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Based on a review of medical records and interview with Employee Identifier (EI) # 1, the Director of Nursing, it was determined the facility staff failed to document interventions tried to prevent the use of restraints in 2 of 3 restrained patients. This affected Medical Record (MR) # 5 and # 6.

Findings include:

Refer to A169 for the policy on restraints.

1. MR # 5 was admitted to the facility 5/6/10 with diagnoses of an Acute Right Parietal Infarct, Enterococcus Urinary Tract Infection, Atrial Fibrillation, Congestive Heart Failure and Anemia.

On 5/6/10 at 2045 a physician's order was written, " Restrain PRN."
A sticker was applied under this written order with the title of Physical Restraint Order. The sticker was marked for soft vest restraint, reason for restraint- safety, criteria for release- non-combative. The date at the top was 5/6/10 time-2245. The physician signature line was dated 5/9/10 -0800.

There was no documentation of less restrictive methods tried with the patient.

The facility policy was not followed for the correct documentation of the use of a restraint order.

2. MR # 6 was admitted to the facility on 11/11/10 with diagnoses of Large Bowel Obstruction and History of Mental Retardation.

On 11/12/10 at 0100 an order was written, " May use wrist restraints now to prevent dislodgement of medical equipment per pt."

There was no documentation of less restrictive methods tried with the patient.

The facility policy was not followed for the correct documentation of the use of a restraint order.

In an interview with the Director of Nursing, Employee Identifier (EI) #1, on 2/24/11 at 8:00 A.M., it was confirmed there was no documentation of the less restrictive care tried before the use of restraints.

Based on medical record review and interviews with administrative staff, the hospital failed to assure there were physician's orders for the use of restraints. This affected 1 of 3 records reviewed with restraints and had the potential to affect all patients serviced by the hospital.

Findings include:

Emergency Record #6 was admitted to the Emergency Room(ER) 1/14/11 with a diagnosis of Schizophrenia.

Review of the Emergency Room Record dated 1/14/11 revealed documentation by the Skilled Nurse(SN) at 1830 that "Pt placed in 4 point restraints per orders from physician."

Review of the Physician's order sheet dated 1/14/11 revealed no orders to place patient in restraints.

In an interview with the Director of Nursing, Employee Identifier #1, on 2/24/11 at 8:00 A.M., it was confirmed there were no orders for the restraints.

Based on a review of medical records, facility policy and procedure and interview with Employee Identifier (EI) # 1, the Director of Nursing, it was determined the facility failed to ensure the physician's did not write restraint orders using PRN (as needed). This affected 2 of 3 patients who had orders for restraint and had the potential to affect all patients served by this facility. This affected Medical Record (MR) # 5 and # 6.

Findings include:

Facility Policy: Restraint and Seclusion Policy
Effective date: 10/2001
Policy:
1. Behavior management restraint/seclusion use is limited to emergencies in which there is imminent risk of harm to self or others.
2. Acute medical surgical restraint is limited to situations in which the restraint directly supports the medical healing of the patient...
3. Restraint will be implemented in the least restrictive manner.
4. The use of restraint/ seclusion will be addressed in the patient's plan of care and/or treatment plan.

Purpose:
The purpose of this policy is to provide guidelines for the use of restraint and seclusion... Restraint and seclusion will only be used if less restrictive interventions have been ineffective.

Physician's Orders:
1. Orders for restraint and seclusion must be either written or verbally given by a licensed independent practitioner.
2. Orders can never be written as a PRN or as a standing order.

4. Orders for restraint/seclusion must contain the following elements:
a. Date and time
b. Reason for restraint/seclusion
c. Type of restraint/ seclusion to be used
d. Duration (time limit) for restraint
e. If verbal order, signature of RN ( registered nurse)/LPN (licensed practical nurse) writing order
f. Physician signature, date and time...

7. When applying restraints for behavior management, the physician must see the patient face to face and evaluate the need for the restraint/seclusion within one hour after initiation of the intervention.

Medical record findings:

1. MR # 5 was admitted to the facility 5/6/10 with diagnoses of an Acute Right Parietal Infarct, Enterococcus Urinary Tract Infection, Atrial Fibrillation, Congestive Heart Failure and Anemia.

On 5/6/10 at 2045 a physician's order was written, " Restrain PRN."
A sticker was applied under this written order with the title of Physical Restraint Order. The sticker was marked for soft vest restraint, reason for restraint- safety, criteria for release- non-combative. The date at the top was 5/6/10 time-2245. The physician signature line was dated 5/9/10 -0800.

The physician failed to correctly write the restraint order and used the term PRN.

The facility policy was not followed for the correct documentation of a restraint order.

In an interview with the Director of Nursing, Employee Identifier (EI) #1, on 2/24/11 at 8:00 A.M., it was confirmed the order was written as a PRN order for the restraints which was not acceptable.

2. MR # 6 was admitted to the facility on 11/11/10 with diagnoses of Large Bowel Obstruction and History of Mental Retardation.

On 11/12/10 at 0100 an order was written, " May use wrist restraints now to prevent dislodgement of medical equipment per pt."

The use of the term "may" is as needed or PRN.

The physician failed to correctly write the restraint order. The facility policy was not followed for the correct documentation of a restraint order.

In an interview with the Director of Nursing, Employee Identifier (EI) #1, on 2/24/11 at 8:00 A.M., it was confirmed the order was written incorrectly.

Based on a review of medical records and interview with Employee Identifier (EI) # 1, the Director of Nursing, it was determined the facility staff failed to ensure the patient received a face to face visit from the physician or a licensed independent practitioner within an hour of being placed in restraints in 2 of 3 restraint patients. This affected Medical Record (MR) # 5 and # 6.

Findings include:

Refer to Restraint policy A169


1. MR # 5 was admitted to the facility 5/6/10 with diagnoses of an Acute Right Parietal Infarct, Enterococcus Urinary Tract Infection, Atrial Fibrillation, Congestive Heart Failure and Anemia.

On 5/6/10 at 2045 a physician's order was written, " Restrain PRN."
A sticker was applied under this written order with the title of Physical Restraint Order. The sticker was marked for soft vest restraint, reason for restraint- safety, criteria for release- non-combative. The date at the top was 5/6/10 time-2245. The physician signature line was dated 5/9/10 -0800.

There was no documentation the patient received a face to face evaluation from a physician within 1 hour of the restraint being applied.

The facility policy was not followed for the correct documentation of a restraint order.

2. MR # 6 was admitted to the facility on 11/11/10 with diagnoses of Large Bowel Obstruction and History of Mental Retardation.

On 11/12/10 at 0100 an order was written, " May use wrist restraints now to prevent dislodgement of medical equipment per pt."

There was no documentation the patient received a face to face evaluation from a physician within 1 hour of the restraint being applied.

In an interview with the Director of Nursing, Employee Identifier (EI) #1, on 2/24/11 at 8:00 A.M., it was confirmed the patient did not have documentation of a face to face encounter.

Based on medical record review and an interview with administrative staff, it was determined the facility failed:
1. To ensure wound care was provided as ordered by the physician.
2. To ensure orders were obtained for wound care.
3. To assess wounds upon admisssion which includes wound measurements.
3. To obtain and document the specific Foley catheter size.
This affected Medical Record (MR) # 4, # 12 and # 13.

Findings include:

1. Medical Record(MR) #12 was admitted to the facility 11/1/10 with Pressure Ulcers to the Right Lower Extremities and History of Cerebrovascular Accident(CVA).

Review of the Nurse Assessment Sheet dated 11/1/10 revealed the following wound documentation by the Skilled Nurse(SN): Rt(right) leg large black area and multiple areas." There was no documentation of wound measurements, no descriptions of the "multiple wounds", drainage associated, or signs/symptoms of infection.

Further review of the medical record revealed a physician's order dated 11/1/10 to "Insert Foley Catheter." The size of the catheter was not specified.

In an interview 2/24/11 at 8:00 A.M the Director of Nursing, Employee Identifier(EI) #1 confirmed the above information.

2. MR #13 was admitted to the facility 3/18/10 with End Stage Renal Disease.

Review of the Nurse Assessment Sheet dated 3/10/10 revealed documentation by the SN of 2 Stage II Ulcers on the patient's perianal area. #1 ulcer measured 7 x 9"(inches) and #2 ulcer measured 2 x 3 1/2". There was no documentation in the record of a Physician's order for wound care, neither was there documentation of any wound care provided during the patient's hospital stay.

In an interview 2/24/11 at 8:10 A.M the Director of Nursing, EI #1 confirmed the above information.







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3. MR # 4 was admitted to the facility 10/12/10 with diagnoses of Pancreatitis, Sacral Decubitus, Colostomy and Ileostomy.

Review of the Nurse Assessment Sheet dated 10/12/10 revealed documentation by the SN of a decubitus on sacrum 12 cm x 8 cm. There was no depth of the decubitus measurement or stage of the decubitus. The physician's orders included, " Silvadene dressing change post changing sacral wound BID ( twice a day)."
The nurses failed to document wound care 10/14/10, 10/15/10 and 10/16/10 according to the MAR (medication administration record). The MAR documented, " By family".
The decubitus was not assessed by the nurse, measured or staged.

The nutritional screening tool completed by the registered nurse on admission listed the patient not at nutritional risk. The form was not completed under the nursing section which asked if the patient had a stage and decubitus ulcer. If the patient had a stage III or IV decubitus it would have been an automatic referral to the dietitian. The form was incomplete and the patient was not assessed for services available.

In an interview 2/24/11 at 8:10 A.M. the Director of Nursing, EI #1 confirmed the above information.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation, review of manufacturers instructions and interview with Employee Identifier (EI) #3, the scrub technician, it was determined the facility failed to assure single use items were used only as directed in the use of brush cleaners for cleaning diagnostic scopes. This had the potential to affect all patients who had colonoscopies.

Findings include:

Manufacturer directions:

For Single Use Devices

A review of the manufacturers instructions revealed under warnings and precautions:

"These items are intended for single use only. Any institution, practioner, or third party who reprocesses, refurbishes, remanufactures, resterilizes, and/or reuses these disposable devices must bear full responsibility for their safety and effectiveness."

1. On 2/23/2011 at 8:45 A.M., the surveyor observed EI #3 clean a dirty colonoscope. The scrub technician (tech) put the scope into a cleaning solution and cleaned the outside of the scope, then the tech took the brush and cleaned the ports. After cleaning the ports with the brush, the tech hung the brush on a hanger near the sink. The surveyor then asked if the tech planned to reuse the brush on other scopes that day since it had not been thrown away. The scrub tech stated "yes".

Based on record review, interview with Employee Identifier (EI) #1 and review of the Alabama State Board of Health Chapter 420-4-4, it was determined the hospital failed to follow the reporting requirements to the Alabama State Board of Health in 1 of 2 Emergency Room (ER) records reviewed with animal bites. This affected ER record # 18.

Findings include:

Alabama State Board of Health

Alabama Department of Public Health

Division of Disease Control Administrative Code

Chapter 420-4-4 Rabies Control Program

420-4-4-.04 Reporting Exposures

(1) Who Must Report. Any health care professional who treats an animal bite or exposure, any veterinarian who has knowledge of an animal bite or exposure, and any law enforcement personnel, including animal control officials, who have been informed of or investigated an animal bite or exposure must report the incident.

1. ER record # 18 came to the ER on 2/23/2011 with a dog bite. There is no documentation present in the record to show the staff notified law enforcement or animal control.

An interview on 2/23/2011 at 3:00P.M. with EI #1 verified the lack of documentation.