HospitalInspections.org

Based on review of departmental policies and procedures and interview with staff, the facility failed to follow their policy for review of departmental manuals.

Findings include:

The policy titled "Policy and Procedure Process (P& P)" included, "...All policy requires administrative concurrence. Generally the policy is also approved by the manager of the originating department... All department manuals should be reviewed on an annual basis at the start of the year. The P & P Coordinator will provide a reviewal sheet on request."

During the survey departmental manuals to include Dietary, Nursing, Emergency Room, Radiology, Rehabilitative Services, Medical Records, Laboratory, Pharmacy, Obstetrics and Operating Room were reviewed. There was no documentation of an annual review and no reviewal sheet was available for review when requested by surveyors.

An interview with Employee Identifier # 1, (Chief Quality Officer) on 5/12/10 at 2:30 PM confirmed no policy review signature sheet was available for review.

Based on observations and interviews with facility staff, it was determined the Hospital failed to post written instructions informing outpatients and emergency room patients of the right to file a complaint with the State agency. This had the potential to affect all patients admitted through the Emergency and Outpatient departments.

Findings include:

1. During a tour of the emergency room (ER) on 5/11/10 at 11:45 AM it was noted that the hospital did not have posted the toll free state hot line phone number for patients to call to voice grievances.

An interview with Employee Identifier (EI) #2 (Associate Director of Nursing Services) and EI #3 (ER Manager), on 5/11/20 at 11:50 AM verified the hospital did not have the toll free state hot line phone number posted to which ER patients can voice grievances.

2. During a tour of the outpatient department (OD) on 5/11/10 at 11:10 AM it was noted the hospital did not have posted the toll free hot line number for patients to call to voice grievances.

An interview with EI # 1 (Chief Quality Officer) on 5/11/10 ar 11:20 AM verified the hospital did not have the toll free state hot line phone number posted to which OD patients can voice grievances.

Based on observation, medical record review, and review of the facility's policies and procedures the facility failed to assure daily written Physician orders for soft wrist restraints were obtained for Patient Identifier (PI) # 4. PI# 4 was one of three medical records reviewed for restraints.

The findings include:

The Policy and Procedure # 2151 Restraint Policy revised 9-14-09 documented, "Policy: ... Restraint Application for Non-Behavioral Health Purposes- (Restraint Clinical Protocol): ... 5. The patient should be assessed/ evaluated each calendar day by the MD (Medical Doctor) for continued need for restraint and an order entered on the Restraint Clinical Protocol Order Form."

PI# 4 was admitted to the facility on 4/28/10 with the primary diagnosis of Acute Exacerbation of Congestive Heart Disease and Respiratory Insuffiencey. The initial restraint order for soft limb upper extremities was obtained on 5/2/10 at 2:12 AM. The nurse documented, "Pt (patient) consistently attempting to get out of bed, pulling at lines, Foley, etc."

There was no documentation of a physician order for the soft limb restraints on 5/7/10, 5/8/10, 5/9/10, 5/11/10, and 5/12/10.

During an observation of care on 5/12/10 at 1:30 PM, the surveyor observed the patient had soft bilateral wrist restraints applied.

During an interview on 5/12/10 at 2 PM, with the Chief Nursing Officer, Employee Identifier (EI)#4, he verified there was no documentation of a physician order for the restraints on the above listed dates.

Based on hospital policy review, medical record review and interviews with the staff, the hospital failed to assure orders for the use of restraints were not written on an as needed basis for Patient Identifier (PI) # 3. PI # 3 was one of three medical records reviewed with restraints.

Findings include:

The Policy and Procedure # 2151 Restraint Policy revised 9-14-09 documented, "Policy: ... Restraint orders may not be written as a standing order or on an as needed basis (prn)."

PI # 3 was admitted to the hospital on 4/9/10 with diagnoses including Nausea/Vomiting, End Stage Renal Disease and Bacteremia. Review of the Inpatient Hemodialysis Orders, dated 5/3/10 included, "...Restraint (R) (right) arm for dialysis, PRN (as needed)..."

An interview on 5/13/10 at 11:00 AM with Employee Identifier # 1 (Chief Quality Officer) confirmed the policy for restraint orders had not been followed.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on record review and interviews the facility failed to follow their emergency department (ED) policy for reporting 2 of 2 patients (Patient Identifier #'s 1 and 2) admitted with animal bites.

Findings include:

The policy titled "Animal Bites (Rabies Protocol) included, "Reporting of animal bites: the emergency staff is responsible for reporting animal bite incidents. 1. Animal bites occurring within ...County should be reported to the ........County Health Department."

1. Patient Identifier (PI) # 1 was admitted on 4/10/10 with a diagnosis of dog bite. A review of the medical record revealed no documentation of this incident being reported to the county health department as stated in their policy.

2. PI # 2 was admitted on 4/13/10 with a diagnosis of dog bite. A review of the record revealed no documentation of this incident being reported to the county health department as stated in their policy.

An interview on 5/13/10 at 2:00 PM with Employee Identifier # 1 (Chief Quality Officer) confirmed these two incidents had not been reported.