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Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the order for the use of a restraint was never written as an as needed (PRN) order for one of four restraint medical records reviewed (MR58).

Findings include:

Review on March 14, 2014, of the facility policy "Restraint or Seclusion," revised April 2008, revealed "All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. ... I. Definitions ... A. Restraint is: ... b. A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. ... IV. Policy A. Care provided by patients requiring the use of restraint or seclusion is governed by the following guidelines: ... 3. The use of a restraint or seclusion must be ordered by a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by Medical Staff privileging. Orders for restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). ... Nursing staff will refuse to accept a physician order for restraint or seclusion that does not meet the Medicare requirements. ..."

Review on March 13, 2014, at 1:20 PM of MR58 revealed the patient was admitted to the Emergency Department on September 8, 2013. Review of the physician orders revealed an order on September 8, 2013, at 19:24 for Lorazepam (Ativan) [a benzodiazepine used to treat anxiety disorders] 2 milligrams (mg) intramuscular (IM) prn agitation. Documentation noted the patient was acting out, and the Lorazepam was administered in the left deltoid at 2340.

Interview on March 13, 2014, at 1:30 PM with EMP1 confirmed the physician ordered the Lorazepam for agitation PRN, and the medication was administered to MR58.

Continued review of MR58 revealed a Seclusion/Behavior Management Restraint Order Sheet. On September 10, 2013, at 23:29, the physician ordered "Restrain patient with: Four (4) Point Velcro Restraints. Chemical restraint Haldol 5 mg IM q (every) 2 hours PRN agitation." Nursing notes on September 10, 2013, following the physician's order, noted the patient was acting out, and the Haldol was administered.

Interview on March 13, 2014, at approximately 2:00 PM with EMP1 confirmed the physician ordered Haldol PRN for agitation on the Seclusion/Behavior Management Restraint Order Sheet, and the PRN Haldol was administered by nursing staff, as documented in the nursing notes.

Based on review of facility policies and staff interview (EMP), it was determined the facility failed to review and revise the Obstetrical Department nursing policies annually.

Findings include:

Review on March 10, 2014, of the facility policy "Nursing Policies and Procedures," last reviewed August 2013, revealed "Nursing Service Policies and Procedures pertaining to specialty areas are reviewed and revised annually. ..."

Review on March 10, 2014, of the speciality area, Obstetrical Department, nursing policies and procedures revealed the following:

1) The facility policy "RH Hemolytic Disease - Identification, Reporting, and Preventing" was last reviewed and revised in September 2012.

Interview conducted on March 10, 2014, at approximately 10:20 AM, with EMP3 confirmed the facility policy "RH Hemolytic Disease - Identification, Reporting, and Preventing" was last reviewed and revised in September 2012.

2) The facility policy "Admission of Coaches to the Birthing Room" was last reviewed and revised in February 2013.

Interview conducted on March 10, 2014, at approximately 10:20 AM, with EMP3 confirmed the facility policy "Admission of Coaches to the Birthing Room" was last reviewed and revised in February 2013.

3) The facility policy "Use of Oxytocic Drugs in the Obstetrical Department for the Induction or Stimulation of Labor" was last reviewed and revised in September 2012.

Interview conducted on March 10, 2014, at approximately 10:20 AM, with EMP3 confirmed the facility policy "Use of Oxytocic Drugs in the Obstetrical Department for the Induction or Stimulation of Labor" was last reviewed and revised in September 2012.

4) The facility policy "Newborn Feeding Policy" was last reviewed and revised in September 2012.

Interview conducted on March 10, 2014, at approximately 10:20 AM, with EMP3 confirmed facility policy "Newborn Feeding Policy," was last reviewed and revised in September 2012.

EMP3 confirmed this was a pattern, and the speciality area, Obstetrical Department, nursing policies and procedures were not reviewed/revised as required by the facility's policy.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure the high touch points on the exercise equipment were sanitized after each patient use in the cardiac rehabilitation area.

Findings include:

Review on March 12, 2014, of the facility policy "Infection Control," last reviewed February 2014, revealed "Infection prevention and control - Purpose: To minimize the risk of acquiring and/or transmitting infection related to participation in the outpatient cardiac rehabilitation program ... Procedure Steps: ... I. Equipment cleaning a. exercise equipment - staff is required to wipe the handle/guide bars and other commonly touched surfaces of each piece of exercise [sic] twice a day, once at the end of the morning session, and again at the end of the day. The EPA [Environmental Protection Agency] approved hospital disinfectant is used. Patients are also encouraged to wipe equipment [as needed] after use, especially when sweating, coughing, sneezing, etc. during exercise. ... More complete cleaning of each piece of equipment is done by the housekeeping staff. ..."

Observation on March 12, 2014, at 10:40 AM, in the Cardiac Rehabilitation area, revealed a patient completing use of an exercise machine. The patient left the machine and went to another workout area. The handle/guide bars of the first exercise machine were not sanitized.

Interview conducted on March 12, 2014, at 10:40 AM with EMP7 confirmed facility staff sanitize the exercise equipment handle/guide bars and other commonly touched surfaces at the end of the morning sessions and the end of the day.

Interview conducted on March 14, 2014, at approximately 8:30 AM, with EMP5, confirmed high touch points should be cleaned more often. EMP5 confirmed the high touch points should be cleaned after each patient use. EMP5 confirmed high touch points include the handles or hand grips of the exercise equipment.