HospitalInspections.org

Based on medical record review, Idaho state hospital rules review, policy review, and staff interview, it was determined the facility failed to ensure PRN restraint orders were not written for 1 of 2 patients (Patient #30) whose records were reviewed and included restraints. Additionally, the facility failed to maintain a facility-wide restraint log, which captured restraints for 2 of 2 patients (#30 and #32) whose records were reviewed and included restraints. This had the potential for adverse patient outcomes and to jeopardize patient safety. Findings include:

Idaho Administrative Rules for Hospitals IDAPA 16.03.14.231.01 stated "Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN)."

Idaho Administrative Rules for Hospitals IDAPA 16.03.14.011.31 included the definition of a restraint as: "A restraint is (1) any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or (2) a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

Idaho Administrative Rules for Hospitals IDAPA 16.03.14.233.07 stated " Restraint and Seclusion Log. Each hospital must maintain a log of restraint and/or seclusion use that must include:

a. The name of the patient;

b. The type of restraints and/or seclusion used;

c. The date and time restraints and/or seclusion were applied and discontinued; and

d. Any injury or adverse consequence to the patient incurred during the restraint and/or seclusion."

These rules were not followed. Examples include:

1. A facility policy titled "Restraint Policy and Procedure," approved 6/04/20, stated, "Orders for restraints will not be written on a PRN or standing order basis." This policy was not followed.

Patient #30 was a 57-year-old male admitted to the facility on 9/18/20, and discharged on 9/25/20. He was admitted with a primary diagnosis of auditory hallucinations. Additional diagnoses included delusions and schizophrenia.

Patient #30's medical record documented he was admitted to observation status to await placement in a psychiatric facility. His record included an instance where his agitation escalated, and further de-escalation techniques were working to manage his agitation. Patient #30's medical record documented his RN administered PRN Geodon for his agitation, and he agreed to the administration. Geodon is an atypical antipsychotic; when administered as an intramuscular injection, it is used for the acute treatment of agitation in schizophrenic patients.

Patient #30's medical record included his MAR which documented an order for Geodon IM 20 mg every 4 hours PRN for agitation.

The CEO and Nursing Supervisor were interviewed together on 5/18/21 beginning at 2:24 PM. When asked what Geodon was used for, the Nursing Supervisor stated it was used to manage Patient #30's agitation. The CEO and Nursing Supervisor both stated the Geodon was used as a chemical restraint for Patient #30. The CEO confirmed the order for the Geodon should not have been written as a PRN order, as restraints could not be written PRN. He stated they identified the PRN restraint order in Patient #30's chart review, however he could not find documentation his chart was reviewed or any documentation the PRN restraint order was identified.

The facility failed to ensure PRN orders were not used for restraints.

2. The Compliance Director for the facility was interviewed on 5/17/21 beginning at 2:23 PM. Surveyors requested a facility restraint log for all restraints which had been used in the facility for the last year. The Compliance Director stated she was unaware if the facility maintained a patient restraints log.

Patient #30 and # 32's record were reviewed. Both charts documented restraints had been used in the management or these patients' behavior. Patient #30's medical record included the use of a chemical restraint. Patient #32's medical record included the use of a mechanical restraint.

The CEO and Nursing Supervisor were interviewed 5/18/21 beginning at 2:24 PM. The CEO confirmed both Patient #30 and #32 had documented restraints, however the facility did not have a current restraint log.

The facility failed to maintain a patient restraint log.

Based on medical record review and staff interview, it was determined the facility failed to ensure medical records were complete for 1 of 1 patient (Patient #2), who left the hospital against medical advice (AMA). This resulted in incomplete AMA documentation and a lack of clarity as to the course and outcome of patient care. Findings include:

Patient #2 was a 2 year old male who was admitted to the ED on 8/05/20 with suspected medication ingestion. A nursing note on 8/05/21 at 21:30 stated, "Pts. [sic] mother stating she wants to leave AMA because she doesn't believe the Pt. ingested a large amount of Excedrin."

Patient #'2's medical record included a "AGAINST MEDICAL ADVICE - AMA AND/OR PATIENT REFUSAL," form. The AMA form was missing a date and time by the mother and the RN.

It was unclear when Patient #2 left AMA.

The CEO was interviewed on 5/20/21, beginning at 11:10 AM. Patient #2's medical records were reviewed in his presence. He stated the expectation was for the patient or authorized representative and an RN to sign and date the AMA form. He confirmed Patient #2's AMA form was not complete.

Patient #2's medical record was not accurately documented.

Based on observation, review of CDC hand hygiene guidelines, nursing care standards review, and staff interview, it was determined the facility failed to ensure proper hand hygiene was performed by 1 of 1 direct care staff who was observed during patient care. This failure directly impacted 1 of 2 patients (Patient #33) whose care was observed. It had the potential to impact all patients receiving care at the facility by placing them at risk of cross contamination and infection. Findings include:

The CDC website, accessed on 5/25/21, stated:

"Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene:

- Immediately before touching a patient
- When hands are visibly soiled
- Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices
- Before moving from work on a soiled body site to a clean body site on the same patient
- After touching a patient or the patient's immediate environment
- After contact with blood, body fluids or contaminated surfaces
- Immediately after glove removal"

Perry & Potter, Clinical Nursing Skills and Techniques, 7th edition, stated:

"If hands are not visibly soiled, use an alcohol-based hand rub in the following situations:

- Before having direct contact with patients
- Before putting on sterile gloves...
- After contact with patient's intact skin...
- When moving from a contaminated body site to a clean body site during care
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
- After removing gloves

You may also wash hands with an antimicrobial soap and water in these situations."

These guidelines were not followed. The following breaches in hand hygiene were observed:

Patient #33 was a 78 year old female who came into the facility on 5/02/21 at 1:20 PM, for suture removal, blood draw from her port, and wound care.

- RN did not perform hand hygiene after removing sutures and donning new gloves.

- RN did not perform hand hygiene after touching bedside table, preparing saline flushes, and opening dressing kit prior to donning sterile gloves.

- RN did not perform hand hygiene after removing sterile gloves and donning new gloves prior to removing port dressing.

- RN did not perform hand hygiene after removing old wound dressing prior to donning new gloves to clean wound with saline.

- RN did not perform hand hygiene after measuring wound and prior to touching keyboard.

The RN was interviewed after completing Patient #33's nursing care. She stated she did not know that CDC guidelines recommended hand hygiene between glove changes.

The Infection Preventionist was interviewed on 5/12/21, beginning at 9:35 AM. She stated that the facility followed CDC guidelines for infection prevention and Perry & Potter for patient care nursing standards. She confirmed that the RN should have performed hand hygiene between glove changes.

The facility failed to ensure staff performed hand hygiene.

Based on observation, review of manufacturers' instructions for use, facility document review, and staff interview, it was determined the facility failed to maintain a functional and sanitary environment for patients receiving care at the facility. This had the potential to impact all patients receiving services at the facility and placed patients at an increased risk for infections. Findings include:

A tour of the facility was conducted with the Nursing Supervisor and Director of Compliance on 5/19/21, beginning at 10:05 AM

An ice machine, dedicated for patient use, was observed in a supply room, next to the main hall of the facility. The cleaning and maintenance log for the ice machine was requested. The Director of Compliance provided a calendar which stated, "Ice maker cleaning;" the cleaning was performed monthly and signed by the maintenance manager. There was no documentation of what type of cleaning was expected or performed during the monthly cleaning, the 6-month preventative maintenance, or the weekly cleaning.

The manufacturer's recommendations for cleaning and maintenance for the ice machine stated:

"Weekly: remove grill from scrap ice tray and wipe splash panel, scrap ice tray and grill with sanitizer and water solution. Pour excess solution in scrap tray to clear drain."

The instructions also contained a sanitizing procedure to be performed every 6 months:

"This procedure must be performed a minimum of once every six months.
- All ice must be removed from the bin
- The ice machine and bin must be disassembled, cleaned and sanitized
- The ice machine produces ice with the cleaner and sanitizer solutions
- All ice produced during the cleaning and sanitizing procedures must be discarded."

The Director of Compliance was interviewed 5/19/21 beginning at 2:30 PM. The manufacturer's recommendations for the ice machine were reviewed in her presence. She confirmed the lack of documentation on the cleaning and disinfecting of the patient ice machine.

The facility failed to provide a sanitary environment.