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Based on a review of clinical records and policy review, the facility failed to ensure a history & physical (H&P) for one of two patient's (#49) identified an assessment relevant to the patient's chief complaint. The finding includes the following:


Patient #49 presented to the ED on 9/10/14 with complaints of rib pain after a fall and alcohol intoxication. Review of the pain assessment on 9/10/14 at 2:41 PM identfied that the patient rated his/her pain as a 9 on a scale of 1-10 (10 being the worst possible pain) and at 3:20 PM stated the rib pain was worse with movement. Review of the history & physical failed to reflect an assessment related to the patient's rib pain. Review of the discharge instructions indicated that the patient was treated for alcohol intoxication with discharge medications that included in part Oxycodone 4 mg every six hours as needed and Lidoderm patch one patch daily.

Review of the medical bylaws indicated the H&P should include pertinent and relevant information. Specific elements should include the chief complaint and details of the present illness.

Based on a review of clinical records and hospital policies, for two of two patients (Patient #49 and 64) reviewed for restraints, documentation failed to identify that least restrictive measures and/or alternative measures were tried and determined to be ineffective prior to administration of chemical restraints. Documentation further failed to specify the patient's specific behavior that posed a risk to self/others necessitating the use the chemical restraints. The findings include:

a. Patient #49 presented to the ED on 9/10/14 with complaints of rib pain after a fall and alcohol intoxication. Record review with the Nurse Manager indicated that at 4:08 PM the patient attempted to leave the facility and when the patient was redirected to return, refused to get on the stretcher and change into a hospital gown. The patient was informed that if he/she did not cooperate, the patient would be medically and physically restrained. The patient began yelling, biting and kicking and was placed in four-point locked restraints, and received Ativan 2 mg intravenously (IV) and Haldol 5 mg intramuscularly (IM). Review of the restraint flowsheet dated 9/10/14 at 4:15 PM with the Nurse Manager identified staff documented non-specific behaviors that included, agitation, restless, trying to hurt self and others, yelling and disoriented. At 4:21 PM, Geodon 20 mg IM was administered, absent documentation that reflected attempts at deescalation and/or alternatives attempted, prior to the administration of psychotropic medication.

A nurse's note dated 9/10/14 at 5:00 PM reflected that the patient requested to use the bathroom and was offered the bedpan. The note further indicated the patient was informed she would not be able to use the bathroom, however, failed to specify the rationale.

The restraint flow sheet dated 9/10/14 at 5:15 PM identified the patient remained in four-point locked restraints, was resting, talking to self, disoriented and yelling. At 5:26 PM, Haldol 5 mg was administered, absent documentation that reflected a specific behavior that warranted the administration of psychotropic medication.

The restraint flow sheet at 7:00 PM identified the patient remained in four-point locked restraints, was restless and disoriented. At 7:14 PM, the patient received Ativan 1 mg IM per MD order, absent documentation that reflected a specific behavior that warranted the administration of psychotropic medication. The record reflected that leg restraints were removed at 8:50 PM as the patient was noted to be sleeping and wrist restraints were removed at 9:18 PM secondary to calm demeanor.

b. Patient #64 was brought to the ED on 9/5/14 at 1:30 PM by the police secondary to alcohol abuse. The triage note indicated the patient arrived combative (not specific), yelling and hostile (not described), and was placed in four-point locked restraints and received Haldol 5 mg IM, Ativan 2 mg IM and Geodon 20 mg IM at 1:26 PM. Review of the physician's order with the Nurse Manager failed to specify indications/behaviors warranting the use of chemical restraints and or alternatives attempted prior to the administration of three psychotropic medications.

Review of the restraint policy indicated that in emergency situations alternatives may not be of use initially, but they should be considered prior to continuing the use of seclusion or restraints. The use of restraints should be frequently evaluated and ended at the earliest possible time.

Based on clinical record review and policy review the facilty failed to ensure that restraints for one of two patients (Patient #49) in the ED were discontinued at the earliest possible time. The findings include the following:

Patient #49 presented to the ED on 9/10/14 with complaints of rib pain after a fall and alcohol intoxication. Review of the record with the Nurse Manager indicated that at 4:08 PM the patient attempted to leave the facility and when the patient was redirected to return, refused to get on the stretcher and change into a hospital gown. The patient was informed that if he/she did not cooperate, the patient would be medically and physically restrained. The patient began yelling, biting and kicking and was placed in four-point locked restraints, and received Ativan 2 mg intravenously (IV) and Haldol 5 mg intramuscularly (IM). Review of the restraint flowsheet dated 9/10/14 at 4:15 PM identified staff documented non-specific behaviors that included, agitation, restless, trying to hurt self and others, yelling and disoriented. At 4:21 PM, Geodon 20 mg IM was administered. The restraint flow sheet dated 9/10/14 at 5:15 PM identified the patient remained in four-point locked restraints, was resting, talking to self, disoriented and yelling. The record failed to reflect that attempts were made to reduce the use of four-point locked restraints when the patient was not a danger to self and/or others. The record further reflected that Haldol 5 mg was administered at 5:26 PM. The flow sheet indicated that during the period of 5:30 PM through 7:30 PM, the patient exhibited the following behaviors agitation (not described), restlessness (not described), talking to self, disorientation and quiet/cooperative that necessitated the continued use of four-point locked restraints. The restraint flow sheet at 7:00 PM reflected the patient remained in four-point locked restraints, was restless (not described) and disoriented with Ativan 1 mg IM administered at 7:14 PM. The record reflected that leg restraints were removed at 8:50 PM as the patient was noted to be sleeping and wrist restraints were removed at 9:18 PM secondary to calm demeanor.

Review of the restraint policy indicated that the use of restraints should be frequently evaluated and ended at he earliest possible time based on the assessment of the patient.

Based on clinical record review and policy review, for two of two patient's reviewed for restraints (Patients #49 and 61) the hospital failed to ensure the physician or a licensed independent practitioner (LIP) evaluated the patient within one (1) hour of restraint application. The findings include the following:

a. Patient #49 presented to the ED on 9/10/14 with complaints of rib pain after a fall and alcohol intoxication. A physician's note dated 9/10/14 at 4:00 PM identified the patient attempted to flee, is uncooperative and will be medicated and possibly restrained. The record indicated that at 4:08 PM the patient attempted to leave the facility and was placed in four-point restraints. Record review with the Nurse Manager failed to reflect that a physician and/or licensed independent practitioner evaluated the patient one hour following the application of restraints.

b. Patient #64 presented to the ED on 9/5/14 at 1:30 PM with acute alcohol intoxication. The record indicated that the patient was placed in four-point locked restraints at 1:48 PM secondary to threatening combative behaviors. Record review with the Nurse Manager failed to reflect that a one to one evaluation was completed by the licensed independent practitioner within one hour of restraint application.

Review of the restraint policy directed that a physician or a licensed independent practitioner (LIP) must see the patient and evaluate the need for restraints within one hour of the initiation of restraints.

Based on observation and review of hospital protocol, the hospital failed to follow AORN accepted guidelines to ensure the integrity of the sterile field according to hospital expectations of practice. The finding includes:

Observation of the set-up of a sterile field in the interventional radiology department on 9/17/14 at approximately 9:50 AM, identified that although the staff member setting up the field wore gloves and a mask, the staff member failed to ensure the hair was covered. The field, uncovered, was left in an area of high traffic and conversation. Request for the hospital protocol identified that the hospital follows the 2014 AORN Edition of Perioperative Standards & Recommended Practices for Inpatient and Ambulatory Patients which advocates that hair covering was mandatory while setting up a sterile field. The field should be set-up as close to use as possible and placed in an area away from traffic and conversation which increases the chance of field contamination.







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1. Based on observation, interview and review of hospital policy, the hospital failed to ensure that facial and hair on the head was covered according to hospital policy within the restricted and semi-restricted areas of the operating arena. The findings include:

Observation during tour of the operating suite on 9/16/14 at approximately 10:30 AM, with the Director of Peri-operative Services, identified several staff members who failed to have facial and head hair covered according to hospital policy. Several staff were observed to have hair exposed at the back and sides of the head from beneath the cap within the confines of the restricted areas of the OR. Another staff member, although garbed with a hood and facial mask, had facial hair that failed to be covered between the edges of the mask and hood. During interview on 9/16/14, the Director stated that it was the staff's responsibility to ensure that all hair was covered prior to stepping into the restricted areas. The Director added that additional mirrors had been placed within areas of the OR to ensure that staff could see that all hair was covered. Additionally, the Director stated that it was an expectation that team members would alert each other when corrections needed to be made to hair coverings. Review of the hospital policy for Operating Room Attire directed that hats and/or hoods should cover all facial and head hair including sideburns and necklines.

2. Based on observation, interview and policy review, the hospital failed to ensure that the system in place was followed ensuring that operating rooms were cleaned between cases and/or that cleaning of the OR furniture was completed in an aseptic manner. The finding includes:

a. Observation of room cleaning between operative cases in the OR on 9/16/14, identified that as trash bags were removed from OR #3, a staff member entered and began to open a sterile pack when cleaning of the environment had not yet been accomplished. The Director of Perioperative Services intervened and the opened pack was removed and cleaning of the room commenced. During interview on 9/16/14 at approximately 11:20 AM, the Director stated that the staff member opening the sterile pack stated that she "thought the room had been cleaned". The Director stated staff verbally confirm when the room was ready and that no other system was in place.

b. Observation of the cleaning of OR #3 by the scrub tech identified that a single cleaning wipe was utilized to clean a cart, from top to bottom, including the lower legs and wheel hubs. The same wipe was then utilized to begin cleaning the mayo stand beginning at the top. Review of the hospital policy for routine cleaning of the OR, identified that after all surgical cases, the cleaning of OR was completed using the "seven step method" which includes cleaning from high to low. Additionally, a clean wipe would be expected to be utilized on a second piece of equipment.



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Based on review of the clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for two post-operative patients (Patient #41 and 54), documentation and interviews failed to reflect that an operative report was completed and/or that a post-operative note was written immediately post surgery. The finding includes:

a. Patient #41 was admitted to the hospital on 9/14/14 with a right hip hematoma, status post (s/p) bilateral hip replacements that were completed on 9/3/14. The patient underwent an incision and drainage (I & D) of the hematoma on 9/16/14. Review of the clinical record and interview with RN #11 on 9/18/14 failed to reflect that an Operative Report was completed as per Medical Staff Rules and Regulations.

b. Patient #54 underwent a vaginal hysterectomy in the morning of 9/16/14. A review of physician orders dated 9/16/14, identified that the patient would be kept for observation for 23 hours post surgery. Review of the record on 9/17/2014, failed to reflect that a post-operative note was written immediately post surgery. Review of the Medical Staff Rules and Regulations identified that a note should be written immediately post surgery and prior to the patient's discharge to the next level of care.




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19952

Based on a review of clinical records and interview, for 2 of 2 outpatient surgical records reviewed (Patients #51 and 53), the hospital failed to ensure that a post anesthesia evaluation was completed by anesthesia prior to the patient's discharge from the hospital. The findings include:

a. Patient #51 underwent the placement of a supra-pubic tube secondary to a urethral stricture, initially as an outpatient, on 9/16/14. Review of the record failed to identify that the anesthesiologist completed a post procedure evaluation. During interview on 9/16/14, at approximately 1:15 PM, the covering anesthesiologist stated he had written an order to discharge the patient according to hospital protocol.

b. Review of the surgical record for Patient #53 who underwent a gastroscopy on 9/16/14 and received Propofol, failed to reflect the completion of a post anesthesia evaluation prior to the patient's discharge. During interview on 9/17/14 at 2:05 PM, the Chief of Anesthesia stated that the department "dropped the ball" when the anesthesia record /paperwork/electronic documentation was changed about two years ago. The anesthesiologist stated that while patients who were admitted were seen by anesthesia within 48 hours for evaluation, the outpatients failed to have an anesthesia evaluation prior to discharge.





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