HospitalInspections.org

Based on hospital policy review, grievance file review, electronic mail documentation review, staff interview, medical record reviews, Hospital Restraint/Seclusion Death Report Worksheet review, Restraint (Performance Improvement) Log review, and observations as referenced in the Life Safety Report of survey completed 07/18/2012, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights, an effective quality assessment and performance improvement program, and a safe environment for patients, staff, and visitors.

The findings include:

1. The hospital failed to promote and protect patients' rights by failing to: provide written notice of grievance resolutions; ensure use of restraints was in accordance with the order of a physician; ensure renewal orders for restraint used to manage violent or self destructive behaviors were time limited; ensure patients restrained for the management of violent or self-destructive behaviors received a one-hour face to face evaluation after initiation of restraint; ensure the date and time of the report to the Centers for Medicare and Medicaid Services (CMS) of the death of a patient that occurred while restrained and/or within 24 hours after being removed from restraints, was documented in the medical record.

~cross refer to 482.13 Patient Rights' Condition: Tag A0115

2. The hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients by failing to ensure effective monitoring of its restraint program.

~cross refer to 482.21 Quality Assessment/Performance Improvement Condition: Tag A0263

3. The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

Based on hospital policy review, grievance file review, electronic mail documentation review, staff interview, medical record reviews, and Hospital Restraint/Seclusion Death Report Worksheet review, the hospital's staff failed to protect and promote patient's rights by failing to: provide written notice of grievance resolutions; ensure use of restraints was in accordance with the order of a physician; ensure renewal orders for restraint used to manage violent or self destructive behaviors were time limited; ensure patients restrained for the management of violent or self-destructive behaviors received a one-hour face to face evaluation after initiation of restraint; ensure the date and time of the report to the Centers for Medicare and Medicaid Services (CMS) of the death of a patient that occurred while restrained and/or within 24 hours after being removed from restraints, was documented in the medical record.

The findings include:

1. The hospital's staff failed to provide a written notice of the resolution of a grievance for 3 of 3 grievances reviewed.

~cross refer to 482.13(a)(2) Patients' Rights Standard: Tag A0123

2. The hospital's staff failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner for 1 of 5 sampled patients who were restrained.

~cross refer to 482.13(e)(5) Patients' Rights Standard: Tag A0168

3. The hospital's staff failed to ensure a time limited renewal order of no longer than four (4) hours for 1 of 1 sampled adult patients that was restrained for the management of violent or self-destructive behaviors.

~cross refer to 482.13(e)(8) Patients' Rights Standard: Tag A0171

4. The hospital's staff failed to ensure a patient was seen face-to-face within 1-hour after the initiation of restraints by a physician, licensed independent practitioner, or other qualified professional for 1 of 1 sampled patients restrained for the management of violent or self-destructive behaviors.

~cross refer to 482.13(e)(12) Patients' Rights Standard: Tag A0178

5. The hospital's staff failed to ensure the date and time of the report to the Centers for Medicare and Medicaid Services (CMS) of the death of a patient that occurred while restrained and/or within 24 hours after being removed from restraints was documented in the medical record for 1 of 1 sampled patient deaths reported to CMS.

~cross refer to 482.13(g) Patients' Rights Standard: Tag A0214

Based on hospital policy review, grievance file review, electronic mail documentation review, and staff interview, the hospital's staff failed to provide a written notice of the resolution of a grievance for 3 of 3 grievances reviewed (#8, #9, #10).

The findings include:

Review of current hospital policy "Complaint/Grievance Process" Policy Number 10-2-14 (effective 09/02; last reviewed 05/2012) revealed "....III. DEFINITIONS: ...Patient Grievance - a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, while in the hospital or after discharge, when a patient complaint cannot be resolved promptly by the staff present at the time of the complaint. ...*If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action for resolution, then the complaint is a grievance for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. ...VII PROCEDURE FOR GRIEVANCES ...9. Subsequently, a written Notice of Investigation Results will be sent to the complainant within 7 days from the CEO or hospital Patient Representative and will contain the following: * Nature of the grievance * Contact person designated to lead the investigation of the grievance....* Steps taken to investigate *Results of investigation/Hospital decision regarding grievance *Internal Appeal Process * External Appeal Information..."

1. Grievance file review on 07/18/2012 for Patient #8 revealed the patient's representative (mother) submitted a written grievance in-person to a hospital representative on 01/29/2012 regarding quality of care issues during Patient #8's visit to the emergency department (ED) on 01/29/2012. Review of the "Grievance Report" form dated 01/29/2012 revealed the section for "Findings/Conclusions" and "Actions Taken" were blank. Review of electronic mail documentation dated 01/31/2012 at 1612, 02/02/2012 at 1015 and 1111, respectively, between a Hospital Ambassador, the ED Director, and the Chief Nursing Officer (CNO) revealed the grievance was investigated. Further review revealed no documentation of a written notice of resolution sent to the patient and/or patient's representative as of 07/18/2012 (171 days after grievance received).

Interview on 07/18/2012 at 0955 with the Quality Management Director revealed she oversees patient complaints and the grievance process. Interview confirmed Patient #8's representative (mother) submitted a written grievance regarding quality of care issues to the hospital on 01/29/2012. Interview revealed the grievance file was considered closed. Interview confirmed the patient and/or patient's representative did not receive a written letter of resolution. Interview revealed, "She should have received a letter." Interview confirmed the hospital's grievance policy was not followed by staff.

2. Grievance file review on 07/18/2012 for Patient #9 revealed electronic mail documentation dated 03/27/2012 at 1934 sent from the nursing Float Pool Manager to the ED Director and CNO. Review revealed Patient #9 presented to the hospital in-person on 03/27/2012 to file a complaint regarding quality of care issues during her visit to the emergency department (ED) the day before on 03/26/2012. Further review revealed, "I told her (Patient #9) that she would get a phone call on Wednesday and that this would be investigated. Please make sure to give her a call." Review of electronic mail documentation dated 04/09/2012 at 1014 (14 days after grievance received) from the ED Director to the Float Pool Manger and CNO revealed, "...Just FYI, I have made multiple attempts to reach (Patient #9's name) including leaving her voicemails, without success." Review failed to reveal documentation of the dates and times of the attempts made to contact Patient #9. Further review revealed no documentation of a written notice of resolution sent to the patient as of 07/18/2012 (113 days after grievance received).

Interview on 07/18/2012 at 0955 with the Quality Management Director revealed she oversees patient complaints and the grievance process. Interview confirmed Patient #9 presented in-person to the hospital on 03/27/2012 to file a grievance. Interview confirmed the patient complained about having to pay for the cost of a taxi ride home after discharge. Interview confirmed the patient also complained about quality of care issues related to pain management. Interview revealed the patient's grievance was "treated as only a billing issue". Interview revealed the grievance file was considered closed. Interview confirmed the patient did not receive a written letter of resolution. Interview confirmed the hospital's grievance policy was not followed by staff.

3. Grievance file review on 07/18/2012 for Patient #10 revealed an electronic mail dated 06/13/2012 at 1432 by a Patient Accounts Supervisor to the ED Director. Review revealed, Patient #10's representative (mother) telephoned the hospital on 06/13/2012 "upset about the care that was given to her child in the emergency room." Review revealed the grievance was referred to the ED Director for investigation. Review of an electronic mail dated 06/13/2012 at 1630 from the ED Director to the Quality Management Director and copied to a Physician revealed "...I called this mother back....In the end she thanked me for calling, but in all honesty she did not sound happy and I do not think I can state that her concerns are alleviated. ...". Further file review revealed the patient's medical record was reviewed by a physician for appropriate care. Review of electronic mail documentation dated 06/27/2012 at 1323 from the CNO to the ED Director revealed "....Did we send a letter as this is a complaint..." Further review revealed no documentation of a written notice of resolution sent to the patient and/or patient's representative as of 07/18/2012 (35 days after grievance received).

Interview on 07/18/2012 at 0955 with the Quality Management Director revealed she oversees patient complaints and the grievance process. Interview confirmed Patient #10's mother telephoned the hospital on 06/13/2012 and complained to a Patient Accounts Supervisor about the care Patient #10 had received during an ED visit on 06/10/2012. Interview confirmed the grievance was referred to the ED Director for investigation and to a physician for review. Interview revealed "(ED Director's Name) and I discussed this and felt it was resolved from the phone call." Interview revealed "we did not ask the mother if she was satisfied." Interview revealed the ED Director documented in her e-mail the mother was "not satisfied." Interview revealed the grievance file was considered closed. Interview revealed the mother "should have received a written letter of resolution." Interview revealed "this was our mistake." Interview revealed "it was clearly missed." Interview confirmed the patient and/or patient's representative did not receive a written letter of resolution. Interview confirmed the hospital's grievance policy was not followed by staff.

Based on hospital policy review, medical record reviews, and staff interview, the hospital's staff failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner for 1 of 5 sampled patients who were restrained (#30).

The findings include:

Review of current hospital policy "Restraint Policy and Procedure" Policy Number: 14-1D-210 (revised 01/2012) revealed, "...NON-VIOLENT OR NON-SELF-DESTRUCTIVE USE OF RESTRAINTS ...A. Authorization and Ordering of Restraints ...* Restraint is initiated only upon the order of a physician or other licensed independent practitioner. The order is time-limited not to exceed 24 hours and includes the specific reason for the intervention. ...*Restraint orders must be dated and timed when signed by physician, and include: 1) criteria for release; 2) type of restraint used; 3) reason for restraint; 4) and specify duration of restraint order...."

Closed record review on 07/18/2012 for Patient #30 revealed a 55 year-old male admitted to the hospital on 04/01/2012 for Altered Mental Status. Record review revealed while hospitalized the patient was placed into restraint's to protect medical interventions (non-violent use of restraints) from 04/12/2012 to 04/15/2012 and 04/20/2012 to 05/01/2012. Review revealed the patient was subsequently discharged on 05/05/2012.

Review of nursing documentation on a "Non-Violent/Non-Behavioral Restraint Flowsheet" dated 04/23/2012 revealed every 2 hour documentation of nurse monitoring of the patient while in restraints. Review revealed documentation the patient was restrained with bilateral soft wrist restraints from 2400 to 2200.

Review of a "Restraint Orders" form signed by a physician dated 04/23/12 at 0815 revealed the form was not completed by the ordering physician. Review of the form revealed the "Alternative Implemented" section was not completed, the "Indications for Restraint" section was not completed, the "Restraint Device" section was not completed, and the "Maximum Length of Restraint" section was not completed.

Review of nursing documentation on a "Non-Violent/Non-Behavioral Restraint Flowsheet" dated (04/24/2012) revealed every 2 hour documentation of nurse monitoring of the patient while in restraints. Review revealed documentation the patient was restrained with bilateral soft wrist restraints from 2400 to 1600 and 2000 to 2200.

Review of a "Restraint Orders" form signed by a physician dated 04/24/12 at 0815 revealed the form was not completed by the ordering physician. Review of the form revealed the "Alternative Implemented" section was not completed, the "Indications for Restraint" section was not completed, the "Restraint Device" section was not completed, and the "Maximum Length of Restraint" section was not completed.

Interview on 07/19/2012 at 1344 with the Hospital's Clinical Educator revealed restraint training is provided to clinical staff upon hire and on an annual basis. Interview revealed the restraint training included review of the hospital's restraint policy and procedures. Interview revealed the restraint policy was revised in 01/2012. Interview revealed a physician's order is required for the application of restraint. Interview revealed the policy requires restraint orders to be dated and timed when signed by physician, include the criteria for release type of restraint used, reason for restraint, and must specify duration of restraint. Interview confirmed per documentation by nursing staff Patient #30 was restrained with bilateral soft wrist restraints on 04/23/2012 and 04/24/2012. Interview confirmed the restraint orders dated and signed on 4/23/2012 at 0815 and 04/24/2012 at 0815 by the ordering physician's were not complete. Interview confirmed the nursing staff did not have a valid and/or appropriate order to restrain the patient. Interview confirmed the hospital staff failed to follow the restraint policy.

Based on hospital policy review, medical record review, and staff interview, the hospital's staff failed to ensure a time limited renewal order of no longer than four (4) hours for 1 of 1 sampled adult patients that was restrained for the management of violent or self-destructive behaviors (Patient #29).

The findings include:

Review of current hospital policy "Restraint Policy and Procedure" Policy Number: 14-1D-210 (revised 01/2012) revealed "...USE OF RESTRAINT FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR ...B. Authorization and Ordering of Restraints ...*Written and verbal orders for restraints are time limited. The physician determines the duration of the restraint order. The order can be less than the following lengths of time but cannot exceed 4 hours for adults 18 years and older; 2 hours for children and adolescents ages 9 to 17; or 1 hours for children under age 9. *After the original order expires (referring to the 4 hour - 2 hour - 1 hour order outlined in A. above)....The original order may only be renewed in accordance with these limits for up to a total of 8 hours for ages 18 and over and 4 hours for patient ages of seventeen and under. ..."

Closed medical record review on 07/18/2012 for Patient #29 revealed a 65 year old female admitted to an inpatient nursing unit of the hospital on 03/13/2012 after presentation to the emergency department for increased shortness of breath. The patient was subsequently discharged on 03/19/2012 with a diagnosis of Chronic Obstructive Pulmonary Disease exacerbation with hypoxia and tachypnea. Review of the medical record revealed the patient was restrained by the hospital's staff for the management of violent or self-destructive behaviors on 03/15/2012 at 1500 through 03/16/2012 at 0400 (13 hours) with monitoring every 15 minutes by nursing staff.

Review of the initial physician's "Violent Restraint" order dated 03/15/2012 at 1445 (Original order to expire at 1845, 4 hours later) revealed under "Maximum Length of Restraint","Original Order" with a check mark in a box adjacent to "4 hours for adult". Further review revealed "Renewal" with a check mark in a box adjacent to "8 hours for patients 18 years of age and older". Review of nursing documentation on the "Violent/Behavior Restraint Flowsheet" dated 03/15/2012 revealed the patient was restrained with Leather wrist and ankle restraints from 1500 to 1845 (3 hours and 15 minutes).

Review of a physician's "Violent Restraint" renewal order dated 03/15/2012 at 1845 (Renewal Order #1, to expire four hours later at 2245) revealed under "Maximum Length of Restraint","Original Order" with a check mark in a box adjacent to "4 hours for adult". Further review revealed "Renewal" with a check mark in a box adjacent to "8 hours for patients 18 years of age and older". Review of nursing documentation on the "Violent/Behavior Restraint Flowsheets" dated 03/15/2012 and 03/16/2012 revealed the patient continued to be restrained with Leather wrist and ankle restraints from 1845 (03/15/2012) to 0400 (03/16/2012) (additional 9 hours and 15 minutes). Review failed to reveal a physician's time-limited order for restraint renewal, upon the expiration of Renewal Order #1 at 2245 on 03/15/2012. Further record review revealed the next physician's restraint order for renewal was at 0245 on 03/16/2012 (8 hours after Renewal Order #1 had expired at 2245 on 03/15/2012).

Interview on 07/19/2012 at 1355 with a Nursing Informatics nurse confirmed no available documentation in Patient #29's medical record of a physician's order for restraint renewal at 2245 on 03/15/2012 (after the initial physician's restraint order for the management of violent or self-destructive behaviors expired on 03/15/2012 at 2245).

Interview on 07/19/2012 at 1344 with the Hospital's Clinical Educator revealed restraint training is provided to clinical staff upon hire and on an annual basis. Interview revealed the restraint training included review of the hospital's restraint policy and procedures. Interview revealed the restraint policy was revised in 01/2012. Interview revealed restraints for the management of violent or self destructive behaviors are time limited. Interview revealed the initial order for restraint is time limited to 4 hours for adults 18 and older. Interview revealed she had been teaching the current policy to clinical staff. Interview confirmed no documented evidence of a time-limited physician's order for restraint renewal for the management of violent or self-destructive behaviors at 2245 on 03/15/2012 for Patient #29.

Interview on 07/19/2012 at 1630 with the Chief Nursing Officer revealed the time limit printed on the pre-printed restraint order form was incorrect. Interview revealed it was a "printing error". Interview revealed the form should have had a "4" instead of an "8" printed on the form under the order renewal section and should have read "4 hours for patients 18 years of age and older".

Based on policy review, medical record review, and staff interviews, the hospital's staff failed to ensure a patient was seen face-to-face within 1-hour after the initiation of restraints by a physician, licensed independent practitioner, or other qualified professional for 1 of 1 sampled patients restrained for the management of violent or self-destructive behaviors (#29).

The findings include:

Review of current hospital policy "Restraint Policy and Procedure" Policy Number: 14-1D-210 (revised 01/2012) revealed, "...USE OF RESTRAINT FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR ...B. Authorization and Ordering of Restraints ...* A physician, or other licensed independent practitioner authorized to order restraints, must see and evaluate the patient in-person within one (1) hours of the initiation of restraints. A telephone call is not adequate. ..."

Closed medical record review on 07/18/2012 for Patient #29 revealed a 65 year old female admitted to an inpatient nursing unit of the hospital on 03/13/2012 after presentation to the emergency department for increased shortness of breath. The patient was subsequently discharged on 03/19/2012 with a diagnosis of Chronic Obstructive Pulmonary Disease exacerbation with hypoxia and tachypnea. Review of a preprinted "Restraint Orders" form dated 03/15/2012 at 1445 revealed a telephone physician's order received by a nurse for use of "Violent Restraint". Review revealed "Definition: Danger to self and others" preprinted under "Violent Restraint" on the top of the form. Further review revealed under "Clinical Justification" a check mark placed into a box adjacent to "Injury to self (describe)" with "Pulling out IV (intravenous) - pulling off O2 (oxygen)-" hand written on a line. Review revealed under "Type of Restraint" a check mark in the box adjacent to "Leather limb (check all that apply)" and check marks in the boxes adjacent to Left Wrist, Right Wrist, Left Ankle, Right Ankle. Review revealed under "Maximum Length of Restraint","Original Order", a check mark in a box adjacent to "4 hours for adult." Further review revealed "4 pt (point) Leathers initiated 1500 > Violent" handwritten on the form. Review of nursing documentation on the "Violent/Behavior Restraint Flowsheets" dated 03/15/2012 and 03/16/2012 revealed Leather wrist and ankle restraints were initiated on 03/15/2012 at 1500 and were removed on 03/16/2012 at 0400 (13 hours later). Record review failed to reveal any available documentation Patient #29 was assessed face-to-face by a physician, licensed independent practitioner, or other qualified professional within 1-hour (no later than 1600 on 03/15/2012) after the initiation of Leather 4-point restraints for the management of violent or self-destructive behaviors.

Interview on 07/19/2012 at 1355 with a Nursing Informatics nurse confirmed no available documentation in Patient #29's medical record of the patient being assessed face-to-face by a physician, licensed independent practitioner, or other qualified professional within 1-hour (no later than 1600) after the initiation of Leather 4-point restraints for the management of violent or self-destructive behaviors on 03/15/2012 at 1500.

Interview on 07/19/2012 at 1344 with the Hospital's Clinical Educator revealed restraint training is provided to clinical staff upon hire and on an annual basis. Interview revealed a physician or other licensed independent practitioner is to perform a face-to-face evaluation within 1 hour after the initiation of a restraint for the management of violent or self-destructive behaviors. Interview revealed if the patient was placed into restraint for the management of violent or self destructive behaviors on 03/15/2012 at 1500, the patient should have a face-to-face evaluation no later than 1600. Interview confirmed no documented evidence of the patient being assessed face-to-face by a physician, licensed independent practitioner, or other qualified professional within 1-hour after the initiation of Leather 4-point restraints for the management of violent or self-destructive behaviors on 03/15/2012 at 1500. Interview confirmed the staff failed to follow the hospital's restraint policy.

Based on hospital policy review, Hospital Restraint/Seclusion Death Report Worksheet review, medical record review and administrative staff interview, the hospital's staff failed to ensure the date and time of the report to the Centers for Medicare and Medicaid Services (CMS) of the death of a patient that occurred while restrained and/or within 24 hours after being removed from restraints, was documented in the medical record for 1 of 1 sampled patient deaths reported to CMS (#7).

The findings include:

Review of current hospital policy "Restraint Policy and Procedure" Policy Number: 14-1D-210 (Revised 01/2012) revealed "...DEATH REPORTING REQUIREMENTS
The hospital must report deaths associated with the use of restraints. The hospital will report the following information to CMS: *Each death that occurs while a patient is in restraints *Each death that occurs within 24 hours after the patient has been removed from restraints *Each death known to the hospital that occurs within one week after restraints where it is reasonable to assume that use of restraints contributed directly or indirectly to a patient's death. 'Reasonable to assume' in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation. Each death meeting these criteria must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patients death." Further policy review failed to reveal a requirement for the hospital staff to document in the patient's medical record the date and time the death was reported to CMS.

Review on 07/18/2012 of a "Hospital Restraint/Seclusion Death Report Worksheet" for Patient #7, revealed a 71 year-old patient admitted to the hospital on 04/05/2012 for Acute Renal Failure and Hypotension. Further review revealed the patient expired on 04/08/2012 at 2247. Review revealed the patient expired within 24 hours of removal of two point soft wrist restraints. Review revealed the CMS Regional Office was notified of the death via facsimile on 04/10/2012 (no time indicated). Review revealed the worksheet was completed by the Quality Management Director.

Closed medical record review for Patient #7 on 07/18/2012 failed to reveal any available documentation in the patient's medical record of the date and time the death was reported to CMS.

Interview on 07/18/2012 at 1335 with the Quality Management Director revealed she was responsible for notifying CMS for all deaths associated with the use of restraints. Interview revealed she is notified by nursing staff of the death and the Restraint/Seclusion Death Report form is completed and faxed to CMS. Interview revealed the Director was "unaware" of the requirement to document the date and time of CMS notification in the patient's medical record. Interview confirmed no available documentation in the medical record of the date and time Patient #7's death was reported to CMS.

Based on review of Restraint (Performance Improvement) Log and staff interviews, the hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients by failing to ensure effective monitoring of its restraint program.

The findings include:

1. The hospital staff failed to ensure effective monitoring of its restraint program.

~ cross refer to 482.21(b)(2)(i) QAPI Quality of Care - Standard Tag A0275.

Based on review of Restraint (Performance Improvement) Log and staff interviews, the hospital staff failed to ensure effective monitoring of its restraint program.

The findings include:

Review on 07/18/2012 of the Restraint (Performance Improvement) Log from January 2012 to July 2012 revealed restrained patients entered onto audit sheets in the log each day. Log review revealed the following information documented on the dates sampled:

a. 05/01/2012 - "Not completed d/t (due to) needs of house" handwritten on the bottom of the log page.

b. 04/14/2012 - Review revealed Patient #30 was entered into the restraint log. Review revealed the reason for the patient's restraint was documented as "B" for "Behavior." Closed record review on 07/18/2012 for Patient #30 revealed a physician's order dated 04/14/2012 at 1630 for the use of "Non Violent Restraint" for protection of medical interventions. Record review failed to reveal a physician's order for restraint to manage violent or self-destructive behaviors on 04/14/2012. Record review revealed the information documented on the restraint log was incorrect.

c. 03/06/2012 - "Info not obtained 2 (secondary to) needs of the house" handwritten on the bottom of the log page.

d. 02/26/2012 - Review revealed Patient Rooms: ICU3, ICU 8, ICU 6, 200, and 328 listed as rooms with patient's in restraints. Review revealed "Info (Information) not obtained" handwritten on the bottom of the log page.

Interview on 07/19/2012 at 1030 with the manager of the Intensive Care Unit revealed, "I do not do PI (performance improvement) monitoring on restraints. The house supervisors do that monitoring. I just keep a log of restraints."

Interview on 07/19/2012 at 1533 with the Quality Management Coordinator (QMC) revealed the house supervisors are responsible for performing daily restraint audits and maintaining the restraint log. Interview revealed when the house supervisors identify areas of concern it is "fixed on the spot". Interview revealed an e-mail notification is then sent to the appropriate department Director for follow-up. Interview revealed the restraint audit sheets are then forwarded to the QMC at the end of the month. Interview revealed she then compiles the data and enters it into the computer. Interview revealed the Department Director then "fills in the analysis findings and recommendations". Interview revealed the data is then reported to the quality council and discussed in nursing leadership meetings. Interview revealed, "I have noticed concerns with the data collection by the nursing supervisors due to missing information in the log." Interview revealed this concern was reported to the Quality Management Director and Chief Nursing Officer. Interview confirmed the Restraint log contained inaccurate and incomplete data.

Interview on 07/19/2012 at 1630 with the Chief Nursing Officer revealed the house supervisors round nightly to identify existing patients and/or new patients who have been placed into restraints. Interview revealed the data collected by the nursing supervisors is sent to Quality. Interview revealed Quality enters the information and issues that "fall out" are followed up on by the department Directors. Interview confirmed the restraint log data was inaccurate and incomplete. Interview revealed, "The quality process should have picked up on the issues but it did not."

Based on policy review, observations during tour, and staff interviews, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure cookware and dinnerware were cleaned and stored in a sanitary condition for patient meal services.

The findings include:

Review of current hospital policy "Storage of Pots, Dishes, Flatware, Utensils" Policy Number F017 (revised 04/2010) revealed, "POLICIES: Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means. PROCEDURES: Dish Handlers, Trayline Area Employees *Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. ..."

Observation during tour of the main kitchen on 07/19/2012 from 1052 to 1210 revealed the following:

1. Observation at 1100 revealed a clean warming cabinet located at the patient trayline. Observation revealed the warming cabinet contained plates (dinnerware) used for patient meal service. Observation of a sample of five (5) plates removed from the warming cabinet revealed visible clear liquids on the outer and inner surfaces of the plates. Interview during tour with the Dietary Manager revealed the plates in the warming cabinet were ready for use for patient meal service. Interview revealed the plates should not have been stored wet in the warming cabinet. Interview revealed the plates should have been completely air dried before being placed into the warming cabinet. Interview confirmed the dietary staff failed to follow hospital's dietary policy.

2. Observation at 1110 of a clean dry storage rack, stored adjacent to the triple "pot" sink, revealed pots/pans (cookware) being stored for later use to prepare food. Further observation revealed visible clear liquids on the outer and inner surfaces of a sample of four (4) stainless steel pans and two (2) eighteen (18) quart clear plastic containers being stored on the rack. Interview during tour with the Dietary Manager revealed cookware stored on the rack is available for use to prepare foods for patient consumption. Interview revealed the cookware should not have been stored wet on the dry storage rack. Interview revealed the cookware should have been completely air dried before being placed onto the clean dry storage rack. Interview confirmed the dietary staff failed to follow hospital dietary policy.

Based on observations as referenced in the Life Safety Report of survey completed 07/18/2012, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710.

2. The hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709.

3. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701.

Based on observations as referenced in the Life Safety Report of survey completed 07/18/2012, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

A. Observations of Building 1 on 07/17/2011 - 07/18/2011 revealed the following:

1. Emergency lighting is incomplete due to the following:
a) lack of emergency lighting for medication preparation room #326;
b) lack of emergency lighting connected to the Life Safety Branch of the essential electrical system in the materials management area near the exit discharge; and
c) exit access doors and hardware from walk-in coolers and freezers cannot be seen in all lighting levels - located in kitchen area on the first floor.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0046.

2. Exit sign directional symbols are improperly located for direction to required exit - located on third floor of north wing beyond nurse's station.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0047.

3. The kitchen mechanical system is incomplete due to the following:
a) deep fryer within sixteen inches of range cooking surface - no baffle is provided between fryer and cooking surface; and
b) doors to kitchen are left in the open position with airflow pulled from corridor areas of laundry and front entrance lobby through the dining room to the kitchen area. Exhaust air is not replaced primarily through the filtered makeup air unit.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0069.

4. The medical gas piping system is incomplete due to the following:
a) medical gas piping is not identified by labels on both sides of partitions penetrated by piping system - corridor area near birthing center; and
b) medical gas cylinders are not protected from extremes of weather in the outdoor oxygen bank area. The cylinders are gang secure, and supported directly on the concrete pad with rust accumulation on cylinders.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0077.

5. Operating room #2 medical gas sensor did not respond to a loss of pressure by closing the zone valve and opening valve at ancillary equipment outlet.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0141.

6. The facility is noncompliant with the National Electrical Code due to the following:
a) there is a multi-outlet power tap used in room 319 of the Dialysis Unit. Receptacles in patient care areas shall be wired in metal raceways with redundant ground path as required by NFPA 99; and Section 517 of the National Electrical Code;
b) lack of minimum number #10 green insulated bonding jumper between normal and emergency panels serving the same patient vicinity - located in electrical room on second floor south wing;
c) receptacle under sink is not equipped with ground-fault interrupter protection - located in kitchen;
d) lack of damp-proof rated emergency light fixture at loading dock exit discharge - lens of existing fixture has a hole in lens and covered with wire mesh;
e) lack of label on fire alarm control panel identifying the utility power supply from the Life Safety Branch panel circuit breaker serving the main fire alarm control panel - panel is located in the first maintenance room near the engineering office; and
f) temporary wiring in hospital conex units containing hospital supplies - exposed bulb fixtures are located directly above combustible supplies; and romex wiring is exposed and installed improperly without junction boxes and proper fasteners.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147.

B. Observations of Building 2 on 07/18/2011 revealed the following:

There are no emergency lights at the exit discharges serving the Rehabilitation Services Building.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0046.

Based on observations as referenced in the Life Safety Report of survey completed 07/18/2012, the hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

The findings include:

A. Observations of Building 1 on 07/17/2011 - 07/18/2011 revealed the following:

1. There is fireproofing missing from structural column in electrical room beside room #145 - first floor cardiopulmonary area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0012.

2. Doors and hardware are incomplete in the following areas:
a) room 318 dutch-type door - upper an lower door leaf cannot be closed with a single motion of the hand;
b) room 314 - positive latching hardware is broken and will not latch properly;
c) office impact room located on the third floor south near the ICU - room is equipped with a key-activated deadbolt lock from both sides of the door. There is no positive latching hardware provided for the referenced room; and
d) doctor's dictation room located on second floor North wing - wedge observed under door to room.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018.

3. The smoke damper did not close during activation of the facility fire alarm system - located at smoke barrier near room 212 on the second floor north wing.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0025.

4. The clean supply room is greater than one hundred square feet without one hour fire resistive enclosure. The room is located within the operating room suite - above ceiling partitions are not equipped with fire code gypsumboard on both sides of studs.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029.

5. There is a key-activated deadbolt latch greater than forty-eight inches above finished floor in the outpatient surgery room #132.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038.

6. The fire alarm system is incomplete due to the following:
a) There is no single line wiring diagram posted at the main facility fire alarm panel - the diagram must illustrate the electromagnetic locking system arrangement and the interface with the fire alarm control system.(located in maintenance and engineering room on first floor); and
b) There is no smoke detector located in the vicinity of the main fire alarm control panel - panel is located in the maintenance and engineering room on the first floor.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0051.

7. The sprinkler system is incomplete due to the following:
a) lack of sprinkler coverage for the lower landing of stairwell #5;
b) lack of sprinkler in NICU closet - located on second floor;
c) lack of sprinkler in ER electrical room - the room does not meet all exceptions for exclusion of sprinkler; most specifically, the two hour fire resistive enclosure; and
d) lack of sprinkler in closet of operating room #4.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056.

8. Main control valves in outdoor valve pit are not electrically supervised. The valve pit cover could not be opened for observation during the survey. Erosion appeared to occur at the perimeter of valve pit; and pit is not equipped with sump pump connected to emergency power system.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0061.

9. The mechanical systems are incomplete due to the following:
a) Lack of an emergency shutdown switch for the air handling units serving the third floor north, east and west wing;
b) Lack of an emergency shutdown switch for the air handling unit serving the ICU located on the south wing of the third floor; and
c) air handling unit shut-down switch did not shut-off air handing unit #11 during activation - located in first floor GI Lab.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067.

10. There are impediments in the means of egress that are not in immediate and continuous use. The following areas were observed with carts and other impediments: first floor - corridor leading to exit discharge near the laundry and maintenance area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0072.

11. The generator annunciator panel is not located in a continuously supervised area. The maintenance room and engineering office is not staffed for twenty-four hours, seven days a week. Audible alarm signals from panel cannot be heard in corridor areas due to ambient sound levels from mechanical equipment room.

12. There is no low fuel level alarm signal for a three hour operating capacity in the main fuel tank serving the emergency generators.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0106.

B. Observations of Building 2 on 07/18/2011 revealed the following:

1. The storage room adjacent to the rehabilitation room is not equipped with sprinklers and a one hour fire resistive enclosure. The room is greater than one hundred square feet in area.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0029.

2. There is (are) no emergency shut-down switch(es) for air handling units serving the Rehabilitation Services Building.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067.

Based on observations as referenced in the Life Safety Report of survey completed 07/18/2012, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Based on observations as referenced in the Life Safety Report of survey completed 07/18/2012, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

A. Observations of Building 1 on 07/17/2011 - 07/18/2011 revealed the following:

The required exits are impeded in the following areas due to incomplete electromagnetic locking arrangements:
a) room 316 - access controlled egress locking arrangement is not equipped with a switch less than five feet from the exit access door containing the magnetic lock;
b) ICU exit access doors are not equipped with release switches located less than five feet from the door containing the electromagnetic lock;
c) lack of master release switch in ER Suite , and on/off release switch beside exit access door from ER suite;
d) exit discharge door at materials management area near the kitchen - the access controlled egress lock is not equipped with a release switch less than five feet from the door in accordance with NFPA 101; Section 7-2.1.6;
e) lack of release switch less than five feet from the exit access controlled egress door in the second floor C-Section anesthesia room; and
f) Labor and Delivery unit - the locks did release with activation of on/off release switches within the unit.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0032.

B. Observations of Building 2 on 07/18/2011 revealed the following:

The exit discharge does not terminate at the publicway by way of a solid, slip-resistant surface other than grass or soil.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0032.

Based on policy review, medical record review, observations, staff interview, Hand Hygiene Monitoring Tool log review, and CDC (Center for Disease Control) Guidelines review, the hospital's Infection Control Officer failed to ensure the control of infections by failing to: A) ensure staff utilized personal protective equipment (PPE) and handwashing techniques per policy for 2 of 2 sampled patients on isolation precautions (Patients #32 and #33); B) ensure clean equipment was stored separately and away from dirty equipment; C) ensure the prevention of cross-contamination in the hemodialysis unit by failing to ensure staff wore gloves when touching contaminated equipment during hemodialysis treatments; and D) ensure a sterile environment was maintained in the operating room.

The findings include:

A) Review of the hospital's policy on "Standard Precautions and Transmission-Based Precautions" revised on 06/2012, revealed " ... Fundamentals of Isolation Precautions: ... Hand Hygiene and Gloving: Hand cleansing is frequently called the single most important measure for preventing spread of infection. Cleansing hands as promptly and thoroughly as possible, between patient contacts and after contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them, is an important component of infection control and isolation precautions. In addition to hand cleansing, gloves play an important role in the prevention of the spread of infection. Wearing gloves does not replace the need for hand cleansing. Failure to change gloves between patient contacts is an infection control hazard ..."

Review of the hospital's policy on "Hand Hygiene" reviewed on 10/2010, revealed " ... Hand hygiene reduces the risk of infection transmission from patient to patient to healthcare provider ... Indications for hand washing and hand antisepsis: ... Before and after direct contact with patients, blood/body fluids or equipment and environmental items touched by patient ... Supplies: ... Hand hygiene products should be accessible at the point of patient care (when possible/feasible) and (at minimum) at entrance to patient's room, at bedside or other convenient locations ... "

Review of the hospital's policy on "Methicillin Resistant Staph Aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) Screening Procedures" revised on 03/2012, revealed: "... Purpose: To reduce the transmission of Methicillin Resistant Staph Aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) between patients by early identification and isolation of high risk patient populations. ... Procedure: A. 1. Patients to be isolated upon admission: History of MRSA or History of VRE, Admitted from a nursing home, Admitted from an assisted living facility, Admitted from a long term care facility ..." Further review revealed a Frequently Asked Questions about MRSA attachment noting: " ...To prevent MRSA infections, doctors, nurses, and other healthcare providers: Clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. Carefully clean hospital and medical equipment, Use contact precautions when caring for patients with MRSA. Contact Precautions mean: ... Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA ... When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands ... "

Review of the hospital's undated "MRSA Screening Protocol" revealed "1. Check all applicable for patient: (Screening Criteria) ... Has been transferred from a hospital, long term care facility, long term acute care facility, or other medical center; Resident of a group home, assisted living facility, or inmate ... Patients with MRSA history will be placed on contact isolation. Place contact precaution isolation sign on patient room door with an Isolation box obtained from materials management."

Open medical record review of Patient #32 revealed a 64 year-old who was admitted on 07/10/2012 with a chief complaint of "change in mental status." Further review revealed Patient #32 had been residing in a nursing home prior to admission. Further review revealed diagnoses of Altered Mental Status and Urinary Tract Infection. Further review revealed contact isolation was maintained from 07/10/2012 - 7/17/2012 to rule out MRSA.

Open medical record review of Patient #33 revealed a 70 year-old who was admitted on 07/08/2012 with chief complaints of shortness of breath and chest congestion. Further review revealed Patient #33 had been residing in a nursing home prior to admission. Further review revealed laboratory results noting a MRSA swab was collected on 07/09/2012 with results on 07/12/2012 of "... MRSA screen positive ..." Further review revealed contact isolation was maintained from 07/09/2012 - 07/17/2012 due to an active MRSA infection.
Record review revealed Patient #33 was discharged on 07/17/2012 and transferred to a nursing home.

Observation on 07/17/2012 at 1430 revealed "Contact Precautions" signs posted on Patients #32 and #33's doors. Further observation revealed isolation boxes containing PPE were hanging from Patients #32 and #33's doors. Observation revealed Patient #32 lying on a stretcher that Certified Nursing Assistant (CNA) #1 pushed partially into the hallway. Further observation revealed CNA #1 was not wearing gloves. Further observation revealed CNA #1 stopped pushing the stretcher and applied gloves. Further observation revealed CNA #2 walked into Patient #33's room without gloves on. Further observation revealed CNA #2 walked out of Patient #33's room wearing gloves. Further observation revealed CNA #2 did not remove her gloves, wash her hands, or use hand sanitizer before touching Patient #32 on the foot. Further observation revealed CNA #2 walked to the end of Patient #32's stretcher, touched Patient #32 on the foot, and then assisted CNA #1 with transporting Patient #32 off the nursing unit.

Interview on 07/17/2012 at 1430 with the Director of the 3rd floor Nursing Unit revealed Patients #32 and #33 were on contact isolation. Further interview revealed CNAs #1 and #2 had not followed the hospital's policy and procedure for contact precautions. Interview revealed CNA #1 was not wearing gloves during direct contact with Patient #32. Interview revealed CNA #1 should have been wearing gloves. Interview revealed CNA #2 had not removed her gloves, washed her hands, or used hand sanitizer after leaving Patient #33's room and touching Patient #32.

Interview on 07/19/2012 at 1400 with the Infection Control Preventionist revealed contact precautions consisted of the use of gloves and gowns when staff were in direct contact with patients and their surrounding environments and equipment/furnishings. Further interview revealed she expected personal protective equipment to be stored at the entrance of the rooms of patients on contact precautions. Further interview revealed staff should change gloves and sanitize their hands when going from one patient's room to another patient's room. Further interview revealed all hospital staff had received training about the appropriate use of personal protective equipment. Further interview revealed the hospital employed "secret shoppers" to monitor hand hygiene on nursing units. CNAs #1 and #2 had not been reported for improper hand hygiene.

Review on 07/19/2012 of the hospital's "Hand Hygiene Monitoring Tool" logs dated June 2011 - July 2012 revealed CNAs #1 and #2 had not been reported for improper hand hygiene.

B) Observation on 07/17/2012 at 1430 of room #313 revealed IV poles and pumps covered with clear plastic bags stored in the same room with uncovered IV poles, IV pumps, and toilet chairs that did not have any labels indicating that they had been cleaned.

Interview on 07/17/2012 at 1430 with the Director of the 3rd floor Nursing Unit revealed housekeeping staff may have put the IV poles and IV pumps in room #313. Further interview revealed bags were supposed to be placed over clean IV poles and pumps. Interview revealed the Director was unable to tell if the uncovered IV poles, IV pumps, and toilet chairs had been cleaned.

Interview on 07/18/2012 with the Director of Environmental Services revealed housekeeping staff cleaned IV poles and pumps in patients' rooms and did not remove them from the rooms. Further interview revealed plastic bags were placed over IV poles and pumps after they were cleaned. Further interview revealed he did not know if the uncovered IV poles, IV pumps, and toilet chairs in room #313 had been cleaned. Further interview revealed he did not know who put the IV poles, IV pumps, and toilet chairs in room #313.

Interview on 07/19/2012 at 1400 with the Infection Control Preventionist revealed clean equipment should not be stored with dirty or contaminated equipment. Interview revealed IV poles and pumps are identified with a clear plastic bag covering them after cleaning has been completed. Interview revealed IV poles and pumps that are stored without bags covering them are considered dirty.



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C) Review of current hospital policy entitled "Standard Precautions and Transmission-Based Precautions" dated 06/2012 revealed, "...II. PURPOSE: Implementation of these Precautions is the primary strategy for successful nosocomial infection control....III. POLICY:...Standard Precautions apply to: Blood...All body fluids, secretions and excretions regardless of whether or not they contain visible blood...Non-intact skin...Mucous membranes. See attachment #1 (CDC 2007 Table #4 Recommendations for Application of Standard Precautions for the care of all patients in all healthcare settings.)..."

Review of CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings: Table 4 - Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare Settings revealed gloves are recommended to be worn "for touching blood, body fluids, secretions, excretions, contaminated items...".

Observation on 07/17/2012 at 1210 of the Hemodialysis Unit revealed the unit consisted of 4 dialysis stations in 1 room. Observation revealed Patient #3 was connected to a hemodialysis machine and was undergoing hemodialysis. Observation revealed the nurse was at the patient's bedside. Observation revealed the nurse touched the hemodialysis machine, then touched the patient's medical record on the bedside table, then touched the patient, then touched the machine again, and then the patient's medical record again, all without wearing gloves or sanitizing her hands.

Interview on 07/17/2012 at 1210 with the nurse at the time of observation revealed, "We wear gloves when drawing blood. Not when touching the machine, even if the patient is running (on hemodialysis treatment) because it is a closed system."

Interview on 07/17/2012 at 1210 with Dialysis Unit Director at the time of observation revealed the Director was not aware staff should wear gloves when touching hemodialysis machines while patients were receiving hemodialysis and had not educated her staff to wear gloves when touching the machines. Interview revealed the Director agreed the machine could potentially be contaminated during treatment and could potentially be a source of cross-contamination. Interview revealed the Director planned to immediately educate her staff to wear gloves when touching the machines during hemodialysis.

Interview on 07/19/2012 at 1400 with the hospital's Infection Control Preventionist (ICP) revealed the ICP rounded in the Hemodialysis Unit at least twice per year as part of environmental surveillance. Interview revealed the ICP was not aware hemodialysis machines were sources of potential cross-contamination during hemodialysis treatments. Interview revealed, "I don't consider a dialysis machine to be dirty if the patient is on the machine. Staff need to wear gloves when setting up the machine and initiating treatment or if breaking down and cleaning the machine (after treatment), but not when touching the machine during treatment." The surveyor informed the ICP of the observation made in the Hemodialysis Unit on 07/17/2012 at 1210. Interview revealed, "I can see now that there would be potential for cross-contamination. I did not think of it that way before. I was thinking the machine was clean."





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D) Observation during tour of the operating room on 07/18/2012 at 1430 revealed a wall inside operating room #4 was being repaired. Observation revealed drywall dust on the electrical receptacles and baseboard underneath the wall. Interview with operating room staff revealed OR #4 was available for surgical procedures. Interview revealed the drywall dust did not meet standards for maintaining a sterile environment in the operating room.