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Based on record reviews and interview, the hospital failed to ensure patients admitted for being at risk for harm to themselves or others received care in a safe setting. This deficient practice was evidenced by failure of the hospital to ensure measures were in place to mitigate the safety risk (potential ligature) for patients with continuous oxygen/oxygen tubing in the patient's environment of care for 2 (#1,#3) of 2 sampled patients reviewed with continuous oxygen/oxygen tubing.

Findings:

Review of the hospital policy titled,"Environmental Safety-Room Safety Checks" revealed in part: Policy: It is the policy of this hospital to provide a safe environment for our patients by eliminating safety hazards. Further review revealed no documented evidence that oxygen tubing was identified/addressed as a safety risk in the patients' environment of care.

Review of the hospital policy titled, "Care of Patients-Precautions" revealed in part: Purpose: to provide guidelines for increased supervision as a means to ensure the well-being, safety, and security of a patient who is actively a danger to himself/herself, others, or property, or at risk to elope. Further review revealed no documented evidence that oxygen tubing was identified/addressed as a safety risk in the patients' environment of care and what measures would be taken to mitigate the risk that the oxygen tubing presented.

Patient #1
Review of Patient #1's medical record revealed an admission date of 9/22/17 with an admission diagnosis of Depression. Further review revealed Patient #1 was PEC'd due to being gravely disabled and unwilling to seek voluntary admission. Additional review revealed the patient was brought to an area ED via ambulance due to making threats to family members.

Review of Patient #1's nursing notes revealed the patient was placed on ordered oxygen via nasal cannula at 2 liters/minute continuously on 9/24/17 at 3:00 p.m. Further review revealed no documented evidence that measures had been put into place to mitigate the potential ligature risk that the oxygen tubing presented in the patient's environment.

Review of Patient #1's observation records for 9/24/17 revealed the patient was on q15 minute observations. Further review revealed no documented evidence that measures had been put into place to mitigate the potential ligature risk that the oxygen tubing presented in the patient's environment.

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/30/17 with an admission diagnosis of Depression and co-morbid diagnosis of Chronic Obstructive Pulmonary Disease. Further review revealed the patient's legal status was CEC due to increasing suicidal ideation. Additional review revealed the patient was admitted on continuous oxygen at 2 liters/minute via nasal cannula.

Review of Patient #3's physician's orders revealed the patient was placed on ordered oxygen via nasal cannula at 2 liters/minute continuously on admit. Further review revealed no documented evidence that measures had been put into place to mitigate the potential ligature risk that the oxygen tubing presented in the patient's environment.
Additional review revealed the patient remained on continuous oxygen throughout her hospital stay due to her diagnosis of Chronic Obstructive Pulmonary Disease.

Review of Patient #3's observation records for 11/30/17 through 12/6/17 revealed Patient #3 was on q15 minute observations. Further review revealed no documented evidence that measures had been put into place to mitigate the potential ligature risk that the oxygen tubing presented in the patient's environment.

In an interview on 12/27/17 at 2:44 p.m. with S2CNO, she confirmed Patient #1 and Patient #3 had no documented evidence measures had been put into place to mitigate the potential ligature risk that the oxygen tubing presented in the patient's environment. S2CNO reported it was not the hospital's current policy to routinely put measures into place to mitigate the potential ligature risk that the oxygen tubing presented in the patient's environment.

Based on record review, observation and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to ensure all patient care staff adhered to the hospital's infection control policies/practices for 1 (#R3) of 1 total patients observed on isolation precautions for influenza.

Findings:

Review of the hospital policy titled," Infection Control- Patients with Influenza", revealed in part: I. Purpose: to outline the control measures for staff in order to prevent spread of influenza to patients and employees of this hospital. II. Policy: This hospital shall adhere to the current Centers for Disease Control guidelines for the management of patients with Influenza. Influenza is primarily transmitted from person to person via large airborne droplets that can settle on mucosal surfaces of the respiratory tract of susceptible people. This occurs within a 6 foot radius. III. Procedure: 2. Patients who are diagnosed with Influenza by a physician should be maintained on Droplet and Contact Precautions for 7 days from the onset of illness. 3. The patient should be maintained in a single room, co-horted with another patient with Influenza, or in a blocked room. 4. Staff should wear cover gowns if soiling of clothing is possible with respiratory secretions. 5. Staff should wear a mask for direct patient contact. A N-95 mask should be worn for aerosoling procedures that produce sputum such as nebulizer treatments. 6. Staff should wear gloves for direct patient contact or contact with patient care items in the environment. 8. Staff should remove all protective attire before they leave the room and then perform proper hand hygiene. The patient's room should be cleaned daily following the routine hospital cleaning protocol, including horizontal surfaces, as the Influenza virus may survive on inanimate surfaces.

Review of Patient #R3's medical record revealed an admission date of 12/08/17 with an admission diagnosis of Bipolar Disorder. Further review revealed the patient tested positive for Influenza on 12/23/17. Additional review revealed the patient was placed on contact/droplet precautions.

On 12/28/17 at 9:00 a.m. a review was made of a video recording of staff monitoring/supervision of patients on the Senior Care Unit. The timeframe reviewed was from 1:00 a.m. to 5:00 a.m. (viewed in 15 minute increments) on the night shift ( 7:00 p.m. - 7:00 a.m.) of 12/24/17 (Christmas Eve-Christmas day ). The following infection control breaches were observed during the review of the video recording :

12/25/17 1:15 a.m.: S6MHT was observed entering Patient #R3's room with gloves and a mask on. She was observed leaving the patient's room with the isolation mask and gloves still on. S6MHT walked across the hall and proceeded to make rounds on Patients #R4, #4, #R5, and #R6 with the same mask and gloves on. S6MHT then walked down the hall, sat down, pulled the mask down around her neck, and had a snack and a drink of a beverage with her gloves on. S6MHT still had the same mask and gloves on at this time.

12/25/17 1:30 a.m.: S6MHT entered Patient #R3's room with the same mask worn during the 1:15 a.m. observation and she had no gloves on. She kept the mask on after exiting Patient #R3's room. S6MHT failed to perform hand hygiene prior to entering the rooms of Patients #R4, #4, #R5, and #R6 to observe them for q 15 minute rounds.

12/25/17 2:08 a.m.: S6MHT was observed entering Patient #R3's room with gloves and a mask on. She was observed leaving the patient's room with the isolation mask and gloves still on. S6MHT walked across the hall and proceeded to make rounds on Patients #R4, #4, #R5, and #R6 with the same mask and gloves on. S6MHT again walked down the hall, sat down, pulled the mask down around her neck, and had another bite of her snack and a sip of a beverage with her gloves on. S6MHT still had the same mask on at this time that she had donned originally at 1:15 a.m.

12/25/17 2:24 a.m.: S6MHT was observed entering Patient #R3's room with the same mask on and no gloves. She was observed leaving the patient's room with the isolation mask still on and she again failed to perform hand hygiene after leaving Patient #R3's room. S6MHT again walked across the hall and proceeded to make rounds on Patients
#R4, #4, #R5, and #R6 with the same mask on. S6MHT then walked down the hall and sat down with her mask on.

12/25/17 2:38 a.m.: S6MHT was observed entering Patient #R3's room with a mask and no gloves. She kept the mask on after exiting Patient #R3's room. S6MHT also failed to perform hand hygiene after exiting Patient #R3's room and prior to entering the rooms of Patients #R4, #4, #R5, and #R6 to observe them for q 15 minute rounds. S6MHT then walked down the hall with the mask on and sat down in a chair in the hall.

12/25/17 2:18 a.m.: S5LPN was observed entering Patient #R3's room with a mask on and no gloves. S5LPN exited Patient #R3's room with her mask on and failed to perform hand hygiene prior to entering the rooms of Patients #R4, #4, #R5, and #R6 to observe them for q 15 minute rounds.

12/25/17 3:51 a.m.: S6LPN was observed entering Patient #R3's room with a mask and new gloves. S6LPN was observed leaving Patient #R3's room with the isolation mask and gloves still on. S6MHT again walked across the hall and proceeded to make rounds on Patients #R4, #4, #R5, and #R6 with the same mask and gloves. S6MHT then walked down the hall and sat down with the same mask and gloves on. S6MHT was observed rubbing her face and chin with the same gloves she had worn when making her q 15 minute observations on Patient #R3.

In an interview on 12/28/17 at 9:15 a.m. with S4RNMgr he confirmed the above referenced infection control breaches (he had observed them with the surveyor) noted during the video review. He indicated it was the hospital's policy that staff should have been wearing gloves and a mask when entering the contact isolation patient's room (Patient #R3). He also confirmed it was the hospital's policy that the mask and gloves should have been discarded when leaving the isolation patient's room, hand hygiene should have been performed with glove removal, and a new mask and gloves should have been used with each entry into Patient #R3's room. S4RNMgr also indicated the mask and/or gloves worn by staff when observing Patient #R3 should never have been worn while conducting observations of any of the other above referenced patients.