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Based on observation and interview, the facility failed to maintain patient privacy while providing care for 1 patient (#3) of 35 patients reviewed.

The findings included:

Medical record review revealed Patient #3 was admitted to the facility 1/20/16 and had a tracheostomy (tube inserted in the throat to assist with breathing).

Observation with the Respiratory Therapist (RT) on 2/1/16 at 2:40 PM, in the patient's room, revealed the RT was performing tracheostomy (trach) care for Patient #3 and the door to the patient's room was opened. Further observation revealed there were visitors in the hallway outside the patient's room and the visitors were looking into the patient's room while the RT was performing the trach care.

Interview with the RT and the facility Administrator on 2/1/16 at 2:50 PM, outside the patient's room, confirmed the RT failed to provide privacy for the patient during the trach care.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide clinical justification for the use of a restraint for 1 patient (#33) of 3 patients reviewed for restraints of 35 records reviewed.

The findings included:

Review of facility policy "Restraints and Seclusion" last revised on 6/12, revealed "...every use of a restraint is to be documented in the patient's record...at a minimum documentation must include...the justification for restraint (restraint assessment and physician's order)..."

Patient #33 was admitted to the hospital on 1/13/16 with diagnoses including Respiratory Failure and acute Renal Failure.

Medical record review of a Restraint Order/Assessment Sheet dated 1/30/16 at 8:20 AM revealed "...clinical justification for restraint use (check at least one)..." Further review revealed there were no clinical justifications checked or documented for the continued use of restraints. Continued review revealed "...type of restraint...right upper wrist..."

Medical record review of a Restraint Order/Assessment Sheet dated 1/31/16 at 8:40 AM revealed "...clinical justification for restraint use (check at least one)..." Further review revealed there were no clinical justifications checked or documented for the continued use of restraints. Continued review revealed "...type of restraint...right upper wrist..."

Observation on 2/3/16 at 1:00 PM, in the patient's room, revealed the patient had a soft wrist restraint applied to the right wrist.

Interview with the Administrator on 2/3/16 at 1:30 PM, in the 5th floor nurses station, revealed "...a clinical justification for the restraint use should be documented on the restraint order and assessment sheet..." Further interview confirmed there was no documentation on 1/30/16 and 1/31/16 to indicate a clinical justification for the restraint use and the facility failed to follow the policy.

Based on facility policy review, medical record review, and interview, the facility failed to monitor vital signs for 2 patients (#11 and #12) of 6 patients reviewed for blood transfusions of 35 patients sampled.

The findings included:

Review of facility policy, Blood/Blood Components Administration, last revised on 7/10/12, revealed "...take patient's BP [blood pressure] and TPR [temperature, pulse, respirations] for baseline and record on Blood Transfusion Record...for each separate infusion, vital signs (including temp) [temperature] should be recorded prior to starting, at 15 minutes, and immediately post-transfusion..."

Patient #11 was admitted to the hospital on 9/16/15 for diagnoses including Sepsis, Acute Renal Failure, and Osteomyelitis.

Medical record review of a physician's order dated 10/10/15 revealed "...transfuse 2 units PRBCs [packed red blood cells]..."

Medical record review of a transfusion record dated 10/10/15 revealed the first unit of PRBCs was started at 4:10 PM and the infusion was complete at 7:10 PM. Continued review of the transfusion record revealed the patient's post transfusion vital signs were not documented.

Patient #12 was admitted to the facility on 10/24/15 for diagnoses including Respiratory Failure and Hypoxia.

Medical record review of a physician's order dated 11/13/15 revealed "...type cross transfuse 2 units PRBCs..."

Medical record review of a transfusion record dated 11/13/15 revealed the first unit of PRBCs was started at 4:40 PM and infusion was complete at 8:56 PM. Continued review revealed the patient's post blood transfusion temperature was not documented.

Interview with the Administrator on 2/2/16 at 1:15 PM, in the conference room, confirmed patient #11 and #12's post transfusion vital signs were not monitored and the facility failed to follow facility policy.

Based on review of facility policy, observation, and interview, the facility failed to dispose of expired medications in 1 of 10 medication carts observed.

The findings included:

Review of facility policy, Drugs Returned to the Pharmacy, last revised on 12/2003, revealed "...expired or otherwise unstable returned drug products will be disposed of using normal channels...examples include placing the items in expired drug storage or destroying them...expired, unusable items must be returned to the pharmacy to avoid accident [accidental] use..."

Observation and interview with the Infection Control Preventist on 2/3/16 at 10:20 AM, of the back hall medication cart, revealed a one half-full vial of insulin with an expiration date of 1/29/16. Interview with the Infection Control Preventist confirmed the insulin was expired and available for patient use.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to follow hand hygiene guidelines during incontinence care for one patient (#8) of two patients reviewed and failed to maintain equipment in 2 of 11 patient rooms toured.

The findings included:

Review of facility policy "Hand Hygiene" last revised on 10/15 revealed "...when...before and after every patient contact...between glove changes...after removing gloves...after any contact with body fluids, dressings, patient linen..."

Review of facility policy "Guidelines for Reducing of Urinary Tract Infections" last revised on 4/1/13 revealed "...Secure foley with securement device..."

Review of the facility policy, Environment of Care, Medical Equipment Management Activities, revised 7/1/15, revealed "...hospital provides equipment that is safe for use...clinical and physical risks are assessed...through inspection...staff trained and educated in proper...care..."

Patient #8 was admitted to the facility on 1/5/16 with diagnosis including Acute Respiratory Failure, Pneumonia, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus.

Medical record review of a Physician's order dated 2/2/16 at 4:45 AM revealed "...place foley catheter..."

Observation with Certified Nursing Assistant (CNA) #1 and CNA #2 on 2/2/16 at 10:00 AM, in the patient's room, revealed CNA #1 and CNA #2 performed incontinence care for Patient #8. Continued observation revealed both CNAs donned gloves, provided the incontinence care, removed the soiled gloves, and without sanitizing or washing the hands, donned clean gloves. Further observation revealed the foley catheter was not secured to the patient's leg with a securement device and the foley catheter dangled freely off the side of the patient's hospital bed.

Interview with CNA #1 and CNA #2 on 2/2/16 at 10:20 AM, outside the patient's room, confirmed the CNAs did not sanitize or wash the hands after removing the soiled gloves and before donning clean gloves.

Observation and interview with Registered Nurse (RN) #1 on 2/2/16 at 10:25 AM, outside the patient's room, confirmed the urinary catheter was not secured to the patient's leg.

Interview with the Infection Control Preventist on 2/2/16 at 10:30 AM, outside the patient's room, confirmed the facility failed to follow the facility's hand hygiene policy and failed to properly secure the urinary catheter.



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Observation on 2/2/16 at 2:05 PM, with the Infection Control Preventist on the 5th floor, revealed in patient room 5026, an upholstered recliner chair with a tear in the seated cushion with exposed interior foam. Continued observation in patient room 5014, revealed an upholstered recliner with a tear in the cushion seat of the upholstery.

Interview with the Infection Control Preventist on 2/2/16 at 2:20 PM, on the 5th floor, confirmed the facility failed to maintain patient furniture in a safe and sanitary manner.








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