HospitalInspections.org

Based on interviews with staff, review of equipment maintenance records, and observations made during tours of the facility it was detemined that the facility lacked a system to track and monitor maintenace performed on vendor provided or contracted patient care equipmentas evidence by:

On September 12, 2012 during the re-certification survey the Sanitarian surveyor interviewed the Director of Clinical Engineering (DCE) and Senior Technician. At the time of the interview the staff members presented a newly acquired computerized program with detail for required preventative maintenance for all equipment owned by the hospital. Upon inquiry about rented equipment the sanitarian was informed that per the hospital's contracts with the vendors, the vendors were responsible for any maintenance of the equipment. The Director of Clinical Engineering, when asked about monitoring of maintenance of rented equipment, stated that the facility plans to do so in the future but has no current system in place as noted in the deficiecy at A0724


Engineering having responsibility for oversight of all medical equipment in the facility, whether it is maintained by his technicians, outside vendors or is channeled through Central Supply, there was no indication that he has been able to provide sufficient oversight of the equipment from outside vendors or central supply as there was no reliable method in place for determining what equipment is in the building and who holds responsibility for maintenance.

Further the governing body is responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services in this case for rented or contracted equipment, has performed the required maintenance to ensure the safety and operation of the patient care and other equipment ..

Based on record review of two open records for patients #33 and 34, the facility, 1) failed to allow patient #33 to sign informed consent and notification of her Medicare rights, due to the fact that she was in restraints 2) admitted patient #34 to a medical unit against his will and 3) failed to respect patient #34's his right to refuse treatment and medications.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Two rights notifications appear in the Emergency Department record, the Universal Consent to Treat and the Important Notice from Medicare. Both forms indicate the patient could not sign as she was in restraints but there was no evidence of follow up by the staff to obtain patient #33 consent and notification information.



Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4:15 pm to the emergency department (ED) after being found, per emergency medical technicians (EMS), on the ground acting as if " ...on PCP. " Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. Patient #34 presented in police-handcuffs, and was noted to have flight of ideas. The RN triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact," but also, "confused." Patient #34 was seen by a physician who in part, found patient #34 to be oriented x 3 with normal affect. Additionally, the physician found patient #34 to have "paranoid language, grandiose comments, and flight of ideas."


The physician wrote in part, "Medically indicated to perform bloodwork will restrain if needed," and "Refused IV - we are allowing po (by mouth) ___ & he has had = 1 L (liter) thus far." Patient #1 had blood drawn. On return of patient #34's labs, it was revealed that he had severe rhabdomyolysis (muscle breakdown) and acute renal (kidney) failure. He received diagnoses of PCP Abuse and Rhabdomyolysis.


Patient #34 refused treatment, though no documentation indicates any attempts to leave the ED. The physician made out an Emergency Petition (EP) for patient #34 stating on the petition, "delusions of grandeur, paranoid, delusions, flight of ideas," and "He has medical condition and is refusing treatment."


According to the EP Endorsement and Order, an ED may not keep the individual longer than 30 hours. Based this law, the individual must be evaluated and a decision is made as to whether the patient requires further evaluation. If the patient requires further evaluation, the patient may be admitted on a voluntary or involuntary basis for further evaluation of the mental disorder. If the ED evaluation finds the patient requires further evaluation, but will not admit voluntarily, two physicians or a physician and a psychologist must examine and certify that the individual requires inpatient observation. Patients may be compelled to have further evaluation, but retains their right to refuse treatment.


While patient #34 allowed his blood to be drawn, the hospital initially respected patient #24's right to refuse treatment e.g., giving him fluids by-mouth instead of forcing an IV which he was refusing. However, at 6:30 pm, when the physician made out the EP, patient #34 was simultaneously restrained in 2-point hard-locked restraints. At that time he received ativan 2 mg IM, Benadryl 25 mg IM, and Geodon 10 mg IM. At 6:45 pm, an IV bag of 1 liter normal saline was started and infusing. No documentation indicated a need for restraint or emergency IM medications.

An ED nursing note of 6:30 pm states "Pt refusing pulse ox @ this time. Pt ambulating through ER." An ED nursing note timed 6:25 pm states, " Pt (patient) refusing IV and fluids @ this time. MD and staff attempted to inform pt concerning the importance of treatment. Pt continues to refuse treatment. Petition placed on pt and pt placed into 2 pt restraints."

The restraint order was written for non-violent or non-self destructive restraints at 6:30 pm for 2-point restraint, but documentation was every 15-minutes, and orders every 4 hours as for behavioral restraints. Additionally, patient #34 was placed in hard-locked restraint as opposed to soft-wrist restraint that would are utilized for violent restraints.

The reason for restraint was given as, confusion/disorientation (patient not responsible for safe decision-making) and actual/potential harm to self. It is not clear how patient #1 was considered a potential danger to himself unless staff felt he might elope if not restrained. Neither potential elopement, confusion nor disorientation are of themselves reason to restrain. It should be noted that patient #34 was previously assessed as oriented x 3 by both the nurse and physician. Alternatives were documented as 1) moving patient #34 closer to the nursing station, and 2) reorienting him to the environment. The facility did not attempt a 1:1 staff prior to restraint.


A nursing note of 1900 states "Staff again attempted to explain to pt about the need for IV fluids. Pt continues to argue and yell @ staff. Pt medicated per Dr. orders. Assumed care of pt @ this time. Pt is irrational @ this time. Pt is to be admitted to the hospital due to rhado (sic), " and at 2055, " IV started and fluids up @ this time ...no irrational behavior noted." Patient #34 was admitted to a medical unit at approximately midnight.

According to the Maryland patient information booklet, in part, "Rights of Persons in Maryland's Psychiatric Facilities" regarding Involuntary Admission: " If two physicians or one physician and one psychologist complete certificates for involuntary admission, you will be taken into observation status. In order for you to be involuntarily admitted, all of the following must be true:

· you have a mental illness;
· you need inpatient care or treatment;
· you present a danger to yourself or to others;
· you are unable or unwilling to be admitted voluntarily;
· there is no available, less restrictive form of care or treatment to
meet your needs.

If you are certified and taken into observation status at a hospital: (1) You have the right to be evaluated by a psychiatrist within 24 hours after you enter the hospital. (2) You have the right to request a change of your admission status to voluntary at any time. (3) If your status does not change, you are entitled to an involuntary admission hearing within 10 days. The hearing may be postponed for no more than 7 days. The purpose of the hearing is to determine whether you meet the criteria described above. You must be released if you do not meet these criteria. (4) You will be given oral and written notice of the hearing date and an explanation of your rights at the hearing. A copy of this notice will be given to you, placed in your medical record, and sent to your parent, guardian, or next of kin. "


While the ED physician's intent was to have the mental status examination of patient #34, who had an emergency medical condition, and who was simultaneously refusing treatment for that condition, there was no documentation of physician certifications are found. The certifications would have compelled patient #1 into an involuntary admission. Certificates for involuntary admission were not completed until 9/8 at 1:10 pm. Likewise, no statements of incapacity are found indicating patient #34 was unable to make his own healthcare decisions, allowing admission for treatment. Therefore, patient #34 who had a right to refuse treatment was treated in the ED, and admitted against his will and his right to refuse treatment.

A Medical/Surgical Admission Order sheet of 9/7/12 at 9:15 pm reveals in part, " Psychiatry consult for delusions and aggressive behavior, " and " Keep in restraints for patient safety. To that point, no documentation had indicated aggressive behavior, nor was any aggressive behavior noted until 9/9 at 8 am. However, documentation to that point revealed patient #34 ' s adamant refusal of treatment.

Additional orders included normal saline IV 150 ml/hr, EKG on admission is not already done, lovenox 40 mg subcutaneously Q 24 hours, protonix 40 mg po (by mouth) daily, ativan 2 mg IV Q 4 hr as needed for agitation. Laboratory orders included Chem 7, ___, ___, myoglobulin Q12 hours, urine toxicology,

An H & P (history and physical) of 9/7/12 at 2324 states in part, " ...the patient was found to be aggressive, and was restrained and blood was sent for analysis, " and " Admission was requested for hydration, " and " The patient is currently restrained, and he is getting IV fluid. " Additionally, the H & P states, " The ER physician petitioned him to be under restraints and for psychiatric evaluation. " Under the psychiatric portion of the H & P, the physician wrote, " The patient seems to be alert, oriented to time person, and place, but he seems to lack insight and he is refusing medication and treatment; he does not think he is sick. " The physician documented his assessment and plan for patient #34 in part as, " The patient will be restrained and will be on one-to-one observation with a sitter .... and " Psychiatry evaluation pending until morning. " The physician continued to treat patient #34 against his will.

Though patient #34 had orders to remain in restraint, nursing documentation of 9/8 at 0130 and 0330 reveals that he was up to the bathroom, was calm and cooperative. Patient #34 was discharged from the medical floor to behavioral health on 9/8 at 0820.

A psychiatric consult of 9/8 at 1 pm states in part, " Pt. is delusional, agitated angry demanding to leave. Pt has long H/O (history of) Schizoaffective disorder with multiple psych admissions in past, living with cousin. Alert & oriented to self and others, labile and angry and uncooperative_____ delusional paranoid, poor judgment. Denies SI (suicidal ideation) + HI (homicidal ideation), " and " Needs inpatient psych treatment. "

A transfer summary of 9/8 at 2:55 pm states in part, "When he came to the ER he was very agitated and aggressive. He required restraints in the ER and was given IV ativan. " This statement related to the level of patient #34 ' s agitation is not supported by actual ED documentation. No aggression was documented in the ED. However, patient #34 continued to refuse treatment as was his right. The summary continues, " The patient refused many treatments. He refused blood draws. He refused physical examination. He was pressuring to go home. He was a very poor historian. He denies any medical problems, " and " He has repeat blood work done. His CPK level is coming down, " and " The patient is refusing anything medical on the medical floor. He does not want to have any more blood draws and does not want to have any more IV hydration. Therefore, we think he is better off to go to the psychiatric floor and get his psychosis treated. We are going to follow up tomorrow with BMP as well and CPK and see what it is. " Overall, this patient states he feels better and he feels back to his baseline. He does not think he needs to be admitted. "

The Summary continues, " He was seen by psychiatrist ___ who knows this patient very well and states that he has a history of being very aggressive and very irrational. He could do something very irrational if he is left to go to the hospital. Therefore, this patient was committed. We had to petition (the psychiatrist) and I had to sign orders to have this patient involuntarily admitted to the psychiatric floor ... "

An untimed psychiatric consultation conducted on 9/8 states in part, " He became very aggressive and agitated on the medical floor. He had to be restrained and had to be medicated. Security was called several times. He became aggressive and wants to leave, claiming he has to do work. Patient is very confused, delusional, and does not make any proper sense that he has to leave, " and " Patient is dangerous to himself and other. He is very aggressive. He is paranoid and delusional with no insight or judgment. "

Documentation of patient #34 ' s aggression while in the ED and on the medical/surgical unit is not supported by documentation prior to his transfer to the behavioral health unit (BHU). Hospital security documentation reveals that the only security interaction was when they were called to walk patient #34 to the BHU on transfer, and that on incidents occurred during transfer. There is a demonstrated disparity in documentation related to patient #24 ' s behavior throughout the record.

Once on the BHU unit, orders for " Haldol 5 mg po prn Q4 hours, psychosis, Ativan 1 mg po prn q 4 hours, agitation, Benadryl 25 mg po prn q 4 hours EPS (extrapyramidal side effects) / Give IM if patient refuses po. Additionally, patient #24 ' s Certifications for Involuntary Admission reveal Haldol and Ativan as " Emergency Medication. " These prn orders do not meet regulatory directives. Patients have a right to refuse medication, and emergency medications are never to be written prn. Based on the psychiatrist ' s order, the RN could administer IM medication to a patient refusing prn medication without consulting the psychiatrist, in the absence of an emergency, and without benefit of a Clinical Review Panel.

A Clinical Review Panel (CRP) determines if medications may be given against a patient's will. The CRP is designed to protect the patient's right to refuse medication in all circumstances excepting those where the patient represents an ongoing danger to self or other. The patient rights are as noted below:

(2) At a panel, an individual has the following rights:
(i) To attend the meeting of the panel, excluding the discussion conducted to arrive at a decision;
(ii) To present information, including witnesses;
(iii) To ask questions of any person presenting information to the panel;
(iv) To request assistance from a lay advisor; and
(v) To be informed of:
1. The name, address, and telephone number of the lay advisor;
2. The individual's diagnosis; and
3. An explanation of the clinical need for the medication or medications, including potential side effects, and material risks and benefits of taking or refusing the medication.

The physician prn order effectively by-passed the CRP process and patient #34's right to refuse medication.

A nursing note of 9/10 at 0930 states in part, "Patient's speech is pressured, loud and disruptive - profane language in milieu towards writer and staff. Patient escorted to room, security present. Patient continued to posture while ambulating to room, argumentative. Pt initially refused PO medications, repeated encouragement from staff & security - patient eventually compliant. 5 mg Haldol, 25 mg Benadryl and 1 mg Ativan given, patient given time out for 30 minutes."


On 9/11/12 at 1525, a nursing note states "Patient continues to curse and disrupt milieu, easily agitated and hostile, unable to follow verbal re-direction, refused po prns. Security notified. Patient given IM injections will continue to monitor."


The facility failed to honor patient #1's right to refuse medications when the psychiatrist wrote for IM medication if the patient refused the by-mouth doses. Additionally, IM medication for a refusing patient could well require restraint in order to administer the IM, thus creating a safety issue for the patient with each refusal. Further, staff intimidation/coercion to take medications not ordered by CRP violates patient #34's right to refuse medication.

In summary, patient #34 was brought to the hospital via ambulance after being found on the ground. Blood work obtained with his permission revealed severe rhabdomyolysis. The ED physician simultaneously filled out an emergency petition, restrained patient #34 and gave him medication and fluids against his expressed refusal for treatment. Patient #34 was subsequently admitted to the hospital against his will, and without benefit of certifications for further psychiatric evaluation. He continued to receive fluids and medications against his expressed and documented refusals. Patient #34 was then transferred to the BHU under newly written certificates for involuntary admission for dangerous behaviors which are not documented elsewhere in the record.

In the absence of an appropriately executed statements of Incapacity, Physician Certificates on admission for involuntary admission, and a Clinical Review Panel for forced medications, the facility grossly violated patient #34 ' s rights to make decisions regarding his care and his right to refuse care. The facility grossly failed to protect and promote patient #34's rights through all clinicians, three discreet areas of care, and all regulatory/law processes designed to deliver care while maintaining patient rights.

Based on record review of two open records for patients who were restrained, it was determined that the facility failed to allow patient #33 to sign informed consent and notification of her Medicare rights, due to the fact that she was in restraints.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma.



On presentation, patient #33's triage assessed her as "uncooperative" having thoughts of harm to self with a plan, and the means to carry out that plan. She was also assessed as being a risk for self harm or elopement. The RN documented that that patient #33 was not in police custody. Under the Nursing Assessment for Violence, the RN checked the box for "No risk identified."



Two rights notifications appear in the Emergency Department record. The first of these is a Universal Consent. In the place indicated for the patient signature, a staff member wrote "Pt unable to sign" and found below the signature line in the space provided to indicate why the patient was unable to sign, were the words, "In restraints."



The second notification is the Important Message from Medicare which under the signature portion of the form states, "Pt (patient) unable to sign in restraints." No staff follow-up to give patient #33 her consent and notification information is found in the record.

Based on record review of two open records for patients #33 and 34, the facility:
1) the facility failed to obtain an order for patient #33's continuation of restraint while on the behavioral health unit (BHU),
2) the facility failed to release patient #33 at the earliest possible time,
3) the facility restrained patient #34 without behavioral justification in the emergency department, and failed to release patient #34 at the earliest possible time in the ED and on the behavioral health unit.
4) the facility wrote an order for IM medications if patient #34 did not take prn medication for psychosis and agitation.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma.


On presentation, patient #33's triage assessed her as "uncooperative" having thoughts of harm to self with a plan, and the means to carry out that plan. She was also assessed as being a risk for self harm or elopement. The RN documented that that patient #33 was not in police custody. Under the Nursing Assessment for Violence, the RN checked the box for "No risk identified." Patient #33 was admitted to the behavioral health unit (BHU) on 9/6 at 7 pm.


On 9/9/12 at 6:20 am, patient #33 was noted to escalate on the BHU, punch, bite, and kick. An order for restraint appears in the record for reasons of "Combative behavior, danger to self and/or others, and disruptive to therapeutic milieu. " Patient #33 was placed in 4-point hard-locked restraints.


The Close Observation Flowsheet (COFS) on which staff document every-15-minute observations reveals that patient #33 was in 4-point, hard-locked restraint from 6:20 am until 1:15 pm, approximately 7 hours. While a renewal of restraint was required at 10:20 am, no renewal of restraint order is found in the record as required.


The RN Assessment/Reassessment for Use of Restraints reveals documentation only through 10 am of "C" which represents "Continue restraints; behaviors unchanged." However, under the every-15-minute "Visual Observation" portion of the COFS, patient #33 is noted from 7 am through 12 pm as "Restless and Crying" then "Awake, calm, cooperative" through the remainder of the restraint episode until 1:15 pm. Therefore, patient #33 no longer represented a danger to herself or others after the first 15 minutes of restraint, yet was kept in restraint for a total of 7 hours.


Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4 pm to the emergency department (ED) after being found per emergency medical technicians (EMS), on the ground acting as if on "PCP." Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. He presented in police-handcuffs, and was noted to have flight of ideas. The triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact" but also "confused."


Patient #34 was seen by a physician who in part, found patient #34 to be oriented x 3 with normal affect. The physician wrote in part, " Medically indicated to perform bloodwork will restrain if needed, " and "Refused IV - we are allowing po (by mouth) ___ & he has had = 1 L (liter) thus far." On return of patient #34 ' s labs, it was revealed that he had severe rhabdomyolysis and acute renal failure. He received diagnoses of PCP Abuse and Rhabdomyolysis. Patient #34 was refusing treatment, but allowed initial blood work. After that, patient #34 continued to refuse all treatment as documented by nursing and physicians.


An ED nursing note of 6:30 pm states "Pt refusing pulse ox @ this time. Pt ambulating through ER." An ED nursing note timed 6:25 pm states, " Pt (patient) refusing IV and fluids @ this time. MD and staff attempted to inform pt concerning the importance of treatment. Pt continues to refuse treatment. Petition placed on pt and pt placed into 2 pt non-violent restraints, but documentation was every 15-minutes, and orders every 4 hours as for behavioral restraints. Additionally, patient #34 was placed in hard-locked restraint as opposed to soft-wrist restraint that would be utilized for non violent restraints.


The reason for restraint was given as, confusion/disorientation (patient not responsible for safe decision-making) and actual/potential harm to self. It is not clear how patient #34 was considered a potential danger to himself based on the documentation on the record. Neither potential elopement, confusion nor disorientation is of themselves reason to restrain. It should be noted that patient #34 was previously assessed as oriented x 3 by both the nurse and physician. Alternatives were documented as moving patient #34 closer to the nursing station; and reorienting him to the environment.


A nursing note of 7 pm states "Staff again attempted to explain to pt about the need for IV fluids & continues to argue and yell @ staff. Pt medicated per MD orders" and at 1930, "Assumed care of pt @ this time. Pt is irrational @ this time. Pt is to be admitted to the hospital due to Rhabdo."


The restraint Assessment Flowsheet (RAF) reveals that patient #1 was initiated into 2-point restraints at 6:30 pm. However, at 8 and 9 pm, patient #34 was increased to 4-point restraint, then back to 2-point by 10 pm. There were no new orders when going to a more restrictive restraint as required by regulation. Visual observations on the flowsheet do not begin until 11:30 pm. However, a nursing note of 2155 states "IV started and fluids up @ this time. Pt. is resting (with) eyes closed. Easy to arouse @ this time. No irrational behavior noted. Report faxed at this time."


RN documentation for every-15-minute assessments reveals "C" a code for "Continue restraints, behaviors unchanged" yet no initiating behaviors, or ongoing behaviors are documented. Additionally, RAF documented behaviors from 9/7 at 11:30 pm until release on 9/8 1:45 am, of 2.25 hours reveal that patient #24 was sleeping or awake, calm and cooperative.

In summary, staff gave no objective behavioral documentation to support restraining patient #24, for either violent or non-violent types of restraint while he was in the ED. While non-violent restraint orders were in place, those orders were written every 4 hours as for violent restraints. Additionally, patient #34 was largely monitored every 15-minute as for violent restraints, and within that monitoring, no behavioral justification for restraint initiation or continuation is found. Potential elopement is not justification for restrain, nor is the fact that an Emergency Petition for evaluation is in place. Likewise, once restrained, staff has an obligation to release a patient at the earliest possible time which did not occur for patient #1 who was restrained for at least 5 hours without documented justification.


The admitting physician History and Physical note states in part, "The patient was found to be aggressive, and he was restrained" and " The ER physician petitioned him to be under restraints and for psychiatric evaluation" and "the patient will be restrained and will be on one-to-one observation with a sitter." The physician documentation is not supported by the ED record. Nursing and physician ED documentation reveals patient #34's refusal for treatment, but does not reveal any aggression on the part of patient #34.


On 9/9 at 8 am, following admission to the behavioral health unit, patient #34 was noted to become angry and threatening to a peer and staff. Patient #34 was initiated into restraint at 8 am. All visual observations from 8 am through 12 noon reveal that patient #34 was "Awake, calm, and cooperative." There is a disparity to the simultaneous nursing notes of 8:45 am and 12 noon which stated patient #34 remained alternately, restless, argumentative and agitated; none of which demonstrate violent behavior, nor are they criterion for restraint. Staff did not document behaviors which demonstrated that patient #34 continued to be a danger to self or other. Thus, patient #34 was not released at the earliest possible time.



Once on the BHU unit, orders for haldol 5 mg po prn Q4 hours, psychosis, Ativan 1 mg po prn q 4 hours, agitation, Benadryl 25 mg po prn q 4 hours EPS (extrapyramidal side effects)/Give IM if patient refuses po. Patients have a right to refuse medication unless they are compelled to take medication due to a Clinical Review Panel (CRP) ordering the patient to take medications against their will. Patient #34 was not under a CRP.


Per the hospital policy Use of Restraints April 26, 2012, "Physical Holding for Forced Medications": The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint.


A nursing note of 9/10 at 0930 states in part, "Patient's speech is pressured, loud and disruptive - profane language in milieu towards writer and staff. Patient escorted to room, security present. Patient continued to posture while ambulating to room, argumentative. Pt initially refused PO medications, repeated encouragement from staff & security - patient eventually compliant. 5 mg Haldol, 25 mg Benadryl and 1 mg Ativan given, patient given time out for 30 minutes."


Patient #34 was willing to take time out in his room, evidenced by him walking there, yet staff and security repeatedly encouraged he take medications which would otherwise be forced IM.


On 9/11/12 at 1525, a nursing note states "Patient continues to curse and disrupt milieu, easily agitated and hostile, unable to follow verbal re-direction, refused po prns. Security notified. Patient given IM ( intramuscular) injections will continue to monitor."


While patient #34 may have been difficult to manage, neither of the nursing entries indicated that an emergency was occurring. Administration of IM medication for a refusing patient in a non-emergency or on a prn basis is noncompliant with regulation, and could well result in an unnecessary restraint event; and thus creating a safety issue for the patient and staff with each refusal. Further, the threat of IM medication as a means to coerce a patient who is otherwise refusing is a violation of the patients' right to refuse.

Based on a review of hospital policy and two open records for patients #33 and #34, it is revealed that the hospital failed to modify their Interdisciplinary Plan of Care (ITP) following events of restraint.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma. Patient #33 was admitted on a voluntary basis to the Behavioral Health Unit.


On 9/9/12 at 6:20 am, patient #33 was noted to escalate on the BHU, punch, bite, and kick. An order for restraint appears in the record for reasons of "Combative behavior, danger to self and/or others, and disruptive to therapeutic milieu." Patient #33 was placed in 4-point hard-locked restraints. Patient #33 was kept in restraint for a total of 7 hours.


Patient #33's Interdisciplinary Care Plan reveals problem #18, which was added on 9/6 with a target date of 9/9. The goal is listed as "Will demonstrate appropriate coping skills." The intervention for this problem is listed as "Restraint for violent or self-destructive behavior." This problem was reviewed on 9/10 and according to the care plan, remains unchanged even though a restraint event occurred. Nowhere on the care plan was it documented that patient #33 had gone into restraints.


Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4 pm to the emergency department (ED) after being found per emergency medical technicians (EMS), on the ground acting as if on "PCP." Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. He presented in police-handcuffs, and was noted to have flight of ideas. The triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact" but also "confused." Patient #34 was admitted to a medical unit, and then transferred to a behavioral health unit.


Likewise, patient #34 also has problem #18, which was added on 9/8 and had a target date of 9/11. The goal is listed as "Will demonstrate appropriate coping skills." The intervention for this problem is listed as "Restraint for violent or self-destructive behavior." This problem was reviewed on 9/10 and according to the care plan, remains unchanged even though a restraint event occurred. A care plan note reveals in part, "Will confirm if pt. is on conditional release. Restrained x 2 days ago ___ ___ volatile, labile, unpredictable behavior."

While a treatment plan problem existed for both patients #33 and #34's mentioning the potential use of restraints, neither ITP evaluation indicated an actual modification to the treatment plans, and on acknowledgement was found for patient #33's restraint at all..

Based on a review of two open records for patients #33 and #34, and one closed record for patient #41, 1) only one order was found for patient #33 who was in restraint for 7 hours; 2) No order is found for patient #34 when staff increased restraint points from 2 to 4; and 3) two Posey bed and one 2-point restraint orders were missing for patient #35.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma.



On presentation, patient #33 was assessed at triage as "uncooperative" having thoughts of harm to self with a plan, and with the means to carry out that plan. She was also assessed as being a risk for self harm or elopement. The RN documented that that patient #33 was not in police custody. Under the Nursing Assessment for Violence, the RN checked the box for "No risk identified."



On 9/9/12 at 6:20 am, patient #33 was noted to escalate on the BHU, punch, bite, and kick. An order for restraint appears in the record for reasons of "Combative behavior, danger to self and/or others, and disruptive to therapeutic milieu." Patient #33 was placed in 4-point hard-locked restraints. Patient #33 was kept in restraint for a total of 7 hours. However, a second order to continue restraint beyond 4 hours is not found. Therefore, patient #33 was restrained for up to 3 hours without a physician order.

Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4 pm to the emergency department (ED) after being found, per emergency medical technicians (EMS), on the ground acting as if on "PCP." Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. He presented in police-handcuffs, and was noted to have flight of ideas. The triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact" but also "confused."



An ED nursing note of 6:30 pm states "Pt refusing pulse ox @ this time. Pt ambulating through ER." An ED nursing note timed 6:25 pm states "Pt (patient) refusing IV and fluids @ this time. MD and staff attempted to inform pt concerning the importance of treatment. Pt continues to refuse treatment. Petition placed on pt and pt placed into 2 pt restraints."



The restraint Assessment Flowsheet (RAF) reveals that patient #1 was initiated into 2-point restraints at 6:30 pm. However, at 8 and 9 pm, patient #34 was increased to 4-point restraint, then back to 2-point by 10 pm. No new orders are found per regulation when going to a more restrictive restraint.



The restraint order was written for non-violent or non-self destructive restraints at 6:30 pm for 2-point restraint, but orders were written every 4 hours, and observations were every 15-minute as for behavioral restraints. Additionally, patient #34 was placed in hard-locked restraint as opposed to soft-wrist restraint that would are utilized for violent restraints.



Closed record patient #41 is a 74-year-old male who was admitted on 6/5/2012 due to periods of confusion agitation, and attempts to destroy the furniture in the home. Patient #41was found to have an old infarct with chronic small vessel ischemic disease and cerebral atrophy, and was managed as Alzheimer's dementia. Patient #41 needed 1:1 care and alternately two-point restraints and a Posey bed due to restlessness and multiple attempts to get out of bed. Patient #41 suffered multiple falls.


A review of the record reveals that patient #41 did not have every 24 hour orders for a Posey bed on 6/22 and 6/23/12. Additionally, he was in 2-point restraints on 7/14, yet no order is found.

Based on a review of policy and two open restraint records, for patient #33 and #34, it is determined that a standing order for restraint was written for patient #34.


Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4 pm to the emergency department (ED) after being found per emergency medical technicians (EMS), on the ground acting as if on "PCP." Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. He presented in police-handcuffs, and was noted to have flight of ideas. The triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact," but also "confused." Patient #34 was admitted to a medical unit.


A Medical/Surgical Admission Order sheet of 9/7/12 at 9:15 pm reveals in part, "Psychiatry consult for delusions and aggressive behavior" and "Keep in restraints for patient safety." The order for continuous restraints represents a standing order which is not in compliance with regulation. It appears that patient #34 was in fact released from restraint, evidenced by documentation of him ambulating to the bathroom. However, the fact that a standing order was written is a violation of patient #34's rights. An order to continue restraint was written at 10:30 pm, and patient #1 was released on 9/8 at 1:30 am.


The H & P (history and physical) of 9/7/12 at 2324 states in part, "The ER physician petitioned him to be under restraints and for psychiatric evaluation." Under the psychiatric portion of the H & P, the physician wrote "The patient seems to be alert, oriented to time person, and place, but he seems to lack insight and he is refusing medication and treatment; he does not think he is sick." The physician documented his assessment and plan for patient #34 in part as, "The patient will be restrained and will be on one-to-one observation with a sitter .... and "Psychiatry evaluation pending until morning."


A review of hospital restraint policy reveals that "An order for PRN restraint use is NOT permitted." The hospital policy does not address standing restraint orders.

Based on a review of two open records for patients #33 and #34, 1) patient #33 received an incomplete face-to-face in part, conducted by a clinical staff who is not a licensed independent practitioner (LIP), 2) patient #34 received a face to face in the emergency department which did not serve the elements of the regulation.


The hospital has recently adopted a "Face- to- Face" evaluation form on which physicians may document their findings.

Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma.


On presentation, patient #33's triage assessed her as "uncooperative," having thoughts of harm to self with a plan, and the means to carry out that plan. She was also assessed as being a risk for self harm or elopement. The RN documented that that patient #33 was not in police custody. Under the Nursing Assessment for Violence, the RN checked the box for "No risk identified." Patient #33 was admitted to the behavioral health unit (BHU) on 9/6 at 7 pm.


On 9/9/12 at 6:20 am, patient #33 was noted to escalate on the BHU, punch, bite, and kick. An order for restraint appears in the record for reasons of "Combative behavior, danger to self and/or others, and disruptive to therapeutic milieu." Patient #33 was placed in 4-point hard-locked restraints.


A physician Face-to-Face was required within the first hour of restraint. The BHU uses a facility form on which there are pre-printed assessment boxes in which to check various findings. For patient #33, the face to face evaluation is timed at 6:50 am. However, the physician assessment portion was checked-off in the handwriting of the RN rather than the physician evidence by both a different handwriting style and the use of a different writing instrument than that of the documented physician signature and date. Additionally, the physician assessment portion which indicates is there is an underlying medical cause responsible for the patient behavior, and whether restraint should continue, are not filled out.


There was no physician progress note in the record until 2 pm. The progress note states in part, "Pt. is under two point restraints. She was fighting staff ... " Restraint documentation for patient #23 ended at 1:15 pm.


Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4 pm to the emergency department (ED) after being found per emergency medical technicians (EMS), on the ground acting as if on "PCP." Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. He presented in police-handcuffs, and was noted to have flight of ideas. The triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact," but also "confused."


Patient #34 was seen by a physician who in part, found patient #24 to be oriented x 3 with normal affect. The physician wrote in part, "Medically indicated to perform bloodwork will restrain if needed," and "Refused IV - we are allowing po (by mouth) ___ & he has had = 1 L (liter) thus far." On return of patient #24's labs, it was revealed that he had severe rhabdomyolysis and acute renal failure. He received diagnoses of PCP Abuse and Rhabdomyolysis.


Patient #24 was refusing treatment, but allowed initial blood work. After that, patient #34 continued to refuse all treatment as documented by nursing and physicians.

An ED nursing note of 6:30 pm states "Pt refusing pulse ox @ this time. Pt ambulating through ER." An ED nursing note timed 6:25 pm states "Pt (patient) refusing IV and fluids @ this time. MD and staff attempted to inform pt concerning the importance of treatment. Pt continues to refuse treatment. Petition placed on pt and pt placed into 2 pt restraints."


The restraint order was written for non-violent or non-self destructive restraints at 6:30 pm for 2-point restraint, but documentation was every 15-minute, and orders every 4 hours as for behavioral restraints. Additionally, patient #34 was placed in hard-locked restraint as opposed to soft-wrist restraint that would are utilized for violent restraints.


No face-to-face form is found in the record or other documentation indicating the requirements of the face-to-face. Other than a physician order of 6:30 pm, documentation regarding patient #34 is found at 4 pm, and on admission orders at 9:15 pm, neither of which are contemporaneous within one hour of restraint, and neither which describe the elements of the face-to-face.

Based on a review of two open records for patients #33 and #34, no behavioral documentation is found which supports patient #34's restraint event in the emergency department.


Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4:15 pm to the emergency department (ED) after being found, per emergency medical technicians (EMS), on the ground acting as if " ...on PCP." Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. Patient #34 presented in police-handcuffs, and was noted to have flight of ideas. The RN triage assessment found patient #34 to be "Oriented, cooperative, normal affect and has eye contact," but also, "confused." Patient #34 was seen by a physician who in part, found patient #34 to be oriented times 3 with normal affect. Additionally, the physician found patient #34 to have "paranoid language, grandiose comments, and flight of ideas."


The physician wrote in part, "Medically indicated to perform bloodwork will restrain if needed," and "Refused IV - we are allowing po (by mouth) ___ & he has had = 1 L (liter) thus far." Patient #1 had blood drawn. On return of patient #34 ' s labs, it was revealed that he had severe rhabdomyolysis (muscle breakdown) and acute renal (kidney) failure. He received diagnoses of PCP Abuse and Rhabdomyolysis.


Patient #34 refused treatment, though no documentation indicates attempts to leave the ED. The physician made out an Emergency Petition (EP) for patient #34 stating on the petition, "delusions of grandeur, paranoid, delusions, flight of ideas," and "He has medical condition and is refusing treatment."

An ED nursing note of 6:30 pm states "Pt refusing pulse ox @ this time. Pt ambulating through ER." An ED nursing note timed 6:25 pm states "Pt (patient) refusing IV and fluids @ this time. MD and staff attempted to inform pt concerning the importance of treatment. Pt continues to refuse treatment. Petition placed on pt and pt placed into 2 pt restraints."


The restraint order was written for non-violent or non-self destructive restraints at 6:30 pm for 2-point restraint, but documentation was every 15-minutes, and orders every 4 hours as for behavioral restraints. Additionally, patient #34 was placed in hard-locked restraint as opposed to soft-wrist restraint that would are utilized for violent restraints.


The reason for restraint was given as, confusion/disorientation (patient not responsible for safe decision-making) and actual/potential harm to self. It is not clear how patient #1 was considered a potential danger to himself unless staff felt he might elope if not restrained. Neither potential elopement, confusion nor disorientation is of themselves reason to restrain. It should be noted that patient #34 was previously assessed as oriented times 3 by both the nurse and physician.


The facility failed to document any meaningful behaviors related to patient #34's restraint event.

Based on a review of two open records for patients #33 and #34, the facility 1) failed to document Assessment/Reassessment and circulation/skin assessments for patient #33 during a restraint event, and 2) failed to document visual observations, interventions, circulation/skin assessments, and Assessment/Reassessments for patient #34 during a restraint event in the emergency department and on the behavioral health unit.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma. Patient #33 was admitted to the behavioral health unit.


On 9/9/12 at 6:20 am, patient #33 was noted to escalate on the BHU, punch, bite, and kick. An order for restraint appears in the record for reasons of "Combative behavior, danger to self and/or others, and disruptive to therapeutic milieu." Patient #33 was placed in 4-point hard-locked restraints.


The Close Observation Flowsheet (COFS) on which staff document every-15-minute observations reveals that patient #33 was in 4-point, hard-locked restraint from 6:20 am until 1:15 pm, approximately 7 hours.


On the Assessment/Reassessment portion of the Restraint Assessment Flowsheet (RAF), hourly assessments for continuation of restraints are found only through 10 AM, whereas patient #33 did not come out of restraint until 1:30 PM. Circulation and skin assessments are found completed only through 10 am as well.


Open record patient #34 is a 32-year-old male who presented via ambulance on 9/7/12 at approximately 4:15 PM to the emergency department (ED) after being found, per emergency medical technicians (EMS), on the ground acting as if " ...on PCP. " Patient #34 had been on the ground an unknown period of time. He denied alcohol and drug use, but the EMS reported possible PCP use. Patient #34 presented in police-handcuffs, and was noted to have flight of ideas. The RN triage assessment found patient #34 to be " Oriented, cooperative, normal affect and has eye contact, " but also, " confused. " Patient #34 was seen by a physician who in part, found patient #34 to be oriented x 3 with normal affect. Additionally, the physician found patient #34 to have " paranoid language, grandiose comments, and flight of ideas. "


The physician wrote in part, "Medically indicated to perform bloodwork will restrain if needed, " and " Refused IV - we are allowing po (by mouth) ___ & he has had = 1 L (liter) thus far." Patient #1 had blood drawn. On return of patient #34 ' s labs, it was revealed that he had severe rhabdomyolysis (muscle breakdown) and acute renal (kidney) failure. He received diagnoses of PCP Abuse and Rhabdomyolysis.


An ED nursing note of 6:30 pm states "Pt refusing pulse ox @ this time. Pt ambulating throught ER." An ED nursing note timed 6:25 pm states "Pt (patient) refusing IV and fluids @ this time. MD and staff attempted to inform pt concerning the importance of treatment. Pt continues to refuse treatment. Petition placed on pt and pt placed into 2 pt restraints."


The restraint order was written for non-violent or non-self destructive restraints at 6:30 PM for 2-point restraint, but documentation was every 15-minutes, and orders every 4 hours as for behavioral restraints. Additionally, patient #34 was placed in hard-locked restraint as opposed to soft-wrist restraint that would are utilized for violent restraints. Patient #34 was in restraint from 6:30 pm until 9/8 at 1:30 AM, a total of 7 hours.


The RAF reveals no visual observations of behavior from the time of initiation until 11:45 PM, and no interventions for the same time period such as restraint adjustment, range of motion, offered liquids, food/meals, toileting and hygiene. Additionally, no circulation/skin assessments were done for the first two hours of restraint.


Patient #34 was admitted to a medical unit and was subsequently transferred to the behavioral health unit. On 9/9 at 8 am, patient #34 is documented as yelling, cursing and verbally threatening another patient on the unit. He was unable to follow staff direction, and made threats to staff. He was placed in 2-point restraint from 8 am until 12:30 PM


The RAF reveals assessment/reassessments and interventions until 12 PM and no circulation/skin assessments at all.

Based on review of 34 inpatient medical records it was detemined that in two of 34 records reviewed the hospital failed to ensure that the nursing staff followed the nursing care plan for the patients in a timely manner to address the patient's health care needs .

Patient # 33 is a 45 year old male, admitted to the hospital on 09/05/12 with multiple medical conditions that included: Congestive Heart Failure (CHF) and infiltrates of the lungs.
Based on review of the medical record, a physician's order dated 09/05/12 and written at 10 AM, ordered that the patient have a sputum culture and intravenous antibiotic therapy of Levaquin (broad spectrum antibiotic) 750milligrams (mg) daily after blood culture draws. A review of the patient's medical record on 09/11/12 revealed that the nursing staff did obtain a sputum specimen on 09/06/12 at 04:31. However, review of the laboratory detail report indicated that the specimen was processed on 09/06/12 at 10:21 and noted that the specimen was "determined unacceptable for culture by gram stain, informed RN(registered nurse) at 10:19, requested another specimen".
Interview of the 5th floor Unit Director of the Telemetry Floor revealed the following:
(1) A 2nd sputum specimen had not been obtained by the nursing staff as the lab requested, (2) There was no note found written by a physician pertaining to the sputum request, and (3) no note by the nursing staff that the physician was notified about the need for a second sputum specimen.
On 09/12/12 in the morning the surveyor conducted a second review of this patient's medical record. The review revealed that a nursing progress note was written by [AA, RN] on 09/12/12 (7 days after admission) at 10:25AM that mentioned the patient was being requested to provide a sputum specimen and if unable to do so, then respiratory therapy would be called to provide "sputum induction."
The surveyor questioned the Unit Director at 11AM as to whether the physician had ever been notified about the sputum not being repeated as requested by the lab and to see if the physician still wanted the test since the patient had already received intravenous antibiotic therapy. After surveyor intervention, the patient's physician was called by Nurse[AA-RN] who obtained a telephone order dated 09/12/12 at 11:05AM to discontinue the obtaining of a sputum specimen for culture and sensitivity. Failure by the nursing staff to obtain laboratory tests in a timely manner: (1) potentially places a patient at risk for a delay in needed treatment, important in maintaining or achieving, the patient's highest well being and (2) fragmenting the continuity of care.


Patient # (26) 10049422 is a 59 year old male, admitted to the hospital on 09/10/12, who had multiple medical conditions that included syncopal episode, chronic kidney disease, acute renal failure and suspected dehydration.
Observation and review of the patient ' s medical record on 09/12/12 revealed that on 09/11/12 at 9:15 PM the physician [Dr. A] ordered that the patient have a urinalysis and urine culture with sensitivity. Interview of the 5th floor Unit Director on 09/12/12 revealed that as of 11:30AM the nursing staff had not obtained a urine specimen from the patient, even though the patient's Patient Care/Treatment Record dated 09/11/12 indicated that the patient was voiding using a urinal and had a 24 hour output of 600cc. The nursing staff failed to obtain the ordered urine specimen in a timely manner (12-17 hours after the order) which potentially placed the renal compromised patient at risk for a delay in treatment.

Based on review of (34) open records and (23) closed medical records, it was determined that 2 of the (23) closed records lack date and time for verbal orders signed by the prescribing physician.

Closed record no. 21 was a patient who was admitted July 6, 2012. Her record contained multiple VO/TO orders taken by the RN, signed by the prescribing physician but no date or time. Please note that during the closed record review on September 13, 2012 the following orders were observed to be signed but not dated or timed:
Albuterol order taken by the RN on July 12, 2012 at 0710
Amp D50 order taken by the RN on July 12, 2012 @ 0825
NPO except meds taken by the RN on July 12, 2012 @ 1020
HD treatment today taken by the RN on July 12, 2012 @ 1730
Senokot now taken by the RN on July 12, 2012 @ 2235
Dialyze the patient today taken by the RN on July 13, 2012 @ 1910
Potassium level stat taken by the RN on July 13, 2012 @ 2155
Dilaudid stat and PRN taken by the RN on July 17, 2012 @ 2030
Use right upper A-V graft for HD today taken by the RN on July 18, 2012 @ 0845
Femoral Quinton catheter may now be used taken by RN on July 18, 2012 @ 1200
Repeat CBC taken by the RN on July 19, 2012 @ 0530

Based on a review of ( 34 ) open records and ( 23 ) closed medical records, it was determined that 2 of the (23) closed records contained verbal orders that were not signed by the prescribing physician for weeks after the order was given.

Closed record no. 17 was a patient who was admitted to the hospital on June 3, 2012. Her physician order sheets contained one verbal order/ telephone order (VO/TO) taken by the nurse on June 4, 2012 but not signed until June 12, 2012.
Closed record no. 21 was a patient who was admitted July 6, 2012. Her record contained one VO/TO that was taken by the RN on July 8 but not signed until August 20, 2012. This record also contained one VO/TO that was taken by the RN on July 13, 2012 but that had not been signed until August 9, 2012.

Based on record review of two open records for patients #33 and 34, the facility, 1) failed to document any information regarding a restraining event of patient #33 while she was in the emergency department, and 2) failed to note patient #33' s allergy to onions on her behavioral health unit record, and her dietary sheet.


Open record patient #33 is a 41-year-old disabled female who presented to the emergency department (ED) via Police with Emergency Petition on 9/6/2012 at 12:08 pm after starting a fight in her group home and complaining of suicidal ideation with a plan to cut herself with broken glass. Patient #33 was recently discharged from the hospital behavioral health unit after an extended stay. Patient #33 has a medical history of diabetes mellitus, hypertension and bronchial asthma.



On presentation, patient #33 ' s triage assessed her as " uncooperative, " having thoughts of harm to self with a plan, and the means to carry out that plan. She was also assessed as being a risk for self harm or elopement. The RN documented that that patient #33 was not in police custody. Under the Nursing Assessment for Violence, the RN checked the box for " No risk identified. "


Two rights notifications appear in the Emergency Department record. The first of these is a Universal Consent. In the place indicated for the patient signature, a staff member wrote, " Pt unable to sign, " and found below the signature line in the space provided to indicate why the patient was unable to sign, were the words, " In restraints. "


The second notification is the Important Message from Medicare which under the signature portion of the form states, " Pt (patient) unable to sign in restraints. " No documentation of any kind is found to indicate why patient #33 was in restraint, nor was an order for, nor monitoring of restraints found.


Patient #33 was noted in the ED to have allergies to "onions, haldol, PCN (penicillin) and codeine." Following patient #33's admission to the Behavioral Health Unit (BHU), all medicine allergies were noted. However, the onion food allergy is not listed on the History & Physical, any BHU records, nor is it listed on patient #33's dietary orders or documentation.

Based on the deficiency cied at A0724 it was determined that the Conditiona of Physiical Environment is not met as the facility lacks documented evidence of ongoing oversight of maintenace performed on equiment provided under contract otr by a vendor . The facility had no records to indicate that the performance of the vendors or contractors was monitored by Environment of Care staff to ensure that the necessary preventive or routine maintenance was performed.

Based on observation it was determined that facility staff failed to maintain the facilityand equipment to ensure the safety of the patients and staff

1. On September 11, 2012 the surveyor accompanied by the food service director observed the following maintenance concerns in the main kitchen:

(a) One curtain was missing in the dishmachine. Curtains prevent the mixing of air and sprays from the different cycles in the dishmachine. This is especially important between the outside of the dishmachine and the final rinse where the outside air could cool the final rinse preventing proper sanitization.

(b) Approximately two dozen fruit flies and two sewer flies were noted in the cart wash area.

(c) The grate for the exhaust vent above the cart wash area was not clean.

(d) Several reel hoses which have trigger-type shut-off devices and used for cleaning purposes were not equipped with a backflow prevention device. Since the device is under constant pressure due to the shut-off, the backflow device must be a pressure type, either a dual check or pressure-type backflow preventer. These installations were accomplished while the surveyor was present.

(e) Janitor's closet - the wall adjacent to the chemical dispenser was in disrepair and presents an uncleanable surface.

(f) The floor behind the Alladin brand one-door refrigerator was not clean and had some refrigerator racks stored there which were missing in a freezer unit.

(g) The surveyor during the inspection of the main kitchen asked for test strips to check the concentration of the quaternary ammonium sanitizer in a bucket sitting below a preparation table. When the surveyor questioned a cook about how he prepared the sanitizer he responded by saying he went to the three-compartment sink and dispensed it directly from the pump. This method provides concentrated sanitizer with no dilution with water as directed by the manufacturer.

(h) Salad Preparation, Victory brand, one-door refrigerator - the vinyl covering on the shelving is worn off and has rusted presenting an uncleanable surface. The door hinge is broken also.

(i) The floor in the three-compartment sink room is uncleanble and is not sloped toward the floor drain causing water to pool under the sink and attached tables.

(j) Loading Dock - one hosebibb is not equipped with a backflow preventer. There is no shut-off at the end of the hose and the installation of an atmospheric backflow preventer is permissible. The surface under the grease storage tank is covered with grease.

(k) Patient Pantries - when checking the exhaust vents in the Ninth and Seventh Floor pantries it was observed that they not removing air from the pantries. A leak was observed above the cabinets in the Third Floor pantry, Maternity and the cabinets were damaged due to the water. An electrical receptacle behind the ice machine is not attached to the wall.

2. On September 11, 2012 the surveyor accompanied by the vice president of security observed the following concerns in ancillary areas of the facility:

(a) Laboratories - Wash Room sink, the needle nose had a hose attached to the faucet with no backflow prevention device and a hose attached to the faucet under the hood did not have one either.
(b.) First floor Mechanical Room - storage was noted in front of the electrical panels and the exterior door is not rodent proofed.

Based on observation it was determined that facility staff failed to maintain records to verify that patient care equipment provided through a vendor or under contract was maintained to ensure the safety of the patients and staff as evidenced by:


On September 12, 2012 during the re-certification survey the Sanitarian surveyor interviewed the Director of Clinical Engineering (DCE) and Senior Technician. At the time of the interview the staff members presented a newly acquired computerized program with detail for required preventative maintenance for all equipment owned by the hospital. Upon inquiry about rented equipment the sanitarian was informed that per the hospital's contracts with the vendors, the vendors were responsible for any maintenance of the equipment. The Director of Clinical Engineering, when asked about monitoring of maintenance of rented equipment, stated that the facility plans to do so in the future but there is no current process in place.


The Sanitarian surveyor continued touring the building with the Senior Technician on September 12, 2012 to review preventative maintenance records of equipment used for patient care. During the tour, a fetal monitor was found in Triage # 2 of Labor and Delivery that did not have stickers typically used to identify items for maintenance provided or due on the equipment. The only date sticker found on the unit was for April 2007. The technician informed the surveyor that the sticker was not one used by the facility. The surveyor subsequently requested information about maintenance on that particular monitor and an inventory of all rented medical equipment in the facility. As there was no on site listing of rented equipment on September 12, 2012, a listing of equipment maintenance records and contracts from each of four preferred vendors was requested by the surveyor.


Upon receipt of the inventory and maintenance records from the preferred vendors, the information was provided to the surveyor. Information included, maintenance records for three of seven wound vacuums being rented by the hospital. The DCE was unable to account for maintenance of the other four units and informed the surveyor that they were currently being stored in the facility and not in use.


On September 13, 2013, the Director of Clinical Engineering informed the surveyor that the hospital had no record of the fetal monitor that had been identified in Triage # 2 of Labor and Delivery on the previous day; neither was there documentation of the monitor in the facility inventory or the listing provided by the preferred medical device vendors.


Review of the maintenance records for hospital owned fetal heart monitors showed annual preventative maintenance. However, based on the information available for the unit, the completion of annual preventative maintenance could not be verified. The DCE stated that the facility would take responsibility for the monitor, including preventative maintenance.
The hospital's Risk Manager was able to obtain and provide the surveyor records of maintenance for the additional four wound vacuums which had been identified on September 12, 2012. The risk manager also informed the surveyor that she had obtained the records from Central Supply; however, the DCE was unaware that Central Supply maintained records for part of the rented medical equipment for the facility.


Based on review of policies and procedures dated August 10, 2012 for Incoming Inspection of medical equipment, it was determined that the policy states that "if equipment is to be in the hospital for greater than six months, the user or Purchasing Department must notify Clinical Engineering so that maintenance can be monitored." However, review of the document and interview with the DCE revealed that there is no Standard Operating Procedure (SOP) in place to ensure compliance with this policy. The method for reviewing maintenance of rented equipment is access by internet or fax, with no maintenance records on site.
Random sampling of rented equipment maintenance by hospital staff is the method for determining if vendors are compliant. " Random review " is not defined in the policy and no random checks had been completed at the time of the survey. In addition, at the time of the survey, the DCE was unable to provide contracts for the preferred medical equipment vendors.


On September 13, 2012 the Risk Manager was able to locate three of four contracts for preferred vendors. The method for ensuring maintenance of rented equipment, according to the DCE and the Policies and Procedures for Incoming Inspection of Medical Equipment is vendor contract. Without a copy of the contract, the facility is not able to determine if the vendor is abiding by contracted maintenance requirements. Despite the Director of Clinical Engineering having responsibility for oversight of all medical equipment in the facility, whether it is maintained by his technicians, outside vendors or is channeled through Central Supply, there was no indication that he has been able to provide sufficient oversight of the equipment from outside vendors or central supply as there was no reliable method in place for determining what equipment is in the building and who holds responsibility for maintenance..

Based on a tour of the facility it was determined that on Behavioral Health, the refrigerator in the dining area was holding 46 degrees Fahrenheit as determined by product temperature and air temperature. Refrigerators used to store potentially hazardous foods must maintain 41 degrees Fahrenheit or below.