HospitalInspections.org

Based on review of video surveillance, medical record review, staff interview, observation, policy review and review of other hospital documents, it was determined that 8 of 12 (67%) restrooms failed to be maintained to ensure a safe setting for all patients in the hospital. Findings include:

The hospital document entitled "Patient Rights and Responsibilities" stated, "...You have the Right...to receive care in a safe setting..."

The hospital policy entitled "Safety Management Plan" stated, "...will provide a functionally safe environment of care...to reduce the risk...of injury for patients, staff and visitors..."

I. On 7/14/11, the State Survey Agency became aware of an incident on 5/26/11 in which hospital staff were unable to gain access to a patient (Patient #1) that had experienced an event in a locked emergency department (ED) restroom.

A. Review of the ED video surveillance for 5/26/11 revealed the following timeline of events:

9:42 AM - Patient #1 walked into the ED registration area
9:52 AM - Patient #1 walked back to triage area
10:10 AM - First security officer responded to ED
10:12 AM - Security Manager A responded to ED
The restroom in which the incident occurred was not under video surveillance.

B. Review of the 5/26/11 "Nurse Notes" timed 10:59 AM, revealed that Triage Nurse A sent Patient #1 to the restroom for a urine specimen at 10:00 AM. At that time, it was documented that Patient #1 was ambulating with a steady gait and verbalized understanding of urine specimen instructions.

C. During an interview with Triage Nurse A on 7/20/11 at 11:45 AM, Triage Nurse A reported the following:

- During the triage assessment, Patient #1 was ambulatory, alert and oriented to person, place and time, talkative and able to answer questions appropriately
- Triage Nurse A escorted Patient #1 to the restroom (1166) and explained the procedure to collect a urine specimen using the antiseptic wipe.

D. During an interview with registered nurse (RN) B on 7/19/11 at 10:10 AM, RN B reported the following:

- Heard a commotion in the restroom area and responded to the area
- Went to retrieve a key to unlock the restroom door (1166)
- There was no key to unlock the restroom door (1166)
- Maintenance was called to the area by radio
- Plant Maintenance Employee A responded to the area and unlocked door (1166) within five to eight minutes

E. Review of the "Planned Work Order" revealed that the lock on door 1166 had been replaced on 6/22/10. During interviews with ED Nurse Manager A on 7/19/11 at 10:03 AM and 7/20/11 at 9:25 AM, ED Nurse Manager A reported that neither she nor the charge nurse were provided a key when the lock had been replaced.

II. On 7/19/11 at 9:03 AM, Surveyor B entered the public restroom (1148A) in the ED waiting area, locked the door, activated the restroom's emergency call alarm and started the stopwatch. At 9:50 AM, forty-seven (47) minutes after the emergency call alarm had been activated, there had been no attempt/response by hospital personnel to answer the emergency call alarm. Surveyor B called Surveyor A by telephone at 9:42 AM and at 9:48 AM and provided a rescue update. At 9:48 AM, Surveyor A accompanied by the Director of Patient Relations and Case Management proceeded to the ED restroom (1148A). The Director acknowledged the activated emergency call alarm and the response time on the stopwatch.

On 7/19/11 at 10:00 AM, the Director of Patient Relations and Case Management confirmed that although the emergency call alarm in the ED's public restroom (1148A) was activated, the alarm failed to notify the ED of its activation.

III. An environmental tour was conducted on 7/19/11 from 11:20 AM to 12:20 PM with the Director of Patient Relations and Case Management and Security Manager A. The tour continued on 7/19/11 from 1:25 PM to 2:55 PM with the Director of Accreditation and Security Manager A. During the tours, the following observations were made and confirmed at the time of discovery:

A. The following public restrooms were found to have non-functioning emergency call alarms:

1. First Floor (1332)
2. Third Floor Orthopaedics (3024)
3. Fifth Floor (5001)

B. The emergency call alarm in the Second Floor Waiting Area restroom alarmed into an overflow unit that was not occupied by patients or hospital staff at the time the alarm was activated.

C. The emergency call alarm in the public restroom in the hallway by Cardiovascular Services alarmed in the Cardiovascular Services area. The Cardiovascular Services area was staffed until 5:00 PM; however, this restroom was accessible to the public until 9:00 PM.

IV. On 7/20/11 at 9:07 AM, Surveyor B entered the public restroom (1148B) in the ED waiting area, locked the door, activated the restroom's emergency call alarm and started the stopwatch. Nine (9) minutes and 37 seconds after the emergency call alarm had been activated, there had been no attempt/response by hospital personnel to answer the emergency call alarm. At that time, Surveyor A accompanied by Security Manager A proceeded to the ED restroom (1148B). Security Manager A acknowledged the activated emergency call alarm and the response time on the stopwatch.

On 7/20/11 at 9:17AM, Security Manager A confirmed that although the emergency call alarm in the ED's public restroom (1148B) was activated, the alarm failed to notify the emergency department of it's activation.

Based on medical record review, policy review, staff interview and job description review, it was determined that for 1 of 5 (20%) patients in the sample (Patient #1), the medical record contained inaccurate information. Findings include:

The hospital policy entitled "Management of Information Medical Record Department" stated, "...The medical record will be reviewed to determine if the record clearly, completely and accurately reflects the diagnosis...conditions..."

Review of the hospital policy entitled "Medications: Reconciliation" stated, "...Emergency Room...patient's current medication list, strengths and dosages (including OTC [over the counter] and herbals) are obtained from the patient and entered into the IBEX (electronic record) system...If questions arise as to the medications that the patient is currently taking, the patient's family...serve as information resources..."

Review of the emergency department (ED) job description for the registered nurse (RN) stated, "...Expected achievement...Documents triage and admission assessments accurately..."

A. Review of Patient #1's 5/26/11 ED medication reconciliation documentation completed by Triage Nurse A revealed:

9:58 AM - "Current Medications...No home meds, per patient"

9:59 AM - "LMP (last menstrual period)...on birth control"

Interview with ED Nurse Manager A on 7/21/11 at 10:20 AM confirmed that the medication reconciliation was inaccurate. ED Nurse Manager A reported that the triage nurse should have obtained the name of the birth control prescription and documented the information in the medical record.

B. Review of Patient #1's ED medical record documentation revealed:

5/26/11 9:58 AM - "...Age: 14..."

5/26/11 9:59 AM - Triage Nurse A documented "Sepsis Screening...Sepsis Screen Negative"

5/27/11 5:44 AM - "...Diagnosis Final: Primary: Sepsis..."

During an interview with ED Nurse Manager A on 7/20/11 at 10:55 AM, ED Nurse Manager A reported that Patient #1 was evaluated for sepsis during the 5/26/11 ED encounter. ED Nurse Manager A reported that the "Sepsis Screening" section of the triage assessment, a data collection tool utilized by the hospital for early identification of sepsis to decrease morbidity and mortality in individuals 18 years of age and older, was not appropriate for Patient #1's age group. ED Nurse Manager A reported that in this case, staff should have left the "Sepsis Screening" tool area blank.

On 7/20/11 at 11:25 AM, Surveyor A, RN A and ED Medical Director A accessed Patient #1's electronic "Sepsis Screening" tool. It was confirmed at that time that Triage Nurse A had not utilized the "Sepsis Screening" tool, but had manually entered "Sepsis Screen Negative". ED Medical Director A reported that the screening tool was not to be used for individuals under 18 years of age, and that the area was checked as "negative" because the tool was not being used for "this age group".

On 7/20/11 at 11:45 AM, Surveyor A, Triage Nurse A and ED Nurse Manager A reviewed the electronic "Sepsis Screening" tool for Patient #1. Review of the screening tool revealed that the tool had not been utilized for Patient #1. Triage Nurse A reported that Patient #1 was not screened with the "Sepsis Screening" tool and was unable to recall why she documented "Sepsis Screen Negative".

Based on medical record review, policy review, job description review and staff interview, it was determined that for 1 of 5 (20%) patients (Patient #1) in the sample, the medical record entries failed to contain complete documentation of vital sign and pulse oximetry readings at the time of assessment. Findings include:

The hospital policy entitled "Assessment, Reassessment and Documentation Standards" stated, "This policy provides the guidelines for...documentation of patient care in the Emergency Department (ED)...Documentation...Monitoring of patient's behavioral and physiological status especially in relation to presenting symptoms...Additional vital signs shall be obtained depending on patient's condition..."

The hospital job description for the ED registered nurse (RN) stated, "...Expected achievement...Documents and maintains complete records...Documents triage and admission assessments accurately..."

On 7/14/11, the State Survey Agency became aware of an incident on 5/26/11 in which hospital staff were unable to gain access to a patient (Patient #1) that had experienced an event in a locked ED restroom.

During an interview with RN A on 7/19 and 7/21/11 at 10:17 AM, RN A reported that Patient #1 experienced an unwitnessed event in the ED restroom on 5/26/11. Per RN A, Patient #1 appeared to be in a post-ictal state (state following a seizure) following the rescue from the ED restroom, and was immediately placed on a cardiac monitor in the hallway. The cardiac monitor recorded Patient #1's blood pressure, heart rate and oxygen saturation levels every 15 minutes or more often if the "button was pushed". RN A reported that "monitoring strips" were available to print out while Patient #1 was still in the system; however, once the information was manually cleared by staff, the information was lost. ED Nurse Manager A, who was also present during the 7/21/11 10:17 AM interview, confirmed that the vital sign documentation ("monitoring strips") could not be retrieved.

Review of Patient #1's medical record failed to provide documented evidence of vital sign and pulse oximetry (oxygen saturation level) readings between 9:55 AM and 12:24 PM. Monitoring included the following:

A. 5/26/11
- RN C placed Patient #1 on a cardiac monitor with a non-invasive blood pressure monitor and continuous pulse oximetry at 10:15 AM.

B. Late entry electronically stamped on 6/2/11 at 2:12 PM for entry on 5/26/11 at 12:55 PM (scribe noted that times were approximations):
- 12:00 PM: Pulse oximetry 99% on room air; Vital signs were less tachycardic (rapid heart rate) with "normotensive (normal)" blood pressure
- 12:05 PM: Decision to transfer to Room #1 to prepare for intubation (artificial airway) and lumbar puncture
- 12:15 PM: Transferred to Room #1 with cardiac monitor

During an interview with ED Nurse Manager A on 7/20/11 at 10:25 AM, ED Nurse Manager A reported that it was "best practice" to perform vital signs after an event, and that Patient #1's vital signs had been monitored continuously after the unwitnessed event. ED Nurse Manager A confirmed that Patient #1's medical record documentation failed to provide evidence of blood pressure, pulse and pulse oximetry readings following the unwitnessed event in the ED restroom.

Based on observation, medical record review, policy and document review and staff interview, it was determined that the hospital failed to ensure that restrooms were maintained in a manner to ensure safety (refer to A 701). In addition, the hospital failed to ensure that emergency call alarm systems were maintained in 7 of 12 (58%) restrooms in the sample resulting in potential harm for 71 of 71 (100%) hospitalized patients as well as staff and the public. An Immediate Jeopardy to the patients and the public was created by these deficiencies. Findings include:

The hospital policy entitled "Utility Systems Management Plan" stated, "...plan describes how...will provide a functionally safe environment...designed to assure effective preparation of staff responsible for the use or maintenance and repair of the equipment and thereby support a safe patient care environment...to assure continual availability of a...safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients and staff..."

The hospital policy entitled "Safety Management Plan" stated, "...will provide a functionally safe environment of care...to reduce the risk...of injury for patients, staff and visitors..."

I. On 7/19/11 at 9:03 AM, Surveyor B entered the public restroom (1148A) in the emergency department (ED) waiting area, locked the door, activated the restroom's emergency call alarm and started the stopwatch. At 9:50 AM, forty-seven (47) minutes after the emergency call alarm had been activated, there had been no attempt/response by hospital personnel to answer the emergency call alarm. Surveyor B called Surveyor A by telephone at 9:42 AM and 9:48 AM and provided a rescue update. At 9:48 AM, Surveyor A accompanied by the Director of Patient Relations and Case Management proceeded to the ED restroom (1148A). The Director acknowledged the activated emergency call alarm and the response time on the stopwatch. At 9:50 AM, the Director of Patient Relations and Case Management was informed that an immediate jeopardy existed based on the failure of staff to respond over a 47 minute period to the activated emergency call alarm in the emergency department waiting room restroom.

II. An environmental tour was conducted on 7/19/11 from 11:20 AM to 12:20 PM with the Director of Patient Relations and Case Management and Security Manager A to determine evidence of staff education and knowledge of actions to be taken in response to a locked door/room, and response times to activated emergency call alarms. The tour continued on 7/19/11 from 1:25 PM to 2:55 PM with the Director of Accreditation and Security Manager A. During the tours, staff interviews were conducted and the following observations were made/confirmed at the time of discovery:

A. The following public restrooms were found to have non-functioning emergency call alarms:

1. First Floor (1332)
2. Third Floor Orthopaedics (3024)
3. Fifth Floor (5001)

B. The emergency call alarm in the Second Floor Waiting Area restroom alarmed into an overflow unit that was not occupied by patients or hospital staff at the time the alarm was activated.

C. The emergency call alarm in the public restroom in the hallway by Cardiovascular Services alarmed in the Cardiovascular Services area. The Cardiovascular Services area was staffed until 5:00 PM; however, this restroom was accessible to the public until 9:00 PM.

D. Interviews with Patient Care Assistant A, registered nurse (RN) C, RN D, Secretary A, RN E, RN F, RN G and Certified Nursing Assistant A confirmed that education had been provided and that all interviewed staff had knowledge and were able to successfully demonstrate his/her response to a locked door/room.

E. Surveyor B activated the emergency call alarm in the ED waiting room restroom (1148A) again at 1:25 PM and verified that the emergency call alarm was repaired and functioning at the time of activation. Plant Engineer A reported that the certified technician had identified a "glitch" in the computer program.

F. At 2:46 PM, Surveyor B entered the ED restroom (1166), locked the door, activated the emergency call alarm and started the stopwatch. RNs H and I unlocked the restroom door at 2 minutes and 27 seconds after the emergency call alarm had been activated. Upon rescue, it was observed that the key lock box located directly outside the restroom, had been broken to gain access to the locked door.

Based on the observational tour information, staff interviews and evidence provided by the hospital, the immediate jeopardy was abated at 3:00 PM on 7/19/11. Additional actions taken on 7/19/11 included:

- Maintenance was called to repair identified non-functioning emergency call alarms at time of discovery
- Every hospital emergency call alarm was tested to ensure functionality
- Manufacturer representative was contacted to test emergency call alarms

III. On 7/20/11 at 9:07 AM, Surveyor B entered the public restroom (1148B) in the ED waiting area, locked the door, activated the restroom's emergency call alarm and started the stopwatch. Nine (9) minutes and 37 seconds after the emergency call alarm had been activated, there had been no attempt/response by hospital personnel to answer the emergency call alarm. At that time, Surveyor A accompanied by Security Manager A proceeded to the ED restroom (1148B). Security Manager A acknowledged the activated emergency call alarm and the response time on the stopwatch.

On 7/20/11 at 9:17AM, Security Manager A confirmed that although the emergency call alarm in the ED's public restroom (1148B) was activated, the alarm failed to notify the ED of it's activation. During an interview with the Director of Patient Relations and Case Management on 7/20/11 at 10:03 AM, it was reported that the equipment manufacturer representative had been notified and the hospital requested a same day on-site visit.

During an interview on 7/20/11 at 3:40 PM, the Director of Accreditation provided an e-mail sent to all staff on 7/20/11 at 2:56 PM. The e-mail stated the following, "...immediate attention and action to ensure every team member knows how to unlock a bathroom door if a patient/visitor/team member is inside...you must do this now/today and continue as other team members report to work...three types of locks on our bathroom doors and each requires a different tool to open the door...red breakaway boxes are located in many halls near bathrooms...keys inside of them to get into bathrooms...in the process of ordering more of these boxes and will place them in more patient care areas...Use a sign in sheet as staff are taught/demonstrate how to unlock bathroom doors..."

On 7/21/11 at 9:34 AM, the Director of Patient Relations and Case Management reported that the emergency call alarm in the public restroom (1148B) in the ED waiting area was repaired on 7/20/11. The equipment manufacturer representative identified a computer issue and a short circuit. On 7/21/11 at 1:21 PM, surveyors received written confirmation that the equipment manufacturer representative had performed operational checks and certification of all hospital emergency call alarms.

Based on observation, medical record review, review of policy, document and video surveillance and staff interview, it was determined that for 8 of 12 (67%) restrooms in the sample, the hospital failed to ensure that restrooms were maintained in a manner to ensure safety. Findings include:

The hospital policy entitled "Utility Systems Management Plan" stated, "...plan describes how...will provide a functionally safe environment...designed to assure effective preparation of staff responsible for the use or maintenance and repair of the equipment and thereby support a safe patient care environment...to assure continual availability of a...safe, and effective patient care environment through a program of planned maintenance, timely repair, and evaluation of all events that could have an adverse impact on the safety of patients and staff..."

The hospital policy entitled "Safety Management Plan" stated, "...will provide a functionally safe environment of care...to reduce the risk...of injury for patients, staff and visitors..."

A. On 7/19/11 at 9:03 AM, Surveyor B entered the public restroom (1148A) in the ED waiting area, locked the door, activated the restroom's emergency call alarm and started the stopwatch. At 9:50 AM, forty-seven (47) minutes after the emergency call alarm had been activated, there had been no attempt/response by hospital personnel to answer the emergency call alarm. Surveyor B called Surveyor A by telephone at 9:42 AM and 9:48 AM and provided a rescue update. At 9:48 AM, Surveyor A accompanied by the Director of Patient Relations and Case Management proceeded to the ED restroom (1148A). The Director acknowledged the activated emergency call alarm and the response time on the stopwatch.

On 7/19/11 at 10:00 AM, the Director of Patient Relations and Case Management confirmed that although the emergency call alarm in the ED's public restroom (1148A) was activated, the alarm failed to notify the ED of its activation.

B. An environmental tour was conducted on 7/19/11 from 11:20 AM to 12:20 PM with the Director of Patient Relations and Case Management and Security Manager A. The tour continued on 7/19/11 from 1:25 PM to 2:55 PM with the Director of Accreditation and Security Manager A. During the tours, the following observations were made and confirmed at the time of discovery:

1. The following public restrooms were found to have non-functioning emergency call alarms:

a. First Floor (1332)
b. Third Floor Orthopaedics (3024)
c. Fifth Floor (5001)

2. The emergency call alarm in the Second Floor Waiting Area restroom alarmed into an overflow unit that was not occupied by patients or hospital staff at the time the alarm was activated.

3. The emergency call alarm in the public restroom in the hallway by Cardiovascular Services alarmed in the Cardiovascular Services area. The Cardiovascular Services area was staffed until 5:00 PM; however, this restroom was accessible to the public until 9:00 PM.

C. On 7/20/11 at 9:07 AM, Surveyor B entered the public restroom (1148B) in the ED waiting area, locked the door, activated the restroom's emergency call alarm and started the stopwatch. Nine (9) minutes and 37 seconds after the emergency call alarm had been activated, there had been no attempt/response by hospital personnel to answer the emergency call alarm. At that time, Surveyor A accompanied by Security Manager A proceeded to the ED restroom (1148B). Security Manager A acknowledged the activated emergency call alarm and the response time on the stopwatch.

On 7/20/11 at 9:17AM, Security Manager A confirmed that although the emergency call alarm in the ED's public restroom (1148B) was activated, the alarm failed to notify the emergency department of it's activation.

D. On 7/14/11, the State Survey Agency became aware of an incident on 5/26/11 in which hospital staff were unable to gain access to a patient (Patient #1) that had experienced an event in a locked ED restroom.

1. Review of the ED video surveillance for 5/26/11 revealed the following timeline of events:

9:42 AM - Patient #1 walked into the ED registration area
9:52 AM - Patient #1 walked back to triage area
10:10 AM - First security officer responded to ED
10:12 AM - Security Manager A responded to ED
The restroom in which the incident occurred was not under video surveillance.

2. Review of the 5/26/11 "Nurse Notes" timed 10:59 AM, revealed that Triage Nurse A sent Patient #1 to the restroom for a urine specimen at 10:00 AM. At that time, it was documented that Patient #1 was ambulating with a steady gait and verbalized understanding of urine specimen instructions.

3. During an interview with Triage Nurse A on 7/20/11 at 11:45 AM, Triage Nurse A reported the following:

- During the triage assessment, Patient #1 was ambulatory, alert and oriented to person, place and time, talkative and able to answer questions appropriately
- Triage Nurse A escorted Patient #1 to the restroom (1166) and explained the procedure to collect a urine specimen using the antiseptic wipe.

4. During an interview with RN B on 7/19/11 at 10:10 AM, RN B reported the following:

- Heard a commotion in the restroom area and responded to the area
- Went to retrieve a key to unlock the restroom door (1166)
- There was no key to unlock the restroom door (1166)
- Maintenance was called to the area by radio
- Plant Maintenance Employee A responded to the area and unlocked the restroom door (1166) within five to eight minutes

5. Review of the "Planned Work Order" revealed that the lock for the restroom (1166) had been replaced on 6/22/10. During interviews with ED Nurse Manager A on 7/19/11 at 10:03 AM and 7/20/11 at 9:25 AM, ED Nurse Manager A reported that neither she nor the charge nurse were provided a key when the lock had been replaced.