HospitalInspections.org

Based on observation, staff interview, and document review the facility failed to ensure patients were notified of their rights before providing care or discontinuing care for 6 of 24 medical records reviewed (Patient #'s 2, 4, 5, 6, 8, and 10). The hospital's failure to ensure that patients receive and understand their Patient Rights put all patients at risk for not understanding their rights to information about their care, the privacy regarding their care, the participation in the planning of their care, and the safety, protection and comfort during their care for all patients admitted to the hospital.


Findings include:

- Patient #2's medical record was chosen because he was an Emergency Department (ED) patient with a diagnosis of Suicidal Ideation (thoughts of suicide) on 10/1/2016. The medical record review revealed the record lacked acknowledgement that the patient or representative received a copy of their patient rights.

- Patient #4's medical record was chosen because she was an ED patient with a diagnosis of vaginal bleeding on 8/30/2016. The medical record review revealed the record lacked acknowledgement that the patient or representative received a copy of their patient rights.

- Patient #5's medical record was chosen because she was an ED patient with a diagnosis of hyperglycemia (high blood sugar) on 8/5/2016. The medical record review revealed the patient signed the consent for treatment form, but the record lacked documentation that the patient or representative received a copy of their patient rights.

- Patient # 6's medical record was chosen because he was an ED patient with a diagnosis of hyperglycemia (high blood sugar) on 9/9/2016. The medical record review revealed the patient signed the consent for treatment form, but the record lacked documentation that the patient or representative received a copy of their patient rights.

- Patient # 8's medical record was chosen because he was an ED patient with a diagnosis of Suicidal Ideation (thoughts of suicide) on 10/20/2016. The medical record review revealed the patient signed the consent for treatment form, but the record lacked documentation that the patient or representative received a copy of their patient rights. .

- Patient #10's medical record was chosen because she was an ED patient with a diagnosis of Altered Mental Status on 10/23/2016. The medical record review revealed the patient signed the consent for treatment form, but the record lacked documentation that the patient or representative received a copy of their patient rights.


Compliance Officer Staff AA interviewed on 10/27/2016 at 10:40 AM indicated they were unable to locate the patient rights acknowledgement for patient #'s 2, 4, 5, 6, 8, and 10 who were treated and released from the emergency department.

Risk Manager Staff A interviewed on 10/27/2016 at 11:15 AM indicated they do not currently have a policy directing staff to provide patient rights to emergency department patients prior to treatment and did not document that consistently until yesterday (10/26/2016) when the error was brought to staffs attention. Staff A indicated they have corrected this issue and verified there is a place to document patient acknowledgement of rights.

Policy titled "Patient's Rights" reviewed on 10/27/2016 at 11:15 AM directed "...It is the responsibility of all staff to ensure that these rights are preserved for each patient.

Based on record review and policy review the hospital failed to ensure safety through ongoing assessment of patients for 4 of 5 patients reviewed with soft restraints (Patient's #21, 22, 23, and 24). Failure to ensure safety at all times for patients had the potential for an unsafe physical and emotional environment.


Findings included:


- Patient #21's medical record review on 10/26/16 at 9:00 am revealed an admission date of 10/17/2016 with diagnosis of ascending aorta dilation (localized or diffuse dilation of an artery with a diameter at least 50% greater than the normal size of the artery). Further review of Patient #21's medical record revealed the patient had multiple medical devices inserted and the patient made multiple attempts to remove the devices. The patient was assessed by the physician and bilateral soft wrist restraints were ordered and applied 10/17/2016 at 4:30 pm. The restraints were reordered daily 10/17/2016, 10/18/2016, 10/19/2016, 10/20/2016, 10/21/2016, 10/23/2016, and 10/24/2016 and discontinued four times during the identified time frame. The nursing staff did not perform the required every two hour nursing assessment during restraint use of Patient #21 on 10/19/2016 at 6:00 am, 10/20/2016 at 6:00 am, 10/25/2016 at 2:00 am, and 10/25/2016 at 6:00 am.


- Patient #22's medical record review on 10/26/16 at 9:30 am revealed an admission date of 10/14/2016 with diagnosis of brain cancer. Further review of Patient #22's medical record revealed patient had multiple medical devices inserted and the patient made multiple attempts to remove the devices. The patient was assessed by the staff RN and bilateral soft wrist restraints were ordered and applied 10/25/2016 at 12:00 am. The restraints were reordered 10/26/2016. The nursing staff did not perform the required every two hour nursing assessment during restraint use of Patient #22 on 10/16/2016 at 6:00 am.


- Patient #23's medical record review on 10/26/16 at 10:00 am of revealed an admission date of 10/23/2016 with diagnosis of facial fractures. Further review of Patient #23's medical record revealed patient had multiple medical devices inserted and the patient made multiple attempts to remove the devices. The patient was assessed by the staff RN and bilateral soft wrist restraints were ordered and applied 10/23/2016 at 3:28 am. The restraints were reordered daily 10/24/2016, and 10/25/2016. The nursing staff did not perform the required every two hour nursing assessment during restraint use of Patient #23 on 10/23/2016 at 10:00 am, 10/23/2016 at 2:00 pm, and 10/23/2016 at 6:00 pm. The restraints were discontinued on 10/25/2016.


- Patient #24's medical record review on 10/26/16 at 10:30 am revealed an admission date of 10/21/2016 with diagnosis of subdural hematoma (a collection of blood over the surface of the brain). Further review of Patient #24's medical record revealed patient had multiple medical devices inserted and the patient made multiple attempts to remove the devices. The patient was assessed by the staff RN and bilateral soft wrist restraints were ordered and applied 10/23/2016 at 2:20 am. The restraints were reordered daily 10/24/2016, 10/25/2016 and 10/26/2016. The nursing staff did not perform the required every two hour nursing assessments during restraint use of Patient #24 as required on 10/25/2016 at 6:00 pm.


Interview with Intensive Care Unit (ICU) RN Staff U and ICU RN Staff V both confirmed frequent education regarding restraint use including frequency of patient assessment, kind of assessment, movement of the patient, renewal of orders for restraints and recent review of the modules regarding restraint use. RN Staff U acknowledged "we cannot use restraints on any patient until we have completed the education component for restraints. The education modules come up for required review about every 6 months, I believe".


Review of policy "Restraint Use for Non-Violent Behaviors" directed "...c. The RN shall monitor and document as follows: Every 1 hour-Observe patient hourly and interact with patient, if possible and appropriate. Every 2 hours-assess/document for early release, assess/document for injury associated to restraint, circulation, skin integrity and musculoskeletal function, off food, fluids and toileting, every 4 hours-range of motion ..."

Based on observation, staff interview and policy review, the infection control officer failed to assure an effective on going infection control program that identified potential environmental infection control risks. The hospital failed to ensure performance of hand hygiene before and after entering patient rooms during observations of the Family Medicine Progressive Care Unit (CFP) (RN Staff X and unidentified physician) and failed to ensure staff compliance with appropriate attire in the semi-restricted and restricted OR areas (Surgeon Staff G, Physician Staff F, and Chief Surgical Resident). These deficient practices have the potential to expose all patients to infectious diseases.

Findings include:

- Observation during tour of the facility on 10/26/2016 at 9:30 am revealed RN Staff X entering and exiting patient room #16 on CFP without washing hands. Hand hygiene gel container is mounted on the wall outside the patient room and signage on the room door was present with the requirements to be met for contact precautions.

RN Manager Staff V acknowledged the lack of hand hygiene by RN Staff X.

- Further observation during tour of the CFP unit revealed unidentified physician donning gown and entering contact precaution room #12. Signage on the door identified that the patient had contact precautions including gown and gloves. The unidentified physician had a personal stethoscope hanging around his neck when he entered the room. Hand hygiene was not performed prior to or upon exiting the room by the physician. The physician removed his gown and began typing on a unit computer thus potentially contaminating the keyboard. Hand hygiene gel container is mounted on the wall outside the patient room.

RN Compliance Officer Staff AA approached the physician and discussed the observation to the physician. The physician used hand gel at that time and explained he did not use his stethoscope in the room.

RN Manager Staff V acknowledged that patient specific "stethoscopes are left in the room and are patient specific when there are any kind of isolation or contact precautions".

Interview with Infection Preventionist RN Staff Y and Infection Preventionist RN Staff Z confirmed that active surveillance of hand washing occurs throughout the hospital regularly using the "secret shopper" approach by both peers and other staff, with ongoing education modules and one on one education, and that "we do have the support of the medical staff " . Reports of outcomes to all patient care groups throughout the hospital organization are presented regularly.

Policy review "Hand Hygiene" on 10/27/2016 at 10:30 am directed "...health care workers should perform hand hygiene before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient, after touching patient surroundings/environment, on entering and leaving a patients room ..."

- Observation of OR semi restricted and restricted area on 10/25/2016 at 9:30 AM revealed Surgeon Staff G in OR suite 7, Attending Physician Staff F in OR suite 5, Chief Surgical Resident in OR suite 2, all with hair exposed from their skull caps or bouffant. Senior OR Director RN Staff I and Vice President of OR Perioperative Services RN Staff H acknowledged the exposed hair.

Policy titled Surgical Attire reviewed on 10/25/2016 at 11:00 am directed " ...All staff (hospital employees, physicians and students) who enter semi-restricted and restricted areas will wear hospital provided attire ... ...All personnel must wear hospital provided disposable hair covering or hood when in the semi-restricted and restricted areas or during an invasive procedure. Areas that must be covered include: head (bald or shaved), all hair, sideburns and neckline. If skullcap does not provide adequate hair coverage, a bouffant must be worn. ... "

Review of AORN recommended practices, " Implementing AORN Recommended Practices for Surgical Attire " , June, 2012, directed "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squamous and hair shed from the scalp from falling onto the sterile field. Skull caps are not recommended because they do not completely cover the wearer's hair and skin; they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck.