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Based on restraint policy review, closed record review and staff interview, the emergency department nursing staff failed to ensure the least restrictive restraint intervention was used for 1 of 9 sampled restrained patients (#14).

The findings include:

Review of the hospital's "Patient Restraint" policy revised 07/22/2010 revealed "...II. Application and Use: A. Each episode of clinical restraint protects the patient's rights and dignity including: ...5. Using the least restrictive device possible...." Further review of the policy revealed no guidelines related to the use of handcuffs as a means of restraint.

Closed record review on 12/01/2010 for Patient #14 revealed a 38 year-old male that presented to the hospital's emergency department (ED) on 07/29/2010 at 1351 with altered mental status. Review of the triage notes at 1352 revealed the patient was "roaming around the ED initially looking for brother, patient acting increasingly hostile, possibly hallucinating, patient speaking in Spanish, hung up on interpreter line, cooperative after Sheriffs department arrival. Patient states pain in left chest after talking with police." Nursing notes dated 07/29/2010 at 1603 recorded the patient refused Haldol (medication for behavior) after "multiple attempts." Nursing notes dated 07/29/2010 at 1555 documented "Haldol 10mg (milligrams) IM (intramuscular) was administered. The notes recorded "given to patient after lengthy discussion with law enforcement and behavior health during which patient escalated and required 4 sheriffs, 3 nurses and the physician to restrain patient. Patient was restrained physically prone on the floor during administration." Review of nursing notes revealed at 1600 the "patient escalated and required physical restraint by (sheriff department). Patient medicated IM (intramuscular) by (registered nurse) while restrained by (sheriff department) in handcuffs. Patient then helped to stand and 4 point soft restraints applied." Review of the "Medical Surgical Restraint Initiation" nursing documentation revealed bilateral wrist and ankle restraints were applied at 1600. Nursing notes at 1600 recorded the restraints were indicated for "cognitive impairment that interferes with medical care, medical devices, tubes and dressings removed. Wandering that interferes with medical care. Unable to follow safety instructions. Less restrictive methods have been determined ineffective."

Interview on 12/02/2010 at 1230 with the physician that wrote the restraint order revealed the patient wandered into the ED with bizarre behavior, appeared acutely psychotic and spoke very little English. Interview with the physician revealed the patient was wandering through the ED and wanted to leave.
The ED physician stated the patient needed antipsychotic medication and resisted administration of the medication. Interview revealed the patient became violent and the police were in the ED and applied handcuffs to restrain the patient. Interview revealed the medication was administered, handcuffs were removed and four point restraints were applied to manage the patient's aggressive behaviors. Interview revealed the hospital had an emergency code for assistance when patients behaviors are escalating out of control called "Dr. Strong" that would provide additional trained staff immediately to the area to respond to the behaviors. Interview revealed the behavior emergency response "Dr. Strong" was not initiated during this incident. The physician stated "If the police were not there, we would have handled it as best we could.... No, we do not have handcuffs. They are not appropriate."

Interview on 12/02/2010 at 1145 with an administrative nursing staff member revealed the patient was restrained for behaviors that presented a risk for safety because he was wandering throughout the ED, wanting to leave and refusing medication. Interview confirmed a "Dr. Strong" was not called and ED staff allowed the sheriff department to restrain the patient. Interview confirmed the sheriff department staff were not hospital employees and were not trained by the hospital with restraint application. Interview confirmed the patient was not placed under arrest. The interview revealed there was no evidence of attempts to use less restrictive measures prior to the use of handcuffs by the sheriff department.

Based on hospital policy and procedure review, medical record review, and staff interviews the hospital's staff failed to document a physician's order for a restraint per hospital policy for 1 of 9 sampled patients with restraints (#10).

The findings include:

Review of hospital policy, "RESTRAINT, PATIENT (REVISED 7/22/2010)," revealed "...POLICY...Restraint Order shall include reason, type of restraint, alternatives attempted prior to restraint, and be time limited...ACUTE MEDICAL-SURGICAL RESTRAINT, A. Indications:...Standing, protocol, and PRN (as needed) orders for restraint are prohibited...B. Initiation of Restraint: 1. A physician's order is required immediately for each episode of restraint...D. Continuation of Restraint: The patient shall be monitored every two (2) hours to determine if restraint shall be continued. A new order shall be obtained at least every 24 hours or for every new episode of restraint after assessment by the physician..."

Medical record review for Patient #10 revealed an 84 year old female admitted to the Gero-Psych Unit on 08/02/2010 with a diagnosis of "Dementia (deteriorating cognitive function) with behavioral disturbances." Record review revealed a physician's order dated 08/03/2010 at 1043 to initiate use of a "roll belt" restraint "for patient safety to prevent unintentional injury." Record review of nursing documentation dated 08/04/2010 at 0500, 1100, 1300, 1500, 1700, 1900, 2100, 2352, and 08/05/2010 at 0113, 0306, 0507, 1100 revealed "Monitoring Type of Restraint - Medical restraint... Order obtained to continue restraint - No." Review of nursing documentation dated 08/04/2010 at 1517 revealed, "...Pt (patient) has been up in gerichair with rollbelt for safety..." Review of nursing documentation dated 08/04/2010 at 2329 revealed, "...Rollbelt, bed alarm and q (every) 15 min. (minutes) checks for safety..." Record review revealed physician's order dated 08/05/2010 at 0922 to "initiate and manage" restraint of Patient #10. Record review revealed Patient #10 was in restraints from 08/04/2010 at 1044 to 08/05/2010 at 0921 (22 hours and 37 minutes) without a written physician's order.

Interview on 12/02/2010 at 1350 with a nurse educator confirmed there was no available documented evidence of a written physician's order for the restraint of Patient #10 from 08/04/2010 at 1044 to 08/05/2010 at 0921.

Based on review of restraint policy and procedure, medical record review and staff interview, the hospital staff failed to ensure a time limited restraint order was obtained for 2 of 9 restraint records reviewed (#14 and #13).

The findings include:

Review of the hospital's "Patient Restraint" policy revised 07/02/2010 revealed .... Behavioral Management (Time Limited) A. Indication: Restraint for behavioral management shall be used only in an emergency or crisis situation for violent and aggressive behavior. It is used on any clinical unit for emergencies only.... Each order for behavioral restraint is limited to: 1. four (4) hours for age 18 and above."

1. Closed record review on 12/01/2010 of Patient #14 revealed a 38 year-old male that presented to the hospital's emergency department (ED) on 07/29/2010 at 1351 with altered mental status. Review of the triage notes at 1352 revealed the patient was "roaming around the ED initially looking for brother, patient acting increasingly hostile, possibly hallucinating, patient speaking in Spanish, hung up on interpreter line, cooperative after sheriffs department arrival. Patient states pain in left chest after talking with police." Record review revealed a physician's order at 1602 for "soft, routine restraints, for patient safety to prevent unintentional injury." Review of the restraint order revealed no evidence of a time limited order for the use of the restraints. Review of nursing notes revealed at 1600 the "patient escalated and required physical restraint by (sheriff department). Patient medicated IM (intramuscular) by (registered nurse) while restrained by (sheriff department) in handcuffs. Patient then helped to stand and 4 point soft restraints applied." Further review of nursing notes revealed bilateral wrist and ankle restraints were applied at 1600.

Interview on 12/02/2010 at 1230 with the physician that wrote the restraint order revealed the patient wandered into the ED with bizarre behavior, appeared acutely psychotic and spoke very little English. The ED physician stated the patient needed antipsychotic medication and resisted administration of the medication. Interview revealed the patient became violent and the police were in the ED and applied handcuffs to restrain the patient. Interview revealed the medication was administered, handcuffs were removed and four point restraints were applied to manage the patient's aggressive behaviors. Interview with the physician confirmed the restraint order was not time limited to four hours.

Interview on 12/02/2010 at 1145 with an administrative nursing staff member revealed the patient was restrained for behaviors that presented a risk for safety. The interview revealed there was no evidence of a time limited order for the use of the restraints. The staff member confirmed the patient was a 38 year-old and should have had a time limited order of four hours for the restraint use. The interview confirmed the order was not consistent with hospital policy.

2. Closed record review on 12/01/2010 of Patient #13 revealed a 48 year-old female that presented to the hospital's emergency department (ED) on 08/05/2010 at 2056 with altered mental status and alcohol intoxication. Record review revealed a physician's order dated 08/06/2010 at 0145 for "restraints." Review of the restraint order revealed no evidence of a time limited order for the use of the restraints. Review of nursing notes revealed bilateral wrist restraints were applied on 08/05/2010 at 2230 (3 hours and 15 minutes before the order was obtained). Review of restraint monitoring records revealed the patient required restraints due to agitation. Further review of nursing notes revealed Haldol and Ativan (medications for behavior) were ordered to be given stat (immediately) for the patient's aggressive behaviors. Record review revealed the patient was medicated with Haldol 2.5mg (milligrams) intravenously (IV) stat on 08/05/2010 at 2236, Haldol 5mg IV now at 2242, Ativan 2mg IV now on 08/06/2010 at 0144, Haldol 5mg IV now at 0403, Ativan 1mg orally stat at 0747 and 1250. Review of nursing notes dated 08/05/2010 at 2230 recorded the patient was pulling at IV line, attempting to kick the nurse and get out of bed. Notes on 08/06/2010 at 0209 recorded the patient had increased agitation, yelling and unable to sit in bed safely without wrist restraints.

Interview on 12/02/2010 at 1145 with an administrative nursing staff member revealed the patient was restrained for aggressive behaviors that presented a risk for safety and to minimize harm to staff. The interview revealed there was no evidence of a time limited order for the use of the restraints. The staff member confirmed the patient was a 48 year-old and should have had a time limited order of four hours for the restraint use. The interview confirmed the order was not consistent with hospital policy.

Based on policy review, medical record review, observation and staff interview the hospital's nursing staff failed to monitor restrained patients per policy for 5 of 9 sampled restrained patients (#6, #2, #13, #14, #4).

The findings include:

Review of the hospital's "Patient Restraint" policy revised 07/02/2010 revealed "... Acute Medical Surgical Restraint... E. Monitor/Interventions: The patient shall be monitored and restraints removed at least every two (2) hours and assessed to provide for the following. Assess 1. Circulatory/skin integrity 2. Respiratory rate 3. That the restraint is intact and positioned correctly 4. Cognitive evaluation and level of distress if any 5. Level of pain 6. Need for continued restraints Provide: 1. Fluids, nutrition 2. Toileting 3. Range of motion.... Behavioral Management (Time Limited)... E. Monitor/Interventions: The patient shall be monitored 1:1 while in behavioral restraints by a staff member with current BLS (Basic Life Support) certification. Monitoring and documentation is to be done at least every 15 minutes during the restraint episode and continue for 30 minutes after behavioral restraint is discontinued: 1. Circulation/skin integrity 2. Respiratory rate 3. That the restraint is intact and positioned correctly Interventions shall be offered to provide the needs. Interventions that shall be documented at least every two hours: 1. Fluids, nutrition 2. Toileting 3. Range of motion 4. Cognitive evaluation and level of distress if any 5. Level of pain..."

1. Open record review on 12/01/2010 for Patient #6 revealed a 93 year old female admitted to the Gerontology-Psychiatric (Gero-Psych) unit on 11/15/2010 from a skilled nursing/assisted living facility for treatment of Dementia and Delirium. Record review revealed the patient was restrained on multiple days from 11/19/2010 until 12/01/2010 (date of survey). Record review of an electronic computerized physician order entry (C.P.O.E.) for Restraints electronically signed by a physician on 11/20/2010 at 1221 revealed an order to "Initiate and manage restraint, medical." Further review of the order revealed "Roll belt, routine, for patient safety to prevent unintentional injury." Review of nursing documentation revealed the patient was restrained as ordered. Review of nursing documentation revealed a restraint monitoring assessment was documented by a nurse at 1744 on 11/20/2010 and the next restraint monitoring assessment was documented at 0700 on 11/21/2010 (13 hours 14 minutes later). Review of nursing documentation failed to reveal any available documented evidence restraint monitoring assessments were performed every 2 hours from 1744 on 11/20/2010 to 0700 on 11/21/2010 per policy. Further record review revealed a C.P.O.E. for Restraints electronically signed by a physician on 11/24/2010 at 0907 revealed an order to "Initiate and manage restraint, medical." Further review of the order revealed "Roll belt, routine, for patient safety to prevent unintentional injury. Review of nursing documentation revealed the patient was restrained as ordered. Review of nursing documentation revealed a restraint monitoring assessment was documented by a nurse at 1300 on 11/24/2010 and the next restraint monitoring assessment was documented at 1610 on 11/24/2010 (3 hours 8 minutes later). Review of nursing documentation failed to reveal any available documented evidence restraint monitoring assessments were performed every 2 hours from 1300 on 11/24/2010 to 1610 on 11/24/2010 per policy. Continued record review of an electronic computerized physician order entry (C.P.O.E.) for Restraints electronically signed by a physician on 11/29/2010 at 0900 revealed an order to "Initiate and manage restraint, medical." Further review of the order revealed "Roll belt, routine, for patient safety to prevent unintentional injury. Review of nursing documentation revealed the patient was restrained as ordered. Review of nursing documentation revealed a restraint monitoring assessment was documented by a nurse at 0100 on 11/30/2010 and the next restraint monitoring assessment was documented at 0700 on 11/30/2010 (5 hours 58 minutes later). Review of nursing documentation failed to reveal any available documented evidence restraint monitoring assessments were performed every 2 hours from 0100 on 11/30/2010 to 0700 on 11/30/2010 per policy.

Interview on 12/02/2010 at 1350 with a nurse educator that conducted restraint training revealed the patient was placed in a roll belt restraint to prevent injury related with falls. Interview revealed all patients placed in restraints for medical reasons should have monitoring and assessment documented every two hours to ensure safety during the use of the restraint. The staff member reviewed the restraint record and confirmed the nursing staff failed to monitor the patient every two hours as required by the hospital restraint policy.



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2. Open record review on 12/01/2010 of Patient #2 revealed a 91 year-old female admitted 11/19/2010 to the Gero-Psych unit for dementia with behavioral disturbances. Record review revealed a roll belt restraint was applied on 11/20/2010 at 1300 for safety (acute medical surgical restraint). Review of the nursing restraint record revealed the patient was assessed on 11/20/2010 at 1500, 1746 (2 hours and 46 minutes since prior assessment), 1900, 2118 (2 hours and 18 minutes since prior assessment), 2337 (2 hours and 19 minutes since prior assessment), 11/21/2010 at 0103, 0341 (2 hours and 38 minutes since prior assessment), then every two hours through 11/22/2010 at 1500. The next assessment was recorded on 11/22/2010 at 1900 (4 hours since prior assessment), 2131 (2 hours and 31 minutes since prior assessment), then every two hours through 11/23/2010 at 0114, 0358 (2 hours and 44 minutes since prior assessment), then every two hours through 11/23/2010 at 1300. The next assessment was recorded at 1600 (3 hours since prior assessment), then every two hours through 2101, 2352 (2 hours and 51 minutes since prior assessment), 11/24/2010 at 0113, 0322 (2 hours and 9 minutes since prior assessment), then every two hours through 1900. The next assessment was recorded on 11/24/2010 at 2139 (2 hours and 39 minutes since prior assessment), then every two hours through 11/25/2010 at 0311, 0526 (2 hours and 15 minutes since prior assessment), then every two hours through 11/25/2010 at 2300. The next assessment was recorded on 11/25/2010 at 0118 (2 hours and 18 minutes since prior assessment), then every two hours through 11/26/2010 at 2100, 2318 (2 hours and 18 minutes since prior assessment), 11/27/2010 at 0140 (2 hours and 12 minutes since prior assessment), 0311, 0551 (2 hours and 40 minutes since prior assessment), 0800 (2 hours and 9 minutes since prior assessment), 0900, 1110 (2 hours and 10 minutes since prior assessment), then every two hours through 11/27/2010 at 1918. The next assessment was recorded on 11/27/2010 at 2132 (2 hours and 13 minutes since prior assessment), then every two hours through 11/28/2010 at 1900, 2125 (2 hours and 25 minutes since prior assessment), 2306, 11/29/2010 at 0105, 0319 (2 hours and 14 minutes since prior assessment), then every two hours through 0900. Review of the restraint record revealed the patient was changed to wrist restraints for safety on 11/29/2010 at 1100 with every two hour monitoring through 11/30/2010 at 0900 when the patient was changed back to a roll belt restraint. The record revealed every two hour assessments through 12/01/2010 at 1300 when the patient was changed back to wrist restraints due to agitation.

Interview on 12/02/2010 at 1350 with a nurse educator that conducted restraint training revealed the patient was placed in a roll belt restraint to prevent injury related to falls. Interview revealed all patients placed in restraints for medical reasons should have monitoring and assessment documented every two hours to ensure safety during the use of the restraint. The staff member reviewed the restraint record and confirmed the nursing staff failed to monitor the patient every two hours as required by the hospital restraint policy.

3. Closed record review on 12/01/2010 of Patient #13 revealed a 48 year-old female that presented to the hospital's emergency department (ED) on 08/05/2010 at 2056 with altered mental status and alcohol intoxication. Record review revealed a physician's order dated 08/06/2010 at 0145 for "restraints." Review of nursing notes revealed bilateral wrist restraints were applied on 08/05/2010 at 2230 (3 hours and 15 minutes before the order was obtained). Review of nursing notes dated 08/05/2010 at 2230 recorded the patient was pulling at IV line, attempting to kick the nurse and get out of bed. Notes on 08/06/2010 at 0209 recorded the patient had increased agitation, yelling and unable to sit in bed safely without wrist restraints. Review of restraint monitoring records revealed the patient required restraints due to agitation. Further review of nursing notes revealed Haldol and Ativan (medications for behavior) were ordered to be given stat (immediately) for the patient's aggressive behaviors. Record review revealed the patient was medicated with Haldol 2.5mg (milligrams) intravenously (IV) stat on 08/05/2010 at 2236, Haldol 5mg IV now at 2242, Ativan 2mg IV now on 08/06/2010 at 0144, Haldol 5mg IV now at 0403, Ativan 1mg orally stat at 0747 and 1250. Further review of the record revealed the patient remained in bilateral wrist restraints through 08/06/2010 at 0320. Review of the restraint assessment documentation revealed the patient was assessed every 30 minutes while restrained from 08/05/2010 at 2330 through 08/06/2010 at 0130, then 0150 (20 minutes since prior assessment), then 0220 (30 minutes since prior assessment), 0300 (40 minutes since prior assessment), 0320 (20 minutes since prior assessment). The restraints were released on 08/06/2010 at 0320. Review of the record revealed no evidence of assessment of the patient's condition every 15 minutes during the restraint use.

Interview on 12/02/2010 at 1145 with an administrative nursing staff member revealed the patient was restrained for aggressive behaviors that presented a risk for safety and to minimize harm to staff. Interview revealed all patients placed in restraints for behavioral reasons should have ongoing monitoring and document monitoring and assessment every 15 minutes to ensure safety during the use of the restraint. The staff member reviewed the restraint record and confirmed the nursing staff failed to document assessments and monitoring of the patient every 15 minutes as required by the hospital restraint policy.

4. Closed record review on 12/01/2010 of Patient #14 revealed a 38 year-old male that presented to the hospital's emergency department (ED) on 07/29/2010 at 1351 with altered mental status. Review of the triage notes at 1352 revealed the patient was "roaming around the ED initially looking for brother, patient acting increasingly hostile, possibly hallucinating, patient speaking in Spanish, hung up on interpreter line, cooperative after sheriffs department arrival. Patient states pain in left chest after talking with police." Nursing notes dated 07/29/2010 at 1603 recorded the patient refused Haldol (medication for behavior) after "multiple attempts." Nursing notes dated 07/29/2010 at 1555 documented "Haldol (medication for behavior) 10mg (milligrams) IM (intramuscular) was administered. The notes recorded "given to patient after lengthy discussion with law enforcement and behavior health during which patient escalated and required 4 sheriffs, 3 nurses and the physician to restrain patient. Patient was restrained physically prone on the floor during administration." Review of nursing notes revealed at 1600 the "patient escalated and required physical restraint by (sheriff department). Patient medicated IM (intramuscular) by (registered nurse) while restrained by (sheriff department) in handcuffs. Patient then helped to stand and 4 point soft restraints applied." Review of the "Medical Surgical Restraint Initiation" nursing documentation revealed bilateral wrist and ankle restraints were applied at 1600. Nursing notes at 1600 recorded the restraints were indicated for "cognitive impairment that interferes with medical care, medical devices, tubes and dressings removed. Wandering that interferes with medical care. Unable to follow safety instructions. Less restrictive methods have been determined ineffective." Review of the restraint assessment documentation revealed the patient was assessed at 1630 and restraints were removed at 1700. Review of the record revealed no evidence of assessment of the patient's condition every 15 minutes during the restraint use.

Interview on 12/02/2010 at 1230 with the physician that wrote the restraint order revealed the patient wandered into the ED with bizarre behavior, appeared acutely psychotic and spoke very little English. Interview with the physician revealed the patient was wandering through the ED and wanted to leave. The ED physician stated the patient needed antipsychotic medication and resisted administration of the medication. Interview revealed the patient became violent and the police were in the ED and applied handcuffs to restrain the patient. Interview revealed the medication was administered, handcuffs were removed and four point restraints were applied to manage the patient's aggressive behaviors.

Interview on 12/02/2010 at 1145 with an administrative nursing staff member revealed the patient was restrained for behaviors that presented a risk for safety because he was wandering throughout the ED, wanting to leave and refusing medication. Interview revealed all patients placed in restraints for behavioral reasons should have ongoing monitoring and document monitoring and assessment every 15 minutes to ensure safety during the use of the restraint. The staff member reviewed the restraint record and confirmed the nursing staff failed to document assessments and monitoring of the patient every 15 minutes as required by the hospital restraint policy.

5. Observation during tour of the Medical-Psych unit on 11/30/2010 at 0955 revealed Patient #4 sitting in a wheelchair in the day room with a roll belt restraint in place.

Open record review on 12/01/2010 of Patient #4 revealed a 76 year-old female admitted to the Medical-Psych unit on 11/15/2010 with vascular dementia with behavioral disturbances. Review of the record revealed the patient was placed in a roll belt restraint on 11/25/2010 at 0900 for safety (acute medical surgical restraint). Review of the restraint monitoring documentation revealed the patient was assessed every two hours through 11/30/2010 at 1700 with the next assessment documented at 2000 (3 hours since prior assessment).

Interview on 12/02/2010 at 1350 with a nurse educator that conducted restraint training revealed the patient was placed in a roll belt restraint to prevent injury related with falls. Interview revealed all patients placed in restraints for medical reasons should have monitoring and assessment documented every two hours to ensure safety during the use of the restraint. The staff member reviewed the restraint record and confirmed the nursing staff failed to monitor the patient every two hours as required by the hospital restraint policy.

Based on hospital policy and procedure reviews, observations during tour, and staff interviews, the hospital's nursing staff failed to maintain the facility in a manner to ensure an acceptable level of safety and quality by failure to dispose of medical waste in a timely manner for 2 of 3 patient care rooms observed with intravenous tubing/fluids/pumps being stored (#4, #2).

The findings include:

Review of current hospital policy "Nursing Guidelines" revised 12/12/08 revealed, "...Waste Disposal * Non-regulated waste: Solid waste from all patient rooms will be placed in a regular non-biohazardous trash receptacle and discarded with the general hospital waste. ..."

Review of current hospital policy, "IV PERIPHERAL ACCESS-ADULT (revised 09/09/2010)," revealed, "...POLICY:...6. Primary tubing changed every 96 hours, 7. Secondary tubing changed every 24 hours,...9. Tubing labels shall have the date and time the tubing is hung..."

1. Observation during tour on the Medical-Psych (Med-Psych) unit on 11/30/2010 at 1024 revealed patient room 205 (#4). Observation inside room 205 revealed an Intravenous (IV) pole with an IV pump attached to the pole, being stored in the room. Observation revealed hanging on the IV pole was an empty IV "piggy back" medication (Levofloxin) bag and secondary IV tubing set labeled (Red label) with a "change by" date and hour of 11/24/2010 at 1800 (5 days, 16 hours, and 24 minutes prior). Further observation revealed hanging on the IV pole a full 1000 Milliliter bag of 0.9% Normal Saline IV solution bag and a primary IV tubing set labeled (Red Label) with a "change by" date and hour of 11/27/2010 at 1700 (2 days, 17 hours, and 24 minutes prior). Observation revealed the IV tubing was not connected to a patient. Interview during tour, at the time of the observation with the staff nurse assigned to room #205, revealed the IV tubing and medication/fluid bags had been hanging in the room since 11/24/2010. Interview revealed the IV tubing and medication/fluid bags should have been discarded into the trash after use before today. Interview revealed IV tubing is to be changed and discarded by the expiration date written on the red label. Interview revealed secondary medication sets are to be changed every 24 hours and primary IV fluid sets are to be changed every 96 hours. Interview revealed the nurse did not know why the staff did not discard the used IV tubing and medication/fluid bags before now. Interview revealed it was an oversight.


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2. Observations on 11/30/2010 at 0930, during a tour of the Med-Psych unit, revealed Patient #3 sitting in a geriatric chair in her assigned room #204. Observation in the patient's room revealed a 1 Liter IV solution bag of 0.9% Normal Saline containing 10-20 ml (milliliter) of clear fluid with tubing attached and inserted into an infusion pump hanging from an IV pole in a corner of the room. Observation revealed the IV tubing was not connected to the patient. Further observation revealed the bag of 0.9% Normal Saline and tubing were not labeled (Red Label) indicating the date and hour to "change by." Interview during tour, at the time of the observation with the staff nurse assigned to room #204 confirmed the bag of 0.9% Normal Saline and tubing were not labeled with a "change by" date and hour. Interview revealed the date and hour the fluid and tubing needed to be changed and discarded was unknown. Interview revealed IV tubing is to be changed and discarded by the expiration date written on the red label. Interview revealed primary IV fluid sets are to be changed every 96 hours. Interview revealed the nurse did not know why the staff did not discard the used IV tubing before now. Interview revealed it was an oversight.

Based on policy review, open medical record reviews, observations during tours, and staff interviews, the hospital's infection control officer failed to effectively monitor the hospital's staff to ensure compliance with all infection control policies and procedures in order to prevent and control the spread of infections and/or communicable diseases for 3 of 3 patients sampled requiring isolation precautions (#2, #6, #5).

The findings include:

Review of current hospital policy "Isolation Precaution Guidelines" reviewed 06/19/2009, revealed "...Contact Precautions ...Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission thorough environmental contamination (e.g., ...C. Difficile,... ). ...Syndromic and Empiric Applications of Transmission-Based Precautions Diagnosis of many infections requires laboratory confirmation. Since laboratory tests, especially those that depend on culture techniques, often require two or more days for completion, Transmission-Based Precautions must be implemented while test results are pending based on the clinical presentation and likely pathogens. (See Clinical Syndrome or Condition table). ..."

Review of the Clinical Syndrome or Condition Table (Page 5 of 17) of the Isolation Precaution Guidelines policy revealed "Clinical Syndromes Or Conditions Warranting Empiric Transmission-Based Precautions In Addition to Standard Precautions Pending Confirmation of Diagnosis" revealed "Clinical Syndrome or Conditions Diarrhea Acute diarrhea with a likely infectious cause in an incontinent or diapered patient Potential Pathogens Enteric pathogens [C. Difficile] Empiric Precautions Contact Precautions (pediatric and adult). ..."

Review of current hospital policy "Multi Drug Resistant organisms (MDRO)" revised 08/13/10, revealed "...Infection Preventionist: Upon notification of a positive inpatient MDRO culture, the IP will verify that the patient is in the appropriate isolation... Nursing Unit: ...4. Patients colonized or infected with MDRO will require isolation precautions. For patients on contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus), gloves and gowns will be worn when entering the patient's room. ...6. Remove all PPE (personal protective equipment) at the doorway when exiting the patient's room. Remove the gown first and then the gloves. ...8. Perform hand hygiene (HH) immediately upon exiting an isolation room. ...For patients with Clostridium difficile HH must be done with soap and water."

Review of current hospital policy "Nursing Guidelines" revised 12/12/08, revealed "...Hand Hygiene ...Hands hygiene will be performed before and after contact with the patient or their environment, between patients and after handling soiled articles....Isolation....Nursing will initiate appropriate isolation precautions for undiagnosed clinical conditions such as diarrhea, respiratory illnesses....when an infections cause is suspected. ..."

Review of current hospital policy "Infection Prevention and Control-Linen Change" reviewed 10/10/08, revealed "...5. Staff will use gloves when handling any used linen and hold the soiled linen away from their uniform in order not to contaminate clothing. ..."

Review of current hospital policy "Infection Prevention and Control-Isolation Precautions" revised 10/10/08, revealed "Activities 1. Patients colonized, infected or infested requiring isolation may use common living, recreational, and dining areas, if they meet the following criteria: ...b. patient must wear clean clothes, changed daily and when soiled, or a clean cover gown. c. hands must be washed whenever contaminated and before they leave their rooms for common areas. ..."

Review of current hospital policy "Responsibility For Isolation Precautions" revised 12/12/08, revealed "...Staff is responsible for following all transmission-based isolation precautions in addition to using Standard Precautions with all patients. ..."

1. Open record review on 12/01/2010 of Patient #2 revealed a 91 year-old female admitted 11/19/2010 to the Medical-Psychiatric (Med-Psych) unit for dementia with behavioral disturbances. Record review revealed the patient was having diarrhea and a physician's order was written on 11/27/2010 at 1529 to obtain a stool culture for C(lostridium) difficile Toxin A and B (communicable disease). Review of laboratory reports revealed the stool culture was positive for C difficile on 11/28/2010 at 1306 and results were called to the hospital's infection control nurse at that time. Review revealed a physician's order was written on 11/28/2010 at 1306 for isolation precautions. Review of the nursing notes revealed the patient was placed on contact isolation precautions on 11/28/2010 at 1727 (25 hours and 58 minutes after the C difficile culture order was written).

Interview on 12/02/2010 at 0910 with the hospital's infection control officer revealed the patient should be placed on contact precautions as soon as C difficile is suspected. The staff member stated the patient should be placed on contact precautions as soon as signs or symptoms of C difficile present or when an order is written to obtain a culture for C difficile to minimize the spread of communicable disease.

Interview with administrative nursing staff on 12/02/2010 at 1200 confirmed an order was written on 11/27/2010 at 1529 for stool for C difficile and contact precautions were initiated on 11/28/2010 at 1727. Interview confirmed there was a delay in placing the patient on contact precautions. Interview confirmed the nursing staff failed to follow the hospital's infection control policy.



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2. Open record review on 12/01/2010 for Patient #6 revealed a 93 year old female admitted to the Gerontology-Psychiatric (Gero-Psych) unit on 11/15/2010 from a skilled nursing/assisted living facility for treatment of Dementia and Delirium. Record review revealed a past medical history of MRSA (Methicillin Resistant Staphylococcal Aureus). Further record review revealed a nare swab was collected on 11/15/2010 at 2215 for a Culture for MRSA. Record review revealed the final report for the MRSA culture was verified on 11/17/2010 at 0855 and confirmed the patient was "Positive for Methicillin Resistant Staph Aureus Multidrug Resistant Organism." Record review revealed the results were reported to the Gero-Psych nursing staff and Infection Control on 11/17/2010 at 0855. Review of nursing documentation revealed the patient was placed on contact isolation on 11/17/2010 at 2138. Further record review revealed the patient was continued on contact isolation on 11/30/2010 (date of surveyor observations).

Observations during tour of the Gero-Psych Unit on 11/30/2010 at 1045 revealed patient room 236. Further observation revealed signage posted on the outside door frame of room 236. Review of the signage revealed "STOP Contact Precautions." Further review of the signage revealed check marks in boxes next to "Perform hand hygiene before entering and when leaving room" and "Wear gloves when entering room and when touching patient's intact skin, surfaces, or articles" and "Wear gown when entering room" and "Use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between patients." Continued observation revealed Patient #6 sitting in a bedside chair inside of room 236. Further observation revealed a nursing assistant (CNA #3) performing hair care on Patient #6. Observation revealed CNA #3 had donned gloves but did not have on a protective gown. Further observation revealed the clothing of CNA #3 came into contact multiple times during the observation with the chair where Patient #6 was sitting. Further observation revealed after completion of hair care, CNA #3 sat down in a chair next to Patient #6 (leaning forward in close proximity of Patient #6's face) assisted the patient with writing in a note book with a ink pen. Concurrent observation of a nursing assistant (CNA #2) also in room 236, revealed CNA #2 was changing the bed linens for Patient #6. Observation revealed CNA #2 did not have on gloves nor a protective gown. Observation revealed CNA #2 gathered and removed the contaminated linens from the bed in his arms/hands and carried the linens out into the common hallway and disposed of the linens in a linen hamper stored in the hallway down from room 236. Observation revealed the contaminated linens were in contact with the CNA's arms and uniform. Further observation revealed CNA #2 then proceeded back into room 236 and made the patient's bed. Further observation revealed upon completion of the linen change, CNA #2 proceeded into the patient's bathroom at the rear of the room and washed his hands then exited the room. Further observation revealed CNA #3 removed her gloves and proceeded to exit the room without washing hands. Observation revealed personal protection equipment (PPE) was not readily available for use by staff outside of the patient's room.

Interview with the Chief Nursing Officer during tour of the Gero-Psych Unit and at the time of the above observations confirmed the signage posted on the door frame outside of room 236, indicated Patient #6 was on contact isolation precautions (for MRSA). Interview revealed the staff should have been wearing gloves and gowns when in the room. Interview revealed the staff should be washing their hands before entering and after exiting the room. Further interview revealed "the staff obviously have not followed policy."

Continued observation on the Gero-Psych unit on 11/30/2010 at 1100 revealed a licensed practical nurse (LPN #1) preparing medication for administration to Patient #6. The nurse was mixing medication in ice cream and stated "She will probably refuse the meds. She usually spits and scratches." Observation revealed the nurse applied gloves in the medication room, exited the medication room, walked down the hall and entered Patient #6's room (Rm. 236). Observation revealed signage for contact precautions remained posted on the door frame outside of room 236. Observation revealed no PPE readily available outside of the doorway for staff use. Observation revealed LPN #1 with gloves on entered the patient's room without donning a protective gown before entering the room. The nurse was observed to carry a medicine cup with six different medications that had been mixed in ice cream, a bottle of artificial tears to administer drops into the patient's eyes and a cup of water into the room. The nurse checked the patient's arm band and then attempted to administer the oral medication. The patient was observed to refuse the medication while trying to stab at the nurse with a pen. The patient became agitated and tried to scratch the nurse during the attempt to administer the medication. The nurse was observed to leave the patient's room carrying all the items that she entered the room with. The nurse returned to the medication room and proceeded to place the medication cup and artificial tears on the counter (same location where other medications are prepared). The nurse began to document in the computer while still wearing the same gloves that she had on when she entered and exited the patient's room. The nurse then disposed of the ice cream with medication in the sink and removed the gloves to wash her hands. The nurse stated she was going to administer an injectable medication for the patient's behavior and prepared the medication. Observation at 1115 revealed the nurse requested assistance from two nursing assistants to administer the medication. The nurse was told to wear a gown prior to entering the patient's room by a certified nursing assistant (CNA #1). The nurse stated "We don't have any gowns." The staff were observed to don gowns and gloves before entering the Patient #6's room at 1115 (after being prompted).

Interview during the tour with the three staff members (LPN #1, CNA #1 and CNA #2) that entered the room at 1115 revealed a safety concern was identified with the contact precaution carts that were used throughout other areas of the hospital and the Gero-Psych unit did not use the supply carts. The staff were unable to identify how long it had been since the supply carts had been used but indicated it had been over a year. Interview revealed the staff receive yearly training related to infection control and contact precautions and they were aware of the need to wear gowns. The staff stated that they just carried gloves in their pockets and did not have time to go get gowns to put on. CNA #1 stated "You don't have time to go get a gown. You have to take care of the patient when you see they need you."

Interview on 11/30/2010 at 1130 with nursing administrative staff that were present during the tour revealed the staff should be wearing gloves and gowns when they enter the patient's room. Interview revealed the gowns and gloves should be removed prior to exiting the patient's room and handwashing should be done immediately after exiting the patient room. Interview revealed there was no hand sanitizer solution on the Gero-Psych unit due to the safety risk. Interview confirmed the staff failed to follow the infection control policy.

Interview on 11/30/2010 at 1500 with the hospital's infection control officer revealed she reviews electronic infection control documentation daily and physically performs infection control surveillance rounds as needed. Interview revealed she last performed surveillance rounds on the Gero and Med-Psych units "a couple of weeks ago." Interview revealed she had not identified any infection control issues during the recent surveillance rounds. Interview revealed she stops by the units and "makes an appearance" and speaks with staff about any problems or concerns with infection control. Interview revealed when a patient is placed on contact isolation, signage is posted out side of the door. Interview revealed the staff are to follow the hospital's policies on infection control and the instructions listed on the signage. Interview revealed when the surveyor observations during tour of the Gero and Med-Psych units on 11/30/2010 were described to the infection control officer she stated "that is a big problem."



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3. Open record review of Patient #5 revealed a 77 year old admitted on 11/19/2010 with a diagnosis of "Dementia" with "increased agitation, combative and inappropriate behaviors." Medical record review revealed a MRSA (Methicillin Resistant Staphylococcus Aureus) culture was obtained on 11/19/2010 at 1400 from the patient's nostrils. Medical record review revealed laboratory's "Final Result: Methicillin-Resistant Staphylococcus aureus Multidrug resistant Organism Result called to (staff initials) by (staff initials) at 11/21/2010 9:55:29 Results read back and confirmed. Results Called to Infection Control." Medical record review revealed patient #5 was placed on "Contact Precautions" on 11/21/2010 at 0956.

Observations during tour on 11/30/2010 at 1045 of the Gero-Psych unit revealed Patient # 5 exiting a group therapy session in a wheelchair. Observations revealed the patient moved down the hallway without assistance from group therapy back into his room and then exited his room and returned out into the hallway. Observations revealed "Contact Isolation" signage posted outside Patient #5's room door. Observations revealed Patient #5 touched his face and nose with his hands and then touched the hallway hand rails to help him move down the hall in his wheelchair. Observations revealed the patient opened the door to the group therapy room and re-entered the group session. Observations into the group therapy room revealed other patients and staff engaged in activities. Observations revealed the patient was not wearing protective garments or using waterless hand wash after touching his nose.

Interview on 11/30/2010 at 1100 with nursing staff (CNA#1) confirmed Patient #5 was on contact isolation for positive MRSA cultures. Interview revealed the patient should have an isolation gown over his clothing when he joins the group.

Interview on 12/01/2010 at 1000 with staff psychiatrist (Physician #1) revealed geriatric psychiatric patients are difficult to isolate when on "Contact Precautions." Interview revealed geriatric patients are sometimes confused and wander. Interview revealed, on the Geriatric Psychiatry Unit, "Infection Control has not been on the agenda. I don't disagree that Infection Control should be on the agenda."

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