HospitalInspections.org

Based on policy and procedure review, medical record review, and personnel interview, the trained registered nurse failed to consult the attending physician or other licensed independent practitioner who is responsible for the care of the patient after completion of the 1-hour face-to-face evaluation as required by facility policy and procedure for 2 of 2 (N3 and N4) closed medical records reviewed who had a restraint/seclusion incident.

Findings:

1. Policy No.: 11.2.050P, titled "Special Treatment Procedure/Seclusion/Restraint" was reviewed on 2/4/14 at approximately 1:40 PM, and indicated on pg. 2, under Seclusion and/or Restraint section and point D. 2., "The treating LIP (Licensed Independent Practitioner) must be consulted as soon as possible after seclusion and/or restraint..."

2. Review of closed medical records at approximately 9:44 AM on 2/4/14, indicated patient:
A. N3 had a physical hold documented on 1/19/14 at 8:45 PM; N4 had a seclusion hold documented on 12/12/13 at 12:16 PM. Both lacked "Physician/APN (Advanced Practice Nurse) signature and date" on the Restraint and Seclusion Form under the section titled "Physician/APN/RN's Report".

3. Personnel P12 was interviewed on 2/4/14 at approximately 9:30 AM, and confirmed the above-mentioned closed patient medical records lacked documentation of signature and date of the Physician/APN as required by facility policy and procedure on the Restraint and Seclusion Form under the section titled "Physician/APN/RN's Report. This signature indicates the trained registered nurse consulted the attending physician or other licensed independent practitioner who is responsible for the care of the patient after completion of the 1-hour face-to-face evaluation.

Based on policy and procedure review, personnel record review, and personnel interview, the infection control officer failed to ensure a system for identifying, reporting, investigating, and controlling infections and communicable diseases of personnel as required by facility policy and procedure for 9 of 10 (P1-P8 and P10) personnel records reviewed.

Findings:

1. Policy No.: HE 38.1.001A, titled "Associate Health Program Infection Control - Employee Health & Education" was reviewed on 2/4/14 at approximately 1:45 PM, and indicated on pg. 3, under Immunizations section and point:
A. c. "MMR - Healthcare (HCP) who work in medical facilities should be immune to measles, mumps, and rubella. HCP born in 1957 or later can be considered immune to measles, mumps or rubella only if they have documentation of laboratory confirmation of immunity or record of appropriate vaccination against measles, mumps and rubella...";
B. d. "Varicella (chicken pox) - It is recommended that all HCP be immune to Varicella as evidenced by documentation of 2 doses of Varicella vaccine given at least 28 days apart, history of Varicella or herpes zoster based on physician diagnosis or laboratory evidence of immunity..."

2. Review of personnel records at approximately 12:30 PM on 2/4/14, indicated personnel P1-P8 and P10 provide direct patient care and lacked documentation of immunization and/or communicable disease history for rubella, rubeola, and Varicella.

3. Personnel P15 was interviewed on 2/4/14 at approximately 9:12 AM, and confirmed personnel P1-P8 and P10 provide direct patient care and lacked documentation of immunization and/or communicable disease history for rubella, rubeola, and Varicella as required by facility policy and procedure.