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Based on interview and record review the facility failed to ensure restraints (device applied to limit mobility) and seclusion (involuntary confinement in a room or area) initially applied in the Emergency Department (ED) to two current (#37, #39) and two discharged (#38, #40) of four patients reviewed were applied with an order from a physician authorized to write restraint/seclusion orders. This deficient practice had the potential to permit patients to be restrained or be placed in seclusion without an evaluation by a physician who was responsible for the patient's care. The facility census was 359. The Behavioral health Unit (BHU) census was 48. The ED maintained 40,000 to 50,000 visits per year with approximately one to two restraint or seclusion episodes per ED shift.

Findings included:

1. Review of the facility's Medical Staff Rules and Regulations, dated 07/15/14 showed the directive for physicians to:
-Use physical restraint of a patient in response to psychiatric behavior which posed a threat of injury to the patient or others;
- The restraint or seclusion required a written order from the provider; and
- The order for physical restraint or seclusion should be written as soon as possible after the determination/notification of the need but within one hour of the application of the restraint or seclusion.

Record review of the facility's policy titled, "Violent Restraint and Seclusion Policy," dated 05/07/15, showed the directive for staff to obtain an order as soon as possible, not to exceed one hour.

2. Record review of the facility Restraint and Seclusion Log dated 07/31/15 at 12:38 PM showed current Patient #37 was placed in seclusion in the ED.

Record review of the patient's ED physician's progress note dated 07/31/15 at 1:34 PM showed the physician assessed the patient with uncooperative, belligerent, anxious, hostile behavior. The physician further assessed the patient with suicidal, homicidal psychotic thoughts.

Record review of the patient's ED physician's orders dated 07/31/15 one hour before and after 12:38 PM showed the physician failed to document an order for seclusion.

3. Record review of current Patient #39's ED physician's progress note dated 07/29/15 at 10:59 AM showed the physician assessed the patient was agitated with suicidal ideation and violence towards others.

Record review of the facility Restraint and Seclusion Log dated 07/29/15 at 12:45 PM showed the patient was placed in seclusion with four point restraints (immobilized both arms and both legs).

Record review of the patient's ED progress notes dated 07/29/15 at 2:15 PM showed a second physician assessed the patient was agitated and had to be placed in four point restraints (one and a half hours after the log notation) and without documentation of the patient being placed in seclusion.

Record review of the patient's physician's orders dated 07/29/15 one hour before and one hour after 12:45 PM showed the physician failed to document an order for seclusion or four point restraint.

4. Record review of discharged Patient #38's ED physician's progress note dated 07/31/15 at 2:35 AM showed the physician assessed the patient was anxious, hostile, belligerent with judgment impaired by intoxication and with suicidal, psychotic thoughts.

Record review of the patient's ED nurse's notes/care plan dated 07/31/15 at 2:40 AM showed the patient was placed in seclusion due to attempts or threats to harm himself.

Record review of the patient's ED physician's orders dated 07/31/15 showed the physician ordered a restraint at 3:55 AM (not for seclusion and one hour and 15 minutes after the patient was placed in seclusion).

Record review of the facility's Restraint and Seclusion Log dated 07/31/015 at 4:40 AM showed the patient was placed in seclusion (not restraint and documented two hours after the application) in the ED.

5. Record review of the facility's Restraint and Seclusion Log dated 07/22/15 at 4:30 AM showed discharged Patient #40 was placed in seclusion.

Record review of the patient's ED nurse's notes/care plan dated 07/22/15 at 4:30 AM showed the patient was placed in seclusion to prevent him from leaving the ED.

Record review of the patient's ED physician's progress notes dated 07/22/15 at 5:57 AM (one hour and 17 minutes after the patient was placed in seclusion) showed the physician assessed the patient had multiple suicide attempts, a neck wound and problems with drug abuse.

Record review of the patient's ED physician's orders dated 07/22/15 showed the physician failed to document an order for seclusion.

During an interview on 08/05/15 at 4:00 PM, Staff EE, Performance Improvement Specialist confirmed that there were no documented ED physician's orders for restraint or seclusion for current Patients #37 and #39 or for discharged Patients #38 and #40.

During an interview on 08/05/15 at 4:01 PM, Staff GG, Clinical Director of Nursing Services, stated the facility policy titled, "Violent Restraint and Seclusion Policy," dated 05/07/15, that directed staff to obtain an order as soon as possible, not to exceed one hour applied to all areas of the facility including the ED.

Based on observation, interview and record review the facility Infection Control staff failed to ensure the environment on the three behavioral health units (BHUs) on 3 South; 2 North and 2 South were maintained in a safe, sanitary condition including:
- Surfaces in two (room 3133; 3135) of six patient bathrooms on the 3 South adolescent unit;
- Surface of one of one examination table (near room 3134) in the 3 South adolescent unit was maintained in a sanitary, sanitary manner;
- Surface of one of one examination table on 2 North was maintained in a clean manner;
- Equipment and surfaces in four (room 2101; 2116; 2120; 2123) of nine patient bathrooms on the 2 South unit;
- Surface of one of one debris covered area rugs in a common area "quiet room" off the television room in the 3 South unit was kept clean;
- One of one drinking fountains was cleaned and maintained in the dining room on 2 South;
- Surfaces in two (room 2302; and the seclusion room bathroom) of nine patient bathrooms on the 2 North unit;
- One of one common area "quiet room" off the television room on 2 South that was soiled with an objectionable odor; and
- Cleanliness of environmental surfaces was objectionable to two alert and oriented patients (#26, #28) of four BHU patients interviewed.
These deficient practices had the potential to contribute to the spread of infection and communicable diseases on the BHU units. The facility census was 359. The BHU census was 48 (seven on 3 South adolescent unit; 20 adults on 2 South; and 21 adults on 2 North).

Findings included:

1. Observation on 08/04/15 from approximately 9:05 AM through 11:23 AM showed the following poorly maintained environmental conditions on the BHU units:
- A broken shower surround (room 3133) with an approximately 18 inch diagonal crack in the surface that exposed a sharp edged break where accumulated debris, soap scum and mold could accumulate;
- A bathroom (room 3135) with multiple black circular spots imbedded in the white caulking between the floor tile and the shower entrance;
- A shower stall (room 3135) with dried hairs covering the drain trap and on the floor along the back wall of the stall and three discolored corners with unknown accumulated debris;
- A commode (room 3135) with light brown discoloration on the floor tile, along the base of the commode.
- An examination room (near room 3134) table with old adhesive tape and tape residue on one corner of the upholstered surface and black, sticky unknown debris accumulated in the V shaped crevice between the two cushions on the table top;
- A soiled examination room table, littered with unknown debris in a locked examination room (across the hall from room 2302) on 2 North;
- A shower stall (near room 2101) with black areas of discoloration and brown discoloration on the tiles by the commode;
- A shower curtain (room 2116) with an approximate 5-6 inch circular blacked, discoloration of unknown debris on the curtain; a 6-7 inch stripe of similar appearing debris near it; and yellowish discoloration on the edge of the shower curtain nearest to the floor;
- A shower stall (room 2120) identified as a handicapped accessible shower with ten blackened discolored (six by six inch) tiles across the back wall of the stall; heavily discolored corners and floor tiles;
- A metal shower chair in a shower stall (room 2120) black discoloration on the joints and cross bars of the chair;
- A shower stall (room 2123) with multiple hairs in the drain trap and black and brown discoloration along the sides of the stall.
- A commode (room 2123) with an approximate one foot circular puddle of water in front of the commode;
- A "quiet room" off the main television room on 3 South, that was reported to be infrequently used with shredded white debris scattered on the dark colored area rug;
- A drinking fountain in the main dining room (just outside of room 2104) with dry white, fuzzy debris in the holes of the drain and multiple gaps between the wall covering and the metal drinking fountain cabinet where debris and splashes could become trapped;
- A sink (room 2302) in disrepair (without faucets and holes for the faucets covered with a rough piece of bare wood);
- A shower stall (room 2302) with brown discolored corners; and
- A bathroom near a seclusion room (across the hall from room 2302) with hair in the drain trap (reported as not used for patients in over a month).

2. During a concurrent observation and interview on 08/04/15 at 10:01 AM, Staff HH, Interim Director, Adolescent Unit and Staff GG, Clinical Director of Nursing Services, both viewed the black circular spots (room 3135) and confirmed the black spots imbedded in the white caulking of the shower was discolored and may have been mold.

3. During a concurrent observation and interview on 08/04/15 at 10:02 AM Staff HH, viewed the shower stall (room 3135) and confirmed presence of dry hairs on the drain trap; along the floor and the discolored floor tile along the commode.

4. During a concurrent observation and interview on 08/04/15 at 10:15 AM, Staff JJ, Nurse Manager of 2 South, viewed the shower stall (near room 2101) and confirmed the black areas in the shower stall and the discolorations on the floor tile by the commode.

5. During a concurrent observation and interview on 08/04/15 at 10:40 AM, Staff JJ, viewed the shower curtain (room 2115) and confirmed the debris and discoloration.

6. During a concurrent observation and interview on 08/04/15 at approximately 11:15 AM, Staff KK, Nurse Manager of 2 North confirmed the faucets for the sink in room 2302 were missing and not repaired; holes for the faucets were covered by a rough piece of bare wood and the bathroom had to be used by up to four patients; and the seclusion room bathroom across from room 2302 had not been used by patients for over a month.

7. Record review of the facility's manual titled, "Healthcare Construction Requirements for Design Consultants and Contractors," effective 05/23/11 showed directives for staff or contractors to report discovery of suspected mold or similar hazardous material to the Planning, Design and Construction (PD&C) team. The PD&C were directed to refer the report to the hospital's Infection Control Department and Engineering Services Department for a coordinated discussion of required steps to assess and remediate (correct) any suspected mold.

8. During an interview on 08/04/15 at 2:00 PM, Staff F, Global Manager of Environmental Services stated that Environmental Services (also called Housekeeping) did not have a specific policy for testing or confirmation of suspected mold or mildew. She stated that if reported by housekeepers, the issue would be referred to Engineering Services immediately for testing and analysis by a laboratory.

During an interview on 08/04/15 at 2:54 PM, Patient #26 stated the unit was not as clean as she would like it to be.

During an interview on 08/04/15 at 3:15 PM, Patient #28 stated that:
- The quiet room off the main television room on 2 South was not used a lot by other patients because one of the patients, with a lot of foot odor walked bare foot on the rug and the odor from his bare feet was transferred into the rug and staff had not cleaned the rug;
- She was afraid that bare foot patient had Athlete's foot and did not want to contract that by walking on the smelly carpet;
- The odor in the room showed staff had not cleaned the floor in the quiet room; and
- She would like to sit in the quiet room more but, she didn't like the odor in the room.

During an interview on 08/04/15 at approximately 9:05 AM, Staff HH, Interim Director of the 3 South adolescent unit stated environmental rounds were done monthly by the nurse manager and she was not aware of any reports of soiled environment or problems on the unit.

During an interview on 08/05/15 at 8:45 AM, Staff ZZ, Manager of Infection Prevention stated that:
- At least one of the five facility Infection Control Preventionists (ICPs) do periodically participate in environmental rounds with the Housekeeping department supervisory staff on the BHUs;
- She could not tell when the last BHU environmental rounds were done;
- There was no schedule for the environmental rounding in the BHUs;
- Discoloration in the bathrooms and shower stalls on BHU was an aesthetic problem and not an infection control problem;
- During ICP rounds, her staff looked for infection problems and hazards;
- They asked staff on the BHUs if they had identified any infection control hazards;
- She felt there was no systematic reporting method to alert her to soiled environmental surfaces in the BHUs that may be infection control issues;
- She felt Housekeeping supervisory staff used a computerized report system for their environmental rounds however, she did not know when the last one was conducted; and
- She felt BHU patients were not at risk for infection control issues.

9. Record review of the environmental rounds showed the following:
- Rounds were conducted by Housekeeping supervisory staff;
- The last documented rounds on the BHU were 03/18/15;
- The report consisted of observations of common areas, used and accessed by facility staff; and
- There were no reports of observations of patient rooms or patient bathrooms on the reports dated in March.


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