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Tag No.: A0171
Based on clinical record review and interviews with facility personnel for two sampled patients (Patient #17 and #18), the facility failed to ensure that restraint orders were renewed and/or timed for patients with violent behaviors.
The findings include:
1. Patient #17 was admitted to the hospital on 6/27/10 with agitation and delirium. Review of the physician's orders dated 6/27/10 identified that the patient was to have restraints for four hours then notify the physician. Further review identified that at 10:21am, Patient #17 had four point restraints applied due to agitation and threatening staff members. Patient #17 was identified as a threat to himself and/or others and remained in restraints from 6/27/10-6/28/10 (23 hours). Further review failed to identify that a physician's order was obtained and/or the physician was notified of the continued need for restraints. Review of hospital policy identified that all re-orders/re-assessments for behavioral restaints must be received within four hours. Interview with the Quality Coordinator #1 on 6/28/10 identified that the renewal/reassessment was not completed per policy.
2. Review of Patient #18's clinical record with the Nursing Director identfied that the patient was admitted on 5/29/10 with schizoaffective disorder and major depression. Review of the clinical record indicated that the patient had been restrained on multiple occasions. Review of the clinical record identfied the patient was placed in four point restraints on 6/21/10 at 3:45 PM. The order form indicated that the need for restraints was re-ordered however the order failed to reflect a time that the order was written.
Review of the facility policy indicated that orders for restraints are good for no longer then four hours for adults.
Tag No.: A0175
Based on clinical record review and interviews with facility personnel for one sampled patient (Patient #17), the facility failed to ensure that the patient was assessed per hospital policy.
The findings include:
1. Patient #17 was admitted to the hospital on 6/27/10 with agitation and delirium. Review of the physician's orders dated 6/27/10 identified that the patient was to have restraints for four hours then notify the physician. Further review identified that at 10:21am, Patient #17 had four point restraints applied due to agitation and threating staff members. The patient was identified as a threat to himself and/or others and remained in restraints from 6/27/10-6/28/10 (23 hours). Further review failed to identify that an RN assessment was completed every hour the patient remained in restraints. Review of hospital policy identified that assessments by a RN or LIP shall occur based on the patient's condition but at least once every 60 minutes. Interview with the Quality Coordinator #1 on 6/28/10 identified that the RN assessment was not completed per hospital policy.
Tag No.: A0179
Based on a review of the clinical record, policy, and interview for one patient (Patient #18), the facility failed to ensure that patients with restraints are assessed within one hour of restraint application per hospital policy. The finding includes:
Patient #18 was admitted on 5/29/10 with schizoaffective disorder and major depression. Review of Patient #18's clinical record indicated that the patient had been restrained on multiple occasions. Review of the restraint orders during the period of 6/2/10 through 6/21/10 failed to identify that face to face evaluations by the LIP were conducted within one hour of being implemented on 6/2/10, 6/3/10, 6/4/10, 6/5/10 and 6/6/10.
In addition review of the restraint order dated 6/21/10 indicated that restraints had been applied at 3:45 PM. The order form indicated that the physician had signed the order and that the face to face evaluation by the LIP within one hour had been completed however the documentation failed to identify the time of the evaluation.
Interview with the Nursing Director on 6/28/10 at 1:30 PM indicated that the face to face evaluation was completed within one hour from the time the physician signed the restraint orders.
Review of the restraint policy indicated that the responsible MD or LIP should perform a face to face assessment of the patient's psychological and physical status within one hour or restraint application.
Tag No.: A0288
Based on review of hospital policies, review of hospital documentation and interviews with hospital personnel regarding quality assurance activities related to a neonatal adverse event, the hospital failed to develop and revise the hospital's policy to clearly define the mechanism for neonatal medical coverage during delivery. The findings include:
1. A review was conducted on 6/28/10 of the quality assurance activities related to a neonatal adverse event. Review of the Neonatal Code 10 Policy dated 5/10 and the Conditions Requiring Pediatric Presence at Delivery Policy dated 6/10 (drafts), review of hospital documentation and interviews with the Perinatal Nursing Director, the Vice President for Patient Care Services and the Director of Quality Resource Management failed to reflect that the revised policies had addressed neonatal medical coverage for infants who required medical interventions during delivery. The revised policies failed to clearly define the mechanism for neonatal medical coverage and therefore, failed to implement preventive actions.
Tag No.: A0347
Based on review of the clinical record for one patient (Patient #11) the hospital failed to ensure that the physician ' s emergency certificate (PEC) included all elements for confinement. The finding includes:
Patient # 11 was brought to the hospital on 5/5/10 after being found at home unresponsive. The patient had a history of bipolar disorder, alcohol abuse and depression. A psychiatric consult completed by MD #2 dated 5/7/10 indicated that the patient admitted to taking extra doses of Klonopin 1 mg tablets due to being anxious and had not kept track of how many pills were ingested. The consult indicated that the patient denied any suicidal intent, however the consult indicated that the patient's allegation of taking a few extra Klonopin was not supported by the patient becoming comatose. The consult indicated that the patient needed to be committed for his own safety to the psychiatric unit for a full psychiatric assessment.
Review of the physician 's emergency certificate (PEC) identified that the patient was alert, drowsy, not hallucinating or agitated. The patient told the physician that extra Klonopin had been taken due to the patient being nervous and that patient denied suicidality. The hospital failed to ensure that the PEC included the physical condition of the patient and/or if the patient was a danger to self, others or gravely disabled and in need of immediate care and the reasons for that opinion in accordance with Connecticut General Statute 17a-502.
Tag No.: A0395
Based on a review of the clinical record, review of policies, and interview for one patient (Patient #20) evaluated in the emergency department, the facility failed to ensure that the patient was reassessed and/or that CIWA assessments were conducted in accordance with facility policy. The findings include:
1. Review of the clinical record identified that Patient #20 presented to the ED on 6/27/10 at 11:13 pm requesting detoxification from heroin. A physician's order dated 6/27/10 at 11:44 pm directed CIWA assessments including vital signs be initiated. Physician orders included Compazine 10 milligrams (mg) every 6 hours as needed for nausea, Bentyl 20 mg every 4 hours as needed for abdominal cramps, Clonidine 0.1 mg every 4 hours as needed for withdrawal symptoms, and Ativan 1-2 mg every four hours as needed for anxiety/agitation. On 6/27/10 at 11:53 PM, the patient had a CIWA assessment score of "1" and received Ativan 1 milligram and Clonidine 0.1 mg at midnight. Review of the clinical record failed to reflect that the patient was reassessed to determine efficacy of the "as needed" medication.
A nurse's note dated 6/28/10 at 11:51 am indicated that the patient called the nurse into the room to inform the nurse that he/she was not feeling well, was having abdominal cramping (3-4 on a scale of 1-10 with 10 being the worst possible pain), diarrhea, and hot/cold sweats. On 6/28/10 at 11:45 am, the patient had a CIWA assessment score of "6" and subsequently received Compazine 10 mg for nausea and Bentyl 20 mg for abdominal cramps at 11:45 am. Review of the clinical record failed to reflect that the patient was reassessed to determine efficacy of the "as needed" medication.
Review of the record failed to identify that the physician was notified of the patient's withdrawal symptoms and/or that the patient was reassessed following as needed medication. Interview with the RN indicated the physician had not been notified of the patient's change of condition and that the physician would only be notified if the change was "overtly disturbing".
2. Review of Patient #20's clinical record identified that CIWA assessments were conducted on 6/27/10 at 11:53 PM, 6/28/10 at 3:05 am, 6:42 am, 10:45 am, and 11:45 am. Review of the protocol for management of withdrawal symptoms directed that the CIWA assessments would be conducted every two hours. The facility failed to ensure this policy was followed.
3. Review of Patient #20's clinical record identified a physician's order dated 6/27/10 at 11:44 pm directed that CIWA assessment flowsheet including vitals be initiated. Review of the 11:45 am CIWA assessment indicated the patient scored a "2" under the indicator of tremor. Review of the protocol failed to reflect that a score of "2" was a choice for this indicator, however, reflected a possible score of 1, 4, or 7. Additionally, a score of "3" was designated for the indicator of anxiety, although choices included 1, 4, and 7, rendering this assessment inaccurate. Review of the CIWA policy identified that patient assessments would be calculated by evaluating the indicators listed on the CIWA guidelines (e.g. sweats, tremor, anxiety).
Tag No.: A0396
Based on review of clinical records, review of policies and interview for two patient's (#11 and #18) the facility failed to develop comprehensive individualized multidisciplinary treatment plans (MTP). The findings include:
a. Patient # 11 was admitted to the hospital on 5/5/10 with a diagnosis of acute respiratory failure due to drug overdose. The patient had a history of bipolar disorder, alcohol abuse and depression. On 5/7/10, the patient was committed to the inpatient psychiatric unit. Review of the Master Treatment Plan dated 5/7/10 failed to identify specific goals and/or individualized interventions developed by the interdisciplinary team to address the needs of the patient. Review of the problem "bipolar disorder/ mood lability" dated 5/7/10 identified interventions by the SW dated 5/10/10 such as "complete psychosocial evaluation, assess need for family meeting and establish after care plan." The patient was discharged home on 5/10/10.
Review of the facility policy indicated that the MTP would be individualized and address the patient's strengths, disabilities, and clinical needs. The patient's long-term goals are to be clearly and objectively stated, in measurable terms. The short-term goals and objectives are specific, clear, reasonable, results oriented, and pertinent.. The treatment plan specifies the methods for achieving the goals.
b. Patient #18 was admitted on 5/29/10 with schizoaffective disorder and major depression. Review of the clinical record on 6/28/10 with the Nursing Director indicated that the MTP had been completed on 6/1/10 with active problems that included: potential for injury, depression, alteration in comfort, self-injurious behavior, medical issues-asthma and alteration in thought processes. Review of the problems for depression, alteration in thought processes-paranoia and self-injurious behaviors identified "complete psychosocial assessment" as the intervention completed by the social worker. The facility failed to develop an individualized plan with specific interventions to address the needs of the patient.
Tag No.: A0628
Based on review of the clinical record, review of hospital policy and interviews with hospital staff for one patient, the facility failed to ensure a comprehensive nutritional assessment was completed. The findings include:
1. Patient #12 was admitted to the hospital on 6/24/10 with diagnoses that included mental status change, bilateral mastectomy, non-Hodgkins lymphoma and status post stomach resection secondary to cancer. Review of the record identified the patient's albumin level was 2.0 (normal 3.4-5.0) on 6/25/10 at 7:15 AM and the patient's weight was 113.8 lbs. Review of the Nutrition Consult dated 6/25/10 at 9 AM recommended a change from a Cardiac II diet to a 4 Gram Sodium diet with a follow-up date, 6/28/10. However, the assessment failed to reflect the below-normal albumin level and/or the need for supplements. Review of the Clinical Nutrition Patient Assessment Policy indicated that patients with altered nutritional status were recognized and assessed on admission. Interview with the Nutrition Supervisor on 6/28/10 indicated that she would expect to see the albumin and/or supplements identified on the assessment.
Tag No.: A0724
Based on observations and interviews with facility personnel, the facility failed to ensure that fluid/blanket warmers temperatures were maintained to ensure safety.
The findings include:
1. During tour of the Operating Room (OR) and post anesthesia care unit (PACU) on 6/28/10, it was observed that both fluid/blanket warmers were outside of acceptable temperature ranges for 33 days from 5/20/10-6/28/10. Review of hospital policy identified that blanket warmers are to be set no higher than 130 degrees and fluid warmers will not exceed 110 degrees. Further review of hospital policy failed to identify what interventions would be implemented when temperatures fell outside the accpetable range. Interview with the Nursing Director of the OR on 6/28/10 identified that the fluid/blanket warmers were out of range and staff did not adjust the temperature.
Tag No.: A0749
Based on observations, interviews with facility personnel and a review of policies and procedures, the facility failed to ensure that infection control practices were maintained.
The findings include:
1. During tour of the Main Operating Rooms (OR) on 6/28/10 it was identified that a door to the sub-sterile area between OR #1 and OR #2 was left open while surgery was being performed. In addition, observation of the scope cleaning room identified that the doors to the main OR corridor and Endo procedure room were left wide open. Interview with the Nursing Director of the OR on 6/28/10 identified that all doors are to be closed while surgery is being performed and closed between any soiled rooms.
2. During tour of the Main Operating Rooms (OR) on 6/28/10, it was identified that the soiled utility room had multiple supply items including light bulbs and clean mop heads stored in a dirty area. In addition, observation of the scope cleaning room on 6/28/10 identified that boxes of supplies including a box of invoices were stored in the soiled area. Interview with the Nursing Director of the OR on 6/28/10 identified that these items were not to be stored in a soiled utility room.
3. During tour of the OR on 6/28/10, it was identified that a Bladder tumor surgery was being performed in OR #1. Further observation identified that four providers were not wearing masks. Review of hospital policy identified that all personnel entering restricted areas of the surgical suite are to utilize masks. In addition, single surgical masks are to be worn in surgical environments where open sterile supplies or scrubbed persons are located. Interview with the Nursing Director of the OR on 6/28/10 identified that he thought the procedure was a dirty case and was unsure of hospital policy.
4. During tour of the Intensive Care Unit on 6/28/10, it was identified that in the storage area, a TV cart and cabinet were heavily soiled, stained and had thick dust. Interview with Qualilty Improvement Staff Person #1 on 6/28/10 identified that the storage areas are cleaned on a daily basis and would have it cleaned immediately.
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5. During tour of the 2nd floor medical-surgical nursing unit a gowned and gloved housekeeping employee was observed in Room 217 ( a patient's room). The sign on the patient's door identified enteric contact precautions (for clostridium difficle). The employee walked from the patient room across the hall into a dirty utility room (touching the doorknob), without the benefit of removing the gloves and gown. Review of the Contact Precautions Policy identified that the employee would remove the gown and gloves and perform hand hygiene before leaving a patient's room.
6. During tour of the 3rd floor medical-surgical nursing unit, linen was observed on the floor in Room 312 (a patient's room). The sign on the patient's door identified contact precautions. Review of the Storage, Collection and Transportation of Linen Policy identified that soiled linen would not be placed on the floor, but would be placed in the soiled linen hamper immediately.
Tag No.: A0821
Based on review of the clinical record, review of policies, and interview for one patient (Patient #20) evaluated in the emergency department, the facility failed to ensure that the patient's status was reassessed prior to discharge. The finding includes:
Review of the clinical record identfied that Patient #20 presented to the ED on 6/27/10 at 11:13 pm requesting detoxification from heroin. A physician's order dated 6/27/10 at 11:44 pm directed CIWA assessments including vital sign monitoring be initiated. Physician orders inclided Compazine 10 milligrams (mg) every 6 hours as needed for nausea, Bentyl 20 mg every 4 hours as needed for abdominal cramps, Clonidine 0.1 mg every 4 hours as needed for withdrawl symptoms, and Ativan 1-2 mg every four hours as needed for anxiety/agitation. On 6/27/10 at 11:53 PM, the patient had a CIWA assessment score of "1" and received Ativan 1 milligram and Clonidine 0.1 mg at midnight.
The Crisis note dated 6/28/10 at 10:04 AM indicated that there were no detox facilities available with a plan to discharge the patient home, continue outpatient treatment and put the patient's name on the waiting list for inpatient detox treatment.
A nurse's note dated 6/28/10 at 11:51 am indicated that the patient called the nurse into the room to inform the nurse that he/she was not feeling well, was having abdominal cramping (pain was rated as a 3-4 on a scale of 1-10 with 10 being the worst possible pain), diarrhea, and hot/cold sweats. On 6/28/10 at 11:45 am, the patient had a CIWA assessment score of "6" and subsequently received Compazine 10 mg for nausea and Bentyl 20 mg for abdominal cramps at 11:45 am.
A Crisis note dated 6/28/10 at 12:19 pm indicated that the patient would not be a candidate for inpatient detox unless the patient was in acute withdrawl then referenced the nurse's note from 11:51 am that indicated the patient was beginning to withdraw, a discrepancy in assessment. Further review of the clinical record failed to reflect an assessment of the patient's status by a physician to determine if the discharge plan should be reevalauted based on the patient's clinical symptoms prior to discharge at 1:43 pm.