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Based on review of facility policy and medical records and interview with facility staff, it was determined the facility failed to ensure less restrictive interventions were attempted for 1 of 2 patients with restraints. This affected Medical Record (MR) # 30 and had the potential to affect all patients served.

Findings include:

Hospital Policy: Special Interventions (Restraints) for Patients
Policy Statement: Restraint is only used if needed to provide patient safety when less restrictive interventions have been ineffective and is discontinued immediately when release criteria are met. Restraint for any other purpose such as coercion, discipline, convenience or retaliation by staff is prohibited.


1. MR # 30 was admitted on 6/15/11 with a diagnosis of Pectus Carinatum.

A review of the medical record on 1/4/12 revealed a Physician's Restraint Order sheet and a Medical-Surgical Restraint Flow Sheet dated 6/15/11. The alternatives used prior to initiation of restraint were not checked to indicate which had been used prior to the use of the soft wrist restraints.

An interview conducted on 1/4/12 at 8:40 AM with Employee Identifier (EI) # 1, Quality Manager, verified the alternatives were not checked prior to the use of the restraint.

Based on review of facility policy and medical records and interview with facility staff, it was determined the facility failed to follow their policy for monitoring restraints for 1 of 2 patients. This affected medical record (MR) # 30 and had the potential to affect all patients served.

Findings include:

Hospital Policy: Special Interventions (Restraints) for Patients

Monitoring the Patient in Restraint for Non-Violent or Non-Self Destructive Behavior.

The RN (Registered Nurse), LPN (Licensed Practical Nurse) or Patient Care Assistant may monitor the patient in non-violent or non-self destructive behavior restraints. Individual patient needs are used to establish the frequency, nature, and extent of monitoring: frequency must be every two hours or less.

Monitoring includes: Observation, interaction with the patient, or direct examination of the patient by qualified staff. Appropriate application of restraint. Assessment of physical and emotional well being of the patient. Maintenance of the patient's rights, dignity and safety. Assessment of whether less restrictive methods are possible or if release criteria have been met.


1. MR # 30 was admitted on 6/15/11 with a diagnosis of Pectus Carinatum.

A review of the PICU (Pediatric Intensive Care Unit) Flow Sheet, dated 6/16/11 from 8:00 AM to 10:00 AM, revealed restraints were continued based on assessments. There was no documentation of observation or direct monitoring of the patient with restraints during this time period.

An interview on 1/4/12 at 8:40 AM with Employee Identifier (EI) # 1, Quality Manager, confirmed monitoring had not been completed.

Based on review of facility policy and medical records and interview with facility staff, it was determined the facility failed to ensure written Physician orders were obtained for soft wrist restraints for 2 of 2 patients who were restrained for non-violent or non-self destructive behavior. This affected Medical Record (MR) # 12 and # 30 and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy
Subject: Special Interventions (Restraints) for Patients

I. Policy Statement
Restraint is only used if needed to provide patient safety when less restrictive interventions have been ineffective and discontinued immediately when release criteria are met...

IV. Restraint for non-violent or non-self destructive behavior
Individual orders ensure clinical justification of restraint use and protect the rights, dignity, and well being of the patient. Orders are placed on the Non-Violent or Non-Self Destructive Behavior Restraint Physician's Order...


1. MR # 12 was admitted to the facility on 1/1/12 with diagnoses including Gun Shot wound to the right groin. The surveyor reviewed the patient's medical record on 1/4/12.

Review of the Non-Violent or Non Self-Destructive Behavior Restraint Physician's Order dated 1/2/12 at 3:00 AM revealed restraints were initiated with a "New Order" and there was no documentation of the type of restraint to be used.

Review of the Non-Violent or Non Self-Destructive Behavior Restraint Physician's Order 1/3/12 revealed a "Renewal of Order" for restraints and there was no documentation of the type of restraint to be used.

Review of the Non-Violent or Non Self-Destructive Behavior Restraint Physician's Order dated 1/4/12 revealed no documentation of the type of restraint to be used or a date or time in which the physician signed this document.


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2. MR # 30 was admitted on 6/15/11 with a diagnosis of Pectus Carinatum.

A review of a signed Medical-Surgical Restraint Physician's Orders form, dated 6/15/11, revealed no documentation of the type of restraint ordered.

An interview with Employee Identifier (EI) # 1, Quality Manager, on 1/4/12 at 8:40 AM confirmed the specific type of restraints had not been included in the physicians order.

Based on record review and an interview, it was determined the hospital failed to obtain consent for treatment for 1 of 16 Emergency Department (ED) records. This affected Medical Record (MR) # 36 and had the potential to affect all patients presenting to the ED.


Findings include:


1. MR # 36 presented to the ED on 12/11/11 with a diagnosis of assault. A review of the record revealed no medical record number was assigned to this patient and no consent form was completed prior to the patient being transferred to another hospital.

An interview conducted on 1/4/12 at 10:30 AM with Employee Identifier (EI) # 1, Quality Manager confirmed there was no consent for treatment at this facility.

Based on review of medical records, facility policy and interview with facility staff, it was determined the facility failed to ensure medical records were complete for 2 of 2 patients who received blood products, to include the amount of blood and/or blood products transfused. This affected medical records (MR) # 11 and 12 and had the potential to affect all patients receiving blood products.


Findings include:

Facility Policy

Subject: Completion of Transfusion Record

A tag is attached to each component or pool of components issued. This serves to identify the intended recipient as well as to document the transfusion procedure...

The Transfusion Record is completed as follows;

The following are in the highlighted area:
... 6. Unit Number of product

Below the highlighted are (area) is the following information:

... 11. Product abbreviation, for example:
PC, LR (packed cells, leukocyte reduced)
FF THAWED (fresh frozen plasma, thawed)...

Documentation of Transfusion:
20. Complete this area to document vital signs, start, and completion of transfusion...

How to handle the Transfusion Tag:
The form was designed so that it can be removed from the bag at the bedside after verification of patient identification is complete. The "peel off" label on the bag keeps the identification on the blood bag throughout the transfusion. The patient's vital signs, the transfusion nurse's and witness signature are recorded on the two copies. Upon the completion of the transfusion:

1. The amount transfused (or check the "all" box adjacent to this blank) and the final transfusionists' signature is recorded...



1. MR # 11 was admitted to the facility on 12/9/11 with an Apgar score of 4-7, Gestational age of 24 weeks 3 days and Respiratory Distress. Review of the medical record revealed a Physician's Order dated 12/30/11 for 9 cc (cubic centimeters) of PRBCs (Packed Red Blood Cells) to be administered over 2 to 3 hours.

Review of the Transfusion Record dated 12/30/11 revealed "PCL" (Packed Red blood cells) unit # W116311128417/1 was transfused and documented the "Amount Transfused: All" was marked. There was no documentation on this record what amount of packed blood cells was transfused. The surveyor was unable to determine the total amount of packed blood cells that were transfused.

Review of the Unit History for unit # W116311128417/1, which was obtained from the facility blood bank, revealed a total volume of 25 cc of irradiated red cells was issued for the patient and sent to the nursing floor.

An interview was conducted on 1/4/12 at 4:10 PM with Employee Identifier # 2, Pediatric Inservice Specialist, who verified there was no documentation of the amount of the packed blood cells that were administered on 12/30/11.


2. MR # 12 was admitted to the facility on 1/1/12 with diagnoses including Gun shot wound to the right groin and Status Post femoral vein repair. Review of the medical record revealed a Physician's order dated 1/2/12 to transfuse 460 milli-liters (ml) of PRBCs to be administered over 4 hours.

Review of the Transfusion Record dated 1/2/12 revealed "PCL" (Packed Red blood cells) unit # W1151 12 026914 was transfused. There was no documented amounts that were transfused.

Review of the Unit History for unit # W1151 12 026914, which was obtained from the facility blood bank, revealed a total volume of 350 cc of irradiated red cells was issued for the patient and sent to the nursing floor.

Review of the medical record revealed a Physician's order dated 1/4/12 to transfuse 1 unit of PRBCs to be administered over 4 hours.

Review of the Transfusion Record dated 1/4/12 revealed "PCL" (Packed Red blood cells) unit # W1151 12 304539 was transfused. There was no documented amounts that were transfused.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on medical record review and staff interview, it was determined the hospital did not ensure 1 of 1 patient discharged to home health was given a list of available home health agencies to choose from. This affected medical record (MR) # 10 and had the potential to effect all patients discharged requiring home health services.

Findings include:

1. MR # 10 was admitted to the hospital on 12/13/11 with a diagnosis of Post-Op (Operative) Wound Infection.

Review of the MR revealed the patient was to be discharged home on 12/21/11 to be followed by home health for Intravenous (IV) antibiotic therapy and wound care. There was no documentation in the MR the patient was given a list of home health agencies to choose from.

During an interview on 1/5/12 at 8:15 AM, Employee Identifier (EI) # 1, the Quality Manager, concurred that the patient had not been given a choice. When the surveyor asked if the hospital had a choice form, she stated, "No".

Based on observation, review of the facility's surgical policies and procedures and staff interviews, it was determined the facility failed to have a policy to assure the operating rooms were monitored for safe parameters of humidity and temperature for 6 of 6 operating rooms. This had the potential to negatively affect all patients who had surgical procedures performed at the facility.

Findings include:

During a tour of the Surgery Department on 1/3/12 at 2:00 PM with Employee Identifier (EI) # 3, Registered Nurse (RN)/Operating Room Nurse Manager, the surveyor observed operating room # 2 had humidity and temperature gauges. The surveyor requested to see the documentation of the monitoring of the temperature and humidity for the 6 operating rooms. EI # 3 was unable to provide documentation of the temperature and humidity monitoring. EI # 3 stated that the operating room (OR) temperature and humidity was monitored by the OR circulators but confirmed there was no documentation of the temperature and humidity of the operating rooms.

The surveyor reviewed the facility's surgical policies and procedures on 1/4/12 at 8:35 AM. There was no policy for the monitoring of the temperature and humidity of the operating rooms.

An interview on 1/4/12 at 8:40 AM with EI # 3 confirmed there was no policy or procedure for the monitoring of the temperature and humidity of the operating rooms.