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Based on medical record review, review of restraint policy, and review of restraint protocol, as well as staff interview, it was determined the facility failed to protect and promote each patient's rights in regard to the use of restraints for five of six patients reviewed (# 38, 45, 46, 47, and 48). The hospital census was 309.

Findings include:

Please see A0168 Patient Rights: Restraints or Seclusion

Based on medical record review, restraint policy review, and staff interview, it was determined that the hospital failed to ensure physician orders for physical restraints was specific and enabled staff to apply the appropriate restraint for five of the six patients reviewed with restraints (#'s 38, 45, 46, 47, and 48). Twenty-one patients were restrained at the time of the review. The hospital census was 309.

Findings include:

The medical record for Patient #38 was reviewed on 03/08/12. The patient was admitted to the Pediatric Intensive Care Unit (PICU) on 03/03/12 with diagnosis which included seizures. According to the record, Patient #38 was intubated and on a ventilator with several medical device lines in place such as Foley catheter and intravenous lines. There was a physician order dated 03/03/12 at 1652 (4:52 P.M.) that called for "soft restraints." The physician order did not state the type of restraint to be applied or the location/extremity/body part to be restrained. These findings were confirmed per interview of Staff R on 03/08/12 at 11:30 A.M. In addition, further record review revealed the patient was restrained from 03/03/12 through 03/08/11. There was no physician order for the restraint on 03/06/12. This finding was confirmed during interview with Staff R on 03/08/12 at 11:30 A.M. Interview with Staff R on 03/08/12 at 11:30 A.M. revealed the patient was restrained with a left wrist restraint to keep from pulling out medical devices. Staff R stated the hospital policy required the physician to write an order every calendar day for continued restrain use.

Review of the policy number XI-20:40, Use of Restraints, was completed on 03/08/12. The policy called for the written restraint order be based upon an individual assessment performed by a licensed practitioner. In addition, the policy called for renewal restraint orders to be obtained every calendar day.


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Patient # 45's medical record was reviewed on 03/08/12. This patient had a non specific restraint order for "soft restraints." Nursing documentation revealed both right and left wrist restrains were used.

Patient # 46's medical record was reviewed on 03/08/12. This patient had a non specific restraint order for "soft restraints." Nursing documentation revealed both right and left wrist restraints were used. A missed restraint physician's renewal order was noted on 02/21/12.

Patient # 47's medical record was reviewed on 03/08/12. This patient had a non specific restraint order for "soft restraints." Nursing documentation revealed left and right wrist restraints were used. A missed restaurant physician's renewal order was noted on 02/08/12.

Patient # 48's medical record was reviewed on 03/08/12. This patient had a non specific restraint order for "soft restraints." Nursing documentation revealed left and right mitts were used.

Based on observations made during the Life Safety Code tour and staff interview, it was determined that the facility failed to maintain a safe environment to protect the health and safety of patients. The facility failed to ensure penetration free smoke barriers and smoke doors with greater than 1/8 inch between door leafs when in the closed position. The facility also failed to ensure a laundry chute door would close and latch properly. The facility census was 309.

Findings include:

Please refer to A0709 : Life Safety from Fire

Based on observations made during the Life Safety Code tour and staff interview, it was determined that the facility failed to maintain a safe environment to protect the health and safety of patients. The facility failed to ensure penetration free smoke barriers and smoke doors with greater than 1/8 inch between door leafs when in the closed position. The facility also failed to ensure a laundry chute door would close and latch properly. The facility census was 309.

Findings include:

Please refer to K-25 Penetrations in smoke barriers.

Please refer to K- 71 Improperly functioning laundry chutes.

Based on observation, staff interview, and review of surgical policies, it was determined the hospital failed to provide precautionary signage to alert personnel entering the surgical suites that radiological procedures and use of radiological equipment were being used. The hospital has 14 operating rooms.
The census was 309.

Findings include:

On 03/06/12 a tour was taken of the main hospital surgical area. At 12:05 P.M. an observation was made through the viewing window of Operating Room #8. Observations revealed the staff in the room to be wearing lead aprons. Staff T (present in the operating room) was identified as being a radiology technician. There was no sign posted to alert staff radiological equipment (C-arm, potential radiation exposure) was being used in this operating room. Interview with Administrative Staff U on 03/06/12 at 12:10 P.M. revealed the precaution sign for x-ray in use is to be brought to the surgical suite by the assigned radiology technician who will be operating the x-ray equipment. An interview with Staff T (radiology technician) was conducted on 03/06/12 at 12:10 P.M. Staff T stated they did not bring any signs from x-ray to post on the surgical suite. Staff T stated they just visually monitored who came in and out of the surgical suite. Staff T was unaware of any procedure to post signs that x-ray was in use. The surgical policies on using x-ray equipment was reviewed on 03/07/12. The surgical policy stated to follow the radiology policy regarding C-arm units. Review of the radiology policy regarding C-arm use states all persons present in the room must wear a full lead apron of at least 0.25 mm lead equivalent and must position themselves outside of the useful beam.