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Based on clinical record review, observations, interviews with staff, and review of policies for two of two patients observed utilizing waist belts, the hospital failed to ensure that the patients were free from restraints. The findings include:

Patients #31 and #32 were observed on 5/2/11 at 10:10 AM sitting in lounge chairs in a community room with waist belts applied around each patient and their chairs. The waist belts were secured with velcro strap type material behind each patient's chair. Staff identified that the waist belts were self-releasing and not considered a restraint. However, because the velcro straps were observed behind each patient's chair, the patient's could not self release their waist belts. Interview with the Nurse Manager on 5/2/11 at 10:10 AM identified that because the velcro straps were out of Patient #31 and Patient #32's reach, the waist belts should have been identified as restraints. According to Hospital policy, an MD, PA, or APRN must write an order to initiate a restraint.

Based on clinical record reviews and interviews with facility personnel, for one of one sampled patients (Patient #21), the facility failed to ensure that a physician assessment was completed with the initiation of a restraint.

The findings include:

1. Patient #21 was admitted to the hospital on 5/3/11 with alcohol withdrawl. Review of the clinical record identified that restraints were applied at 9:14am. Further review failed to identified that a physician assessment was completed. Review of the hospital "Restraint Policy" identified that a physician assessment will be completed with the initiation of restraints. Interview with the MICU Nurse Manager on 5/2/11 identified that the physician assessment was not completed.

Based on review of the clinical record and review of hospital policy, the hospital failed to ensure that for two patients (Patients #24 and #25) who had surgery, that the assessment and reassessment of pain was documented. The findings include:
a. Patient #24, who underwent a right lung biopsy on 5/2/11, was transferred to the PACU at 10:35 AM. The patient rated pain as a 10 (1 being the least pain, 10 being the most) in the right chest, however, the time of the assessment was not documented. Although nursing documentation reflected that pain medication was administered by anesthesia, the record failed to reflect what medication was administered or at what time. Subsequently, analgesics were administered to the patient at 11 AM and 11:10 AM for pain levels of 10. The record lacked reassessment of the patient's pain level until 12:40 PM when additional morphine was given for a pain level of 7/10. The record failed to reflect a reassessment of the patient's pain level subsequent to administration of pain medication.
b. Patient #25 underwent a right laparoscopic inguinal hernia repair on 5/2/11 and arrived in PACU at 8:35 AM. Review of the PACU documentation form identified that although the patient was assessed for pain, the record failed to reflect the time of assessment. Additional documentation (untimed) identified that the patient did have a pain level of 5/10 and was medicated at 9:20 AM with 25mcg of Fentanyl. Review of the clinical record failed to reflect that the patient's pain was reassessed to determine the efficasy of the medication.



19907

Based on review of the clinical record and interviews with facility personnel for one sampled patients (Patient #51), the facility failed to ensure that the patient, who was a high fall risk, was monitored to prevent falls.

The findings include:

1. Patient #51 was admitted to the hospital on 4/26/11 with Pancreatitis. Review of nursing documentation identified that the patient was high risk for falls. Review of the plan of care dated 4/26/11 identified that the patient was a standby assistance/assist of one. Observation of the patient on 5/3/11 identified that the patient was in the bathroom unattended. Interview with the Nurse Manager on 5/3/11 identified that the patient was a high risk for falls and was weak unsteady and assist of one.


29051

A395

Based on review of clinical records, interviews with staff, and review of hospital policy and procedures, the facility failed to ensure that a physician's order was completed and/or a pain reassessment was completed in a timely manner. The findings include:

A. Patient #41 (P#41) was admitted with diagnoses that included intractable nausea, vomitting, protein calorie malnutrition, gastroparesis, abdominal abcess, and septic shock. Review of the clinical record with RN#10 on 5/3/2011 at 9:50 AM indicated that a physician order was entered on 4/7/2011 for P#41 to have a weight taken daily at 8:00 AM. Further review of the All Results Flowsheets for the time period 4/7/2011 through 5//3/2011 indicated that daily weights were entered for 4/7/2011 through 4/17/2011, with missing weights for 4/10/2011 and 4/13/2011. There are no documented weights in the clinical record from 4/17/2011 to 5/3/2011. Review of the clinical record on 5/4/2011 at 12:45 PM with RN#9 (Resource RN) and Director of Cardiology indicated that the daily weight order was an active order and had never been discontinued.

B. Patient #40 (P#40) was admitted on 4/29/2011 with the diagnosis of mild decompensated congestive heart failure (CHF) and a history that included severe aortic stenosis, hyponatremia, hyperkalemia, and hyperthyroidism. Review of the clinical record with Nurse Manager #7 and RN#11 (Assistant Nurse Manager) indicated that an order for daily weights at 8:00 AM was entered on 4/29/2011. Weights were entered for 4/29/2011 and 4/30/2011. However, there were no weights documented for 5/1/2011, 5/2/2011, and 5/3/2011. P#40 was discharged during the afternoon of 5/3/2011.

C. Patient #39 (P#39) presented at the Emergency Department on 5/1/2011 at 9:20 PM with right arm swelling and pain after a fall at home. Review of clinical record indicated that on 5/2/2011 at 6:39 AM, P#39 complained of a pain rating of 8/10 and was administered Acetaminophen 975mg. The next pain rating was not documented until 9:23 AM. Interview with APRN#1 on 5/2/2011 at 11:30 AM indicated that for pain medication taken orally, the expectation would be to reassess within one to two hours. Review of hospital policy titled "Pain Management" directed to reassess and document pain scores after each intervention, and noted that the route of administration and anticipated onset of effectiveness may determine the appropriate interval for reassessment. However, the policy failed to establish a timeframe for the reassessment of pain after the administration of oral pain medication.

Based on clinical record review, observation, and interviews with staff for 1 of 1 patients who was observed receiving medications, the hospital failed to ensure that medications were not left at the patient's bedside. The findings include:

Patient #33 was admitted for a sigmoid volvulus repair. On 5/3/11 at 10:52 AM, RN #8 was observed administering intravenous medications to Patient #33. Following the medication administration, RN #8 instructed Patient #33 and the patient's family member to continue drinking a liquid medication that was in a drinking glass left on the patient's bedside table. Interview with RN #8 on 5/3/11 at 10:52 AM identified that the patient was nauseaus and unable to tolerate drinking the entire glass of medication, so he/she left the medication at the bedside for the patient to drink slowly. The clinical record was reviewed with the Nurse Manager and member of Administration and identified that Patient #33 did not have a physician's order to self administer medications, and that RN #8 should not have left the medication at the bedside.

Based on clinical record review and interviews with staff for 1 of 2 patients who suffered from dementia, the hospital failed to ensure that the patient's first and last name was accurate throughout the clinical record. The findings include:

Patient #32's clinical record was reviewed with the Nurse Manager and a member of Administration on 5/2/11 at 10:10 AM. Throughout the clinical record, Patient #32's first and/or last names were incorrect. Staff identified that they could not be certain of the patient's correct name, and that Patient #32's family would be contacted to provide proper identification.

A450

Based on clinical record review, interviews with staff, and review of hospital policies and procedures for two of four patients (P#42 and P#43), the hospital failed to ensure that the General Consent for Treatment was completed and/or completed in full in the clinical record. The findings include:

During tour of Richardson 7, review of Patient #43's clinical record, who was admitted for reimplantation of a right total knee arthroplasty, indicated that a General Consent for Treatment form was not completed. Although a blank General Consent for Treatment form with the patient's sticker containing identifying information was placed in the clinical record, the form was not dated or signed by the patient or a patient representative. In addition, review of Patient #42's clinical record, who was admitted for right hip fracture, indicated that the General Consent for Treatment form was signed by a patient representative, but was not dated. Interview on 5/2/2011 at 1:45 PM with Nurse Manager #8 indicated that General Consent for Treatment forms should be signed and dated. Review of hospital policy titled "Patient Consent to Medical or Surgical Procedures and Anesthetics" directed that the form entitled "General Consent for Treatment and Patient Authorization Record" shall be signed by every patient prior to any routine diagnostic or therapeutic procedures or medical treatment being performed.

Based on observation, review of hospital policy and procedure and interview with hospital personnel, the hospital failed to ensure that infection control practices were followed. The findings include the following:
a. During tour of the Operating Suites on 5/2/11, observation of several staff members identified a failure to cover the entire head of hair exposing hair either at the sides of the head below a tight fitting cap and/or allowing the bouffant hat to slide back exposing hair about the face. According to hospital policy, head coverings must cover the hair in its entirety.
b. Observation of the fluid bags pre-hung and run through tubing to the 3-way stopcocks in the trauma room at approximately 11 AM on 5/2/11, identified that the fluid bag was labeled with the date 4/31/11 at 6 AM. During interview on 5/2/11, the attending anesthesiologist stated that the fluids were set up daily by the on-call anesthesia staff and were good for 24 hours following set-up. The hospital failed to ensure that the designated staff member resonsible for set-up, removed the outdated fluids and replaced with new fluids as appropriate. Review of the hospital policy identified that all emergency anesthetizing fluids and/or drugs would be labeled with the date, time and the preparer's initials, however, the policy failed to reflect that the preparation was good for 24 hours following preparation.
c. Observation of the ambulatory surgical area (Surgease) on 5/2/11, identified rooms with open shelving and individually wrapped supplies stacked on the shelving that remained in the room from case to case. Additionally, blue cloths were stacked on the shelving which were utilized in the cleaning process between cases. According to AORN standards and a review of the hospital policies for OR cleaning identified that all horizontal surfaces should be damp dusted prior to the first case of the day and the walls should be wiped down during terminal cleaning.
d. During tour of the OR hallway on 5/2/11, OR doors were observed propped open to a room that contained two tables with opened surgical instrumentation. Room staff stated that they were waiting for additional equipment to be delivered prior to the start of the case. During interview on 5/2/11, the VP of Patient Care Services stated that it was not the hospital's standard to keep OR doors open when sterile instrumentation was exposed on the surgical table. According to AORN standards operating room doors should be kept closed to maintain correct ventilation, air flow and air pressure except for the very short time it takes to transport equipment, supplies or the patient through the door.



29051

A749

Based on observations, interviews with staff, and review of policies and procedures, the hospital failed to post a handwashing sign outside of the room for patients identified to have Clostridium difficile (Cdiff) per hospital policy . The findings include:

During tours of Luscomb 10 (Room #1069A) and Schine 9 (Room #0901A), both rooms were identified to have a patient with Cdiff. Although Contact Isolation signs were posted outside the door, there were no signs outside the doors that directed to wash hands with soap and water. Interview with RN#10 on 5/3/2011 at 9:50 AM on Luscomb 10, indicated that there should be a handwashing sign posted for patients with Cdiff. Review of hospital policy titled "Contact Precautions" directed that for patients with Cdiff, hands must be washed with soap and water. The policy also directed that if a patient has Cdiff, a sign noting the need to use soap and water for hand hygiene will be placed outside of the room in addition to the Contact Isolation sign.

Based on a review of clinical records, hospital policy, and interviews with facility personnel for two sampled patients (Patient #22) the facility failed to ensure that the initial discharge evaluation was completed in a timely manner.
The findings include:
a. Patient # 22 was admitted to the hospital on 4/28/11 with mental status changes. Review of the clinical record on 5/2/11 with the MICU Nurse Manager failed to reflect that an initial evaluation by case management was made. Review of the hospital policy "Role of Care Coordination" identified that the care coordinator will contact patient/family within 72 hours of receipt to discuss and assess potential needs for discharge. Interview with the MICU Director on 5/3/11 identified that the intial evaluation was not completed in a timely manner.

Based on review of the clinical record and interview with hospital personnel, for one patient (Patient #24) who underwent surgery, the hospital failed to ensure that the amount of oxygen delivered during transfer to PACU was documented and/or subsequent assessments pertaining to oxygenation was recorded. The finding includes the following:
Patient #24 underwent a right VATS (video-assisted thoracoscopy) lung biopsy on 5/2/11. Review of the anesthesia record identified that the patient was extubated in the OR (operating room) at 10:15 AM and placed on oxygen delivered via a facemask. Although Patient #24's oxygen saturation was documented as 90%, the record failed to reflect how much oxygen the patient received through the facemask during transfer to the PACU (post anesthesia care unit). Review of the PACU record identified that the patient had an oxygen saturation of 89% on a 70% facemask upon arrival from the OR. Review of PACU documentation reflected the patient had an oxygen saturation of 89% on a 98% facemask. The facility failed to note the time and actual assessment of the patient that warranted a change in oxygen flow rate based on the need of the patient. During interview on 5/4/11, the Chief of Anesthesia stated that the amount of oxygen delivered should have been recorded on the anesthesia record.