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Based on medical record review, policy review, and staff interview, the facility failed to ensure restraint use was in accordance with the physician order (A168). The facility failed to ensure each order for restraint use to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy (A173). The facility failed to ensure the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy (A175).

Based on medical record review and staff interview, the facility failed to ensure restraint use was in accordance with the physician order for one of two patients reviewed for restraints (Patient #1). The facility's census was 78.

Findings include:

Review of the policy titled, "Restraints and Seclusion," revised 04/01/23, revealed orders for restraints must be renewed on a daily basis.

Review of the medical record for Patient #1 revealed orders for bilateral soft wrist restraints daily from 10/21/23 through 11/04/23. The medical record contained orders on 11/05/23, 11/07/23, 11/09/23, 11/10/23, and 11/11/23 for bilateral unsecured mittens. The medical record lacked orders for any type of restraint use on 11/06/23 and 11/08/23. The medical record contained documentation of continued restraint use from 10/21/23 through 11/12/23. The medical record contained documentation on 10/23/23 at 6:18 AM through 10/26/23 at 7:27 AM of bilateral secured/tied mittens, not soft wrist restraints as ordered. On 10/26/23 at 7:27 AM through 11/12/23 at 4:00 AM documentation revealed bilateral unsecured mittens were in place. There was no documentation bilateral soft wrist restraints were in place until 11/04/23 as ordered. On 11/12/23 at 4:00 AM the two hour safety checks stopped with no documentation of removal or discontinuation of restraints.

This was verified in an interview on 12/21/23 at 1:00 PM with Staff C.

Based on medical record review, policy review, and staff interview, the facility failed to ensure each order for restraint use to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy for one of two patients reviewed for restraints (Patient #1). The facility's census was 78.

Findings include:

Review of the policy titled, "Restraints and Seclusion," revised 04/01/23, revealed orders for restraints must be renewed on a daily basis.

Review of the medical record for Patient #1 revealed orders for bilateral soft wrist restraints daily from 10/21/23 through 11/04/23. The medical record contained orders on 11/05/23, 11/07/23, 11/09/23, 11/10/23, and 11/11/23 for bilateral unsecured mittens. The medical record lacked orders for any type of restraint use on 11/06/23 and 11/08/23.

This was verified in an interview on 12/21/23 at 1:00 PM with Staff C.

Based on medical record review, policy review, and staff interview, the facility failed to ensure the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy for one of two patients reviewed for restraints (Patient #1). The facility's census was 78.

Findings include:

Review of the policy titled, "Restraints and Seclusion," revised 04/01/23, revealed documentation every two hours of observations of safety, comfort, mobility, skin integrity, food/hydration, and toileting.

Review of the medical record for Patient #1 revealed orders for restraints from 10/21/23 through 11/11/23. The medical record lacked documentation every two hours of safety checks on 10/26/23 from 2:00 PM to 7:00 PM, on 10/30/23 from 12:00 AM to 6:30 AM and from 4:00 PM to 8:00 PM, on 10/31/23 from 12:00 PM to 8:00 PM, on 11/02/23 from 12:00 PM to 4:00 PM, on 11/06/23 from 6:00 PM to 11/07/23 at 1:48 AM, on 11/07/23 from 1:48 AM to 6:07 AM, and on 11/08/23 from 5:32 PM to 11/09/23 at 6:47 AM. On 11/12/23 at 4:00 AM the two hour safety checks stop with no documentation of removal or discontinuation of restraints.

This was verified in an interview on 12/21/23 at 1:00 PM with Staff C.

Based on medical record review and staff interview, the facility failed to ensure a registered nurse evaluated the nursing care for one of ten medical records reviewed (Patient #1). The facility's census was 78.

Findings include:

Review of the medical record for Patient #1 revealed documentation of extensive vascular wounds to both lower legs and feet on admission. On 10/17/23 at 6:59 PM, the nurse noted the aide found the patient's right foot was bleeding. Pressure was applied for 20 minutes until the bleeding subsided. The supervisor was notified, and the physician examined the patient.

The medical record lacked documentation as to what might have caused the wound to bleed.

The physician's Significant Event Progress Note dated 10/17/23 at 6:39 PM noted the nurse reported finding a pool of blood and clots under the patient's right foot with active bleeding on the dorsal right foot with estimated blood loss of 500 milliliters. The physician reviewed the patient's record and determined the patient's overall condition had not changed. Orders were given for the nurse to hold pressure until no active bleeding was seen and to apply a pressure dressing. Orders to check the patient's hemoglobin and type and screen were ordered immediately (STAT) and transfuse if needed. The patient did not need a transfusion.

The medical record lacked documentation the patient's family was notified of the significant event. This was verified on 12/21/23 at 1:00 PM in an interview with Staff C. Staff C stated there was not a place to document updates to family unless a progress note was added.

This deficiency represents non-compliance investigated under Substantial Allegation OH00148123.

Based on tour, policy review, and staff interview, the facility failed to ensure equipment was maintained to ensure an acceptable level of quality. This had the potential to affect all patients receiving services from this facility. The facility census was 78.

Finding include:

A tour of the facility was completed on 12/19/23 at 10:30 AM. Located in a storage room on 2-South was a portable electrocardiogram (EKG) machine observed with dry brown residue on the plastic covered wires. Located in another clean storage room on this unit were feeding pumps with dry residue noted on them. Interview with Staff C during the tour revealed it was environmental services (EVS) job to clean these pumps.

Located on the third floor during the tour, with Staff C, in a clean storage room were three feeding pumps with dry brown residue speckled and splashed on them. Located in rooms 307, 311 and 313 which were empty and designated as clean and ready for a new admission were intravenous (IV) and feeding pumps with dry brown residue noted on them. Room 307 and 311 had clear plastic bags over these pumps to designate as clean.

A request was made to Staff C for policies related to cleaning this equipment. Staff C stated this facility did not have specific policies for cleaning but all EVS and nursing staff had competencies for cleaning equipment. Competencies titled Equipment cleaning, EVS checklist for occupied room and terminal cleaning were provided on 12/19/23 at 2:40 PM. The equipment checklist stated all medical equipment, such as IV pumps, feeding pumps, wheelchairs and telemetry boxes, will be cleaned with low disinfectants and EVS staff will remove the equipment from the room per hospital procedure. Staff A and C stated all staff completed these competencies upon hire but were not sure if any annual competencies had been required related to cleaning equipment.

Interview with Staff L was completed on 12/21/23 at 9:55 AM. Staff L stated they had worked in EVS for over one year, received training by watching videos, was taught how to mix cleaning agents and what type of wipes to use during cleaning. Asked what type of teaching she received for a patient in isolation revealed she was taught if a sign was on door stating eg. contact isolation "we need to put on gown and gloves." If a patient was in respiratory isolation, she needed to put mask on as well. She used non-chlorine wipes when cleaning equipment but respiratory therapy cleaned their own equipment. If feeding tube splashes were on wires she sprayed with Lime Away and it dissolves it since it was pretty hard. Interview further revealed they were taught how to clean the inside of the IV pump by using a wipe or their scraper to clean the inside. Bagged IV and feeding pumps were clean and ready for the next patient. Staff L was asked if patients or family ever complained regarding housekeeping issues with this staff member stating "Yes, our new supervisor gets many complaints." Staff L further stated "EVS had three shifts and many staff members did not do what they were taught to do. She stated they were "just plan lazy but nothing is done about it".

This deficiency represents non-compliance investigated under Substantial Allegation OH00148123.