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Based on observation and interview it was determined for 1 of 2 (room 2) emergency room carts, the CAH failed to ensure the cart was locked and not accessible to unauthorized persons, potentially affecting all patients entering the emergency department.

Findings include:

1. During an observational tour of the emergency department on 8/10/15 at 1:15 PM the following was observed:
- 1:30 PM the equipment cart in room 2 containing intravenous needles was found to be unlocked. This room is next to the ambulance entrance of the CAH and accessible to anyone walking by the room.

2. During an interview on 8/10/15 at 1:35 PM, the Director of Nursing (E #3) stated, "Obviously the cart should be locked if it has needles in it."

Based on observation during the survey walk-through, staff interview, and document review during the life safety code portion of a re-certification survey conducted on August 19, 2015, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.
This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on observation during the survey walk-through, staff interview, and document review during the life safety code portion of the re-certification survey conducted on August 19, 2015, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated August 19, 2015.

Based on document review and staff interview, it was determined for 3 of 5 (Pts #1, 2, and 3) clinical records reviewed for restraints, the CAH failed to ensure monitoring of the patients in accordance with policy.

Findings include:

1. The CAH's policy entitled "Restraints and Safety Devices" (revised 10/8/14) was reviewed on 8/12/15 and required, "...For Behavioral Management: monitoring and care activities shall be recorded on the Restraint Flow Sheet every 15 minutes..."

2. The clinical record for Pt #1 was reviewed on 8/11/15 and included Pt #1 was a 24 year old male admitted to the CAH's emergency department (ED) on 1/13/15 with a diagnosis of suicidal. The ED physician's orders included 4 point restraints for self injurious behavior on 1/13/15 at 11:00 pm. The nurse's notes documented the restraints were initiated on 1/13/15 at 11:00 pm and discontinued on 1/14/15 at 12:05 am. The clinical record lacked documentation of patient monitoring every 15 minutes while in restraints.

3. The clinical record for Pt #2 was reviewed on 8/11/15 and included Pt #2 was a 43 year old male admitted to the CAH's ED on 5/10/15 with a diagnosis of overdose. The ED physician's order dated and timed 5/10/15 at 7:41 pm included 4 point restraints for injury to self. The nurse's notes documented restraints were initiated on 5/10/15 at 6:36 pm and discontinued on 5/10/15 at 8:08 pm. The clinical record lacked documentation of patient monitoring every 15 minutes while in restraints.

4. The clinical record for Pt #3 was reviewed on 8/11/15 and included Pt #3 was a 60 year old female admitted to the CAH's ED on 6/21/15 with a diagnosis of intoxication. The ED physician's order dated and timed 6/21/15 at 9:15 pm included 4 point restraints for physical abuse to others. The nurse's notes documented restraints were initiated on 6/21/15 at 9:11 pm and discontinued on 6/22/15 at 12:10 am. The clinical record lacked documentation of patient monitoring every 15 minutes while in restraints.

5. On 8/12/15 at approximately 3:00 pm, during an interview with the Director of Nursing (E #3), E #3 stated that the "Restraint Nursing Care Flow Sheet" and the "Behavioral Documentation Record" was available in paper form and could also be documented in the electronic medical record (EMR). E #3 stated that it was probably completed on paper and not scanned into the EMR. However, E #3 was unable to find documentation in either form for these 3 patients.

Based on document review, observation and interview, it was determined for 2 of 4 (E#1 and E#2) staff observed in operating room #2, the CAH failed to ensure surgical masks were worn as per policy.

Findings include:

1. The CAH's policy titled, "Dress Code for the Surgical Department (revised 11/12/14)" required, "A surgical mask shall be worn in the operating room (OR) when sterile field is open. The mask shall be worn snugly to prevent air leakage."

2. During an observational tour of OR #2, conducted on 8/11/15 at 7:15 AM to 8:45 AM, the following was observed.
- 7:20 AM - The staff began opening sterile packs in preparation for surgery scheduled at 8:30 AM
- 7:25 AM - Radiology technician (E#1) entered OR #2 with bottom of mask untied
- 7:32 AM - CRNA (certified registered nurse anesthetist) entered OR #2 holding untied mask over face. The mask was tied; however, tied loosely on the bottom which allowed air (breath) to flow freely into the room.

3. During an interview on 8/11/15 at approximately 2:45 PM, the Director of Nursing (E #3) agreed the staff should have had their masks tied before entering the OR.