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Based on interview and document review, the facility failed to obtain physician's orders prior to initiating the use of medical restraints for three of five patients (P2, P3 and P4) reviewed in the sample for the use of restraints.

Findings included:

A review of the closed record for P2 revealed P2 was restrained with left and right soft wrist restraints on 2/24/12, starting at 6:30 p.m. An order was not obtained for the restraints until 2/25/12, at 7:00 p.m. (more then a 24 hour period of time).

An interview was conducted with the registered nurse (RN)-A at 1:00 p.m. on 4/3/12. RN-A acknowledged an order had not been obtained in a timely manner for the use of restraints for P2.



27598

A review of the clinical record for P3 revealed the patient had been restrained with left and right soft wrist restraints on 3/14/12, starting at 11:00 p.m. An order was not obtained for the restraints until 1:57 p.m. on 3/19/12. In addition, the facility's Nursing Restaint Flowsheets indicated that on 3/23, 3/24, 3/25 and 3/31/12, restraints were temporarily discontinued, and were restarted, without staff having obtained physician's orders for the restraint usage.

On 4/3/12, at 2:36 p.m. RN-B verified the staff had not obtained for the use of the restraints and should have.


19200

The hospital did not obtain a physician's order for the start of a medical restraint for P4.

P4 was admitted to the intensive care unit (ICU) at 1:20 p.m. on 3/29/12, following open heart surgery. At 1:30 p.m. soft wrist restraints were applied to the patient without a physician's order. According to P4's medical record, the restraints were still in place at 6:00 p.m. 3/29/12.

During interview with RN-C at 11:00 A.M. on 4/4/12, she stated she thought there was a hospital policy, specific to patients in the ICU, about not having to get an order from the physician for the use of restraints in the first 12 hours.

The hospital's policy entitled, Restraint or Seclusion (revised January 2010), was reviewed. The policy indicated that when a restraint for medical healing was initiated, the RN was to notify the physician of the patient's status, and obtain an order as soon as possible but no later than 12 hours after the initiation of the restraint. Although the policy indicated that mechanisms could be employed temporarily following post surgical procedures, (wrist restraints were not identified), the policy did not indicate that mechanisms could be applied without an order from the physician. No additional policies specific to the ICU were provided for review.

Based on interview and document review, the hospital failed to follow their policy to renew restraint orders no less than every 24 hours for four of five (P1, P2, P3 and P5) patients in the sample reviewed for physical restraint use.

Findings include:

Physical restraints were used for patients without new physician orders having been obtained, in accordance with hospital policy, for each 24 hour period restraints were in use.

P1's closed record revealed he was restrained with left and right soft wrist restraints beginning at 12:00 a.m. on 3/8/12 through 8:30 a.m. on 3/10/12, (more then 24 hour period of time) without a physician order for the continued use of a restraint.

P2's closed record revealed he had been restrained with left and right soft wrist restraints beginning on 2/27 through 2/29/12, (more then 24 hour period of time) without a physician order for the continued use of a restraint. P2 had also been restrained from 3/1 through 3/3/12, (more then 24 hour period of time) without a physician order for the continued use of a restraint.

An interview was conducted with the registered nurse (RN)-A at 1:00 p.m. on 4/3/12. RN-F stated there is an intensive care flow sheet the charge nurse updates to identify who is in restraints, and there are rounds that are held at the bed side so that staff can visualize who is in a restraint. RN-F acknowledged there was not a new order every calendar day for P2's restraint usage and stated new orders should have been obtained according to the hospital's policy.






27598

A review of the clinical record for P3 revealed the patient had been restrained with left and right soft wrist restraints beginning at 11:00 p.m. on 3/14/12, until 4/4/12. No order for the use of restraints was obtained until 1:57 p.m. on 3/19/12, (more then a 24 hour period of time). In addition, no orders were obtained for 24 hour renewal for continued use of restraints on 3/21/12, 3/23/12, 3/24/12, 3/25/12, 3/30/12, or 4/2/12.

P5's clinical record revealed the patient had been restrained with left and right soft wrist restraints from 3/27/12 to 4/4/12. There was no 24 hour renewal order for the continued restraint use for 3/30 or 4/2/12.

On 4/3/12, at 2:36 p.m. RN-B stated no orders were noted for restraints and verified orders should have been obtained.

The hospital's policy titled, Restraint or Seclusion (revised January 2010), indicated the following for restraints used for medical healing: "continued use of restraint requires a new order that clinically justifies the use of restarting. This order is written each calendar day following an examination."

Based on record review and staff interview, the hospital failed to submit reports to the Center for Medicaid/Medicare Services (CMS) Regional Office in a timely manner related to patient deaths for 24 of 24 patients (Ps 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34), when restraints had been utilized during the patients' care.

Findings include:

During review of the reports of patient deaths with associated restraint use from the last eight months (from 8/2011 to 4/3/2012), it was learned that no reports had been submitted to CMS since August 2011.

An interview was conducted with the director of health information management systems (HIMS) at 2:45 p.m. on 4/3/12. The director of HIMS stated she was not aware of the requirement to report to CMS (Center for Medicare Services) any deaths potentially associated with the use of restraints, no later than the close of the next business day following the day in which the hospital knows of the patient's death. The director of HIMS stated she was not aware of a hospital policy to report to CMS any deaths potentially associated with the use of restraints.

The hospital's Restraint Policy (revised January 2010), was reviewed. The policy identified that the hospital would report to CMS any death associated with the use of restraint or seclusion no later than the close of the next business day following knowledge of the patient's death.

Based on observation, interview and document review, the hospital failed to ensure medications were securely stored on 1 of 1 units temporarily closed from patient use.

Findings include:




28593

During the initial tour of the seventh floor on the afternoon of 4/2/12, the adult emergency medication cart/Code Blue cart was observed in an unsecured area on Station 73. There were approximately 8-10 non-medical staff working at the nurses' station.

The hospital's quality coordinator had reported on 4/2/12 at 2:15 p.m., that Station 73 had been closed since 3/24/12.

On 4/3/12, at 8:30 a.m. Station 73 was toured again. The adult emergency medication cart/Code Blue cart was still observed to be unsecured in the main hallway across from the nursing station. The cart was observed to have a quick remove red tag with a numbered identifier. The staff checked the integrity of the tag on the carts daily when the unit was open. The "Code Blue Cart Checklist" for the months of March and April 2012, were reviewed. The checklists indicated the cart had not been checked on the dates that the unit was closed. There was a line drawn through the routine checks that indicated the unit was closed.

The facility provided a list of medications accessible in their Crash Carts: Premixed Syringes-Atropine, Calcium Chloride, Dextrose, Epinephrine, Licocaine, and Sodium Bicarbonate; Vials/Ampules-Adenosine, Amiodarone, Epinephrine, Labetalol, Magnesium Sulfate, Versed, Narcan, Levophed, Pheylephrine and Vasopressin; and Intravenous Infusion Bags-Dopamine.

During interview with the Vice President of Patient Care Services at 10:35 a.m. on 4/5/12, she confirmed that the protocol for closing the unit had not been followed. A checklist for the closure of Station 73 was provided that indicated the "crash cart" should have been move into room 706 (locked supply room) and plugged into the wall during the unit's closure.

The hospital was found out of compliance with the Condition of Participation, Physical Environment (42 CFR 482.41), as evidenced by deficiencies issued as a result of a Life Safety Code inspection completed 4/5/12 during a complaint validation survey.

Findings include:

Refer to Life Safety Code deficiencies - K12, K18, K20, K25, K29, K31, K33, K34, K43, K52, K56, K72, K76, K77, K135, K144, and K161 for additional information.

Based on observation, interview and document review, the facility failed to maintain the environment in a safe manner for 3 of 3 nursing stations on the 2nd floor, 16 patient rooms on the 800,600, 500, 300 and 200 units, 2 patient shower rooms on the 800 and 600 units, and 1 utility room on the 2nd floor.

Findings include:

A tour of the facility was conducted on 4/3/12, at 1:00 p.m. with the Director of Facility Services. During this tour the following potentially unsafe conditions were noted:

Three of three nursing stations on second floor had missing and chipped veneer in multiple areas.

Patient rooms 819; 823: 834; 607; 608; 611; 614; 617; 623; 634 and 637 were observed to have gouged and marred wood surfaces. The wainscoting trim, which was at waist level, and patient closet areas, were observed to have these issues. This resulted in exposed raw wood and splintered edges.

During the tour, random observations of patient rooms revealed very hot tap water temperatures at the patient hand sinks:

Patient room #800- 118 degrees Fahrenheit (F); Patient room 623- 121 degrees F; Patient room #505- 123 degrees F; Patient room #325- 125 degrees F; Patient room #254- 125 degrees F; and Patient room #211- 128 degrees F.

Unsecured toxic chemicals for cleaning were observed in areas accessible to patients and visitors:

In patient shower rooms #804-B and #602-B there were half full quart bottles of liquid HB QUAT (a disinfectant cleaning chemical) available for use. The Quat was not stored in a locked cabinet.

During a tour of the Heart Center Unit (2nd Floor) on 4/3/12 at 1:50 p.m., an unlocked utility room was observed. An unlocked cupboard under the sink contained an aerosol can of Lysol Disinfectant Spray (19 ounce size), a quart of and HB Quat. During interview with Registered nurse-X during the tour, she confirmed these products could be hazardous and should not be unsecured.

The Material Safety Data Sheet for HB Quat was reviewed. Immediate health hazards were identified as: ..."May cause chemical eye burns. May cause chemical skin burns. May cause chemical gastrointestinal burns. Contains a chemical or chemicals which can cause cancer. May cause target organ effects..."

During interview with the Operations Manager of Environmental Services on 4/3/12 at 3:45 p.m., he agreed the splintered woodwork and the unsecured chemicals presented a potential hazard to their patients, and any visitors who would have access to these rooms.

During interview with the Director of Facility Services on 4/4/12 at 1:20 p.m., he stated that the water temperature is set at 140 degrees F at the point of heat exchange and it is suppose to be delivered to patient rooms at 105 degrees F. It was his opinion that these high water temperatures may indicate a problem with the mixing valves.

The facility did not have a policy regarding water temperatures.

Based on observation, interview, and document review, the hospital failed to ensure infection control policies were developed, and practices implemented, to promote sanitary conditions in 1 of 10 off site clinics reviewed; failed to ensure sanitary conditions were maintained for patients who shared blood glucose monitoring equipment for 1 of 1 patient observed (P6), failed to ensure the pathology laboratory was cleaned; and failed to ensure a sanitary dietary environment.

Findings include:

Appropriate infection control precautions were not followed related to cleaning of medical equipment including blood gluose testing equipment and ultrasound monitors, and maintenance of sanitary conditions in the dietary department and pathology laboratory.

During observations on 4/2/12 at 3:30 p.m., a glucometer machine was observed to be utilized to check P6's blood glucose level in a patient room on the 6th floor. The staff member who utilized the machine was a nursing assistant (NA)-A. NA-A set the glucometer machine case directly on P6's bedside stand and obtained the test. The glucometer case was not cleaned prior to being taken back to the utility room for storage.

The hospital's policy, Bedside Blood Glucose Monitoring, included the following directions for cleaning the glucometer after use: "a. All external surfaces of the meter should be cleaned with a germicidal wipe: following testing with every patient.

Registered nurse (RN)-Y was interviewed at 1:59 p.m. on 4/3/12. She confirmed that the all surfaces of the glucometer and case were to be cleaned after each use prior to storage. RN-Y also stated the nursing assistants who utilized the monitors had been trained to provide such cleaning. RN-Y stated there was currently quality assurance data being collected related to glucometer usage.



18617

A tour of the provider based outpatient maternal fetal medicine clinic service area was completed on 4/3/12, at 9:28 a.m. The imaging area in the clinic was observed to have two rooms with ultra sound machines stored in them. During observation of the ultrasound monitors' touch screens, they were both observed to be visibly soiled with debris over multiple areas on the screens.

Registered nurse (RN)-Z, was interviewed at 9:32 a.m. on 4/3/12. She stated both of the machines should have been cleaned prior to storage. RN-Z further added that the ultrasound machines were supposed to be cleansed between use, including the touch screen monitors. RN-Z confirmed the ultrasound monitoring touch screens were soiled with visible debris and had not been stored clean after the last patient's use. Additionally, RN-Z stated she was unaware of a policy for cleaning the medical equipment (ultrasound touch screens) between use.

The hospital's policy including cleaning for Patient Care Medical Devices (revised 5/11), identified the following: "1. Equipment/Items that come into contact with patients will be disinfected and/or sterilized based on the Association for Professionals in Infection Control and Epidemiology (APIC) published guidelines for selection and use of disinfectants."



28230

During a tour of the kitchen on 4/3/12, at 9:00 a.m. with the food service director, a pot and pan sink washing area was observed. The sink was free standing with no back splash. A cart with soiled dishes was pulled up to the left of the sink to begin the washing process. The washing process involved scraping and spraying the food debris off the pans before washing them. A shelving unit was observed to be located directly behind the sink. The shelves contained cases of paper placemats and dishes. On the left side of the shelving, there were cases of snack chips. Behind the sink, and to the right, were tall bakery carts covered in plastic. The cases on the shelving and the bakery carts had evidence of splashing. The food service director verified that the shelving should be protected from splashing per facility policy.

During the tour on 4/3/12 at 9:15 a.m., the dishwashing machine was observed. There was considerable lime scale build-up on the interior of the machine in the first section. The scale was located on the interior working mechanisms that might not be reached by typical de-liming procedures. There was a pink colored wet substance on the lime scale and some between the splash screen strips. The food service director verified at the time of the observation, that the de-liming process had not been adequate to reach all areas of the machine affected by lime scale build-up. He also stated it was the policy of the department to de-lime the machine each week.



19200

The hospital did not maintain a sanitary environment in the Pathology Laboratory (lab).

A tour of the pathology lab was completed at 1:10 P.M. on 4/4/12, with the pathology supervisor, and the Director of Radiology. Although there was no pathology work being done during the tour, the entire pathology area including: three tables, walls and equipment, were observed to be extremely soiled. The first stainless steel table, back wall and back splash, had a whitish substance all over the surfaces. On the table was a wet paper towel with a scalpel on top of it. The toweling appeared to be soiled with a large amount of serous liquid and some droplets of blood. The second pathology table, identified by the pathology supervisor as used for gross tissue and dissection, was the most soiled. It contained a large (approximately 1 foot by 1 1/2 foot) cutting board. The entire top surface of the board was cut up and there were several huge deep cuts in the board. The color of the board surface was black and dark green. The pathology supervisor verified the cutting board had originally been white. The pathology supervisor stated the cutting board was used on a daily basis to cut specimens of body parts or tissue for examination, and stated the board was cleaned daily. Dyes for use on specimens were observed on the back shelf of the table and the entire dye containers were also observed to be heavily soiled. A sink drain connected to the second table had an approximately 1/4 inch build up of a black gritty substance. The third table, opposite the second table, contained various solutions and a microscope. The entire table was observed to be soiled. Next to the third table was a stand alone deep sink. The entire outside and inside surfaces of the sink were soiled with chunky whitish substance and a large build up of rust. There was also a rusted scrub pad in the sink which the supervisor said was used to use to wash glass specimen containers.

During the tour, the pathology supervisor was asked about the lab's cleaning schedule, and she stated the area was to be cleaned daily. However, the pathology lab supervisor agreed that the current condition of the lab indicated that was not being done.

The cleaning schedules for the pathology lab were reviewed for the months of January, February and March 2012. Daily cleaning assignments had been signed off as having been completed.

The hospital's, Pathology Procedure Manual for Infection Control (last revised 5/2/11), was reviewed. The policy for cleaning of work areas was reviewed and indicated that the gross tissue area was to be cleaned daily.