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Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #22 and Pt. #23) clinical records reviewed for behavioral (violent) restraint usage, the Hospital failed to ensure the type of restraint was documented on the monitoring log, as required.

Findings include:

1. On 10/3/18 at approximately 11:00 AM, the Hospital's policy titled, "Restraint: Behavioral" (origination date 8/2008) was reviewed and required, "... VII Procedure for Behavioral Restraint... L. All patients are monitored a minimum of every 15 minutes... 1. Ongoing... documentation is recorded... e. Restraint type..."

2. On 10/3/18 at approximately 1:00 PM, the clinical record of Pt. #22 was reviewed. Pt. #22 was a 22 year old male who came to the ED (Emergency Department) on 7/3/18 due to suicidal ideation. The clinical record indicated that Pt. #22 was in four-point locked restraint (type of restraint used for violent/behavioral problem with restraints on all four extremities) on 7/3/18 from 9:15 PM until 7/4/18 at 1:00 AM. The clinical record lacked the every 15 minute documentation of Pt. #22's restraint type on 7/3/18 from 9:30 PM until 7/4/18 at 12:45AM (approximately 3 hours and 15 minutes).

3. On 10/3/18 at approximately 1:20 PM, the clinical record of Pt. #23 was reviewed. Pt. #23 was a 65 year old female who was admitted on 7/26/18 with a diagnosis of altered mental status. The clinical record indicated that Pt. #23 was in four-way locked restraint on 7/26/18 from 6:37 PM until 8:45 PM. The clinical record lacked the every 15 minute documentation of Pt. #23's restraint type on 7/26/18 from 7:00 PM until 8:45 PM (approximately 1 hour and 45 minutes).

4. On 10/3/18 at approximately 1:30 PM, these findings were discussed with E #10 (RN/Professional Development Specialist). E #10 stated that there was no documentation of Pt. #22 and Pt. #23's restraint type, and that the type of restraint should have been documented every 15 minutes.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #3) clinical records reviewed for pain, the Hospital failed to ensure patients were evaluated for pain prior to receiving pain medication.

Findings include:

1. The Hospital's policy titled, "Pain Management (9/18)" was reviewed on 10/1/18 and required, "1. Pain scales are used to assess and indicate the presence of pain and level of severity. The level of pain severity should serve as a guideline in selecting the appropriately prescribed medication. a. 0-10 Numeric scale [0 - no pain, 10 - severe pain] and/or ... Faces Scale [smile - no pain, grimace - severe pain]... Initial/ongoing pain assessment: is to be documented in the permanent record. Pain is assessed and interventions are performed to ensure minimal side effects from analgesic regimen."

2. The clinical record of Pt. #3 was reviewed on 10/1/18. Pt. #3 was a 62 year old female, admitted on 9/28/18, with the diagnosis of dehydration. The Medication Administration Record included that Pt. #3 was given Tylenol with Codeine (pain medication) on 9/30/18 at 9:16 PM. The clinical record lacked documentation of a pain assessment prior to the administration of the medication.

3. During an interview on 10/1/18 at approximately 10:00 AM, the Charge Nurse (E#2) stated that all patients should be assessed before receiving any medications for pain. E#2 stated, "I do not see an assessment for that pain medication administered [9/30/18 at 9:16 PM]. This patient should have had a face scale completed."

Based on document review, observation, and interview, it was determined, that for 6 of 6 packages of chicken fried steaks, 9 of 9 packages of roast turkey, and 1 of 1 package of sliced turkey, the Hospital failed to ensure that frozen food was labeled with the arrival date or the expiration date, potentially affecting the safety of the 83 patients on census on 10/2/18.

Findings include:

1. On 10/2/18 at 1:00 PM, the Hospital's policy titled, "Food Storage" (effective 7/2017) was reviewed and required, "IV. Storage... Perishable foods - Refrigerate promptly upon receiving. Keep refrigerated as listed below until prepared or served... V. Use... 3. Rotate stock so that older items are used first..." The policy failed to provide instructions on dating frozen food packages with either the receipt date or expiration date.

2. On 10/2/18 at 11:05 AM, an observational tour was conducted in the Dietary Area. In the freezer, there were 6 packages of chicken fried steaks, 9 packages of roast turkey, and 1 package of sliced turkey that did not include labels with the date of arrival or the expiration dates.

3. On 10/2/18 at 11:40 AM, an interview was conducted with the Executive Chef (E #6). E #6 stated that the frozen meat packages arrived this morning (10/2/18) and should have been labeled with the arrival date. E #6 stated that he would label them now.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on October 1-3, 2018, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on October 1-3, 2018, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation, and interview, it was determined, that for 1 of 2 patients (Pt. #5) on Droplet Precautions, the Hospital failed to ensure that visitors wore masks while in a Droplet Precautions room.

Findings include:

1. On 10/2/18 at 8:40 AM, the Hospital's policy titled, "Isolation Precautions" (effective 6/26/17) was reviewed and required, "5. It is recommended that visitors should follow the isolation sign(s) and nursing instructions..."

2. On 10/1/18 at 9:20 AM, an observational tour was conducted on the Y1 Medical Surgical Unit. A Droplet Precautions sign was attached to the door of Room 1023. The Droplet Precautions sign included, "Visitors should wear a surgical mask upon entering." Pt. #5 was in bed, and a visitor, who was not wearing a mask, was sitting in the room.

3. On 10/1/18 at 10:23 AM, an interview was conducted with Pt. #5. Pt. # 5 stated that he did not know why there was a Droplet Precautions sign on his door.

4. On 10/1/18 at 10:24 AM, an interview was conducted with Pt. #5's visitor. The visitor stated that she was Pt. #5's grandmother and saw the Droplet Precautions sign on the door. Pt. #5's grandmother stated that she did not need to wear a mask, and that no one had told her that she needed to wear a mask.

5. On 10/1/18 at 10:30 AM, Pt. #5's clinical record was reviewed. Pt. #5 was a 20 year old male, admitted on 9/30/18, with a diagnosis of pneumomadiastinum (air in the central compartment of the thoracic [chest] cavity). A physician's order, dated and timed 9/30/18 at 10:26 AM, included, "Droplet Precautions." A respiratory pathogen panel, dated and timed 9/30/18 at 1:26 PM, included, "Detected" for Enterovirus/ Rhinovirus Nasopharyngea (viral infection usually found in the nose, frequently resulting in a common cold). There was no documentation that Pt. #5 or Pt. #5's grandmother were instructed about Droplet Precautions.

6. On 10/1/18 at 10:10 AM, an interview was conducted with the Y1 Professional Development Specialist (E #1). E #1 stated that Pt. #5's grandmother should have worn a mask when in the Droplet Precautions room.

B. Based on observation and interview, it was determined, that for clean supplies that were dropped on the floor in the Outpatient Cancer Clinic, the Hospital failed to ensure that contaminated supplies were not returned to a clean storage drawer and available for use, potentially affecting the safety of the approximately 125 - 165 patients receiving chemotherapy at the clinic each month.

Findings include:

1. On 10/2/18 at 9:15 AM, an observational tour was conducted in the Out-Patient Cancer Center. While a Patient (Pt. #13) was having a PICC (peripherally inserted indwelling central catheter) flushed (to reduce the possibility of clotting), a Nurse (E #5) dropped a strip of "Merit Medial Dual Cap IV [intravenous] Pole Strip Disinfection Caps for Needle Free Valves" on the floor. E #5 picked the caps strip up from the floor and set it on the counter. A few minutes later, E #5 returned the contaminated caps strip to the clean supply drawer.

2. On 10/2/18 at 10:40 AM, the Hospital's policy related to disposal of contaminated supplies was requested of the Accreditation Manager (E #11). A policy was not found.

3. On 10/2/18 at 1:25 PM, an interview was conducted with the West Region Infection Prevention Program Director (E #7). E #7 stated that there was no policy for disposal of contaminated supplies, but it is the Hospital's practice that, "supplies should be free from contamination" and the contaminated caps strip should have been disposed of.



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C. Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E #8), in the Pre-Operative area, observed for infection control procedures, the Hospital failed to ensure hand hygiene was performed in accordance with the Hospital's policy.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (effective 8/24/16) was reviewed on 10/3/18 and required, "...Indications for hand hygiene...g. After contact with inanimate objects (including medical equipment)...h. After removing gloves. i. When exiting the patient care space..."

2. On 10/3/18, the policy titled "Glucose Monitoring STAT Strip Glucose Meter" (rev 9/18) was reviewed and indicated, "Maintenance A Cleaning the Meter: 1...a. Clean the meter with...disinfectant wipe...Dispose of used wipes and gloves in appropriate biohazard container. Wash your hand with soap and water or hand sanitizer."

3. On 10/3/18 at approximately 10:00 AM, during an observational tour, the Patient Care Technician (E #8), performed a finger stick blood glucose test using a glucometer, at the patient's bedside in bay #21. At the completion of the test, E #8 discarded the used strip and lancet, removed and discarded her gloves. E #8 donned a glove on one hand, took the soiled gauze from the patient and discarded it along with the used glove. E #8 reached for the glucometer and exited bay #21. E #8 walked to the soiled utility room on the other side of the nurses' station. E #8, with ungloved hands, wiped the glucometer with disinfecting wipes and discarded the wipes. No hand hygiene was performed after disinfection of the equipment. E #8 took the glucometer, exited the soiled utility room and kept the glucometer in her hands as she returned it to the nurses' station, where the equipment was then available for use.

4. On 10/3/18 at approximately 10:05 AM, the Charge Nurse (E #9) was interviewed. E #9 stated that E #8 should have performed hand hygiene prior to exiting the patient's room and again after disinfecting the equipment.