HospitalInspections.org

Based on medical record review, policy review, and staff interview it was determined the registered nurse failed to assess and monitor patients in non- violent restraints every two hours as per policy. This affected three (Patient's #13 #14 and #15 ) of three medical records reviewed with restraints. A total of forty five medical records were reviewed. The census was 256 patients.

Findings include:

Review of the policy and procedure for "Restraint Seclusion Use" (undated) revealed the Registered Nurse is to assess and document at a minimum, every 2 hours for patient needs and responses. This includes proper application, skin, circulation checks, numbness, tingling, respirations, and readiness to discontinue restraint.

1. Review the medical record for Patient #13 revealed the patient was admitted to the facility on 03/07/19 for a diagnosis of acute respiratory failure. The medical record revealed the patient was placed in non-violent restraints to ensure patient safety by maintaining equipment/tubes. Review of the nursing flowsheets revealed the nurse failed to assess and document every two hours as per policy.

a). On 03/08/19 the medical record lacked a two hour check from 3:24 AM through 7:56 AM
b). On 03/08/19 the medical record lacked a two hour check from 1:29 PM through 5:11 PM
c). On 03/10/19 the medical record lacked a two hour check from 9:30 AM through 12:28 PM
d). On 03/11/19 the medical record lacked a two check from 11:38 PM through 2:00 AM

This finding was confirmed with Staff G on 03/13/19 at 3:07 PM

2. Review of the medical record for Patient #14 revealed the patient was admitted on 03/01/19 for an altered mental status. The medical record revealed the patient was placed in non-violent restraints to ensure patient safety by maintaining equipment/tubes. Review of the nursing flowsheets revealed the nurse failed to assess and document every two hours as per policy.

a). On 03/12/19 the medical record lacked a two hour check from 1:14 AM through 5:48 AM

This finding was confirmed with Staff G on 03/12/19 at 3:46 PM.

3. Review of the medical record for Patient #15 revealed the patient was admitted to the facility on 03/05/19 for a peg tube dislodgement/ replacement. The medical record revealed the patient was placed in non-violent restraints to ensure patient safety by maintaining equipment/tubes. Review of the nursing flowsheets revealed the nurse failed to assess and document every two hours as per policy.

a). On 03/06/19 the medical record lacked a two hour check from 3;25 PM through 8:46 PM

This finding was confirmed with Staff G on 03/12/19 at 4:01 PM.

Based on observation, interview, and document review, the facility failed to protect penetrations in barrier between it and other building occupants, to have paths of egress free of obstructions in accordance with NFPA 19.2.1, to ensure each path of egress was marked in accordance with 7.10, NFPA 101, 2012 edition, to protect stairways in accordance with 19.3.1, NFPA 101, 2012 edition, to ensure doors to hazardous areas self closed in accordance with 39.3.2, NFPA 101, 2012 edition, to comply with 14.4.5 and 14.6.2.4, NFPA 72, 2010 edition, to ensure sprinkler system gauges and control valves were inspected monthly in accordance with NFPA 25, 2011 edition, to ensure that doors that opened on the corridor that could self close and latch did so, to protect penetrations in its smoke barriers, to ensure doors in smoke barriers with self closing and latching hardware closed and latched the doors, to implement fire drills wherein the fire alarm signal was transmitted in accordance with 19.7.1.4, NFPA 101, 2012 edition, to ensure portable space heating devices were not present in patient care areas, to maintain its generator in accordance with 8.3.1, NFPA 110, 2010 edition, and to ensure each area that stored oxygen cylinders had a sign in accordance with 11.3.4, NFPA 99, 2012 edition. (A 709) These findings have the potential to affect all patients at the facility. The census was 256 patients.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. These findings have the potential to affect all patients at the facility. The census was 256 patients.

Findings include:

K131 Failed to protect penetrations in barrier between it and other building occupants
K211 Failed to have paths of egress free of obstructions in accordance with NFPA 19.2.1
K293 Failed to ensure each path of egress was marked in accordance with 7.10, NFPA 101, 2012 edition.
K311 Failed to protect stairways in accordance with 19.3.1, NFPA 101, 2012 edition
K321 Failed to ensure doors to hazardous areas self closed in accordance with 39.3.2, NFPA 101, 2012 edition.
K345 Failed to comply with 14.4.5 and 14.6.2.4, NFPA 72, 2010 edition.
K353 Facility failed to ensure sprinkler system gauges and control valves were inspected monthly in accordance with NFPA 25, 2011 edition.
K363 Failed to ensure that doors that opened on the corridor that could self close and latch did so
K372 Failed to protect penetrations in its smoke barriers.
K374 Failed to ensure doors in smoke barriers with self closing and latching hardware closed and latched the doors.
K712 Failed to implement fire drills wherein the fire alarm signal was transmitted in accordance with 19.7.1.4, NFPA 101, 2012 edition.
K781 Failed to ensure portable space heating devices were not present in patient care areas.
K918 Failed to maintain its generator in accordance with 8.3.1, NFPA 110, 2010 edition.
K923 Failed to ensure each area that stored oxygen cylinders had a sign in accordance with 11.3.4, NFPA 99, 2012 edition.