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Based on interview and medical record review the facility had failed to ensure restraints were not ordered and applied on an as needed basis for 1 (#2 ) of 5 reviewed . Also noted was the facility policy was not consistent with current regulations. This is evidenced by:

Findings:

On 1/28/14 review of medical record (# 2 ) revealed restraints were ordered and applied on an as needed basis.

Physicians Orders
7/4/13 at 1700 until 7/5/13 at 1700
7/5/13 at 1800 until 7/6/13 at 1800

Restraint Flow Sheet
7/4/13 at 1200 restraints off
7/5/13 at 1600 restraints on

The "Restraint Flow Sheet" documented restraints were removed on 7/4/13 at 1200 noon. The same Flow Sheet also documented restraints were reapplied on 7/5/13 at 1600 (4:00pm). The restraints were reapplied without a new physician order as required.

The physician signed, dated and timed a restraint order on 7/4/13 at 8:35 am. The order designated a restraint time frame for 7/4/13 at 1700 (5:00pm) until 7/ 5/13 at 1700 (5:00pm). The order for the restraint was signed, timed and dated 8 hours before the time frame the restraints were to be used.

Another physician in the record ordered a restraint time frame for 7/5/13 at 1800 (6:00pm) until 7/6/13 at 1800 (6:00pm).

Review of the facility policy "Restraint Management : Medical/Surgical (Non-Psychiatric Unit)" last revised 1/17/12, states: "A patient should be released from restraints at the earliest point during a 24 hour period. If the patient is reassessed and the RN believes restraints are again necessary he/she may reinstate the restraint with the 24 hour time frame without a new order". Also the facility Restraint Flow Sheet states the RN can reinstate the restraint within a 24 hour time frame. The Policy and Restraint Flow Sheet are not consistent with the regulation..

The above information was confirmed on 1/2914 at 9:30 am with the Chief Nursing Officer.

Based on document review and interview, verbal orders were not dated, timed and authenticated promptly by an authorized provider. Specifically, three telephone orders were not dated, timed or authenticated by an authorized provider.

Findings:

Review of medical record #1 on 1/27/14 at 3:00 pm revealed RN documentation of a 1/24/14 2:30 pm telephone order from physician A which read, "TORB (telephone order read back) for [patient initials] from Dr. A. Start (blood thinner) tonight at 9:00 pm". The RN also documented a second telephone order dated 1/24/14 at 2:30 pm from physician B which read, "TORB for [patient initials] from Dr. B. Give (intravenous antibiotic )..." The orders were not dated, timed or authenticated by authorized providers.

Interview of the RN Clinical Lead on 1/27/14 at 3:30 pm confirmed the findings.

On 1/28/14 at 1:00 pm medical record #2 was reviewed. It revealed on 7/5/13 at 5:00 pm a TORB for restraint use from 7/5/13 at 5:00 pm to 7/6/13 at 5:00 pm. The order was not authenticated by the physician until 11/11/13 and was not timed.

Interview of the Chief Nursing Officer on 1/29/13 at 12:45 pm confirmed the finding.

Review of facility's "Patient Care Services Generic Structures Standards" (reviewed/ revised 12/13) noted: "X. J. 5. c. Telephone / Verbal Orders: 1.a. Telephone Order is an order received via telephone, recorded by the licensed RN, pharmacist, dietitian or respiratory therapist and signed by the physician, physician assistant, nurse practitioner within 24 hours".

Based on findings from observation and interview, the morgue was being used to store potentially hazardous materials and clean items with little or no separation. To avoid cross contamination, hazardous materials and clean items should be stored in separate, well ventilated rooms.
Findings include:
--Per observation at 1:12 pm on 1/17/14, the morgue and in an area adjacent to the morgue that was formerly equipped with a door were being used to store the following items in addition to equipment generally found in a morgue: approximately 85 tissue block containers, autopsy tissue specimens in jars containing formaldehyde, tissue specimens of interest such as placentas also in jars containing formaldehyde, a cytology procedure cart, and a formaldehyde recycling machine.
--Per interview at 1:12 pm on 1/17/14, the Histology Technologist stated that the above items were being stored in the morgue due to a lack of space and that the door on the room adjacent to the morgue had been removed in order to accommodate the width of the formaldehyde recycling machine for storage within the area. He/she agreed that the items were not being stored in a clean and sanitary manner.

Based on observation of an operative procedure in the operating room on 1/28/14 at 1100, the hospital failed to assure that the the delivery of anesthesia services was consistent with recognized standards for infection control measures.

Findings:

While observing an operative procedure in the operating room on 1/28/14 at 1100, the CRNA was observed opening several new medication vials during the procedure. The CRNA entered each new vial with a syringe without first cleansing the rubber diaphragm of each vial. The medications were then administered to the patient.

Both the CDC (Center for Disease Control) and APIC (Association for Professionals in Infection Control and Epidemiology) advise that the rubber septum on a medication vial, including single dose vials, be disinfected prior to piercing.