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Based on interviews and document reviews, it was determined the facility staff failed to consistently implement patient grievance policies for 1 of 33 patients of the survey sample (Patient #15). Staff also failed to consistently implement restraints for 3 of 3 patients sampled for restraint use (Patients #5, #8 and #27).

Due to a pattern of serious deficient practices identified in the implementation of restraints for violent and non-violent patient behaviors it was determined the facility failed to substantially comply with this Condition for Coverage.

The findings include:

Patient #15 made a verbal complaint regarding treatment, which, though reported, was not followed through per the facility policy and procedure for complaints and grievances. Please see A0118 for additional information.

A restraint order for Patient #27 failed to be complete as evidenced by the absence of what body part or body parts needed to be restrained. Please see A0166 for additional information.

Restraint monitoring (safety and dignity checks) for Patient #5, Patient #8, and Patient #27 were not promptly documented. Please see A0167 for additional information.

Patient #8's restraint orders for violent and/or self-destructive behaviors were not renewed within the required time frame. Please see A0171 for additional information.

An assessment by a licensed independent practitioner (LIP) was not documented as occurring within an hour after physician and chemical restraints were implemented for Patient #5. Please see A0178 for additional information.

Patient #27's clinical documentation failed to include what behaviors were being addressed with physical restraints. Please see A0185 for additional information.

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure the facility policy regarding complaints and grievances was followed for one (1) of thirty-three (33) patients of the survey sample, Patient #15.

Patient #15 made a verbal complaint regarding treatment, which, though reported, was not followed through per the facility policy and procedure for complaints and grievances.

The findings included:

Review of the clinical record for Patient #15 revealed a "Patient Notes" entry dated 6/12/17 at 0200 (2:00 a.m.) which evidenced: (sic) "Patient accused of (sic) Nurse harming patient during care after incontinent episode. Nurse attempted (sic) patient is fine and clean after care. Patient called 911 and family report of (his/her) concerns. Nurse attempted again to explain patients (spouse) is ok and clean after nurse care. (Name of RN) Charge Nurse aware, Security/Police arrived charge nurse explain events lead up to patient calling (sic). (Name of RN) House Supervisor notified by (name of RN) Charge Nurse. Call bell in reach. Sitter in room. Nurse ask patient if anything to do to assist or help patient stated no. Patient stated feels nausea nurse offered call MD for nausea medication the patient declined stated don't trust you people (sic). Nurse offer ginger ale help decrease nausea patient accepted."

On 6/14/17 at 9:40 a.m. the surveyor requested to review the facility's follow up concerning the allegation.

On 6/14/17 at 12:15 p.m., Staff Member #21 presented the surveyor with a report dated 6/14/17 and stated, "They reported the concern to the clinical coordinator and supervisor and the issue had been resolved in their mind, but they forgot to document it all. We will re-educate them regarding the proper procedure."

The report document included the following information, in part: "6/14/17 1124 (11:24 a.m.) "The events were reported to myself and (name) by (name) on 6/12/17 at 0800 (8:00 a.m.)...on the night of 6/12/17 around 0200, the (spouse) was incontinent of urine with nursing staff present in room to assist patient with personal care. The (spouse in bed (number) complained that the staff was being "mean" to (spouse) and "abusive. (Name of RN) explained to the patient that they were assisting the patient in (bed number) to be cleaned up with linens changed. (Spouse) proceeded to call 911 to report the "abuse" to the police, then (he/she) complained of nausea to the nurse ...upon getting ready to leave the room after making sure both patients were taken care of, (name) walked out to find the police along with security standing in the hallway...(name/supervisor) was made aware of the situation by (name) that night." Staff Member #21 stated, "they reported the issue and there was the nurses note made but there should have been a documentation regarding the occurrence for us to review..."

The facility policy and Procedure "Patient Complaints/Grievances: Management and Resolution" was reviewed and evidenced, in part: "...Verbal Complaint is a grievance if it cannot be resolved at the time of the complaint by the staff present...3. All complaints should be documented, whether resolved or not, in the Notification system via (name of computer program)..."

Based on interviews and document review, it was determined the facility staff failed to ensure physician restraint orders were complete for 1 of 3 patients sampled for restraint review (Patient #27).

The findings include:

Patient 27's restraint orders failed to provide details as to which parts of the patient's body were to be restrained.

Patient #27's clinical documentation was reviewed with the facility's Risk Manager (Staff Member (SM) #21) on the afternoon of 6/14/17. Patient #27's clinical documentation included an initial restraint order dated 4/4/17 at 9:37PM. This order was for restraints identified as 'non-violent' and 'soft'. This order did not identify where the 'soft' restraints were to be applied. After reviewing Patient #27's clinical documentation, SM #21 acknowledged the restraint order did not identify the body part or parts to be restrained; SM #21 reported the restraints were documented as being applied to the patient's upper extremities.

The following information was found in a facility policy and procedure entitled 'Patient Restraint / Seclusion' (this policy and procedure had a last revised date of 06/2017): "Duration of order for restraint must not exceed twenty-four (24) hours for the initial order, and must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release."

Based on interviews and document review, it was determined the facility staff failed to ensure timely documentation of restraint monitoring for 3 of 3 patients sampled for restraint review (Patient #5, Patient #8, and Patient #27).

The findings include:

Review of the clinical documentation of the three (3) patients sample for restraint review (Patient #5, Patient #8, and Patient #27) revealed that patient safety and dignity checks were not being documented at the time the checks were reported to have been performed instead the safety and dignity checks were being documented as a summary note every two (2) hours and/or at the end of the shift. According to the facility policy and procedure safety and dignity checks are to occur at least three times an hour.

The following information was found in a facility policy and procedure entitled 'Patient Restraint / Seclusion' (this policy and procedure had a last revised date of 06/2017): "A trained staff member monitors each patient in restraint [sic] or seclusion at least three (3) times an hour for safety and to confirm that the patients [sic] rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift. If a paper checklist is used as a summary, recording time and observation form each of the three (3) times an hour check, may be recorded at the end of the shift and the checklist scanned into the EHR/HPF patient record." [sic]

The three aforementioned patients' restraint documentation were reviewed with Staff Member (SM #3) (the facility's Quality Director) on 6/13/17 and/or SM #21 (the facility's Risk Manager) on 6/14/17. The failure to see documentation of the safety and dignity checks at the time the checks were performed was discussed with both staff members.

During an interview on 6/15/17 at 8:35AM, the facility's Quality Director (SM #3) reported the three (3) times an hour safety and dignity checks needs to be documented at the time the checks were completed not as a summary at a later time. SM #3 reported a paper form was being implemented to capture this documentation and the paper forms would be scanned into patients' clinical documentation when completed; SM #3 provided the survey team with a blank copy of this paper form.

Based on interviews and document review, it was determined the facility staff failed to ensure an adult patient's restraint order for violent and/or self-destructive behaviors was renewed within the required time limit for 1 of 3 patients sampled for restraint review (Patient #8).

The findings include:

The facility staff failed to ensure Patient #8's restraint order was renewed as required and/or restraints were not used without a current order.

Patient #8's clinical documentation was reviewed on 6/13/17 and 6/14/17 with the facility's Quality Director (Staff Member (SM) #3). An order was found for soft restraints all extremities for violent and/or self-destructive behavior dated 5/23/17 at 5:09PM. The next order for restraints was dated as being given on 5/24/17 at 9:33AM; this order was for soft restraints all extremities for non-violent behavior. The second order given on 5/24/17 at 9:33AM was greater than four (4) hours from the previous order given on 5/23/17 at 5:09PM. SM #3 was asked when the restraints were discontinued; SM #3 reported the restraints were discontinued on 5/24/17 at 12:59PM.

The following information was found in a facility policy and procedure entitled 'Patient Restraint / Seclusion' (this policy and procedure had a last revised date of 06/2017): "Order for Restraints with Violent or Self Destructive Behavior ... Physician orders for restraint or seclusion must be time limited ... Orders for restraint or seclusion must not exceed: ... Four (4) hours for adults, aged 18 years and older ... To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and call the ordering physician to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed: ... Four (4) hours for adults, aged 18 years or older ..."

Based on interviews and documents review, it was determined the facility staff failed to ensure a patient having restraints in use was evaluated, within the required time limits, by a licensed independent practitioner (LIP) for 1 of 3 patients sampled for restraint use (Patient #5).

The findings include:

Patient #5 did not have an assessment documented by a LIP within the first hour after physical and chemical restraints were initiated due to violent behaviors.

Patient #5's clinical record included the following orders:
- Haldol 2mg IV (intravenously) one time on 2/23/17 at 6:01AM, and
- Soft restraints "all extremities" with the criteria for release being documented as when the patient stops being combative; this order was documented on 2/23/17 at 6:04AM.

The following nurse's note was documented on 2/23/17 at 6:22AM: "(patient) noted to be attempting to hit and kick staff, yelling out. [sic] and pylling [sic] off bipap mask; unable to keep (oxygen) on patient; (oxygen saturation) 78% with mask off and no (oxygen) on; order received and (patient) placed in 4 point soft restraints for (his/her) safety and staff safety and to be able to adequately oxygenation (patient); after restraints applied, (nasal cannula) placed on (patient) and (oxygen saturation) still 84 -85%; haldol ordered and administered and bipap placed on (patient) ..." The physical restraints were documented as being discontinued on 2/23/17 at 6:54AM.

An LIP assessment was not completed until 2/23/17 at 9:49AM; this was greater than one (1) hour after the physical and chemical restraints were initiated. The absence of an LIP assessment within the first hour after restraints were used for violent behaviors was discussed with Staff Member (SM) #3 (the Quality Director) on the morning of 6/13/17. SM #3 stated the residents (physicians) are usually in the ICU between 5AM and 7AM; SM #3 reported that Patient #5 was in the ICU when the restraint order was given at 6:04AM. The first documentation by a LIP after the aforementioned restraint use was documented as occurring on 2/23/17 at 9:49AM; no earlier LIP assessment was found by or provided to the surveyor.

Based on interviews and document review, it was determined the facility staff failed to document details of what behaviors were being addressed with restraints for 1 of 3 patients sampled for restraint review (Patient #27).

The findings include:

Patient 27's restraint documentation failed to provide details as to what behaviors were being addressed with restraints.

Patient #27's clinical documentation was reviewed with the facility's Risk Manager (Staff Member (SM) #21) on the afternoon of 6/14/17. Patient #27's clinical documentation included an initial restraint order dated 4/4/17 at 9:37PM. This order was for restraints identified as 'non-violent' and 'soft'. This order did not identify where the 'soft' restraints were to be applied. The restraints were documented as being for non-violent behaviors for 'unsafe mobile attempts' and 'attempts to remove'. Documentation was not found detailing: (a) what unsafe mobile attempts were being made by the patient and (b) what the patient was attempting to remove. SM #21 was asked about what specifically was Patient #27 attempting to remove; no documentation was found by or provided to the surveyor to explain what Patient #27 was attempting to remove.

The following information was found in a facility policy and procedure entitled 'Patient Restraint / Seclusion' (this policy and procedure had a last revised date of 06/2017): "The Registered Nurse (RN) performs an assessment for risk or seclusion for restraint [sic] when a patient exhibits behaviors that may place the patient at risk for restraint or seclusion. This risk assessment includes: 1. Does the patient have a medical device? 2. Does the patient understand the need to not remove the device? 3. Is the patient required to be immobile? 4. Does the patient understand the need to remain immobile? "

Based on interviews and document review it was determined the facility's Quality Assessment and Performance Improvement (QAPI) Program failed to identify and address issues related to the incorrect implementation of patients' restraints.

The findings include:

The facility staff's use of restraints for three (3) patients (Patient #5, Patient #8, and Patient #27) was reviewed during the survey with a Risk Manager (Staff Member (SM) #21) and/or the Quality Director (SM #3). This included a review of patients' clinical documentation and the facility's restraint monitoring tool.

Findings related to the facility's restraint use included: (a) an incomplete restraint order, (b) delayed documentation of restraint monitoring, (c) delay in renewal of a restraint order, (d) failure to ensure an assessment by a licensed independent practitioner (LIP) was documented as being completed within an hour after physician and chemical restraints were implemented to address a patient's violent behaviors, and (e) a patient's clinical documentation failed to include what behaviors were being addressed by physician restraints. Please see A0166, A0167, A0171, A0178, and A0185 for additional information.

The following information was found in a facility policy and procedure entitled 'Patient Restraint / Seclusion' (this policy and procedure had a last revised date of 06/2017): "Performance Improvement: a. Data on the use of restraint and seclusion is collected to monitor appropriate use and to identify process improvement opportunities. b. Data elements include: 1. Number of patients restrained or secluded 2. Number of restraint hours or seclusion hours 3. Type of restraints 4. Number of restraint or seclusion episodes 5. Number of patient injuries/deaths while restrained or secluded ..."

No evidence was found by or presented to the surveyor to indicate the facility's QAPI program had identified and developed a plan of action to address the aforementioned restraint findings.

Based on interview, medical record review and document review, the facility staff failed to ensure vital signs (VS) were obtained and documented per the facility policy/procedure for 2 of 3 patients reviewed regarding the administration of blood products, Patients #2 and #4.

Findings include:

The facility policy and procedure titled "Blood and Blood Product Administration" included the following information under "Procedure General Guidelines: ...18. Vital signs (TPR, BP) will be checked prior to initiating the transfusion, fifteen minutes after transfusion initiation, and every hour during the transfusion...".

A review of Patient #2's medical record revealed an order written 6/8/17 for the transfusion of two units of FFP (fresh frozen plasma). Nursing documentation in the record was that the first unit of FFP was administered between 7:58 AM and 8:30 AM, with VS documented at 7:58 AM. VS were not documented 15 minutes after the initiation of the first unit of FFP, or after the first hour. VS were recorded next at 10:02 AM.

The second unit of FFP was documented as administered between 9:57 AM and 11:00 AM. VS were documented at 10:02, but did not include documentation of the temperature. There were no VS documented 15 minutes after initiation, or after one hour. VS were recorded next at 1:57 PM.

A review of Patient #4's medical record revealed an order for two units of FFP written on 6/6/17. Documentation was that the first unit was administered between 11:29 AM and 11:51 AM. VS were obtained and documented at 11:10 AM, prior to the initiation of the first unit; there were no VS documented 15 minutes after FFP was started, or after the infusion was completed. At 11:54, there was a nursing note that stated "first unit FFP hung with no reaction, they will start second bag in the OR (operating room).

The concerns were discussed with Staff Members #6, 23, and 33 on 6/13/17 at approximately 1:30 PM. Staff Member #23 searched the record for VS documentation unsuccessfully, and stated "there are no other VS documented with the FFP administration for either patient".

Based on interviews and document review, it was determined the facility staff failed to ensure clinical documentation contained information addressing the implementation of physician orders for 1 of 33 sampled patients (Patient #8). Facility staff also failed to ensure the response to medication was documented for 2 of 2 patients, (Patient #15 and Patient #1) who were administered an anti-anxiety agent.

The findings include:

1. Review of Patient #8's clinical documentation indicated the facility staff failed to implement physician orders for CIWA (Clinical Institute Withdrawal Assessment) including not completing CIWA assessments as ordered and not administering CIWA medications as ordered.

Patient #8's clinical documentation included orders for CIWA assessment dated 5/21/17 at 6:17PM. Patient #8's clinical documentation was reviewed on 6/13/17 and 6/14/17 with the facility's Quality Director (Staff Member (SM) #3).

On 6/14/17 at 9:25AM, SM #3 was asked how soon the first CIWA assessment should be completed. SM #3 stated the first assessment of the CIWA should occur within 1 - 2 hours of the order being given. The following CIWA documentation as found in Patient #8's clinical documentation:
- The first assessment was completed on 5/21/17 at 9:31PM with a score of 9; this was greater than 3 hours after the order was given. Medication orders indicated that for a CIWA score of 8 - 15 that Ativan 1mg should be administered by intramuscular (IM) injection. Patient #8's scheduled Ativan was administered by mouth but the IM injection was not addressed. SM #3 stated the physician should have been contacted for guidance on the Ativan 1mg injection order. The CIWA assessment orders indicated if an assessment score was 8 - 15 then the CIWA needed to be repeated "(e)very 2 hours for 24 hours then every 4 hours while awake."

- The second CIWA assessment was completed on 5/22/17 at 4:31AM; this was greater than 2 hours from the previous CIWA assessment. The second CIWA assessment score was an 8. Based on the physician orders Patient #8 should have been administered Ativan 1mg IM injection; no Ativan was documented as being administered.

- The third CIWA assessment was completed on 5/22/17 at 8:16AM; this was completed according to the time limit required by the orders. The third CIWA assessment was scored as a 12. Based on the physician orders Patient #8 should have been administered Ativan 1mg IM injection; no Ativan was documented as being administered. The CIWA assessment orders indicated if an assessment score was 8 - 15 then the CIWA needed to be repeated "(e)very 2 hours for 24 hours then every 4 hours while awake."

- The forth CIWA assessment was completed on 5/23/17 at 1:26AM; this was greater than 2 hours from the previous CIWA assessment. The forth CIWA score was 4. No medication was required based on this score. The CIWA assessment orders indicated if an assessment score was less than 8 then repeat the CIWA assessment "(e)very 4 hours for 24 hours then every 4 hours while awake".

- The fifth CIWA assessment was completed on 5/23/17 at 8:20AM; this was greater than 4 hours from the previous CIWA assessment. The fifth CIWA score was 1. No medication was required based on this score. The CIWA assessment orders indicated if an assessment score was less than 8 then repeat the CIWA assessment "(e)very 4 hours for 24 hours then every 4 hours while awake".

- The sixth CIWA assessment was completed on 5/23/17 at 11:10AM; this was completed according to the time limit required by the orders. The sixth CIWA assessment was scored as a 14. Medication orders indicated that for a CIWA score of 8 - 15 that Ativan 1mg should be administered by intramuscular (IM) injection. Based on the physician orders Patient #8 should have been administered Ativan 1mg IM injection but Ativan 2mg IM injection was documented as being administered. The CIWA assessment orders indicated if an assessment score was 8 - 15 then the CIWA needed to be repeated "(e)very 2 hours for 24 hours then every 4 hours while awake."

- The seventh CIWA assessment was completed on 5/23/17 at 4:38PM; this was greater than 2 hours from the previous CIWA assessment. The seventh CIWA assessment was scored as a 33. Documentation indicated a physician was notified of the change in the patient's condition at 4:45PM. The physician ordered Versed 2mg IV (intravenously) and 4 point soft restraints.

The aforementioned documentation was reviewed and confirmed with SM #3 on 6/14/17 at 9:25AM.

2. Patient #15 was admitted to the facility on 6/8/17 with diagnoses that included, but were not limited to: right pleural effusion (fluid in the tissues between the lungs and the chest cavity), new atrial fibrillation (irregular heart rhythm) with RVR (rapid ventricular rate), and congestive heart failure.

Review of the clinical record documented Patient #15 received Ativan (Lorazepam- an antianxiety medication) IV (intravenous) on 6/12/17 at 3:31 a.m. The order was written: "Ativan 1mg (one milligram) once IV (intravenous) for agitation or anxiety". There was no documentation in the clinical record as to the reason the medication was administered, and no follow-up documentation as to the effectiveness of the medication once administered.

On 6/12/17 at 22:39 (10:39 p.m.) it was documented the nurse called the physician and again received an order for "Ativan 0.5 mg once IV", however there was no documentation in the clinical record as to why the patient required the medication and no documentation of follow-up as to the effectiveness once administered.

On 6/14/17 at 00:30 (12:30 a.m.) the nurse again called the physician and obtained an order for "Ativan 0.5 mg IV once" for Patient #15. There was no documentation in the clinical record as to the reason the patient required the medication and no documentation as to the follow-up effectiveness once the medication was administered.

On 6/14/17 at 11:20 a.m., the surveyor interviewed Staff Member # 30 regarding the documentation of the Ativan. Staff Member #30 stated, "There should be some documentation in the nurses notes as to why they called the physician for the order and there should be documentation of the effectiveness...the nurse should go back and reassess the patient and document something in the notes. There is follow-up documentation on pain medications but not anxiety meds..."

The concerns were discussed with facility Administration on 6/15/17 at 10:40 a.m

3. A review of Patient #1's record revealed PRN (as needed) orders for the administration of IV (intravenous) Ativan. Documentation in the record was that Patient #1 received 1 mg (milligram) of IV Ativan on 6/10/17 at 7:37 PM; on 6/11/17 at 11:14 AM, 5:39 PM, and 10:32 PM. On 6/13/17 Patient #1 was administered 2 mg of Ativan at 11:09 AM. A post assessment response to the administration of the Ativan was not documented in the record.

On 6/14/17 at 9:55 AM, Staff Member #23 was interviewed about documentation of response to the PRN administration of Ativan, and he/she stated "There are no post assessments for PRN Ativan. That is attached for narcotic/pain medication administration, but it's not there for the Ativan".

Based on the deficiencies identified during the Life Safety Code survey (K100, K161, K211, K222, K223, K293, K311, K321, K324, K341, K351, K353, K363, K372, K374, K511, K911, K920, and K929) the Condition of Participation for Physical Environment is cited.

Based on observations and staff interview, the facility staff failed to ensure that point of care equipment used for more than one patient was cleaned per facility policy, in a manner to prevent transmission of communicable disease, and that the physical environment was sanitary.

Findings include:

While touring the ED (emergency department) on 6/13/17, the surveyor observed the following in the laboratory space adjacent to the triage area:
At 10:30 AM, the surveyor observed equipment used for point of care testing sitting in the charging dock, labeled #3. The equipment had a used cartridge containing blood inserted into the hand-held monitor. There was also dried blood on the side of the equipment. Staff Member #31, who was accompanying the surveyor on the ED tour, stated "the cartridge should have been thrown away, and the I-Stat should be cleaned after use, that blood shouldn't be there". The sharps container sitting in the laboratory had a white latch on it which contained what appeared to be dried blood splatter. Staff Member #31 stated "you're right, that is blood".

On 6/15/17 at 11:00 AM, the surveyor, accompanied by Staff Member #6, observed glucose monitoring on the PCU (progressive care unit). Staff Member #32 gathered the necessary supplies and went into room #204. Staff Member #32 placed a black plastic box containing supplies on a chair, then laid the glucometer on the bed. After obtaining the blood sample and recording the BS (blood sugar) result, Staff Member #32 cleaned the glucometer with sanitizing wipes, picked up the black box, which he/she did not sanitize, placed the clean glucometer on top of the box, and went to room #207 to obtain the next BS.

Staff Member #32 placed the black supply box on a chair, laid the glucometer on the patient's bed, and obtained and ran the test. After removing his/her gloves, Staff Member #32 picked up the black box, and carried the glucometer out of the room and proceeded to room #210. Staff Member #32 did not clean the glucometer or the black box. Staff Member #32 placed the black box on top of the dirty laundry container in room #210, placed the glucometer on the bed, and obtained the patient's BS. After he/she finished, Staff Member #32 cleaned the glucometer, and picked up the black box.

The surveyor discussed the observations that the glucometer was not sanitized between the second and third patient, and the failure to sanitize the black box containing supplies with Staff Member #6, who said yes, I noticed "(Staff Member #32's name) did not clean the glucometer before going to room #210, I don't think there were any wipes in that room.
Staff Member #6 and the surveyor talked with Staff Member #32 about not cleaning the glucometer before exiting room #207 and going to room #210, and he/she stated "there weren't any wipes in the room to use".

The facility's policy and procedure titled "POC Nova Glucose Meter Procedure" was reviewed.
Staff Member #3 advised the surveyor on 6/14/17 at approximately 3:00 PM that the policy was for all POC (point of care) equipment, and not strictly for glucometers. Under the heading "Equipment and Materials, the section "Meter Cleaning" included the following information: "Meters must be cleaned after each patient test. Clean the meter with a cloth that has been dampened with a 10% bleach solution or disinfectant wipe. Immediately follow with a water dampened cloth to remove all cleaning residue. Dry thoroughly with a soft cloth or lint-free tissue".

Staff Member #31 was aware of the concerns at the time of discovery, and responded as noted above.