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Based on interview and document review, it was determined the facility staff failed to follow the facility policy related to non-violent restraint use for two (2) of three (3) patients surveyed for restraint usage (Patients #4 and #9).

The findings include:

On 1/30/18, the medical record for Patient #4 was reviewed with Staff Member #4. The Restraint Orderset, dated 1/23/18 at 9:00 A.M., documented Patient #4 was placed in soft, non-violent bilateral upper extremity restraints. The physician's order did not indicate that it was a verbal order and was not signed by the physician until 1/23/18 at 11:30 A.M.

Staff Member #4 stated, "I see (the form), they (the RN) should have written a verbal order. Most of the time the physician is right there and they sign the form."

Patient #9's medical record was reviewed on 1/30/18 at approximately 10:30 A.M. with Staff Member #4. Patient #9 was placed in restraints on 1/10/18 from 14:00 (2:00 P.M.) until 17:00 (5:00 P.M.). The Restraint Orderset, dated 1/10/18 at 2:00 P.M., did not indicate a verbal order was obtained and a physician had not signed the order at the time of the medical record review.

The Restraint and Seclusion Policy with a revision date of 3/17 was provided on 1/30/18. In the section titled Restraint Process for non-VSD (non-violent self destructive), Process #1 documents the following: "...The RN's decision to use restraints shall constitute a change in the patient's condition and the RN will contact the Physician/credentialed AHP (Allied Health Professionals) immediately to obtain a written or verbal order." Process #5 documents: "The Physician/credentialed AHP must see and examine the patient within the 24 hour time period and sign, date and time the restraint order... "

Based on observations, interviews, and document review, it was determined the facility staff failed to follow facility infection control policies to mitigate the risk associated with contact precaution patients for three (3) of five (5) observations, in two (2) treatment areas.

The findings include:

On 1/29/18 at approximately 2:10 P.M., a tour of 2 South was conducted. At room 2048, Patient #7 was being admitted from the ED (Emergency Department) with family members present. Staff Member #8 and two (2) family members were in the patient's room. On the door was a caddy holding Personal protective equipment (PPE) such as gloves, gowns, mask etc. utilized when a patient is on isolation. When asked if the surveyor had to put on the PPE to enter Patient #7's room, Staff Member #7 stated; "You have to put on a gown and gloves." The surveyor asked why Staff Member #8 did not have on PPE. Staff Member #7 stated, "That is a good question. [He/She] should have on a gown and gloves and the family members should have on a gown and gloves as well."

On 1/29/18 while touring the facility, two (2) unidentified staff members were observed in the room of Patient #11 who was returning from surgery. On the door of the room was an isolation caddy. The two staff members were observed to not be wearing PPE. Staff Member #7 was asked about the two staff members and stated: "I don't know who they are but they are from PACU (Post Anesthesia Care Unit) and should have on gowns."

Patient #11 was admitted from a long-term care facility with the diagnoses of bacterial pneumonia, sepsis, Methicillin-resistant Staphylococcus aureus (MRSA) and lung abscess. Patient #11 was placed on contact precautions. Staff Member #4 was asked if there were other surgeries in the same room as Patient #11 and if so was the room terminally cleaned. Staff Member #4 stated, "There were 2 other surgeries following (Name of Patient #11). There is no record of the room being terminally cleaned prior to the other patients having surgery. We only keep record of the rooms being terminally cleaned at the end of the day."

On 1/30/18 at approximately 11:30 A.M., the following observations were made in the Surgical/Medical Intensive Care Unit (SICU/MICU): A person wearing scrubs, a head bonnet and a facemask around their neck was observed walking toward room 2095. As the person (later identified as a member of anesthesia) walked down the hallway, they would pull the mask over their nose and mouth then lower the mask. The person walked into room 2095. Staff Member #2 was asked who the person was and what were they doing. Staff Member #2 stated, "I don't know but I am going to find out." Immediately after Staff Member #2 walked away another person walked down the hallway wearing scrubs, a head bonnet and a facemask around their neck and entered room 2095. Staff Member #2 exited the room and stated, "They are from surgery and the first person could not decide if they should wear their mask or not."

Staff Member #14 was interviewed on 1/31/18 at approximately 9:15 A.M. and stated, "That should not have happened. We educate the staff at hire and annually as well as do rounds and provide them with education. All patients admitted from a LTC are automatically placed on contact precautions. These patients are tested for MRSA (Methicillin-resistant Staphylococcus aureus) and remain on contact precautions until the lab results come back negative. All staff from surgery should remove their mask and bonnets and shoe covers before exiting the surgery area."

In the facility policy titled "Isolation, Transmission-Based Precautions" (revision date of 5/2016), the section titled "Contact Precautions" - Bullet #4 documents: "Gloves - wear gloves when entering patient room. Change gloves after having contact with infected material that may contain high concentrations of microorganisms (fecal material and wound drainage) and before moving from dirty to clean areas. Remove gloves before leaving the patients' room and perform hand hygiene."
Bullet #5: "Hand hygiene - wash hands with soap and water or use and alcohol-based hand rub immediately after glove removal..." Bullet #6: "Gown - wear gown when entering the patient room. Remove gown before leaving the patient's environment and insure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments and perform hand hygiene."

Based on interview and document review, it was determined the facility staff failed to ensure discharge planning was initiated and/or followed through for four (4) of twelve (12) patients in the survey sample (Patients #4, #6, #8 and #9).

The findings include:

The medical records for Patients #4, #6, #8 and #9 were reviewed on 1/30/18 with Staff Member #4 and the following information was noted:

Patient #4 was admitted on 1/17/18 with the nursing assessment noting Patient #4 had no one to call to assistance after discharge (D/C) and no plan to assist with paying for medications. Both indicators triggered a consult with Care Management. Patient #4 was not seen until 1/25/18 by Care Management/Discharge Planning.

Patient #6 was admitted on 1/21/18 and was uninsured, which should trigger a consult with Care Management. An interview with Staff Member #20 was conducted on 1/30/18 at approximately 2:30 P.M. Staff Member #20 stated, "There should have been Care Management/Discharge Planning notes from 1/22/18." There were no Care Management notes found in Patient #6's medical record at the time of the review on 1/30/18.

Patient #8 was admitted on 1/22/18 with a suspected overdose. Staff Member #19 stated, "He /She should have triggered a consult with Care Management based on admitting information but did not get referred. I will have to look into why not."

Patient #9 was admitted on 1/7/18 and was identified as needing home health services at discharge due to neurosurgery. There were no Care Management notes documented until the day of discharge (1/19/18). Staff Member #19 stated, "There are supposed to be Care Management notes by the insurance carrier in our medical record because they do their own Care Management. But our department should have insured they were being done and we should have had notes indicating what the plan was to be."

Staff Member #19 stated, "All patients referred to Care Management are to be seen within 24 hours of the referral. We have staff here seven (7) days of the week."

The policy titled Scope of Service for Care Management with a revision date of 3/2016 documents: "Initial inpatient level of care status assessments are performed within 24-48 hours of admission...The assessment also includes a review of the patient's medical status, social support systems, activities of daily living (ADLs) and mobility status, home situation and anticipated discharge needs." In the section titled Admission Criteria, bullet #5 documents: "Patients are assessed by a Case Manager within 24 hours of initial referral." Bullet #6 documents: "Frequency of follow-up assessments is determined by the Case Manager upon the patient's needs and medical condition."