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Based on medical record review, interview, and policy review for restraint use (#Drake-PC-2006110980071101), for three patients of seven patients reviewed who were in restraints, the hospital failed to ensure the ordered restraint used to ensure the physical safety of the non-violent patients were renewed according to hospital policy. This affected three patients, patient #10 who was in restraints from 11/19/12 through date of survey, patient #11 who was in restraints from 11/09/12 through date of survey, and patient #26 who was in restraints from 11/02/12 through date of survey. Upon entrance on 12/10/12, there were 13 patients in restraints and the total census was 59 patients.

Findings Include:

The hospital ' s policy entitled Restraints #Drake-PC-2006110980071101 was reviewed on 10/12/12 at 3:00 PM. The policy stated, " Continued use of restraint beyond the first 24 hours is authorized by the physician or physician assistant after the completion of a " face to face " evaluation of the patient. If clinically justified, the physician or physician assistant may issue a new or revised written order every 24 hours. "

Review of the medical record for patient #10 was completed on 12/11/12 at 11:35 AM. Patient #12 was admitted to the hospital 11/19/12 with diagnoses including hyponatremia (low sodium), pneumonia, history of cervical fracture and multiple rib fractures. The patient had a tracheotomy (artificial airway in the neck), and a PEG tube (percutaneous endoscopic gastrostomy, a tube through the skin and wall of the stomach) through which he/she received tube feedings. Review of the medical record revealed the patient was pulling on his/her tubes and intravenous lines and a physicians order was obtained for bilateral soft wrist restraints on 11/19/12. The medical record lacked documentations that the restraint order was renewed every 24 hours on the following dates: 11/22/12, 11/23/12, 11/28/12, 11/29/12, and 12/08/12. This finding was confirmed with staff J on 12/11/12 at 11:45 AM.

Review of the medical record for patient #11 was completed on 12/11/12 at 2:00 PM. Patient #11 was admitted to the hospital 11/08/12 with diagnoses including septicemia (bacterial blood infection) and end stage renal (kidney) disease. Review of the medical record revealed the patient was a high fall risk, attempting to pull at his/her intravenous lines and to get out of bed when his/her right side was flaccid. A physician ' s order for a lock belt restraint (to be used only when the patient was in bed) was obtained 11/08/12. The medical record lacked documentation the restraint order was renewed every 24 hours on the following dates: 11/09/12, 11/12/12, 11/13/12, 11/17/12, 11/22/12, 11/23/12, 11/25/12, 11/27/12, 11/29/12, 12/01/12, 12/04/12, and 12/07/12. This finding was confirmed with staff K on 12/11/12 at 2:30 PM.

Review of the medical record for Patient #26 was completed on 12/11/12 at 3:30 PM. Patient #26 was admitted to the hospital 11/02/12 with diagnoses including a fall with subsequent atrial fibrillation (fast and irregular heartbeat), deep vein thrombosis (blood clot in a vein), tracheotomy (artificial airway in the trachea) and ventilator dependence. Review of the medical record revealed patient #26 was attempting to pull at his/her tubes and intravenous lines. A physician ' s order for bilateral soft wrist restraints was obtained 11/02/12. The medical record lacked documentation the restraint order was renewed every 24 hours on the following dates: 11/03/12, 11/06/12, 11/08/12, 11/10/12, 11/12/12, 11/14/12 - 11/17/12, 11/19/12, 11/21/12, 11/23/12, 11/25/12, 11/26/12, 11/29/12, 12/03/12, and 12/05/12. This finding was confirmed with staff I on 12/13/12 at 3:15 PM.

Based on observation, medical record review, interview and policy review (Drake PC=2008-12-12008 ) it was determined the facility failed to ensure three patients (#1, #3, and #19 ) of 31 sampled patients who experienced pain were reassessed for the effectiveness of the pain medication administered.
The patient census was 59.

Findings include:


Review of the medical record for patient #19 was completed the morning of 12/11/12. The patient was admitted on 11/4/12 with diagnoses including cellulitis and abscess of the leg, except the foot. The medical record revealed the patient had medications including Tylenol 650 milligrams administered every four hours as needed for mild pain, and Percocet 325 milligrams per tablet (two every six hours as needed/moderate pain).
The medical record revealed on 12/05/12 at 10:00 AM the patient had chronic generalized intermittent pain and rated the pain an "8" on a scale from one to ten with ten being the highest for pain. The medical record revealed a medication was given at 10:00 AM but did not specify the type of medication that was given nor was there any documentation of a reassessment for the effectiveness of the pain medication which was given.

The electronic medical record review for patient #1 was completed on 12/10/12 with the assistance of staff K. (nurse manager on 3 South ). The patient was admitted on 11/16/12 with diagnoses that included hypoxia , necrotizing facisitis and respiratory failure. The medical record revealed the patient had medications that included Precocity and Tylenol for pain. On 11/18/12, the patient complained of pain at the level of " 8 "from the scale of 0 to 10 with 10 being the highest pain level. The patient at this time was administered Tylenol 650 milligrams. There was no documentation a follow up was conducted to assess the effectiveness of this medication.

On 12/08/12 the patient complained of pain (not specified to the location) of "7" and no follow up to this pain complaint was documented. On 12/9/12 at 8:00 PM the patient complained of a pain level of " 7" with Percocet given at this time. There was no follow up conducted to determine the effectiveness of the pain medication. Staff K stated during an interview at this time, the reassessment of the medication should be followed up as per agency policy within the one to two hour window.

Review of the policy and procedure for "Pain Management" policy number, Drake-PC-200812-1201, revealed an assessment and a reassessment of pain will be documented on the "Pain Management Flow Record" and pain medication given to patients should be reassessed for effectiveness of the pain medication approximately one to two hours after the administration of the medication and a two point reduction in the pain score should be expected.

This finding was shared during an interview with staff I on 12/12/12 at 3:00 PM with no additional information received.


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The medical record review for patient #3 was completed 12/10/12 at 11:00 AM. Patient #3 was admitted to the hospital on 11/06/12 with a diagnosis of malignant tumor of supraglottis (throat cancer). On 12/10/12 at 11:00 PM, staff M documented patient #3 " denies pain. " At 11:32 PM, staff M administered Oxycodone (a narcotic pain medication) 15 mg (milligrams) by mouth. At 11:34 PM,staff M documented patient #3 was having pain of a six on a 0-10 pain scale, the medical record lacked documentation of the intensity or location of the pain. The medical record lacked documentation a follow up reassessment of the pain was conducted within one to two hours of the administration of the medication.

On 12/11/12 at 4:57 AM, staff M administered Oxycodone 15 mg by mouth. The medical record lacked documentation of the intensity or location of the pain. The medical record lacked documentation a follow up reassessment of the pain was conducted within one to two hours. This finding was confirmed with staff L 12/11/12 at 11:20 AM.

Based on observations, staff interviews, and review of sprinkler inspection reports, and generator testing logs, the facility failed to meet the provisions of the Life Safety Code related to fire safety in regards to exit access door locks, sprinkler inspections, and generator testing. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 59.
Findings include:

During this visit, 12/11/12 through 12/13/12, tour was conducted in the main campus facility with Staff A1, and D4, and on 12/13/12 with Staff A1, B2, and C3, and E5. The following were observed during this tour and inspection report reviews:

On the third floor of this building, two exit access doors on the third floor were equipped with locking devices that resulted in difficulty opening the doors from the inside. Refer to A0710.

In one off-site facility, the facility lacked documentation of quarterly inspection reports and of generator weekly and monthly inspections and testing. Refer to A0710.

Based on observations, staff interviews, and review of sprinkler inspection reports, and generator testing logs, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association related to fire safety in regards to exit access door locks, sprinkler inspections, and generator testing. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 59.
Findings include:

During this visit, 12/11/12 through 12/13/12, tour was conducted in the main campus facility with Staff A1, and D4, and on 12/13/12 with Staff A1, B2, and C3, and E5. The following were observed during this tour and inspection report reviews:

On the third floor of this building, two exit access doors on the third floor were equipped with locking devices that resulted in difficulty opening the doors from the inside. Refer to K38.

In one off-site facility, the facility lacked documentation of quarterly inspection reports and of generator weekly and monthly inspections and testing. Refer to K130.

Based on observation, staff interview, policy review (Policy Number Drake -RS-PC-21-E) and review of the temperature monitoring log (Hydrocollator and Colpak temperature log ) revealed the water in the Hydroplane was out of range and not reported to the biomedical engineer according to the facilities policy and procedure.
The census was 59.

Findings include:

Tour of the outpatient rehabilitation department was completed on 12/12/12 at 2:20 PM. Review of the daily log book for the Hydrocollator revealed from 05/01/12 through 12/13/12 there was a total of 73 days in which the temperature was recorded at 170 degrees. The logs revealed the Hydrocollator temperature should be maintained between 160 to 165 degrees.

On 12/12/12 at 2:20 PM staff H (manager of therapy) checked the water temperature of the Hydrocollater upon surveyor request. The water temperature was checked with a thermometer, being used to check the water in the Hydrocollator, with a reading of 170 degrees.

Interview with staff H on 12/12/12 at 2:20 PM revealed it was the facility's policy to notify the biomedical engineer of the elevation in the temperature and this was not done.

Review of the policy and procedure for "Hydrocollator Packs", Policy Number Drake-RS-PC-21-E on 12/13/12 at 10:29 AM revealed Hydrocollator packs are used to create a rise in tissue temperature.
The policy also revealed the water in the Hydrocollator pack unit are checked daily and recorded on a temperature log and if the temperature falls out of the acceptable range, clinical engineering should be called to check the Hydrocollator unit.

The above findings were shared with staff H on 12/13/12 at 1:00 PM.