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Based on interview and document review, the hospital failed to ensure restraints were utilized only with physician order renewals every two hours as required for 1 of 3 patients (P-1), whose restraint use was reviewed.

Findings include:

P-1 was a fourteen year old child who was placed in four-point behavioral restraints after being combative, and a renewal order was not obtained within the 2-hour maximum period allowed based on the child's age. P-1 was admitted to the pediatric intensive care unit (PICU) from the emergency department (ED) on 12/5/13, for a suicide attempt by intentional ingestion. The patient was placed on a police hold when his mother did not consent to psychiatric placement.

A physician's order dated 12/5/13, at 9:43 a.m. indicated P-1 needed restraints due to, "high risk of injury to self and others. Restraint type: 4 point soft restraints to left arm, left leg, right arm, right leg." It was determined the patient continued to require the restraint after the maximum two-hour period, however, the order was not renewed until 1:46 p.m., four hours, three minutes later.

The patient care supervisor (PCS-A) was interviewed on 12/18/13, at 1:00 p.m. and verified there had been four hours, three minutes between physician orders at the time of P-1's restraint use, although a new order should have been obtained no later than two hours after the initial order. The PCS stated the hospital policy was not followed based on the child's age for behavioral restraint use.

The hospital policy and procedure titled Restraints dated 11/11/13, instructed the hospital staff as follows: "Orders for behavioral restraints shall remain in effect until the patient's behavior or situation no longer requires the use of the restraint, but no longer than:...b. 2 hours for children and adolescents 9 to 17 years of age."

Based on observation, interview and document review the hospital failed to ensure emergency crash carts were secured to prevent unauthorized access in 2 of 4 patient care areas in the St. Paul physical therapy (PT) department, as well as the Minneapolis radiology department.

Findings include:

On 12/16/13, at 10:30 a.m. a tour of the physical therapy (PT) department was conducted. A crash cart was stored just outside of the door entrance and was not visible from the check in area located inside of PT department. The cart was located in a short hallway adjacent to a longer hallway, and no cameras were visible. The PT department manager explained that the cart was stored in the hallway during business hours and was locked overnight. The entrance and hallways to the PT department were not behind secure doors thus allowing patients and visitors free access to the area during business hours.

The top drawer of the crash cart contained the plastic wrapped medication tray with a breakaway plastic tab to indicate the cart had not been tampered with. The plastic tab held the metal guard pieces over the crash cart drawers. Another smaller breakaway plastic tab was further down on the cart right above the drawer which contained syringes. To open the cart, the two plastic breakaway tabs were twisted off and the swinging metal guard was moved and the drawers could be opened.

The crash cart was closed with two plastic breakaway tabs, and the cart contained Adenosine (used to slow the heart temporarily), Amiodarone (used to prevent ventricular arrhythmias), Atropine (used to speed up the heart), Albuterol (respiratory medication to help with breathing), calcium chloride (used to improve pumping of the heart), dextrose (medication to raise blood sugar), epinephrine (medication to improve heart function), Lidocaine (used to prevent ventricular arrhythmia), Naloxone (used to reverse sedating narcotics), magnesium sulfate (used to improve heart function), sodium bicarbonate (used to improve renal function), sodium chloride (a drug used to improve heart function), diphenhydramine (for allergic symptoms), dopamine (used to improve heart function by constricting extremity circulation), and flumazenil (used for reversal of sedation effects).


19200


On 12/16/13, at 2:00 p.m. during the tour of radiology department the location of a crash cart was down the hallway and around the corner from the patient check-in area. The entrance and hallways in the radiology department were not located behind secure doors thus allowing visitors free access to the area. The cart was located next to a public restroom and about 10 feet from an alarmed door which led out to the street. The exit door could be easily opened and had no camera monitoring. The radiology manager explained it was the usual location for the cart 24 hours a day.

The crash cart had the same breakaway tab system as the cart in the PT department, and housed the same medications.

The cart remained in the same location during a return observation on 12/18/13, at 9:00 a.m. with the compliance officer, radiology manager, radiology supervisor. The compliance officer (CO) stated doors within 10 feet of the cart were secure and could only be opened with an employee badge. The CO explained that through those doors and down the hall through another set of secure doors was the emergency department (ED). However, upon trying the doors, one could actually enter and return without the use of a badge. The ED doors could not be entered, but another suet of doors around the corner past the rehabilitation room could be opened. The CO stated they should have been secured and should not have been able to open without the use of a badge. Behind the secured doors to the ED was a trauma room where the doors were observed wide open and no staff were present in the room. All emergency equipment including a crash cart was stored in the trauma room.

The compliance officer and radiology supervisor were interviewed on 12/18/13, at 9:40 a.m. and stated the crash cart in the ED had not been stored securely, and the doors from radiology to the back hall behind the ED should have been secure and were not.

The pharmacy director was interviewed on 12/18/13, at approximately 10:15 a.m. and explained that the overall safety of the crash cart in radiology was the responsibility of the radiology department staff. Although the cart could have been more secure, she stated no narcotic medication was stored in the cart.

The facilities manager was interviewed on 12/18/13, at 3:20 p.m. and reported the hospital had a preventative maintenance system for checking all doors monthly, but the checks did not reveal whether the doors had been manually checked without the use of a badge.

The policy and procedure titled Dr. Blue Emergency dated 3/13/13, for Code Cart Management and Safety indicated, code carts were checked by department staff daily using a crash cart checklist. The crash cart checklist provided from the radiology department for 12/13 indicated the two plastic locks were checked daily for integrity (ensuring they had not been opened). The policy, however, did not address proactively ensuring the carts were not accessed by unauthorized persons.

Based on observation and interview, the hospital was found not in compliance with Life Safety from Fire found at CFR 482.41 (b) and the hospital failed to safely store disinfecting cleaning supplies in a locked storage area.

Findings include:

Refer to Life Safety Code deficiencies: K0017, K0018, K0029, K0050, K0056, K0076, and K0077 for additional information.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safety from fire, therefore, the condition was unmet.


28230

A tour of the kitchen was conducted on 12/16/13, at 10:00 a.m. The food service director, executive chef and clinical nutrition manager for United Hospital where food was received, were present during the tour. The following issues were observed and verified by those present:

The floor of the walk-in cooler was littered with debris. The executive chef said that the floor was to be swept daily. It was verified that the floor looked as though it had not been completed daily. Three of three food bins in the cooks' area were soiled on the outside of the bins. The chef verified that the bins needed to be cleaned. The chef explained that the procedure would be to, "clean as you go." Two of two holding ovens had a considerable amount of burnt debris on the insides of the ovens. The executive chef explained that the ovens were to be cleaned on the weekends.

Cleaning schedules provided showed no specific mention to clean the food bins, to sweep the cooler floor or clean the insides of the ovens. The schedules included a general statement on the entree and pizza cooks' duty list to clean any equipment used.


30951


During an Infant Care Center (ICC) tour on 12/16/13, at 10:00 a.m. two large bottles of Dispatch bleach-based disinfectant was stored on the sink in an unlocked dirty utility room. The room opened into a corridor and large family waiting room in the ICC. A registered nurse (RN)-A and the director of nursing (DON) verified the Dispatch cleaner was in the unlocked dirty utility room. At 11:00 the DON verified the disinfectant should not have been stored in the unlocked room, and said it had been removed and education of staff was provided.

The Material Safety Data Sheet (MSDS) for Dispatch read: "use impervious rubber or nitrile gloves for contact, wear eye protection with side shields to prevent eye splashing. The sheet also noted to avoid contact with eyes, skin, and clothing as that product may produce irritation. Do not allow the product to contact acidic materials as hazardous chlorine gas may be released. Treatment indicated if contact with eyes, rinse the eyes slowly and gently for 20 minutes and contact a poison control center for additional treatment. If exposure to skin wash with soap and water."

A hand written note on the MSDS sheet signed by RN-A read: "Dispatch removed from soiled utility 12/16/13 at 10:00 a.m. No chemicals are stored in dirty utility."

A facility policy titled Toy and Play Equipment Cleaning dated 11/14/12, indicated...
1. Toys cleaned by hand: cleaning/disinfecting by hand requires wiping the toy completely with hospital disinfectant. After being wiped completely with disinfectant, the toy is allowed to dry and is wiped with water to remove residue.

A facility policy titled Worksite Cleanliness for Infection Prevention and Control dated 10/30/13, indicated...Equipment cleaning and disinfection: Items that have had skin contact with a patient, have been placed in the crib or bed of a patient, or have been handled while providing intimate care of a patient must be cleaned and disinfected before use with next patient.. [Note:The use of quaternary ammonium compound (a hospital disinfectant) is the preferred agent used to disinfect reusable patient equipment that does not need sterilizing.]

Based on observation, interview and record review the hospital failed to ensure 2 of 3 doors located in the radiology department that led to the emergency department (ED) were kept secure at all times. This had the potential to affect the 239 patients hospitalized in the Minneapolis location, as well as visitors.

Findings include:

On 12/18/13 observations were conducted in the radiology department on 12/18/13, at 9:00 a.m. with the compliance officer, radiology manager, radiology supervisor. The compliance officer (CO) explained that the doors were kept secure and and could only be opened with an employee badge. The CO explained that through those doors and down the hall through another set of secure doors was the emergency department (ED). However, upon trying the doors, one could actually enter and return without the use of a badge. The ED doors could not be entered, but another set of doors around the corner past the rehabilitation room could be opened. The CO stated they should have been secured and should not have been able to open without the use of a badge.

The compliance officer and radiology supervisor were interviewed on 12/18/13, at 9:40 a.m. and stated that the doors from radiology to the back hall behind the ED should have been secure and were not.

The facilities manager was interviewed on 12/18/13, at 3:20 p.m. and reported the hospital had a preventative maintenance system for checking all doors monthly, but the checks did not reveal whether the doors had been manually checked without the use of a badge.