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Based on document review and interview it was determined the facility staff failed to ensure one (1) of three (3) patients (Patient #11) was not restrained when there was no evidence of the Patient not cooperating or not sleeping.

The findings include:

The medical record of Patient #11 was reviewed on 10/20/16 with Staff Member #2 and the following information was noted:

Patient #11 was admitted from the Emergency Department (ED) to Intensive Care Unit (ICU) on 10/12/16. Patient #11 was admitted with possible sepsis, alcohol abuse and complaining of vomiting and pain all over. Patient #11 was placed in soft wrist restraints in the ED at 13:00 (1:00 P.M.) and remained in restraints at transfer to ICU. The documentation at the time of transfer by ICU staff does not mention restraints in place. Once transferred to ICU the order for UE - L&R (upper extremity - left and right) soft restraints was continued by physician order on 10/12/16 at 5:38 P.M.

The nursing notes documented in ICU from 10/12/16 at 5:38 P.M. to 10/14/16 at 2:52 P.M. state, increased safety measures were put in place, increased supervision, medications and diversions were used as alternates to restraints. But there is no description as to what type of safety measures were used, how the supervision was increased or what diversions were used. Nursing documented Patient #11's behaviors on the following dates and times:

10/12/16:
17:38 (5:38 P.M.) agitated and quiet
19:38 (7:38 P.M.) quiet
21:38 (9:38 P.M.) sleeping
23:38 (11:38 P.M.) sleeping; tries to pull out central line when able

10/13/16:
00:01 (12:01 A.M.) confused
01:38 A.M. sleeping, tries to pull out central line when able
03:20 A.M. sleeping, verbal response appropriate, tries to pull out central line when able
05:04 A.M. restless, sleeping, tries to pull out central line when able
07:38 A.M. sleeping, tries to pull out central line when able, restraint comment box notes; Pt. sleeping tolerating well
09:25 A.M. sleeping, tries to pull out central lines when able, tolerating well
11:38 A.M. agitated restless, tries to pull out central line when able
13:32 (1:32 P.M.) agitated restless, tolerating (restraints) well, tries to pull out central line when able
15:38 (3:28 P.M.) trying to pull off gown, restless, tries to pull out central line when able
17:34 (5:34 P.M.) sleeping, awake and cooperative, (Restraint Comment Box states, "able to remove restraints" at 16:00 (4:00 P.M.)) Assessment says: reason for restraints, to protect the integrity of lines/tubes, Extremity Left UE (upper extremity), Right UE, Type of Restraint soft
17:38 (5:38 P.M.) restless, Assessment says: reason for restraints, to protect the integrity of lines/tubes, Extremity Left UE (upper extremity), Right UE, Type of Restraint soft, Restraint comment box says, "Tolerating well". Physician order to continue restraints
19:38 (7:38 P.M.) restless, tries to pull out central line
21:38 (9:38 P.M.) restless, tries to pull out central line
23:38 (11:38 P.M.) sleeping, tries to pull out central line

10/14/16:
01:38 A.M. agitated, restless, tries to pull out central line
03:38 A.M. sleeping, tries to pull out central line
04:00 A.M. appropriate
07:34 A.M. sleeping, no improvement
08:00 A.M. verbal response confused
09:34 A.M. restless, tolerating well, no improvement
09:38 A.M. restless, tolerating well
11:08 A.M. restless, tolerating well, no improvement
13:38 (1:38 P.M.) sleeping tolerating well, no improvement
14:52 (2:52 P.M.) restless, tolerating well, no improvement
At approximately 5:00 P.M. the physician gave an order to discontinue restraints.

There is no evidence in the nursing documentation listing what increased safety measures were put in place, what increased supervision was provided, and what diversions were used as alternates to restraints. There were times when it was documented Patient #11 was sleeping for 10 to 12 hours yet remained in restraints. Nursing documentation stated Patient #11 was restless but "tolerating the wrist restraints well" and "restless, tolerating the wrist restraints well but no improvement".

Staff Member #2 provided a copy of the Policy #: NRS-125 Restraint: Non Behavioral, which documents in the section "Renewal of Restraint Orders for Non-Behavioral Management" #3: If a change in the patient's condition supports removal of restraints, the episode is ended.

Staff Member #2 stated, "I don't see where the staff documented the alternatives to restraints or why they kept the patient in restraints when [he/she] was sleeping."

Based on document review, observation and interview it was determined the attending physician failed to ensure the protocol for history and physical updates was followed per the medical staff bylaws when the patient is on outpatient status for one (1) of five (5) outpatients, Patient #21.

The findings include:

On 10/19/16 Patient #21 was admitted as an outpatient for a cystourethscopy. Patient #21 had a history and physical (H&P) in the medical record dated 10/10/16. There was a red stamp on the H&P where the physician indicates if there have been any changes or not in the patient's medical condition since the H&P was completed. Staff Member #24 signed and dated the update but failed to indicate if there had been any changes in Patient #21's medical condition since the H&P was originally performed.

A review of the medical staff bylaws page 14, lines 26 - 31, state the following:
"At the discretion of the physician, a history and physical examination performed within 30 days prior to admission/service may be used provided a durable, legible copy or original is in the patient's Hospital medical record ad the history and physical examination is reviewed at the tine of admission/service and updated with 24 hours to include significant changes which may have occurred since the report, but prior to surgery or a procedure requiring anesthesia."

Staff Member #11 stated, "You are correct [he/she] did not complete the update to the H&P."

Based on medical record review and interview it was determined that the facility failed to develop and keep current a nursing care plan for one (1) of ten (10) patients, Patient #6.

The findings include:

A medical record review on October 19 and 20, 2016 of Patient #6 revealed the following:

On October 17, 2016 a Nursing Note reads in part "received patient from Intensive Care Unit. Patients skin on buttocks and back are red but blanchable. Will turn on side and continue to monitor". There is no follow up notes and this is not addressed on the care plan.

An interview with Staff Member #6 revealed that this the only note addressing the patient's skin and it is not documented on the patient's care plan.

Based on medical record review and interview it was determined that the facility failed to maintain an accurate medical record for one (1) of twenty (20) records reviewed, Patient #1.

The findings include:

On October 19, 2016 a medical record review for Patient #1 revealed documentation on the Nursing Admission Assessment stating the patient was admitted from the Emergency Room (ER) on October 17, 2016. Documentation in the History and Physical dated October 17, 2016 revealed that Patient #1 was directly admitted from home for scheduled surgery and not admitted from the ER as documented on the Nursing Admission Assessment.

An interview with Staff Member #5 revealed that Patient #1 was admitted directly from home for surgery on October 17, 2016.

Based on document review and interview it was determined the facility staff failed to ensure two (2) of five (5) outpatients, Patient # 23 and #24, that had outpatient surgical procedures performed had a current history and physical (H&P) prior to the surgical procedure.

The findings include:

On 10/19/16 the medical record of Patient #23 was reviewed with Staff Member #2. The medical record revealed the following:
Patient #23 was admitted and discharged on 10/17/16 for a Bilateral Lumbar T12 - L1 Transforaminal Epidural Steroid Injection. Patient #23 had an H&P performed in August 2016 (the actual date in August was not readable). There was no updated H&P on the medical record.
Patient #24 was admitted on 10/17/16 with an H&P dated 9/8/16. The H&P was 2 days past the accepted 30 day limit.

A review of the Medical Staff Bylaws page 14, lines 26 - 31, state the following:
"At the discretion of the physician, a history and physical examination performed within 30 days prior to admission/service may be used provided a durable, legible copy or original is in the patient's Hospital medical record ad the history and physical examination is reviewed at the tine of admission/service and updated with 24 hours to include significant changes which may have occurred since the report, but prior to surgery or a procedure requiring anesthesia.

Staff Member #11 stated, "You are correct the H&P is outdated and [he/she] did not complete the update to the H&P. I don't know how I missed that since I review the records for a current H&P."

Based on observations, document reviews and staff interviews it was determined the facility staff failed to ensure the physical plant was maintained in a manner to assure the safety and well-being of patients, visitors and staff.

Please see Tags 701 and 749 and the Life Safety Code survey of November 7, 2016 for more detailed information related to this condition level tag.

Based on observation and interview it was determined that the facility failed to maintain the physical plant in such a manner to assure the safety and well-being of staff and patients.

The findings include:

During the initial tour of the facility on October 17, 2016 the following was observed:

The Laboratory Department had countertops with cracks and broken, jagged areas. The corner strips of the counters were sticking out in some areas and held in place with packing tape in other areas. The electrical strip above the counter was rusted in the main laboratory area. In the Blood Bank area there was packing tape holding the side strips of the counter intact.

In the Perioperative Department there was splintered wooden doors and broken plastic kick plates. There were walls torn down to the plaster in the Sterile Supply area. Broken, lumpy tiles were observed in the Post Operative area.

In the Outpatient Physical Therapy Department, the floor tiles were cracked making an uneven walking surface. There was no call bell in the patient restroom for use in the event of an emergency.

The findings were discussed with Staff Members #1 and #2 on October 17, 2016.

Based on document review, interviews and observations it was determined the facility staff failed to follow the infection control plan by ensuring all areas where damage to the facility and facility furnishings could prevent proper cleaning, failure of staff to follow acceptable standards of practice in the storage of IV solutions and syringes with medications were followed, ensuring items taken into a patient's room were cleaned before returning to the nurses station or taken to another patient's room and that appropriate hair covering was worn in the food preparation area of the kitchen.

The findings include:

ED:
On 10/17/16 at approximately 11:30 A.M. during the tour of the facility's ED (emergency department) with Staff Member #3, the waiting area was observed. There were approximately 28 chairs in the waiting area all with wooden arm rest in various stages and amounts of exposed wood. The exposed wood being porous could not be properly cleaned to aid in the reduction of infections. A stool in the triage area was torn with the cotton batting exposed.

Laboratory:
At approximately 12:10 P.M. the laboratory (Lab) area was observed with Staff Member #1. The counter tops of the entire Lab area were in various stages of the need to be repaired. Where specimens enter the Lab the counter tops were chipped and broken leaving exposed wood /particle board (porous surfaces). In at least 2 places the end caps of the counter tops were held on with packing tape. One of which was in the blood bank area. The electric strip running behind equipment was rusted, making any splashes or spills unable to be cleaned properly.

The Lab had a CAP (College of American Pathologist) survey conducted on 8/8/16 and had no deficiencies related to infection control, environment or safety sited.

Staff Member #18 stated the Lab has been in the budget for 2-3 years for repairs.

Kitchen/Dining Area:
On 10/17/16 at approximately 12:50 P.M. the kitchen and dining area were inspected and the following issues were noted:
In the dry food storage area the following items were found opened and exposed and undated as to when they were opened; box of cream of wheat, bag of rice, container of grits, container of bread crumbs, box of croutons, box of cookies and a bag of pancake mix. The container of bread crumbs was wrapped in plastic wrap and returned to the shelf while the tour was taking place.
Dry food once opened should be stored in an airtight container to prevent rodent and pest infestation.
In the freezer a bag of chicken containing 2 chicken breast was found opened and undated. Staff Member #25 stated, "We don't have a policy about wrapping and dating dry goods that have been opened. The chicken should have been dated."
On 10/20/16 at 9:00 A.M. Staff Member #2 was asked to try and locate a policy related to the storage of food opened and accessed and stated, "We do not have a policy related to the wrapping of opened dry goods."
Also during the tour one staff member was observed with braided hair hanging to their waist with no hair covering.
The walls in the dining area had exposed drywall which could not be cleaned.

The policy titled Labeling and Dating Prepared Foods with a revision date of 1/2016 Procedure:
1. Dating Guideline should be followed as follows: Dry good (nuts, chocolate chips, croutons, sunflower seeds, sugar, bread crumbs) - 6 months from opening.
5. Foods which are not labeled or exceed the expiration date will be discarded.

The policy titled Standards of Dress and Behavior effective 4/2014 states, "Hair will be restrained with a hairnet or cap covering all hair".

A Food Establishment Inspection was conducted prior to the surveyor inspection on 10/17/16 and there were no situations for food being protected from contamination.
Virginia Food Regulations 12VAC5-421-240. Effectiveness of hair restraints. A. Except as provided under subsection B of this section, food employees shall wear hair restraints, such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
Nursing Unit:
At approximately 1:30 P.M. in the clean utility room a dirty cast saw was observed stored in the equipment cart. A broken sharps container was hanging on the wall. An IV bag of 100 milliliters sodium chloride had been removed from it outer protective covering and was not dated as to when it should be discarded.
While on the nursing unit with Staff Member #13 and 8 one staff nurse was observed moving the computer cart from room #118 to the nursing station to room #148 and never cleaning the cart after entering the patients' rooms with the cart. Also while on the nursing unit the portable x-ray machine was brought to room #104, used and removed and never cleaned.
Off Site Locations:
On 10/18/16 several offsite locations were observed and the following notations were made:
Building B Office #301: The chair used when drawing blood from patients was torn exposing porous surfaces.
Building A Surgical Specialist Office: Procedure room used for minor procedures had a dusty light and table where patient would be for the procedures.

At 11:00 A.M. the Bone Joint Center was observed which had casting tables with tears on them. The floor molding around the entire office suite was pulling away from the walls, had areas were the floor molding was behind the sub-floor and in places being held to the wall with packing tape. Staff Member #26 stated, "The building landlord put the tape on the floor molding". The molding pulling away keeps the floor and the walls from being properly cleaned in the event of a splatter or spill.
The Hand Room contained a table for had examinations that was dirty with debris.

On 10/18/16 at approximately 12:07 P.M. the surgical suite was observed with Staff Member #11 and the following was noted:
A position wedge in the Endo Room had several tears exposing porous surface which would prevent disinfection cleaning.

The floor in the Post Op area had numerous cracks and worn tiles.

OR #1 a vial of Diprivan 100 ml was found opened and accessed with not expiration date.
A corrugated box was stored in the anesthesia supply cart bottom drawer which also had debris in it. There was also 4 IV bags of 0.9% Sodium Chloride out of their protective outer cover that were not dated for their expiration dates.

OR #2 The surgical table and arm rest had several tears exposing porous surface. There was surgical tape on the supply cabinet. Chipped paint around the room and a red substance on the ceiling tiles over the surgical table that appeared to be blood.

OR #3 a syringe with lidocaine 2 cc (cubic centimeters) dated 10/17/16, untimed and with no initials as to who drew up the medication was found in the anesthesia cart. Staff Member #11 stated, "That should have been discarded yesterday."
There was also 5 IV bags of 0.9% Sodium Chloride out of their protective outer cover that were not dated for their expiration dates.

Sterile Corridor a nursing station had chipped and broken cabinetry leaving exposed bare wood.

Decontamination Room: ceiling tiles appeared to be wet. The pass through window from decontamination to clean room had broken plaster leaving exposed plastic for hold plaster in place on both sides of the window.
Also in the decontamination room there was one area where the dirty to clean process crossed over each other. As you entered the room immediately on the left was the sonic bath. Before items were placed in the sonic bath they had to be cleaned and disinfected in the sink which was to the left of the sonic bath. A soiled item would pass by the sonic bath to the sink then back to the sonic bath then over to the pass through window.

Sterilization/Clean Side: The walls had exposed sheetrock, dirty floors, tiles in the floor broken and chipped.

Based on medical record review and interview it was determined that the facility failed to establish an adequate discharge plan, address all patient needs at discharge and to follow there own policy and procedure for initiating discharge planning on admission for three (3) of ten (10) inpatients, Patients #6, 8 and 11.

The findings include:

A Medical Record Review on October 19 and 20, 2016 for Patient #6 revealed the following:

Patient #6 is a 69 year old admitted to the Intensive Care Unit from the Emergency Department on October 13, 2016. Patient #6 was brought to the Emergency Department by Emergency Medical Services with spouse that lives with the patient complaining of "confused and inability to walk". Patient's admitting diagnoses were symptomatic hyponatremia, metabolic encephalopathy, alcohol dependence, Wernicke's encephalopathy, ataxia and benign essential hypertension.
The Nursing Admission Assessment documentation reveals discharge planning on Patient #6 "lives only with spouse, gets to doctor by self, gets prescriptions by self and takes medications as prescribed" dated October 13, 2016.

The Admission History and Physical (H&P) by the physician documentation reveals Disposition Plan: "Discharge" Timeframe "TBD" dated October 13, 2016.

The General Medical Adult Progress Note for October 14 and 15, 2016 documentation reveals "Disposition Plan: Discharge Timeframe: TBD". On October 16, 2016 "Disposition Plan: Discharge Disposition Plan Details: to: SNF; Timeframe: TBD". On October 17, 2016 "Disposition Plan: Discharge Disposition Plan Details: to: SNF; Timeframe: TBD".

Patient #6 was transferred to the Medical/Surgical Department on October 17, 2016.
On October 17, 2016 Physical Therapy Progress Note documentation reveals "Pt states that feels slightly dizzy and unsteady during gait." Assessment states "Pt did not walk using an assistive device before but it is now recommended that patient use a front wheel walker for community ambulation and house hold ambulation as needed."

Discharge planning notes revealed the following: October 17, 2016 "Discharge placement plan: home with home health with outpatient physical therapy". On October 18, 2016 "Services at discharge: initially, patient was planning on going to SNF (Skilled Nursing Facility). Patient asked writer to discuss choices with spouse. FOC (Freedom of Choice) list was offered and two facilities were chosen, both of which are unable to accept the patient. Spouse stated that could not drive farther to any other facility and asked if patient could discharge home with home health. This was discussed with doctor who approved the plan." On October 19, 2016 there is a note from discharge planning reading in part "spouse call seeking guidance. Home health will see patient on October 20, 2016 and cannot accommodate any sooner and MD was unable to see patient today".

The Physician Discharge Summary shows the patient discharged to "home with home health with outpatient physical therapy services" on October 18, 2016.

Patient #8 is a 73 year old admitted to the Intensive Care Unit from the Emergency Department on October 14, 2016. Patient #8 was brought to the Emergency Department by Emergency Medical Services with "hip pain". Patient's admitting diagnosis was right hip fracture. Patient #8 had surgery on October 18, 2016.

The Nursing Admission Assessment documentation reveals discharge planning on Patient #8 "lives only with spouse, gets to doctor by family/friend, gets prescriptions by family/friend and takes medications as prescribed" dated October 14, 2016.

The Admission History and Physical (H&P) by the physician documentation reveals Disposition Plan: "Discharge" Timeframe "TBD" dated October 14, 2016 .
The General Medical Adult Progress Note for October 15 and 16, 2016 documentation reveals "Disposition Plan: Discharge Timeframe: TBD". On October 17, 2016 "Disposition Plan: SNF Timeframe: TBD".
Discharge Planning Notes revealed the following: On October 17, 2016 "Discharge placement to : TBD - Anticipated SNF for Rehab Post Surgery".


An interview on October 20, 2016 at 10:30 a.m. with Staff Member #9 revealed that Case Management tries to see all patients admitted to the hospital but they have to work on priority and the intensive care unit patients are usually last to be seen.