HospitalInspections.org

Based on observation, medical record review, policy review and staff interview, it was determined that the hospital failed to ensure the safety of 1 of 12 patients in the sample (Patient #12) observed receiving care, and potentially 98 of 98 (100%) patients of the hospital.

Findings include:
The hospital document titled "Patient Guide" stated, "...Patients...have the right...to receive care in a safe setting..."

Hospital policy titled "Nursing Medication Management Policy" stated, "...All syringes will be kept in locked storage at all times...A standardized method to label medications and containers will be used...Labels will include...Preparation date...Expiration date..."

A. Staff failed to ensure the safe administration of intravenous (IV) therapy for 1 patient (Patient #12) in the sample.

Observation on 11/3/22 at 10:42 AM revealed that Patient #12's IV bag (normal saline with 20 milliequivalents of Potassium Chloride) lacked the date and time the IV bag was initiated or would expire.

Quality Accreditation Manager A, present at the time of discovery, confirmed the IV bag should have been labeled with the date and time it was initiated, and when it would expire.

B. Based on observation, policy review and staff interview, it was determined that for 98 of 98 (100%) patients in the hospital, staff failed to ensure a safe and sanitary environment. Findings include:

Observation on 11/3/22 at 10:55 AM on the 6th floor revealed two large red containers across from the elevators, in the hallway outside of the Laboratory door, labeled "Sharps". Lids to both containers were not secured, and could be opened by surveyors.

Quality Accreditation Manager A, present at the time of discovery, confirmed that the "Sharps" containers should be secured properly to not allow access, and did not know why they were in the hallway.

Based on clinical record review, policy review and staff interview, it was determined that for 1 of 2 (50%) restrained patients in the sample (Patient #4), a restraint was applied without a physician's order. Finding include:

The hospital policy titled "Restraint Management" stated, "...A licensed independent practitioner (LIP) enters the order for use of restraint for non-behavioral health purposes...If an (sic) registered nurse initiates use of restraint for non-behavioral health purposes, a LIP will provide a written order within 12 hours of initiation of the restraint..."

Review of the active clinical record revealed that Patient #4 was admitted to the hospital on 11/2/22 with a diagnosis of hyperkalemia (a potassium level in blood that is higher than normal).

Documentation on the electronic medical record band "Restraint Monitoring" located in Patient #4's clinical record, revealed that restraints were applied on 11/2/22 at 7:30 PM.

Review of Physician's Orders revealed order for soft wrist restraints obtained on 11/3/22 at 6:31 PM (23 hours, 1 minute after restraints were applied).

During an interview on 11/4/22 at 1:47 PM, Health Informatics Specialist III A reviewed Patient #4's clinical record and confirmed that Patient #4 did not have a physician's order for restraint application on 11/2/22 until 11/3/22 at 6:31 PM.

The hospital failed to obtain a physician's order prior to, or within 12 hours of the initiation of Patient #4's restraint on 11/2/22.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 2 (50%) restrained patients in the sample (Patient #2), a face-to-face evaluation was not conducted within 1-hour of restraint initiation. Findings include:

The hospital policy titled "Restraint Management" stated, "...Orders for Restraints for Violent/Self-Destructive Management...The physician/LIP [licensed independent practitioner] must see the patient face-to-face and document the need for restraint within one hour after initiation of the intervention..."

Review of Patient #2's medical record revealed:

Physician's order for violent restraint was obtained by Registered Nurse (RN) B from the provider on 8/11/22 at 10:22 PM, and was discontinued on 8/12/22 at 9:48 AM.

"Hospital Medicine Progress Note" from 8/12/22 at 11:32 AM stated, "...Overnight events reviewed. Discussed with Nursing...Patient got agitated last night...kicked one of the staff members and remained agitated and placed back on restrains (sic)..."

Review of Patient #2's medical record revealed no documentation to support that a face-to-face evaluation was conducted within 1-hour of the 8/11/22 violent restraint initiation.

On 11/4/22 at 1:30 PM, Health Informatics Specialist III A reviewed Patient #2's medical record and confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 12 patients (Patient #6) in the sample, the registered nurse failed to supervise and evaluate the nursing care. Findings included:

Hospital policy titled "Clinical Practice Guideline Care of the Emergency Department Patient" stated, "...All patients will be triaged and placed into one of five categories: Emergent: ESI1 (Emergent) thru ESI5 (Nonurgent)...Documentation guidelines for the ESI3 patients...Vital signs every two hours..."

Review of Patient #6's medical record revealed:
- Emergency Department visit began on 9/20/22 at 10:46 AM.
- Patient #6 assigned ESI3 at triage.
- Vital signs taken at 11:10 AM, including temperature, pulse rate, respiratory rate, and blood pressure, all within normal parameters.
- Patient discharged at 5:09 PM.

No evidence that vital signs were obtained every 2 hours for Patient #6 per hospital policy.

Based on medical record review, policy review and staff interview, it was determined that staff failed to develop a nursing care plan for 1 of 12 patients (Patient #5) in the sample. Findings include:

The hospital policy titled "Documentation of Nursing Assessment and Acute Care" stated, "...Interdisciplinary Plan of Care (IPOC)...will be based on patient's needs, assessment, reassessment and results of diagnostic testing within four hours arrival to the assigned unit..."

Medical record review revealed no evidence that a nursing plan of care was developed during the hospitalization of Patient #5 (hospitalized 10/26 to 11/3/22).

This finding was confirmed by Quality Accreditation Manager A and Health Informatics Specialist III A on 11/4/22 at 10:26 AM.