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Based on interview and document review, the facility physician failed to conduct a face to face patient visit for 1 of 4 patients (P1) reviewed for physical restraints.

Findings include:

P1 was placed in 4 point restraints (left wrist, left ankle, right wrist and right ankle) without a face to face visit within 1 (one) hour after the initiation of the intervention of the physical restraints.

P1 was admitted to the hospital on 11/16/12, with a discharge date of 11/20/12. The patient was admitted after overdosing on Tylenol (pain medication). The patient ' s diagnosis on discharge was Tylenol toxicity, suicidal attempt, depression, alcohol abuse and acute alcohol intoxication.

Review of the Emergency Department notes dated 11/15/12 at 11:26 p.m. identified P1 as arriving to the hospital emergency department in 4 point restraints and in police custody. The note stated the patient was uncooperative and violent with the emergency medical technicians (EMS) and police. The 4 point restraints were discontinued at 12: 45 a.m. on 11/16/12, and the patient was admitted to the mental health unit at 4:35 a.m.

Review of P1 admission note to the mental health unit dated 11/16/12 at 4:50 a.m. identified the patient as being combative, uncooperative and violent. The staff obtained a physician order to reapply the 4 point restraints. The restraints were applied at 4:55 a.m.

Review of the flow sheet for monitoring P1 ' s mood and behaviors with restraints, dated 11/16/12 from 5:55 a.m. to 10:00 a.m., identified the patient to be subdued, sleepy and confused.

The most current face to face patient visit conducted by the physician was noted to be on 11/16/12 at 9:44 a.m. The physician ordered the restraints to be discontinued at this time. No other face to face visits were provided when requested from the provider in regards to the initiation of the four point restraint for P1 on 11/16/12.

Interview with patient care director of the mental health department on 11/29/12 at 9:30 a.m., confirmed there had been no physician face to face visit with the patient within 1 hour after the restraints had been ordered. The patient care director also stated that the nursing staff did not do a thorough assessment of the patient ' s mood and behavior for the continued use of the restraints.

Review of the hospitals procedure Behavioral Restraint Application/Use of Seclusion dated 8/10/10, indicates within 1 hour of the application of a physical restraint the licensed independent practitioner is required to complete a face to face assessment. Once the restraints are discontinued, reapplication requires a new order and visit. Once the unsafe situation ends, the use of the restraint must be discontinued as soon as possible.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in a manner to prevent unauthorized access for two portable crash carts located on Two West unit and one portable crash cart located in the outpatient infusion center.

Findings include:

Crash Cart #1.
An emergency crash cart was observed on the 2 West nursing unit on 11/27/2012 at 2:45 p.m. during tour of the unit. The drawers were closed and a numbered red plastic tag held them all closed. A review of the log that identified the cart was inspected daily, identified check marks for areas inspected, and initials of the staff checking the cart. The nurse had initialed the record but the tag numbers were not recorded. The cart was located down a patient hallway and around the corner and not in full view of the nurse ' s desk area. No cameras were observed in or around the area.

Crash Cart #2.
A second emergency crash cart was observed on the short stay observational unit on Two West Unit. The cart again was located down a patient hallway and around the corner in a charting area and not in full view of the nurse ' s desk area. It also had a numbered red plastic tag holding the drawers closed. A review of the log that identified the cart was inspected daily, identified check marks for areas inspected, and initials of the staff checking the cart. The nurse had initialed the record but the tag numbers were not recorded. No cameras were observed in or around the area.

The Two West unit registered nurse manager was interviewed on 11/27/2012 at 2:45 p.m., during the tour of the unit. She verified the locations of the two crash carts and indicated the night staff checked the carts daily for outdates and if the plastic tag was tampered. She verified the logs did not identify the numbered tags were the same number as the one put on by pharmacy. She also stated, during the day shift, staff would be using the charting rooms and the area would be supervised. During the evening and night shifts, it would be possible the carts would not be continuously supervised by staff. The nurse manager stated only cardiac medications were in the two crash carts and no controlled substances.

The Director of Security was interviewed on 11/29/2012 at 1:45 p.m., and verified Two West Unit did not have cameras for continuous observation of the two crash carts.


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Crash Cart #3.
An emergency crash cart was observed in the out patient infusion center on 11/27/2012 at 2:40 p.m. during tour of the unit. The cart was secured with a numbered red plastic tag. The cart was located down a hallway and around the corner, which was not in full view from the nurse's desk. The cart was located right next to a patient/visitor rest room. No patient rooms were located in the hallway. No cameras were observed in or around the area.

On 11/28/12 at 1:50 p.m. registered nurse-B was interviewed and agreed the crash cart was not in a secure location and was accessible to anyone going into the public bathroom right next to the cart. The director of nursing for perinatal services who was present during the interview, agreed the crash cart in its present location was not a secure location.

According to PHARMACY POLICIES AND PROCEDURES: CODE BLUE CART MEDICATIONS-PHARMACY dated 10/10; the Adult Code Blue Cart contained the following medications: Adenosine, atropine, bicarbonate sodium, calcium chloride, epinephrine, lidocain, narcan, amiodarone, vasopressin, and sodium chloride in the top drawer. In the second drawer of the emergency cart, the following medications were listed: dextrose, dopamine, epinephrine, magnesium sulfate, and sodium chloride.

A Mercy Hospital - Wide Policy: Medication System Management policy with effective date of 11/7/11 was reviewed. Under " VIII. MEDICATION STORAGE/SECURITY: A. All medications and medicated IV solutions are secured at all times in secure designated medication area/cabinets/drawers or under constant surveillance."

The hospital was found out of compliance with 42 CFR 482.41, the Condition of Participation for Physical Environment with deficiencies issued as a result of a Life Safety Code inspection.

Findings include:

Please refer to Life Safety Code inspection tags:
K012, K015, K038, K052, K056, K069, K147 and K011 for additional information.

Based on observation, interview, and document review, the facility failed to provide wound care in a manner that minimized the development of infectious disease for 1 of 2 patients (P3) observed for a dressing change.

Findings include:

During observation on 11/27/12, at 9 a.m. a registered nurse (RN)-C changed the surgical wound dressing on the right hip and upper thigh of P3. RN-C donned clean gloves, removed the soiled gauze dressings from the wound, while wearing the soiled gloves RN-C applied clean gauze dressings to the wound, and secured the clean gauze with clean tape. RN-C did not change gloves or perform hand hygiene after the removal of the soiled gauze dressings.

When interviewed immediately after the dressing change, RN-C stated that she did not change gloves because the dressings removed from the wound were not heavily soiled, and she was careful to touch the edges of the soiled dressings.

A facility infection preventionist (IP)-A was also present during the dressing change and was interviewed immediately following the dressing change. When asked if this dressing change was done in accordance with hospital policy, she replied that gloves should be changed after removal of an old dressing, and before the application of a new dressing.

Record review revealed P3 was admitted to the facility on 11/22/12, and on 11/23/12 underwent surgical repair of a right femur fracture, resulting in a surgical wound to the right hip and upper thigh region. A physician's order, dated 11/23/12, read, "Change dressing POD [post-op day] #2, then daily."

Page 1 of the facility's policy on dressing change (Mosby's Skills), read, "9...slowly and carefully remove dressings...10. Fold dressing with drainage contained inside, and remove gloves inside out...Discard gloves and soiled dressing in proper trash receptacle. Perform hand hygiene and apply clean gloves...17. Apply dressing."

Based on observation, interview and document review, the outpatient surgical center did not ensure safe surgical practices were followed in accordance with acceptable standards of practice, related to the safe use of electrocautery equipment in the surgical suite for 1 of 3 patients (P2) surgical procedures observed, in which electrocautery equipment was used. This had the potential to affect all patients undergoing surgery with the use of electrocautery at the surgical center.

Findings include:

Doctor of Osteopath (DO) -A did not utilize a holster device to place the electrocautery device during an observed surgery.

On 11/29/12, P2 underwent a bilateral breast augmentation. During the surgical procedure the electrosurgical (cautery) pencil was not holstered 6 times during the surgery. During observations DO-A would place the cautery pencil on the draped abdomen of the patient. When certified surgical technicians (CTS) - A and B observed the cautery on the drape, they would pick it up and place it in the holster.

Observations made during this surgery are as follows:
At 12:55 p.m. DO-A utilized the cautery pencil and placed it on the patients drape. After 5 seconds CST-A picked it up off the drape and placed it in the holster.
At 12:56 p.m. DO-A utilized the cautery pencil and placed it on the patients drape. After 6 seconds CST-A picked it up off the drape and placed it in the holster.
At 12: 57 p.m. DO-A utilized the cautery pencil and placed it on the patients drape. After 3 seconds CST-A picked it up off the drape and placed it in the holster.
At 1:05 p.m. DO-A utilized the cautery pencil and placed it on the patients drape. After 5 seconds CST-A picked it up off the drape and placed it in the holster.
At 1:09 p.m. DO-A utilized the cautery pencil and placed it on the patients drape. After 6 seconds CST-A picked it up off the drape and placed it in the holster.
At 1:35 p.m. DO-A utilized the cautery pencil and placed it on the drape. After 5 seconds CST-B picked it up off the drape and placed it in the holster.

The Department Nurse Manager (RN-A) was present during the surgical procedure and verified that she had observed DO-A place the cautery pencil on the patients drape at 1:35 p.m. Further interview with RN-A at 2:00 p.m. she indicated that the entire surgical staff had recently been trained regarding fire safety, and that the cautery pencil should have immediately been holstered and not placed on the patients drape.

During interview on 11/29/12, at 2:09 p.m. with CST-A, she confirmed DO-A placed the cautery pencil on the patients drape numerous times during the surgical procedure. She further indicated when she saw the pencil on the drape she would pick it up and place it in the holster. CST-A stated she picked it up off the drape about 5 to 6 times during the surgical procedure. CST-A further included that she felt like she had to "babysit" the physician and that DO-A does this all the time.

During interview on 11/29/12, at 2:15 p.m. with CST-B, she confirmed DO-A placed the cautery pencil on the patients drape several times during the surgical procedure. She further indicated she had picked the cautery pencil up off the drape and placed it in the holster during these times, but could not remember how many times this occurred. CST-B further included that DO-A was aware that the cautery was to be holstered when not in use as he had made several comments before the surgery about fire safety and the need to holster the cautery when not in use.

Review of the facility Fire Safety Competency Validation dated 8/8/12 for DO-A, CST-A and CST-B confirmed that the surgical staff had been educated on Fire Safety procedures for the surgical services department. This Competency test included the fire risk assessment tool that included protocols. The protocols listed were to protect all heat sources when not in use which included the cautery pencil in holster, laser in stand-by mode, etc.

Review of the undated Valley lab Ectrocautery Pencil Manual, with the subject title, "Warning Fire Hazard", directed staff, "Do not place active accessories near or in contact with flammable materials (such as gauze or surgical drapes.). Electrosurgical accessories which are activated or hot from use can cause a fire. When not in use, place active accessories in a holster or in a clean, dry, nonconductive, and highly visible area not in contact with the patient. Inadvertent contact with the patient may result in burns."