HospitalInspections.org

Based on a review of restraint/seclusion documentation for 3 patients, 40, 41 and 42, it is determined that no specific criteria for release from restraint/seclusion was given to the patients.

Patient #40 is a 48-year-old female admitted on 3/14/12 with depression and psychotic symptoms. On 3/19/12 at 12 noon, patient A became upset during a family meeting. She began to push a table, throw papers, and threatened to punch staff while advancing toward staff. Patient #40 was initiated into seclusion from 12 noon through 1:15 pm.

No criteria for release are noted in the documentation. Additionally, a modified treatment plan reveals that at 2:55 pm patient #40 received " verbal info, written material, " and that the nurse " Acknowledged pt ' s feelings, assist to ID source of anger, and assist to set realistic goals. "

No documentation reveals that patient #40 was informed of behavioral criteria by which to terminate seclusion. Therefore, the hospital failed to include patient #40 in the development and implementation of her plan of care.

Patient #41 is a 50-year-old female who presented to the emergency department on 7/25/12. Patient 41 was found to be psychotic and delusional, believing that there was a person inside her. At 10:28 pm, patient became angry about staff taking blood from her, and began to threaten physical harm, specifically attempting to head butt and scratch staff. Patient 41 was placed in 4-point restraint which continued until 12:08 a, of 3/15/12.

No documentation reveals that patient #41 was informed of the behavioral criteria she had to demonstrate to terminate restraints, nor is the criteria stated in the documentation.

Patient #42 is a 33-year-old male who presented to the emergency department after being found sleeping in a yard. Patient #42 asked to take a shower, and was allowed to do so. However, while in the bathroom, he began kicking the door, broke the mirror, and attempted to kick the RN in the face. Patient #42 was placed in 4-point restraint at 1:15 am and remained in restraint until 4 am.

Documentation reveals that patient #42 received education regarding restraints, though the content of the education is not documented. Therefore, the hospital did not give the behavioral criteria required for restraint termination, nor did the hospital document the criteria in the restraint record.

Based on a review of 28 open records and 15 closed medical records, it was determined that three of the fifteen closed records contained verbal orders that were not signed by the prescribing physician for weeks after the order was given.
Closed record no. 29 was a patient who was admitted to the hospital on June 6, 2012. His physician order sheets contained one verbal order/ telephone order (VO/TO) taken by the nurse on June 6, 2012 but not signed until July 12, 2012. Another VO/TO was taken on June 9, and not signed until June 23. A third VO/TO was taken on June 10, 2012 and not signed until June 22, 2012.
Closed record no. 35 was a patient who was admitted June 8, 2012 and discharged June 11, 2012. Her record contained one VO/TO that was taken by the RN on June 8 but not signed until July 11, 2012. This record also contained two VO/TOs that had not been signed as of the date of the survey, one taken on June 8 and the other on June 9, 2012.
Closed record no. 37 was a patient admitted on June 5, 2012. Her record contained three unsigned VO/TO from the same physician taken on June 5, 2012. These VO/TO were routine orders for diet and medication.
The hospital policy Medication:Management/Access/Administration, no. PC164C-08/12, states that all VO/TO must be signed within 30 days of the discharge date. This policy does not meet the standard that all VO/TO should be signed " promptly. " It is apparent from these three medical records that some physicians are not meeting the policy as written.
In addition, the VO/TO on these records were routine orders for diets and medications. Use of VO/TO for routine orders violates both the above hospital policy, which states that " verbal orders are to be taken in emergency situations ONLY, " (emphasis in the original) as well as the COP standard that VO/TO be used rarely.

Based on a review of 28 open records and 15 closed medical records, it was determined that three of the fifteen closed records contained discharge summaries that were not signed within the 30-day timeframe for closed records.
Closed record no. 29 was a patient who was in the hospital from June 6, 2012 to June 11, 2012. His discharge summary was dictated July 16 and not signed until July 22, 2012, 40 days after discharge.
Closed record no. 31 was a patient who was in the hospital from June 5, 2012 to June 11, 2012. His discharge summary was signed on August 1, 2012, seven weeks after discharge.
Closed record no. 37 was a patient who was in the hospital from June 5, 2012 to June 11, 2012. His discharge summary was signed July 26, 2012.

Based on a review of 28 open records and 15 closed medical records, it was determined that one of the fifteen closed records revealed patient #43 nutritional needs were not met.

Based on medical record and policy review and staff interviews, it was determined that the hospital staff failed to complete a physician ordered 3 day calorie count for patient # 43. In addition, the facility staff failed to implement dietitian recommendations for the same patient.

On 8/15/12, medical record review revealed since admission 8/4/12, the patient was ordered a 2000 calorie diabetic diet with Glucerna shake twice daily. On 8/7/12, the physician ordered a 3 day calorie count to assess the amount of nutritional intake because of multiple meal refusals. On the same day, the physician ordered that the patient be provided assistance with meal intake. Interview with employee ES, RN Infomatics revealed on 8/7/12, the calorie count was put into the computer as a nurse communication instead of a nutrition consultation; therefore, the nutrition department was unaware of the MD ordered calorie count. As a result, it was not done. On 8/11/12, 4 days later, an initial nutrition assessment was done to address the patient ' s entire meal refusal since admission to the hospital, 6 days. On 8/11/12, for the first time the patient ate 50% of breakfast and 75% of lunch due to bonding with the tech. A 3 day calorie count was reordered on this day. In addition, dietitian #1 recommended the diet be liberalized to regular and increase Glucerna to four times daily. Interview with dietitian #1 and medical record review on 8/15/12 revealed that these recommendations were not implemented. The dietitian #1 stated that instead of utilizing the nutrition diet order recommendation form, she verbally told the nurse on the unit the nutrition recommendations for the patient. As a result, they were not implemented and there is no documentation to indicate if the physician was ever notified.

On 8/15/12, dietitian #2, recommended that if the patient's discharge from the hospital is delayed, the Glucerna shake be increased to three times daily because patient appears to accept it well. In addition, medical record review revealed inconsistent documentation regarding the physician order on 8/7/12 for staff to assist the patient to eat meals. The documentation included the following: twice the patient ' s meal tray was set up, twice assistance was provided and three times the patient attempted to feed self. The rest of the meals had no documentation to indicate how much assistance was provided to the patient by staff to eat meals. Lastly, the patient's weight was obtained once during the hospital stay on 8/7/12. It was documented as 170 kg instead of 170 lbs and the height was 64 inches. The patient's weight was not checked again.

Based on the standard level deficiencies cirted as part of the Life Safety Code inspection it was determined that the Condition of Physical Environment was not met as evidenced by the following :

The failure to fulfill all fire alarm testing and maintenance requirements under NFPA 72 and NFPA 101 as cited at K052;

The failure to install and maintainthe facility's sprinkler and fire suppression equipment in accordance with NFPA 13, NFPA 14, and NFPA 25 to provide complete coverage for all portions of the building as cited at K056

The failure to have the facility's kitchen hood ventilation and extinguishing system maintained in accordance with NFPA 96 as cited at K069;

The failure to ensure that the full width of aisles and corridors serving as means of egress are clear and unobstructed as cited at K072; and

The failure to provide the required signage for mredical gas storage areas as cited at K076.

On August 15 and 16, 2012 the surveyor accompanied by the food service director, the Infection Control Nurse and the Employee Health Nurse observed the following concerns on the exterior of the building. There was an accumulation of junk and debris near the compactor/loading dock area and behind the medical waste container.

Based on observations made during a tour of the facility it was determined that the following areas of the facility were not maintained in a manner to ensure an acceptable level of safety and quality as evidenced by:

1. On August 15, 2012 the surveyor accompanied by the food service director, the executive chef, the Infection Control Nurse and the Employee Health Nurse observed the following concerns in the main kitchen:
(a.) There was an electrical connection to the condenser inside Walk-in #2 that was not contained in a junction box.
(b.) The floor drain in front of the one-compartment sink was not clean.
(c.)There was a water leak behind Traulsen brand roll-in refrigerator and the floor behind it was not clean.
(d.)The electrical junction box in the Linen Closet did not have a cover on it and the exhaust vent was not clean.

2. On August 15 and 16, 2012 the surveyor accompanied by the food service director, the Infection Control Nurse and the Employee Health Nurse observed that the Fire Department connection on the south side of the building was obscured by branches from a mature holly tree.

3. On August 15 and 16, 2012 the surveyor accompanied by the Infection Control Nurse and the Employee Health Nurse observed the following concerns on the interior of the building:
(a) Behavioral Health - Soiled Utility Room, the vacuum breaker on the flushometer of the clinical sink was leaking.
(b.) Emergency Department, Women ' s Locker Room - the exhaust vent was not removing air from the room.
(c.) Infusion Center, Room 2445 - the exhaust vent was not removing air from the room.
(d.) Orthopedics, Room 2105 - there was a water-stained, moldy ceiling tile.
(e) General comments for patient areas:
(i.) most shower hoses did not have vacuum breaker that was apparent. Some brands have built-in vacuum breakers. If they do not an integral vacuum breaker, one must be installed on the water supply line that exits the wall in the shower stall;
(ii) several bathroom call cords in patient rooms were wrapped around grab rails preventing them from extending to the floor should someone fall.

Based on observation made during a tour of the facility it was determined that ventilation, light, and temperature controls were not maintained as required in the following areas:

1. On August 15, 2012 the surveyor accompanied by the food service director, the executive chef, the Infection Control Nurse and the Employee Health Nurse observed the following concerns in the main kitchen:
(a) The light bulb was missing in the Traulsen brand (#1) roll-in refrigerator.
(b) The grate for the exhaust vent was rusty and no longer cleanable and the duct work was not clean.
(c) The following concerns were noted on the dishmachine: (i) the final rinse pressure gauge was reading 10 pounds per square inch, should be 15 to 25 psi; (ii) the vacuum breaker that serves the garbage grinder leaks; and (iii) the vacuum breaker that serves the water line to the dishmachine is missing a top.
(d) The light bulb in the Traulsen brand reach-in (#13) was not a shatter-proof bulb which eliminates the possibility of glass shattering into food.

2. On August 15 and 16, 2012 the surveyor accompanied by the Infection Control Nurse and the Employee Health Nurse observed the following concerns on the interior of the building:
(a) Emergency Department, Women ' s Locker Room - the exhaust vent was not removing air from the room.
(b.)Infusion Center, Room 2445 - the exhaust vent was not removing air from the room.