HospitalInspections.org

Based on interview and record review the hospital failed to monitor patients that were restrained, in that 1 of 6 (Patient #7) was not monitored while in restraints.

Findings included:

Patient #7 was admitted to the Emergency Department on 10/26/200 for acute respiratory distress and was uncooperative. Patient #7 was intubated and placed on the ventilator. The patient was placed on restraints at 0928 for pulling at lines and tubes. Patient #7 remained in the ED on restraints until 1448 when they were transported to the Intensive Care Unit. There was no documentation of monitoring and care of the restrained patient.

During a chart review ending at 1420 Personnel #4 confirmed there was no documentation of monitoring or care of the restrained patient.

The policy titled Restraints: Non Violent Behavior revised 12/17 reflected..."Monitoring and care...1. A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient..."

Based on interview and record review the hospital failed to report the death of a patient in restraints in that 1 of 1 (Patient #10) patients died while in soft wrist restraints and this death was not listed on the internal restraint log as a death occurring while in restraints.

Findings included:

Patient #10 was admitted to the Emergency Department (ED) on 09/01/2020 at 1548 for chest pain and shortness of breath for days. At 1955 the patient was placed on BiPap. Patient #10 remained in the ED awaiting a bed assignment through out that night and into 09/02/2020. The chart reflected the patient was placed on restraints on 09/02/2020 at 1003 for removal of equipment. At 1256 the patient had a cardiac event and was coded at 1256 and the patient was pronounced deceased at 1327. There was no indication on the Restraint Log that the patient had expired while in restraints.

During a chart review on 12/16/2020 ending at 1440 Personnel #4 stated she was unaware a patient had died while in restraints.
During an interview on 12/16/2020 Personnel #2 stated she was unaware of this death while in restraints. Personnel #2 stated she normally investigates the deaths and if the restraint contributed to the death she would place the information on the Restraint Log.

The policy titled Restraints: Non Violent Behavior revised 12/07 reflected..."Reporting deaths associated with use of restraint...4. If only soft wrist restraints were involved, the hospital were involved, the hospital must document the death no later than sevens days after the death. The internal log must be available in either written or electronic form...Each entry must include the patient's:...E. Date of death..."

Based on interview and observation the hospital failed to employ methods for preventing and controlling the transmissions of infections within the hospitals in that employees were not wearing eye protections when working in the Emergency Department (ED) and the COVID-19 Intensive Care Unit (ICU) as per hospital policy.

Findings included:

During a tour of the facility on 12/16/2020 at 1450 the surveyor toured the main ED. Only 2 personnel out of approximately 12 personnel on duty in ED were wearing eye protection. There was a cart available at the nursing station with eye protection available.

During an interview on 12/16/2020 at 1450 Personnel #3 stated that all personnel in the high risk areas should be wearing eye protection.

The policy titled COVID-19 Universal PPE for Healthcare personnel Formulated 07/2020 reflected..."Eye Protection...The HCP (healthcare personnel) should don eye protection upon arrival in the clinical area and wear it continuously to prevent transmission between patients and healthcare workers and between members of the healthcare team..."