HospitalInspections.org

Based on observations, interviews, and record reviews, the facility failed to ensure that the premises were clean and orderly.

Findings included:

Observations conducted at the facility on 11/08/16, from 11:30 am to 2:00 pm revealed the following:

Operating Rooms:

- In OR [operating room] #1, there were accumulations of dust, paper wrapping debris, and plastic medication vial caps around and under the surgical equipment, electrical cords and behind the anesthesia cart.

- In OR #2, an electronic tourniquet machine had unidentified biological material and fingerprints on the display panel.

In an interview conducted at the time of discovery, the Director of Surgical Services confirmed the above findings. She further revealed OR#1 was last used on the Friday prior to the survey (11\ 04\16) and it should have been terminally cleaned after the last case on that day. When asked about the electronic tourniquet in OR #2, she stated that it was last used in OR#1 during the surgical procedures conducted on 11\04\16, and was wheeled into OR#2 for storage.

Decontamination Room:

- The washing machine, which was used to process surgical instruments, had accumulations of a reddish brown substance around the glass window located in the door. Further observation revealed what appeared to be a silicone patch which had been applied to the glass window in an attempt to stop the leak. The silicone was peeling and in poor condition.

- The cabinet underneath the sink where surgical instruments were scrubbed/ processed had accumulations of a brown substance and unidentified debris.

In an interview conducted at the time of discovery, the Director of surgical services confirmed the above findings.

Medical\ Surgical Floor:

- 3 office chairs were being stored in the egress hallway within the patient care area.


The above was verified at the time of discovery with the Chief Nursing Officer on the afternoon of 11/08/16.

Record review of the facility Infection Control Program and Plan, dated 7/28/10, section entitled Functions of the Infection Control Department, revealed in part the following:

- The activities of infection control are accessible to all individuals, departments, services and consumers involved in patient care. All departments will implement policies of the Infection Control Committee which include, but are not limited to:

- Cleaning methods, including sterilization and disinfection.

Based on record review and interview, the facility failed to ensure nursing assessments, Care Plans, and follow-up evaluations were completed in a timely manner. The facility nursing staffs failed to ensure a complete nursing assessment was conducted, Care Plans implemented, and the physician notified for 1 of 1 patients (#8) who presented with skin breakdown while admitted to the facility.

Findings include:


Review of the clinical record of Patient #8 revealed he was an 92 year old male who came into the Emergency Room (ER) on 09/30/16 for a chief complaint of weakness. He was admitted to inpatient status on 09/30/16 for a diagnosis of Pneumonia. On 10/04/16 he was admitted into a Swing Bed.

Review of the nursing flowsheet dated 11/7/16 at 16:20 Registered Nurse (RN) #5 documented: " 3-Stage II ulcers to buttocks."

Review of the nursing flowsheet dated 11/8/16 at 16:08 revealed: " Stage 2 ulcers to buttocks. "

Further review of the clinical record revealed no evidence that nursing staffs continued to monitor/ track the condition of patient #8's skin, implemented a care plan for skin breakdown, or notified the physician regarding the ulcers in order to obtain physician's orders for treatment.

In an interview conducted on 11/8/16 at 04:30 PM, RN #5 revealed that Patient #8's ulcers to his buttocks were hospital acquired, stating that on 11/7/16 she first observed stage II ulcers on Patient #8's buttocks which were open (first layer of skin gone). During continued interview, RN#5 confirmed that the physician had not been notified of Patient #8's stage II ulcers to his buttocks and/or treatment orders obtained.

In an interview conducted on 11/8/16 at 4:40 PM, the RN Charge Nurse stated she was not aware that Patient #8 had documented staged II ulcers to his buttocks. She further revealed that a care plan should have been implemented for wound care once identified and documented. The care plan would include a detailed assessment using a template to include all the details of the ulcers; and the care plan of keeping the patient turned, cleaned, treatment applied.

Based upon observation, record review, and interview, the facility failed to ensure evidence that 20 of 20 patients reviewed for rights (Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20); were informed of their patient rights orally and in writing, in advance of furnishing patient care; and the mechanism for the initiation, review, and resolution of patient complaints concerning the quality of care.

Specifically the facility failed to ensure:

Patient Rights information was reviewed with patients, posted, and available upon interview/request at the facility's main registration/admission area, and at the facility's registration area of the Emergency Room (ER) Department.

Findings included:

Review of the Facility's Policy for Patient Rights and Responsibilities, undated, revealed in part, "The patient has the right to information at the time of admission about the Hospital's Patient's Rights policy. The patient has the right to obtain information from the Hospital with regard to the Hospital's and the state's mechanism for the initiation, review and resolution of complaints concerning the quality of care received."

Record review of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20's medical records revealed there was no evidence or documentation that Patients were given a copy or informed of their Patient's Rights either orally and/or in writing upon admission and/or registration.

During an interview on 11/08/16 at 04:00 PM with the Registered Nurse (RN) Informatics confirmed that Patient's #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20's medical records did not contain evidence or documentation that Patients were given a copy or informed of their Patient's Rights either orally and/or in writing. The RN Informatics stated Patients were provided a copy of the facility's "Privacy Practices" and placed the signed copy of the Privacy Practices into their medical records.

A.) During an interview on 11/09/16 at 10:15 AM with the Admitting/Patient Registration Clerk (RC #1) of the main admitting area revealed that Patients were only given a copy of the Patient's Rights upon request, and only if they want them. This surveyor requested a copy of the Patients' Rights from this Registration Clerk; and was provided a copy of the "Privacy Practices" and not the Patients Rights. RC#1 confirmed she did not have a copy of any Patients' Rights available upon request.

During an interview on 11/09/16 at 10:25 AM with the Lead Admitting/Registration Clerk (RC #2) of the Emergency area stated that Patients were offered a copy of the Privacy Practices policy during registration. RC#2 was unable to provide this surveyor a copy of the Patients' Rights upon request. RC#2 confirmed she did not review any form titled Patient Rights with Patients; when registering patients for patient care.

Based on record review and interview, the facility failed to ensure specific patient rights to be free from physical restraints implemented for 1 of 1 patient reviewed (Patient #13) with physical restraints. Specifically, the facility failed to ensure physical restraints were in accordance with the regulatory requirements and facility's restraint policy and procedures during the implementation of physical restraints used for safety and the management of behavior.

Findings included:

Review of the facility's policy and procedures regarding Restraints, approved 03/04/14 revealed the following in part:

Physical Restraints were any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove, which restricts freedom of movement or normal access to one's body.

Restraints for Behavior Management should be reserved for those occasions when unanticipated, severely aggressive or destructive behavior places the patient or other in imminent danger.

A physician's order is required for restraint. The order for restraint must specify the reason, the type of restraint, and the duration written for specific episodes and will specify the start and end times.

Restraint orders for behavior management are limited to the following: Adults- four (4) hours.
Renewal/Re-evaluation: When the original order is about to expire, the "Trained RN" must be notified to perform another Face to Face Evaluation to determine need for restraint continuation.

New Restraint Order: If, during the trial release period, it is determined the patient needs to be restrained again, a new order must be obtained if the trial period lasted longer than 60 minutes. Also, when the escalating behavior is not related to the same episode, a new order must be obtained.

Restraints may be removed any time the RN feels the patient's behavior has improved to a controllable level. The minimum amount of physical force needed to control a patient should be employed.

Patient #13's records:

Review of Patient #13's records revealed he was a 56 year old male admitted on 07/04/16 to the med surge floor for Chronic Obstructive Pulmonary Disease (COPD) with shortness of breath. Review of the Physician Orders (PO) for restraint ordered on 07/07/16 at 17:47 revealed "restrain patient with bilateral wrist soft restraints." Further review of the PO for restraint revealed there was no reason for restraint, and no specific duration for restraint.

Review of Patient #13's nursing notes/restraint flowsheets revealed the following:

On 07/07/16 at 17:45 "restraints applied at this time." Bilateral wrist restraints and vest restraint. Due to psychotic behavior with hallucinations and delusions.

On 07/07/16 at 17:47 Registered Nurse (RN) #2 documented Patient #13 "is having an extended psychotic episode with violent behaviors including pushing a nurse, ripping a phone out of the wall and throwing it at nurses, throwing computers and tele monitor screens at nurses."

Patient #13's nursing notes revealed restraints remained on from 17:45 until 20:45 when Licensed Vocational Nurse (LVN) #1 documented at 20:45 "Patient currently cooperative, expressed displeasure with the restraints but verbalized understanding of the need. Patient released at this time for toilet use followed by sitting on the edge of the bed to eat supper tray.

LVN #1 documented on 07/07/16 at 21:55 "Patient cooperative, following commands. Ready for bed, restraints reapplied." Restraints used were bilateral wrist restraints and vest. There was no justification for the need for continued restraints and reapplication upon release at 20:45. There was not a physician order obtained for the reimplementation of the applied restraint when patient was documented to be cooperative. Review of nursing notes revealed Patient #13 remained in restraints from 21:55 until 07/08/16 at 07:54 (9 hours) when restraints were noted to be in place; but not tied. Nursing notes revealed the following documentation during the time Patient #13 remained in restraints:
On 07/07/16 at 23:36- calm and cooperative (in restraints.)
On 07/0816 at 00:44- resting quietly with eyes closed, (in restraints);
At 01:44- Patient's behavior cooperative, (in restraints);
At 03:50- calm and cooperative,
At 05:40 - Patient's behavior cooperative, (in restraints);
At 06:24- Patient resting, cooperative (in restraints);
At 07:54- restraints in place, not tied.

During an interview on 11/09/16 at 11:30 AM with the CEO confirmed the above findings for Patient #13; after review of the records. The CEO confirmed the facility's policy and procedures for restraint were not followed for Patient #13.