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Based on medical record review, staff interview and family member documentation, the hospital failed to ensure that 1 of 1 patients (Patient #4) was given the right to make informed surgical treatment decisions about whether to consent to a procedure. This occurred in a total sample of 4 patients, and has the ability to affect the total patient population of 37 patients.

Findings include:

The 1/10/13 review of patient complaint details written by the spouse of Patient #4 reflects that Patient #4 on 1/17/12 was given a non-emergency CT (computerized tomography) scan with contrast media (medication to improve picture quality) by intravenous (IV) injection (into vein).

On 1/16/13 medical record review verifies the above testing. The "Final radiology Report" dated 1/17/12 reflects "CT of Abdomen and Pelvis" and documents under "Technique: 5 mm sequential axial images through the abdomen and pelvis were obtained after the administration of intravenous contrast and without oral contrast...".

Interview with Director of Quality/Risk Management A on 1/16/13 at approximately 3:40 p.m. reflects that the hospital does not require informed consent for CT with IV contrast. Director A states that when the patient /patient representative signs the admission consent to treatment that it covers this testing. Director A stated that Patient #4 or Patient #4's spouse did not have to sign an additional consent before this test was performed after being ordered by the physician.

The 1/16/13 review of the "Patient Consent to Treatment-Admission Forms" reflects:
"1. Consent to Medical and Surgical Procedures: The patient identified above consents to the procedures that may be performed during this hospitalization or on an outpatient basis, including emergency treatment or services, and which may include but are not limited to laboratory procedures, x-ray examination, medical and surgical treatment or procedures, anesthesia, or hospital services rendered for the patient under the general and special instructions of the physician...". Continued review of this 3 page document reflects that there is no information documented that reflects disclosure of risk/ benefit of treatment given.

Medical record review on 1/16/13 reflects that their is no documented evidence of a signed surgical consent for Patient #4's CT scan with contrast. There was no documented evidence that Patient #4 of Patient #4's representative (spouse) was given the right to utilize an informed consent process that assures patients or their representatives are given the information and disclosures needed to make an informed decision about whether to consent to a procedure, intervention, or type of care that requires consent. Reference guidelines at 42 CFR 482.51(b)(2) pertaining to surgical services informed consent states that a "properly executed informed consent for an operation must be in the patient's chart before surgery, except in emergencies". The definition of "surgery" is defined in 42 CFR 482.51 and states that "...Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs and the central nervous system also in considered to be surgery...". Contrast media would fall under this description.

Based on medical record review and staff interview, the hospital failed to ensure that 1 of 1 sampled patients (Patient #2), in a total sample 4 patients was comprehensively assessed for the risk of injury when bed falls occurred while Patient #2 was physically restrained. This has the potential to affect 3 patients with restraint orders, in a total census of 37 patients.

Findings include:

The 1/16/13 medical record review reflects the following:

Review of the "LifeCare Hospital Incident Report" dated 1/3/13 at 8:15 p.m. documents under occurrence details: "Patient found with restraints intact, kneeling next to bed. No apparent injury...pulse ox(imetery) 84%, patient bagged and pulse ox(imetery) increased 94%". The type of restraint documented as being used was "bilateral wrist restraint".

Review of the "Restraint Order" documents that medical orders for physical restraint using bilateral soft wrist restraints from 1/3/13 through 1/7/13. The reason for the restraint was listed as "disorientation, altered level of consciousness and attempts to pull out tubes (intravenous, feeding, oxygen and airway)".

On the 1/8/13 "Restraint Order", medical orders for physical restraint using bilateral soft wrist restraints and "times 4 side rails on bed" was written by the physician. The reason for the restraint was listed as "disorientation, danger of imminent harm to self or others, confusion, marked fall potential, marked agitation, and attempts to pull out tubes (intravenous, feeding, oxygen and airway)".

Review of the "LifeCare Hospital Incident Report" dated 1/8/13 at 9 p.m. reflects under occurrence details "Found patient at bedside still restrained to bed." The "Life Care Hospital Investigative Analysis" (no date or time documented) found attached to the report, reflects "Certified Nursing Assistant found patient on floor only minutes after leaving room. Patient wrist restraints were connected but loose enough for patient to fall...".

Review of the "Daily Nursing Assessment" for 1/8/13 reflects that Patient #2 was restrained with bilateral soft wrist restraints and 4 bed side rails.

Restraint orders were continued for another 24 hour period, on 1/9/13 at 9 a.m., for bilateral soft wrist restraints and side rails on bed x 4, after this patient was found to have fallen out of bed with bilateral restraints tied and all 4 side rails up. It could not be determined by medical record review of the above documents, if Patient #2 had climbed over or between side rails to exit the bed on 1/8/13, or if restraints or side rails were secured improperly. Patient #2 had/has the potential to strangulate or entrap body parts in the bedframe while attempting to exit bed while wearing restraints.

Interview with Director of Quality/Risk Management A on 1/16/13 at approximately 3:40 p.m. reflects that lowest bed height without siderails is 9 inches to the floor, and that wrist restraints were necessary for medical reasons. Director A stated that she did not know details of the two falls incidents, but that no injury occurred. Director A could not define the position the patient was found in after the 1/3/13 or 1/8/13 falls, to rule out strangulation or siderail /bed board entrapment. There was no documented evidence of a risk assessment being conducted after the falls to define risk/benefit to this patient or to rule out negative responses to wrist and side rail restraint application. There was no documented evidence that hospital staff reviewed the incident to document if restraints were applied appropriately. Director A was asked to seek additional information at that time and present to this surveyor by 1/22/13. As of exit interview, on 1/23/13 at 12 noon, no additional information was submitted.

Based on surveyor observations, hospital and contract environmental services staff interviews and employees education files review, the hospital failed to ensure that contract environmental services staff were competent in their duties, and had comprehensive infection control education that met the needs of the hospital. This occurred in 2 of 2 environmental services contract staff interviewed (Contract staffs D and E). This has the potential of affect the total hospital census of 37 patients.

Findings include:

Surveyor observations on 1/10/13 at approximately 11 a.m. of the Environmental Services cart and closet reflects that "Dispatch Disinfectant solution" is used to do daily (occupied rooms) and terminal (discharged) patient room cleaning.

Interview with contracted ES C (Environmental Services C) on 1/10/13 at approximately 11 a.m. reflects that she states that Dispatch disinfectant solution needs to saturate the inanimate surface "for 12 seconds or less" to kill all bacteria/ germs. ES C states the "air drys it (the disinfectant) quite quickly".

Review of the manufacturing use guideline for Dispatch Hospital Disinfectant on 1/10/13 at approximately 12:30 p.m. reflects that it is a 1:10 bleach solution and requires a 1 minute contact saturation time to kill 99.9 % of germs and a 5 minute saturation contact time to kill Clostridium Difficile spores.

Interview with ES D on 1/16/13 at approximately 12:30 p.m. reflects that when asked how to clean up a blood spill, ES D stated "mop it up". ES D did not know the appropriate CDC (Centers for Disease Control) double wipe procedure for cleaning up blood borne pathogen spills. This procedure requires the cleaner to wipe up the surface with a approved disinfectant wipe and discard, then use a second clean disinfectant soaked wipe to clean the surface again.

Interview with Area Manager E and Director A on 1/16/13 at 12 noon through 1 p.m. verifies that the hospital has no initial hospital orientation paperwork to show that contract ES employees were oriented to the hospital environment before initiating patient environmental cleaning services. Director A verified that the hospital has no documented evidence that ES C and D's infection control training given by the contract environmental services agency has been reviewed to meet the hospital regulatory standards. Director A stated that all contract employee human resources files were maintained by their Area Manager A, not the hospital.

Based on infection control log data and staff interview, the hospital failed to aggregate demographic data on discharged patients with infections, identified by the hospital as being significant for tracking, trending and analyzing; and failed to document periodic analysis of this log data. This occurred in 1 of 1 infection control interviews (Infection Preventionist B (IP B) on 1/14/13 at approximately 12:45 p.m.), and has the potential to to affect 37 total inpatients.

Findings include:

Interview with IP B on 1/14/13 at approximately 12:45 p.m. reflects that she has brought the infection control logs for November 2012, December 2012 and January of 2013 to date.

Review of this log on the date and time above reflects a loose leaf binder divided by Room number tabs. Under each room tab, if the room was occupied with an infected patient, this patient had an infection demographic. This infection control log did not have any data on past discharged nor transferred patients with infections, only current inpatients on the day of 1/14/13.

Continued review of the QAPI (Quality Assessment Performance Improvement) data shows infectious percentage data by month for the total year of 2012. For the hospital acquired infections, there was no documented analysis of cause, monitoring or evaluation of prevention interventions. The data was tracked by following infectious type and organisms: ventilator associated, catheter related/blood infection, surgical site infections and multi resistant organisms such as Clostridium difficile, Vancomycin resistant enterococcus, and Methicillin resistant staphylococcus.

Review of these two infection control documents reflects that there is no periodic documentation of analysis of trends or patterns of infections, and no documented evidence that infection control education was tailored to the analysis of these potential patterns. There was no evidence that the hospital IP was reviewing and analyzing laboratory culture reports hospital wide to identify trends/ patterns or clusters of infectious organisms that might occur outside the organisms listed above.

This was verified by Director A on 1/16/13 interview, at approximately 4 p.m.