conference room, confirmed the patient was chemically restrained and there was no physician's order for the use of the chemical restraint and confirmed the order for the physical restraint was not in accordance with the facility policy to include specific reason, specific type of restraint, and a time limit for the use of the restraint.

Based on medical record review, facility policy review, and interview, the facility failed to ensure chemical restraints were not utilized without a documented condition which indicated the chemical restraint was warranted for one of twenty records reviewed.

The findings included:

Patient #5 was admitted to the Emergency Department (ED) on May 19, 2011, at 9:15 a.m., with the Chief Complaint of Very Combative and Acting Strange.

Medical record review of the Nurse's Notes, dated May 19, 2011, at 9:15 a.m., revealed the patient was ambulatory upon arrival. Continued review revealed the patient's family reported the patient awoke at 5:00 a.m.; came out of bedroom confused, agitated, going from room to room, and didn't know family members. Continued review revealed the patient's last alcohol intake was four days prior and the family reported the patient does not drink daily. Continued review revealed, at 9:15 a.m., the patient was placed in the Trauma room with the assistance of 5 people, was disoriented, combative, cursing, kicking, and biting. Continued review at 9:19 a.m. the patient was given Ativan (anti-anxiety medication) 2 mg (milligrams) IV (intravenous), and the patient remained agitated and was placed in 4 point restraint; had an indwelling urinary catheter placed; and urine specimen and lab work obtained all while the physician was at the bedside. Continued review revealed the patient's blood pressure was 166/95 and the pulse was 130. Continued review revealed at 9:37 a.m., the patient received Ativan 1 mg IV, although the patient remained agitated; at 10:30 a.m., the patient received Thiamine (vitamin) 100 mg IV; at 10:31 a.m., the patient received Ativan 1 mg IV, although the patient remained agitated; and at 10:18 a.m., the patient received Succinylcholine (muscle relaxant to facilitate intubation) 3mg, which induced sedation. Continued review revealed at 10:30 a.m., the physician was arranging a transfer for higher level of care. Continued review revealed at 10:55 a.m., the patient's blood pressure was 166/88, pulse was 117, respiration was 24, and oxygen saturation was 94%. Continued review revealed at 11:10 a.m., the physician was at the bedside to intubate (placement of a tube in the patient's throat utilized to administering breathing) the patient. Continued review revealed at 11:15 a.m., the patient received Versed (sedative) 3 mg IV, and remained sedated; at 11:24 a.m., the patient remained sedated and received Norcuron (muscle relaxant utilized to assist in facilitating intubation) 10 mg and Versed 2 mg IV. Continued review revealed at 11:24 a.m., the patient was being bagged (use of equipment to mechanical breath for the patient). Continued review revealed at 11:50 a.m., the patient was transported to a higher level care hospital by Emergency Medical Services with a final diagnosis of Altered Mental Status.

Review of the Clinical Justification Protocol, dated May 19, 2011, at 9:30 a.m., revealed " ...combative ...mittens right and left ...tethered restraints BLE (both lower extremities) ..."

Review of the Physician's Order, revealed an order, dated May 19, 2011, at 9:30 a.m., "Behavioral Restraint". Continued review did not reveal an order for Chemical Restraints or the reason, types of Behavior Restraints to be utilized, or the length of time the restraint was to be utilized.

Review of the facility policy Restraints/Protective Devices, number PC.050, dated as revised March 2011, revealed " ...use of medical/surgical, behavioral, chemical and special population' restraints ...should only be utilized when it is clinically justified or when warranted by patient behavior that threatens the immediate physical safety of the patient, staff, or others ...types of restraints include: ...mittens ...wrist ...ankle ...leather ...Order for application of restraint ...must indicate reason for restraint usage and type of restraint used ...Behavioral Restraint reason is driven by the primary behavioral health problem such as acute mania, acute psychosis ...each order is ...time limited ...Chemical Restraint: A drug used as a restraint is a medication used to control behavior or to restrict the patient's freedom of movement, and is not a standard of treatment for the patient's medical or psychiatric condition ...A standard treatment for medication used to address a patient's medical or psychiatric condition would include the following ...used within the pharmaceutical parameters approved ...follows national practice standards ...treat a specific patient's clinical condition based on that patient's targeted symptoms ...enables the patient to more effectively or appropriately function in the world around ...Orders - refer to reason for restraint (same requirements) ..."

Interview with the Utilization Review Director, on November 8, 2011, at 10:20 a.m., in the conference room, confirmed the patient was chemically restrained and the medical record did not show any rational for the use of the chemical restraint.