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Based on medical record review and hospital policy review, it was determined that for 1 of 2 sampled patients with restraints (Patient #1), the restraint order was not obtained either during the emergency application of the restraint, or immediately after the restraint had been applied. Findings include:

Hospital policy titled "Restraint and Seclusion" stated, "...An electronic/written or verbal order will be obtained prior to (or in an emergency immediately within 1 hour after) the application of restraints...Restraint/seclusion may not be ordered as a standing order..."

A. Medical record review for Patient #1 revealed:
- Standing order (#95746438) for restraints non-violent or non-self destructive dated 2/23/23 at 11:22 AM by Employee #17.
- Hospital document titled "Patient Care Timeline" documents first restraint assessment completed on 2/23/23 at 11:35 AM and restraint discontinued on 2/23/23 at 1:20 PM.
- No evidence of physician notification of restraint application until verbal cosign of standing order (#95746438) by Employee #16 on 2/23/23 at 1:45 PM; 2 hours and 23 minutes after application of restraints.

Employee #14 confirmed the finding of no evidence of physician notification of restraint application until verbal cosign of standing order on 2/23/23 at 1:45 PM; 2 hours and 23 minutes after application of restraints.

Based on medical record review and hospital policy review, it was determined that for 1 of 2 sampled patients with restraints (Patient #1), the restraint order was entered as a standing order. Findings include:

Hospital policy titled "Restraint and Seclusion" stated, "...Restraint/seclusion may not be ordered as a standing order..."

A. Medical record review for Patient #1 revealed:
- Standing order (#95746438) for restraints non-violent or non-self destructive dated 2/23/23 at 11:22 AM by Employee #17.
- Hospital document titled "Patient Care Timeline" documents first restraint assessment completed on 2/23/23 at 11:35 AM and restraint discontinued on 2/23/23 at 1:20 PM.

Employee #14 confirmed the finding that order (#95746438) for restraints non-violent or non-self destructive dated 2/23/23 at 11:22 AM was entered as a standing order.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 2 sampled patients with restraints (Patient #1), there was no evidence that the physicians who ordered the restraints had knowledge of the hospital policy regarding the use of restraint or seclusion. Findings included:

Hospital policy titled "Restraint and Seclusion" stated, "...In order to have working knowledge of hospital policy, LIPs (licensed independent practitioner) and staff will be trained during their orientation on the Restraint and Seclusion policy..."

A. Review of medical record for Patient #1 revealed:
- Seclusion only (restrains violent) order written by Employee #16 on 2/23/23 at 2/23/23 8:25 AM.
- Standing order written for non-violent or non-self destructive restraints by Employee #17 dated 2/23/23 at 11:22 AM.
- Standing order was cosigned by Employee #16 on 2/23/23 at 1:45 PM.
- Restraints violent or self-destructive order written by Employee #18 dated 3/7/23 at 1:07 PM.

On 3/9/23 at 11:40 AM, surveyor requested documentation verifying Employee #s 16, 17, and 18 completed training of hospital policy "Restraint and Seclusion". Employee #13 provided documentation verifying Employee #17 received restraint training but was unable to provide documentation of restraint training for physician employees #16 and #18.

Interview with Employee #13 on 3/9/23 at 12:11 PM revealed there is no formalized restraint education for physicians. Information is reviewed in meetings. Policy is available online for all physicians and LIPs.

Employee #13 confirmed there is no evidence that Employee #16 and #18 received training on the hospital policy "Restraint and Seclusion" on 3/9/23 at 12:11 PM. Failure to assure physicians who order restraints have a working knowledge of the hospital policy regarding the use of restrains may lead to misuse of restrains, possible patient injury, and possible patient death.

Based on medical record review, policy review and staff interview, it was determined for 1 of 2 sampled patients with restraints (Patient #1), a face to face evaluation was not conducted within 1 hour of restraint initiation. Findings include:

Hospital policy titled "Restrain and Seclusion" stated, "...Orders for the use of restrains...used for the management of violent/self-destructive behavior...face to face within 1 hour after initiation..."

A. Review of medical record for Patient #1 revealed:
- Standing order written by Employee #16 for Seclusion only (Violent Restraints) dated 2/23/23 at 8:25 AM for seclusion and 4-point soft restraints.
- Patient reevaluated by Employee #16 on 2/23/23 at 2:44 PM.
- No evidence that a face to face evaluation was completed within 1 hour of the 2/23/23 8:25 AM violent restraint initiation.

Employee #14 confirmed this finding on 3/9/23 at 11:35 AM after Employee #15 reviewed medical record and was unable to find evidence that a face to face evaluation was completed within 1 hour of the 2/23/23 8:25 AM violent restraint initiation. Failure to complete a face to face evaluation after the initiation of restraints for violent behavior may lead to misuse of restraints, possible patient injury, and possible patient death.

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness in a manner to assure patient safety in 3 of 3 (100%) patient care/activity areas toured. Findings include:

The hospital policy entitled "Infection Control Guidelines for the Emergency Department" stated, "...Procedure...Responsibilities...Nurse Manager...Assure proper equipment maintenance and cleaning...Environmental Services...The contracted environmental services company will maintain oversight of the cleaning maintenance schedule of the Emergency Department per their established standards and guidelines..."

The hospital policy entitled "Infection Control Guidelines for Environmental Services" stated, "...To reduce the risk of healthcare associated infections that may occur as a result of exposure to contaminated surfaces, equipment, air, dust, and other inanimate objects...Patient Rooms...All upward-facing horizontal surfaces (i.e. high touch surface area...)...Hard surface floors...shall be wet-cleaned daily...Upon patient discharge, all surfaces of the bed and mattress shall be wet-cleaned with an approved disinfectant solution before the bed is remade for the next patient...Clean all horizontal upward-facing surfaces of the room...Environmental Services personnel shall report any maintenance need to equipment to supervisor... "


Findings include:
I. Bayhealth - Kent General Hospital (KGH)

A. Emergency Department (ED) - Environmental tour conducted on 03/07/23 accompanied by Employee #10 Nurse Manager of ED at 9:00AM.

1. Trash on floor of hydration area
2. Used gloves on the floor outside of room C-22
3. Trash on the floor in front of room A-5
4. Trash on the floor in front of room A-6
5. Trash on the floor in front of room B-9
6. Trash on the floor next to crash cart #3
7. Mop left in the corner by the elevator

These findings were confirmed by Employee #10 Nurse Manager of ED on 3/7/2023 at 10:08 AM.