HospitalInspections.org

Based on policy review, medical record review, event report review, personnel file review, staff interview and observations as referenced in the Life Safety Report of survey completed 11/01/2011, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

1. The hospital failed to promote and protect patients' rights by failing to implement restraints and seclusion in accordance with safe and appropriate standards of care.

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

2. 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 policy review, medical record review, event report review, personnel file review and staff interview, the hospital failed to promote and protect patients' rights by failing to implement restraints and seclusion in accordance with safe and appropriate standards of care.

Findings include:

1. The hospital failed to ensure a physician's order for patients that were restrained or secluded.

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

2. The hospital failed to ensure restrained patients were monitored by trained staff .

~cross refer to 482.13(e)(10) Patient Rights' Standard: Tag A0175

3. The hospital failed to ensure nursing staff involved in the use of restraints were trained and competent with restraint and seclusion use.

~cross refer to 482.13(f)(2)(vi) Patient Rights' Standard: Tag A0205

4. The hospital failed to monitor quality and assess hospital processes to ensure the health and safety of patients, by failing to measure and analyze data related to patient restraints.

~cross refer to 482.21(a)(2) Quality Assurance Standard: Tag A0267

Based on policy review, medical record review, event report review, and staff interview, the hospital failed to ensure a physician's order for restraint for 2 of 8 sampled patients that were restrained (#26 and #23).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 09/2011 revealed, "...III. General Provisions for Restraint and Seclusion....2. Initiation: Each episode of restraint shall be initiated: a. upon the order of a licensed independent practitioner who is responsible for the patient....4. Duration of Restraint/Seclusion Orders: a. Orders for restraint or seclusion applied to manage violent or self-destructive behavior...shall remain in effect until the patient's behavior or situation is assessed to no longer require restraint or seclusion, but no longer than 4 hours for adults...."

1. Closed medical record review for Patient #26 revealed a 53 year-old female admitted to the 3rd floor Medical/Surgical/Telemetry Unit on 10/11/2011 with altered mental status (later diagnosed with encephalopathy), dehydration, and urinary tract infection. Record review revealed a physician's order dated 10/16/2011 at 0130 to place the patient in bilateral soft upper limb restraints due to "Protective Restraint Order. The patient is interfering with care and is in danger of dislodging medical devices, due to impaired mental status....." Record review revealed no documentation of the time restraints were initiated.

Review of a hospital "Event Report" dated 10/17/2011 at 0100 revealed, "...Restraints ordered and applied...."

Further medical record review of RN #2's (day shift nurse) notes dated 10/17/2011 revealed, "0730 Restraints removed. Pt (patient) less agitated. More cooperative at this time....0830 Restraints reapplied. Pt becoming more agitated, swearing at staff, slapping, pinching. 2.5 mg (milligrams) Haldol (antipsychotic medication) given IM (intramuscular injection)....0930 Restraints off....1100 Restraints removed. D/C (discontinued) at this time...." Record review revealed no documentation of what time restraints were placed back on the patient between 0930 and 1100 (notes at both of those times state restraints were removed). Record review revealed no physician's order for restraints on 10/17/2011 at 0830, when the patient was restrained by RN #2. Further record review revealed no physician's order for restraints on 10/17/2011 between 0930 and 1100, when the patient was restrained by RN #2.

Interview on 11/02/2011 at 1500 with RN #2 revealed a physician's order was needed for restraints and the order must be renewed every 24 hours. Interview revealed, "(Patient #26) had restraints on when I came on (the morning of 10/17/2011). She was calm and not combative, was not pulling at tubes, so I took them (restraints) off." Interview revealed the patient got angry and agitated again and the nurse gave the patient Haldol. Interview revealed the nurse did not call the physician to get a new order for restraint when she placed the patient back in restraints at 0830 and between 0930 and 1100. Interview revealed, "No (I didn't get order) because the order was still good for 24 hours....I have questioned that (need for new restraint order if patient was re-restrained) myself and have been told the order is good for 24 hours....I didn't get a new order."

Interview on 11/02/2011 at 1130 with the Director of the 3rd floor Medical/Surgical/Telemetry Unit revealed a new physician's order is required when restraints are re-applied. Interview confirmed there was no available documentation of a physician's order for Patient #26 to be restrained on 10/17/2011 at 0830 and between 0930 and 1100.


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2. Open medical record review on 10/06/2011 for Patient #23 revealed a 47 year-old female admitted from the Emergency Department (ED) on 10/06/2011 to the hospital's Behavior Unit under petition for involuntary commitment. Review of the ED record revealed the patient was acutely psychotic and agitated upon arrival to the ED at 1400. Review of a "Violent/Self Destructive Restraint Flowsheet" revealed the patient was placed into seclusion on 10/04/2011 at 1400 and remained through 2225. Further review revealed a nursing note that the patient was placed into four point soft restraints on 10/04/2011 at 2225 and remained in restraints through 10/05/2011 at 0110. Review revealed the patient was placed into seclusion at 0110 and remained through 0251 when four point soft restraints were applied. Record review revealed the patient remained in restraints through 0721. Review revealed a physician's order that was time limited for 4 hours written on 10/04/2011 at 1400 for seclusion. Review revealed a new physician's order for seclusion was written at 1800, 2225 (25 minutes after 4 hour time limited order expired) and 10/05/2011 at 0110. Review revealed a new physician's order for four point limb restraints was written on 10/05/2011 at 0251. Review of the record revealed no physician's order for the use of four point limb restraints used on 10/04/2011 at 2225 through 10/05/2011 at 0110.

Interview on 11/03/2011 at 1630 with an administrative nursing staff member revealed the four hour time limited physician's order for seclusion had expired on 10/04/2011 at 2200 and a new order was not obtained until 2225 (25 minutes late). Interview revealed the new physician's order obtained at 2225 was for seclusion. Interview confirmed the patient was placed in four point soft restraints at 2225 and remained in restraints until 10/05/2011 at 0110. Interview confirmed there was no physician's order written for the use of restraints on 10/04/2011 at 2225. Interview confirmed nursing staff should have obtained a new physician's order for the four point restraints and had failed to follow hospital policy for restraint/seclusion use.

Based on policy review, medical record review, event report review, and staff interview, the hospital failed to ensure restrained patients were monitored by trained staff for 4 of 8 sampled patients that were restrained by staff (Patients #26, #35, #24 and #39).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 09/2011 revealed, "...5. Assessment and Monitoring of Restraint/Seclusion a. Monitoring and assessments shall include a minimum of the elements indicated on the current relevant approved forms and templates....c. Restraint not used for the management of violent or self-destructive behavior shall be subject to ongoing monitoring and assessment as specified in the patient's plan of care. Monitoring and assessments shall occur at least every 2 hours...."

1. Closed medical record review for Patient #26 revealed a 53 year-old female admitted to the 3rd floor Medical/Surgical/Telemetry Unit on 10/11/2011 with altered mental status (later diagnosed with encephalopathy), dehydration, and urinary tract infection. Record review revealed a physician's order dated 10/16/2011 at 0130 to place the patient in bilateral soft upper limb restraints due to "Protective Restraint Order. The patient is interfering with care and is in danger of dislodging medical devices, due to impaired mental status....." Review of RN #1's (night nurse) shift assessment on 10/16/2011 (no time) revealed, "...Psychosocial: (box checked)...No signs or symptoms of depression, aggression or anxiety....Restraints: (box checked) Patient behavior does not present a risk of injury....Lines or Other Access:....Progress Note: Except as noted below, patient status remained unchanged during shift, all planned interventions were completed during the shift and the patient/family received teaching if any, with sufficient comprehension. Pt (patient) pulled out IV (intravenous) line 0330 (RN #1's initials)." Record review revealed no documentation the patient was restrained on 10/16/2011 during the night shift (1900-0700). Review of RN #2's (dayshift nurse) notes dated 10/17/2011 at 0730 revealed, "Restraints removed."

Review of a hospital "Event Report" dated 10/17/2011 at 0100 revealed, "Pt (Patient #26) confused, became combative. Attempting to hit and spit on staff. (Physician) aware. Pt pulled out IV and 'flicked' blood at staff. Restraints ordered and applied with extra padding due to low platelet count...."

Further medical record review revealed no documentation staff monitored or assessed the patient at least every 2 hours while she was in restraints on 10/17/2011 from 0100 to 0730, when the restraints were removed (6 hours and 30 minutes).

Interview on 11/02/2011 at 1245 with RN #1 revealed Patient #26 was restrained on 10/17/2011 after she became agitated, confused, pulled her IV out, and wanted to leave. Interview revealed the nurse was unsure of the exact time the patient was restrained, but thought it was around 0100 or 0300. Interview revealed patients restrained for medical (rather than behavioral) reasons should be monitored "I want to say its every 2 hours". Interview revealed assessment and monitoring of restrained patients should be documented on a "form". Interview revealed, "A form is filled out with notations as far as checking (the restrained patient) every one to two hours." Interview revealed the nurse didn't document any restraint assessments for Patient #26. Further interview revealed, "I have to plead really stupid on that because on my way home I realized I didn't pull the form to document restraints on....I have never had to fill one out before. I think it's like an incident report....Typically I document (assessments) on the nurse's notes...."

Interview on 11/02/2011 at 1130 with the Director of the 3rd floor Medical/Surgical/Telemetry Unit revealed restraint monitoring and assessments were no longer documented on a separate restraint form, but rather should be documented on the nursing shift assessment. Interview confirmed there was no available documentation staff monitored or assessed the patient at least every 2 hours while she was in restraints on 10/17/2011 from 0100 to 0730, when the restraints were removed (6 hours and 30 minutes).



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2. Closed medical record review of patient #35 revealed a 73 year old female admitted to the hospital on 09/29/2011 with acute respiratory failure. Record review revealed Patient #35 was intubated on 09/29/2011 at 1845. The physician had ordered protective restraints, soft wrist restraints, bilateral on 09/29/2011 at 1830. This same document indicated the order was initiated by the Registered Nurse on 09/29/2011 at 1830. Review of the record revealed the patient remained in bilateral soft wrist restraints from 09/29/2011 at 1830 through 10/12/2011 at 1935 (13 days, 1 hour and 5 minutes).

Review of the medical record showed every two hour restraint monitoring was done starting 09/29/2011 at 2030 through 10/01/2011 at 1700. Record review revealed no evidence of restraint monitoring from 10/01/2011 at 1900 through 10/02/2011 at 0700 (12 hours). Review of the Nursing Shift Assessment form dated 10/02/2011 (not timed, no shift indicated) revealed no evidence restraint monitoring was done (12 hours). Record review revealed no evidence of restraint monitoring from 10/07/2011 at 0700 through 1900 (12 hours). There was no night shift documentation present and no evidence of every two hour monitoring of the restrained patient on 10/11/2011 at 1900 through 10/12/2011 at 0700 (12 hours). Further record review revealed the patient was extubated on 10/12/2011 at 1050. Nursing documentation on 10/12/2011 at 1935 recorded no restraints in place. Record review revealed no evidence of restraint monitoring on 10/12/2011 from 0700 through 1935 when the restraints were removed. Further review of the record revealed no evidence of every two hour restraint monitoring on 10/01/2011 at 1900 through 10/02/2011 at 0700 (12 hours), 10/02/2011 (not timed, no shift indicated) (12 hours), 10/07/2011 at 0700 through 1900 (12 hours), 10/11/2011 at 1900 through 10/12/2011 at 0700 (12 hours) and on 10/12/2011 from 0700 through 1935 (12 hours and 5 minutes).

Interview on 11/02/2011 at 1045 with the staff nurse and an administrative nursing staff member confirmed the patient was restrained with bilateral soft wrist restraints from 09/29/2011 at 1830 through 10/12/2011 at 1935. Interview revealed the "Nursing Shift Assessment Care Plan/Interventions/Evaluation" form was used to document the every two hour restraint assessments. Interview revealed the response to the restraint and behaviors that required the continued use of the restraint should be assessed and recorded in the nursing notes. Interview confirmed there was no evidence the patient was monitored every two hours while restrained on 10/01/2011 night shift, 10/02/2011 day shift, 10/07/2011 day shift, 10/11/2011 night shift and 10/12/2011 day shift. Interview confirmed nursing staff failed to monitor the patient according to the hospital's restraint policy.

3. Open record review of patient #24 revealed a 79 year old male admitted to the hospital on 10/28/2011 at 1105 with end stage renal failure, cardiac disease and respiratory failure. Review of the medical record revealed the patient had been placed on a ventilator after being intubated in the Emergency Department. Further review revealed the physician had written an order for protective restraints, soft upper limb restraints, bilateral on 10/28/2011 at 1445. Review of a "Nursing Shift Assessment" form dated 10/28/2011 at 1200 revealed..."Pt moving arms /coughing. Soft wrist restraints applied to protect ETT (intubation tube)." Record review revealed the bilateral wrist restraints remained on through 10/31/2011 at 1040 (2 days, 22 hours and 40 minutes).

Review of the Nursing Shift Assessment form dated 10/29/2011 (not timed, no shift indicated) revealed "Planned Interventions" with a check mark beside "Wrist restraints per physician order." Record review revealed no evidence the restraint monitoring was done every 2 hours on 10/29/2011 (12 hours). Record review revealed the patient was extubated on 10/31/2011 at 1040, with restraints removed.

Interview on 11/02/2011 at 1045 with the staff nurse and an administrative nursing staff member confirmed the patient was restrained with bilateral soft wrist restraints from 10/28/2011 at 1200 through 10/31/2011 at 1040. Interview revealed the "Nursing Shift Assessment Care Plan/Interventions/Evaluation" form was used to document the every two hour restraint assessments. Interview revealed the response to the restraint and behaviors that required the continued use of the restraint should be assessed and recorded in the nursing notes. Interview confirmed there was no evidence the patient was monitored every two hours while restrained on 10/29/2011 day shift. Interview confirmed nursing staff failed to monitor the patient according to the hospital's restraint policy.

4. Closed medical record review of patient #39 revealed a 29 year old male admitted to the hospital on 10/11/2011 at 2210 with diagnoses of overdose and respiratory failure. Record review showed the patient was intubated and placed on the ventilator on 10/12/2011 at 0030. An order for protective restraints was written on 10/11/2011 at 2130, for soft upper limb restraints, bilateral. Review of the record revealed no documentation to indicate the time the protective restraints were started. Review of nurses notes dated 10/11/2011 at 2310 revealed the patient was "slightly combative, restraints reapplied...." Review of the record revealed no documented time the restraints were applied prior to 2310 and no evidence of restraint monitoring between 2130 and 2310 on 10/11/2011. Review of the record revealed bilateral wrist restraints remained on through 10/14/2011 day shift. Review of the Nursing Shift Assessment sheet dated 10/14/2011 at 1030 revealed the patient was extubated. There was no documentation found as to the time the protective restraints were removed.

Interview on 11/02/2011 at 1045 with the staff nurse and an administrative nursing staff member confirmed bilateral wrist restraints were reapplied on 10/11/2011 at 2310. Interview confirmed there was no documentation of when the restraints were applied or removed prior to 2310. Interview confirmed there was no documentation of restraint monitoring between 2130 when the order for restraints was written and 2310 when the restraints were reapplied. Interview further confirmed the patient was restrained through 10/14/2011 day shift. Interview confirmed nursing staff failed to document the time the restraints were removed on 10/14/2011. Interview revealed the "Nursing Shift Assessment Care Plan/Interventions/Evaluation" form was used to document the every two hour restraint assessments. Interview revealed the response to the restraint and behaviors that required the continued use of the restraint should be assessed and recorded in the nursing notes. Interview confirmed nursing staff failed to monitor the patient according to the hospital's restraint policy.

Based on policy review, medical record review, event report review, staff interview, and personnel file review, the hospital failed to ensure nursing staff involved in the use of restraints for 1 of 8 sampled restrained patients (Patient #26) were trained and competent with restraint use.

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 09/2011 revealed, "...5. Assessment and Monitoring of Restraint/Seclusion....c. Restraint not used for the management of violent or self-destructive behavior shall be subject to ongoing monitoring and assessment as specified in the patient's plan of care. Monitoring and assessments shall occur at least every 2 hours....IV. Training Designated hospital staff shall receive focused training as appropriate to perform assigned duties under this policy as outlined in Attachment B. Such training shall take place prior to staff being asked to implement the provisions of this policy and shall be assessed for competency periodically....Attachment B Restraint and Seclusion Training Plan....Minimum training shall include:....2. The instruction and competency requirements of hospital staff who assess patients for restraint, determine that restraint is indicated, or who apply restraint including:....f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, and vital signs...."

Closed medical record review for Patient #26 revealed a 53 year-old female admitted to the 3rd floor Medical/Surgical/Telemetry Unit on 10/11/2011 with altered mental status (later diagnosed with encephalopathy), dehydration, and urinary tract infection. Record review revealed a physician's order dated 10/16/2011 at 0130 to place the patient in bilateral soft upper limb restraints due to "Protective Restraint Order. The patient is interfering with care and is in danger of dislodging medical devices, due to impaired mental status....." Review of RN #1's (night nurse) shift assessment on 10/16/2011 (no time) revealed, "...Psychosocial: (box checked)...No signs or symptoms of depression, aggression or anxiety....Restraints: (box checked) Patient behavior does not present a risk of injury....Lines or Other Access:....Progress Note: Except as noted below, patient status remained unchanged during shift, all planned interventions were completed during the shift and the patient/family received teaching if any, with sufficient comprehension. Pt (patient) pulled out IV (intravenous) line 0330 (RN #1's initials)." Record review revealed no documentation the patient was restrained on 10/16/2011 during the night shift (1900-0700). Review of RN #2's (dayshift nurse) notes dated 10/17/2011 at 0730 revealed, "Restraints removed."

Review of a hospital "Event Report" dated 10/17/2011 at 0100 revealed, "Pt (Patient #26) confused, became combative. Attempting to hit and spit on staff. (Physician) aware. Pt pulled out IV and 'flicked' blood at staff. Restraints ordered and applied with extra padding due to low platelet count...."

Further medical record review revealed no documentation staff monitored or assessed the patient at least every 2 hours while she was in restraints on 10/17/2011 from 0100 to 0730, when the restraints were removed (6 hours and 30 minutes).

Interview on 11/02/2011 at 1245 with RN #1 revealed the nurse was a contracted agency nurse that started to work at the hospital on the 3rd floor Medical/Surgical/Telemetry Unit on 10/10/2011. Interview revealed the nurse received restraint training during orientation. Interview revealed, "I was given a booklet that referenced general policies. I had to read and sign. It included restraints (policy)....I didn't do any demonstration of restraints." Interview revealed Patient #26 was restrained on 10/17/2011 after she became agitated, confused, pulled her IV out, and wanted to leave. Interview revealed the nurse was unsure of the exact time the patient was restrained, but thought it was around 0100 or 0300. Interview revealed patients restrained for medical (rather than behavioral) reasons should be monitored "I want to say its every 2 hours". Interview revealed assessment and monitoring of restrained patients should be documented on a "form". Interview revealed, "A form is filled out with notations as far as checking (the restrained patient) every one to two hours." Interview revealed the nurse didn't document any restraint assessments for Patient #26. Further interview revealed, "I have to plead really stupid on that because on my way home I realized I didn't pull the form to document restraints on....I have never had to fill one out before. I think it's like an incident report....Typically I document (assessments) on the nurse's notes....The house supervisor applies restraints....I didn't apply them."

Interview on 11/02/2011 at 1130 with the Director of the 3rd floor Medical/Surgical/Telemetry Unit revealed restraint monitoring and assessments were no longer documented on a separate restraint form, but rather should be documented on the nursing shift assessment. Interview confirmed there was no available documentation staff monitored or assessed the patient at least every 2 hours while she was in restraints on 10/17/2011 from 0100 to 0730, when the restraints were removed (6 hours and 30 minutes).

Review of RN #1's personnel file revealed the contracted agency nurse began working at the hospital on 10/10/2011. Review revealed restraint training and competency validation, including application of restraints and monitoring of patients in restraint, were signed of by the Education Coordinator on 10/10/2011.

Interview on 11/02/2011 T 1620 with the Education Coordinator revealed, "(RN #1) had a half-day orientation with one other traveler. For restraints, we reviewed and discussed policy, I got restraints out and demonstrated them and they return demonstrated. She return demonstrated appropriately. I don't know what else I could have done to ensure she was competent."

Based on policy review, medical record review, event report review, and staff interview, the hospital failed to monitor quality and assess hospital processes to ensure the health and safety of patients by failing to measure and analyze data related to patient restraints for 2 of 8 sampled restrained patients.

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 09/2011 revealed, "V. Performance Improvement Each department director or designee is responsible for identifying the patients on their units who are restrained/secluded and ensuring that interventions to reduce the time in restraints/seclusion is reduced, if possible....Results from the monitoring activities are reported to the appropriate hospital committees at least quarterly...."

1. Closed medical record review for Patient #26 revealed a 53 year-old female admitted to the 3rd floor Medical/Surgical/Telemetry Unit on 10/11/2011 with altered mental status (later diagnosed with encephalopathy), dehydration, and urinary tract infection. Record review revealed a physician's order dated 10/16/2011 at 0130 to place the patient in bilateral soft upper limb restraints due to "Protective Restraint Order. The patient is interfering with care and is in danger of dislodging medical devices, due to impaired mental status....." Record review revealed no documentation of the time restraints were initiated. Review of RN #1's (night nurse) shift assessment on 10/16/2011 (no time) revealed, "...Psychosocial: (box checked)...No signs or symptoms of depression, aggression or anxiety....Restraints: (box checked) Patient behavior does not present a risk of injury....Lines or Other Access:....Progress Note: Except as noted below, patient status remained unchanged during shift, all planned interventions were completed during the shift and the patient/family received teaching if any, with sufficient comprehension. Pt (patient) pulled out IV (intravenous) line 0330 (RN #1's initials)." Record review revealed no documentation the patient was restrained on 10/16/2011 during the night shift (1900-0700). Review of RN #2's (day shift nurse) notes dated 10/17/2011 at 0730 revealed, "Restraints removed."

Review of a hospital "Event Report" dated 10/17/2011 at 0100 revealed, "Pt (Patient #26) confused, became combative. Attempting to hit and spit on staff. (Physician) aware. Pt pulled out IV and 'flicked' blood at staff. Restraints ordered and applied with extra padding due to low platelet count...."

Further medical record review of RN #2's (day shift nurse) notes dated 10/17/2011 revealed, "0730 Restraints removed. Pt (patient) less agitated. More cooperative at this time....0830 Restraints reapplied. Pt becoming more agitated, swearing at staff, slapping, pinching. 2.5 mg (milligrams) Haldol (antipsychotic medication) given IM (intramuscular injection)....0930 Restraints off....1100 Restraints removed. D/C (discontinued) at this time...." Record review revealed no documentation of what time restraints were placed back on the patient between 0930 and 1100 (notes at both of those times state restraints were removed). Record review revealed no physician's order for restraints on 10/17/2011 at 0830, when the patient was restrained by RN #2. Record review revealed no physician's order for restraints on 10/17/2011 between 0930 and 1100, when the patient was restrained by RN #2. Further record review revealed no documentation staff monitored or assessed the patient at least every 2 hours while she was in restraints on 10/17/2011 from 0100 to 0730, when the restraints were removed (6 hours and 30 minutes).

Further review of the Event Report dated 10/17/2011 at 0100 revealed the report was reviewed and signed by the Director of the 3rd floor Medical/Surgical/Telemetry Unit on 10/26/2011 at 1300. Report review revealed, "Director's/Manager's Recommendation/Action: Pt and daughter interviewed 10/17/11 after complaint made to administration. Pt unhappy due to pulling IV out accidentally. Mad at MD (name of physician) and staff for having to replace IV. Pt was having argument c (with) spouse - upset. Disposition - No further action needed." Report review revealed the Risk Manager signed the report on 10/26/2011. Review of the Risk Manager's note on the report revealed, "Order for restraints in chart. Appropriate action taken by staff."

Interview on 11/02/2011 at 1130 with the Director of the 3rd floor Medical/Surgical/Telemetry Unit revealed the Director talked to the patient and her daughter on 10/17/2011 just before lunch time because they were upset that her IV had come out and the physician made the nurse reinsert it, rather than leave it out. Interview revealed the patient was not in restraints and there were no restraints in the room when the Director talked with the patient. Interview revealed, "I spoke with (RN #2) and she said she had removed restraints. I told her if she needs them again we will need a new order. She said she didn't think she would need them again....At about 5 pm she said the patient was getting upset again and may need re-restraint....I was unaware she needed to be restrained again." Interview revealed the Director completed 100% concurrent review of all restraints on the unit using an audit tool. Interview revealed, "I reviewed the restraint (of Patient #26) using the audit tool."

Review of the restraint audit tool dated 10/16/2011 and 10/17/2011 for Patient #26 revealed, "Complete all questions for each episode of restraint/seclusion. Indicators (each followed by a box to document response in): Date of restraint episode (Each daily order represents one restraint episode)...." Review of the audit tool revealed one episode of restraint, which was dated 10/16/2011. Review of the audit tool revealed the Director's documentation on the tool was incomplete, as there were no documented responses to the following indicators: "Alternatives to restraints attempted prior to use" and "Assessment of patients includes safety-circulation checks; Nutrition - fluid and food offered; Elimination - bed pan urinal offered; Hygiene - bath given". Further review of the audit tool revealed "off @ 0730" written at the bottom of the page, followed by the Director's initials.

Further interview with the Director of the 3rd floor Medical/Surgical/Telemetry Unit on 11/02/2011 at 1230 revealed, "It (the audit tool) is not complete (16 days after the patient was restrained). It's due now, today by 5 (pm)."

Interview on 11/02/2011 at 1430 with the Director of Quality revealed 100%, up to total of 30, restraint records are reviewed per unit each month. Interview revealed, "We have been doing 100% restraints review since September 1st (2011)." Interview revealed the unit director completes the audit tool to assess for staff's compliance with the hospital's restraint policy, including restraint orders and monitoring of restrained patients. Interview revealed, "The audit tool should be completed at the time of review. (The unit directors) should look at 100% of patients that are in restraints during the day, including patients that were in and out of restraints since they (directors) were there....(Director of the 3rd floor Medical/Surgical/Telemetry Unit) is supposed to report all audit tools to me by Monday or Tuesday each week. If I don't get them by Tuesday, I send an e-mail and request them." Interview revealed, "I aggregate all of the data from the audits and report it to Quality (Committee)....Reports go from Quality to MEC (Medical Executive Committee)....We discuss areas for improvement. Then it gets reported to BOT (Board of Trustees)." Further interview with the Director of Quality on 10/17/2011 at 1600 revealed the Director had checked her files for the audit tool related to Patient #26's restraint on 10/17/2011. Interview revealed, "I had (Director of the 3rd floor Medical/Surgical/Telemetry Unit)'s audit tool. It is incomplete. I didn't see that until today. (The Chief Nursing Officer) and I had a talk with her about audits. She's obviously not looking at charts thoroughly."


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2. Open medical record review on 10/06/2011 for Patient #23 revealed a 47 year-old female admitted from the Emergency Department (ED) on 10/06/2011 to the hospital's Behavior Unit under petition for involuntary commitment. Review of the ED record revealed the patient was acutely psychotic and agitated upon arrival to the ED at 1400. Review of a "Violent/Self Destructive Restraint Flowsheet" revealed the patient was placed into seclusion on 10/04/2011 at 1400 and remained through 2225. Further review revealed a nursing note that the patient was placed into four point soft restraints on 10/04/2011 at 2225 and remained in restraints through 10/05/2011 at 0110. Review revealed the patient was placed into seclusion at 0110 and remained through 0251 when four point soft restraints were applied. Record review revealed the patient remained in restraints through 0721. Review revealed a physician's order that was time limited for 4 hours written on 10/04/2011 at 1400 for seclusion. Review revealed a new physician's order for seclusion was written at 1800, 2225 (25 minutes after 4 hour time limited order expired) and 10/05/2011 at 0110. Review revealed a new physician's order for four point limb restraints was written on 10/05/2011 at 0251. Review of the record revealed no physician's order for the use of four point limb restraints used on 10/04/2011 at 2225 through 10/05/2011 at 0110.

Interview on 11/03/2011 at 1630 with an administrative nursing staff member revealed the four hour time limited physician's order for seclusion had expired on 10/04/2011 at 2200 and a new order was not obtained until 2225 (25 minutes late). Interview revealed the new physician's order obtained at 2225 was for seclusion. Interview confirmed the patient was placed in four point soft restraints at 2225 and remained in restraints until 10/05/2011 at 0110. Interview confirmed there was no physician's order written for the use of restraints on 10/04/2011 at 2225. Interview confirmed nursing staff should have obtained a new physician's order for the four point restraints and had failed to follow hospital policy for restraint use. Interview further revealed that restraints and seclusion were reviewed daily by nursing administration staff for appropriate use and following hospital policy. Interview revealed the ED Nursing Manager was responsible for this review.

Interview on 11/03/2011 at 1645 with the ED Nursing Manager revealed all restraint/seclusion use was monitored and that the review on this patient's restraint use had been completed. Interview revealed the monitoring of restraints/seclusion for this patient revealed the physician's order for seclusion written on 10/04/2011 at 1800 had expired at 2200 and the new order was written late at 2225. Interview revealed the emergency department nursing staff were re-educated about obtaining physician's orders to renew restraints/seclusion timely. Interview revealed the restraint/seclusion monitoring did not identify that the patient was placed in four point restraints and that no physician's order for the use of restraints was obtained. Interview confirmed the hospital staff failed to analyze the data to determine the use of restraints/seclusion was consistent with hospital policy.

Based on review of hospital policy and procedure, medical record review and staff interviews the nursing staff failed to ensure that all Blood Bank reports were included in the patient's medical record to document evidence of patient monitoring and vital signs according to hospital policy for 1 of 5 sampled patients that received a blood transfusion (#2).

Review of hospital policy titled "Administration of Blood Products: Red Blood Cells, Cryoprecipitate, Fresh Frozen Plasma, Platelets (Revised: 10/2011)" revealed "I. Purpose: The purpose of this policy is to provide guidelines for the safe transfusion of Blood Products ordered by the physician. II. Scope: This policy applies to all RN's and LPN's (Licensed Practical Nurses) who are responsible for the administration of any blood or blood products. III. Guidelines (Procedures): A. Prior to transfusion...5. Complete the pre-transfusion assessment located on the Blood Administration Flowsheet...C. Identification of the patient...5. Each nurse is to sign the...Blood Administration Flow Sheet. The date and time transfusion was started must be documented...D. Transfusing the Blood Product...8. Document blood transfusions on the Blood Administration Flow Sheet...E. Blood Transfusion Reaction and Reporting... 6. Re-check vital signs and all of the patient identification at the bedside and document actions on the Blood Administration Flow Sheet...7. Take...a copy of the Blood Administration Flow Sheet to the blood bank...IV. Documentation: ...Blood Administration Flow Sheet. V. Retention of Records: Patient records will be retained for a minimum of 10 years (30 years for infants)."

Review of the medical record of patient #2 revealed an 84 year-old admitted to on 09/15/2011 at 1857 for complaints of generalized weakness, chills and fever. Record review revealed on 09/20/2011 at 1415 the attending physician ordered "...Type & Cross 2 units of blood & transfuse, Lasix (diuretic) 20 mg (milligram) IV (Intravenous) at end of each unit." Record review revealed the patient signed a "CONSENT TO TRANSFUSION OF BLOOD OR BLOOD PRODUCTS (Form 89249)" on 09/20/2011 (not timed). Record review revealed the blood sample for the Type and Cross was collected on 09/20/2011 at 1420 and received in the Blood Bank at 1431. Record review of "Transfusion Record 8561330" revealed the Type and Cross was completed and two units (Unit #1 and Unit #2) of A POS (positive) compatible RBC (Red Blood Cells) were available on 09/20/2011 at 1526. Record review revealed nursing personnel were issued Unit #1 on 09/20/2011 at 1645 and Unit #2 at 2046. Record review revealed no "Blood Administration Flow Sheet" was available for Unit #1 issued at 1645. Record review revealed no documentation that "product and patient identification" were verified by two licensed nurses, no documentation a "Pre-Transfusion Assessment" was performed, no documentation that vital signs were monitored according to policy (every 15 minutes x 4, then every 1 hr. until transfusion complete), no documentation of transfusion start and end times, and no documentation of whether or not a transfusion reaction occurred.

Interview on 11/02/2011 at 1530 with the RN assigned to Patient #2 on 09/20/2011 from 0700-1900 revealed "I remember giving the blood (Unit #1) and writing the vital signs on the sheet, it started around 1700 and finished around 1945." Interview revealed "I remember reporting to the oncoming nurse about the blood transfusion." Interview revealed the "the vital sign sheet (Blood Administration Flow Sheet) is clipped into the binder...there is a copy (original) in the chart and a copy (photocopy) goes to the Nurse Manager." Interview revealed the nurse manager then forwards the photocopy of the "Blood Administration Flow Sheet" to the Blood Bank.

Interview on 11/02/2011 at 1630 with administrative nursing staff revealed that both the computerized and paper medical record for patient #2 had been searched and the "Blood Administration Flow Sheet" for the transfusion of Unit #1 on 09/20/2011 was not found. Interview revealed the Blood Bank and Laboratory were unable to find a copy of the "Blood Administration Flow Sheet" for the transfusion of Unit #1. Interview confirmed Patient #2's medical record did not contain a "Blood Administration Flow Sheet" for the transfusion of Unit #1, as required by hospital policy.

Based on observations as referenced in the Life Safety Report of survey completed 11/01/2011, 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 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 A0701.

2. 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(a) Physical Environment Standard Tag A0710.

Based on observations as referenced in the Life Safety Report of survey completed 11/01/2011, 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 on 11/01/2011 revealed the following:

1. Automatic flush bolts are not functioning for top section of delivery suite doors located on the second floor - located near room 232.

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

2. The facility is noncompliant with the National Electrical Code due to the following:

a. multioutlet surge suppressors, not listed for health care facilities, mounted to walls in the first floor recovery area.

b. receptacle outlet installed in valve pit, near water storage tank, is not GFI protected and connected to the essential electrical system in accordance with NFPA 70; Article 517.

c. circuit directories, panelboard near CCU, are incomplete; all electrical breakers are not identified.

d. circuit directory, panelboard 3LA, is incomplete; all electrical breakers are not identified.

e. low fuel level alarm, for three hour capacity, could not be verified by staff for the emergency power system.

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

Based on observations as referenced in the Life Safety Report of survey completed 11/01/2011, 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:

1. The travel distance to existing smoke barriers exceeds limitation allowance for a facility not equipped with sprinklers in all spaces. The travel distance is limited to one hundred and fifty feet for facilities not fully sprinklered. Smoke barrier doors serving special delivery suite floor are greater than one hundred and fifty feet from most remote room in delivery suite.

~cross-refer to Life Safety Code Standard - NFPA 101, Tag K0024.

2. The hyperbaric unit is not separated by minimum one hour fire resistive construction. Fire door to room is not equipped with self-closing hardware; and one door to area is rated for less than forty-five minute fire resistive rating.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0029.

3. The facility is utilizing varied incomplete installations of special locking arrangements. The facility is not equipped throughout with a complete automatic sprinkler system or detection system. Specific noncompliance with special locking arrangement minimum requirements are as follows:

a. Delayed egress locks, as installed, did not release during activation of the facility fire alarm system by activation of corridor smoke detectors - located on second floor near stairway exits, and labor/delivery unit.

b. Delayed egress locks, as installed, would automatically relock without manual intervention once thirty second time delay had expired and door had released and returned to closed position.

c. Door signage is incorrect - signs state that when fire alarm sounds, lock will release in thirty seconds. Signs must state: Push alarm will sound, lock will release in thirty seconds

d. There is no on/off keyed switch within three feet of exit door near fourth floor Delta Center - lock release depends on electronic card swipe adjacent to exit door.

e. Master release switch in third floor CCU is not an on/off switch. The switch is a momentary contact switch. The switch is not labeled for staff identification.

f. On/off switch within three feet of exit access door is greater than forty-eight inches above finish floor level - located in third floor CCU unit.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0032.

4. The means of egress is incomplete due to the following:

a. Positive latching hardware is mounted greater than forty-eight inches above finished floor - door to Hyperbaric unit located on fourth floor.

b. Positive latching hardware to storage room OB207 is mounted greater than forty-eight inches above finished floor.

c. Positive latching hardware for exit access door from recovery suite requires greater than a single hand motion to exit area - locate on first floor.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0038.

5. The special locking arrangements did not release during activation of the facility fire alarm by the smoke detection system. (Note: The doors did release with inadequate switching arrangements as provided on date of survey).

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0051.

6. The facility is not equipped with a complete automatic sprinkler system due to the following:

a. Electrical equipment rooms do not meet all exceptions required by NFPA 13 for sprinkler coverage. The rooms are not equipped with two hour fire resistive enclosures.

b. The operating room suite is not covered by sprinklers.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0056.

7. The partially installed sprinkler system is noncompliant due to the following:

a. Based upon sprinkler inspection report dated 12/8/2010, the dry-pipe sprinkler system inspectors test appeared to be clogged when fully opened; contractor record states that no water or air flowed from test orifice. There was no documentation available to verify corrective action for dry-pipe sprinkler system.

b. Staff could not verify location of inspectors test valve for system serving the MRI area.

c. The alarm line valves are not electrically supervised for the dry-pipe sprinkler systems.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0062.

8. The means of egress is obstructed due to the following:

a. inward and outward swinging patient room doors do not swing one hundred and eighty degrees to the corridor wall during outward swing path - in the ninety degree position, doors obstruct half of required corridor width. Maximum door protrusion into corridor width is seven inches in the fully open position.

b. tables, and furniture in corridor area beyond delivery suite doors - located near OB218.

c. Electronic bug light protrudes greater than three and a half inches into corridor width within six feet and eight inch headroom clearance area - located near physical therapy on first floor.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0072.

9. Audible and visual alarms did not function on panel in the first floor rehabilitation area with activation of panel test switch.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag 0140.

Based on open medical record review and staff interviews the hospital failed to ensure physician orders were obtained for ventilator parameters when the patient was placed on the ventilator for 1 of 3 ventilator record reviews (#24).

Findings include:

Open record review of patient #24 revealed a 79 year old male admitted to the hospital on 10/28/2011 at 1105 with End Stage Renal Failure, Cardiac Disease and Respiratory Failure. Review of the medical record revealed the patient had been placed on a ventilator after being intubated in the Emergency Department.

Review of the "Mechanical Ventilator Log" revealed the ventilator had been set at Vt (tidal volume) 500, FIO2 (Oxygen) at 100% and respiratory rate of 12 on 10/28/2011 at 0820. Based on results of ABG's (Arterial Blood Gases) the FIO2 had been decreased to 40%. These parameters had stayed the same until the patient had been extubated on 10/31/201 at 1040.

Further record review of the physician orders revealed no written orders for the ventilator settings. Physician orders on 10/30/2011 revealed orders for ventilator setting, which were the same settings as indicated on the "Mechanical Ventilator Log." These orders did not indicated a late entry for 10/28/2011.

Interview with the department manager for Respiratory Therapy on 10/31/2011 at 1330 revealed the department had no special protocols/guidelines/policies for ventilator settings based on patient weight when a physician orders a patient to be placed on the ventilator. Interview revealed the physician must order the ventilator parameters for the Respiratory Therapist to follow.

Interview with the Respiratory Therapy Department Director on 11/1/2011 at 0930 revealed, after talking with the Therapist who set the ventilator up on 10/28/2011, she set the parameters based on a verbal order from the Physician. This interview revealed no orders had been written for the Ventilator parameters. On 10/31/2011 at 1610 the physician wrote a late entry order for the initial ventilator parameters.