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Based on document review and interview, the facility failed to obtain a complete order for 2 of 5 patients restrained (patient #7 and #9). Findings include:

On 10/01/13 at approximately 1230 during record review for patient #7 it was determined that on 09/21/13 and 09/22/13, the physician signed an order for restraints to be applied to the "Right and Left wrists". There was no time documented by the physician and there was no name on the order sheet. Therefore, the physician signed a blank order sheet.

On 10/01/13 at approximately 1230 during record review for patient #9 it was determined that on 07/28/13 and 07/29/13, the physician signed an order for restraints to be applied. The physician did not designate which limb(s) were to be secured. Additionally, no time was documented by the physician.

On 10/02/13 at approximately 1400 during an interview with Staff C, it was determined that the patients # 7 & # 9 did not have complete orders for restraints.

On 10/02/13 at approximately 1500 during review of the policy titled " Restraints and Seclusion" dated 06/2012 it was determined that the policy does not specify what comprised a complete restraint order.

Based on document review and interview it was determined that the facility's physician wrote standing orders for restraints for 2 out of 5 restrained patients' charts reviewed (patients # 7 and #9). Findings include:

On 10/01/13 at approximately 1230 during record review for patient #7 it was determined that on 09/21/13 and 09/22/13, the physician signed an order for restraints to be applied to the "Right and Left wrists". There was no time documented by the physician, and there was no name on the order. During review of the document titled "Safety: Alarms, Falls, Restraints," it was determined that patient # 7 was not placed in restraints on 09/21/13 and 09/22/13 for the entire 24 hour day.

On 10/01/13 at approximately 1230 during record review for patient #9 it was determined that on 07/28/13 and 07/29/13, the physician signed an order for restraints to be applied. The physician did not designate which limb(s) were to be secured. There was also no time order (of evaluation) documented by the physician. During review of the document titled "Safety: Alarms, Falls, Restraints" it was determined that patient # 9 was not placed in restraints on 07/28/13 and 07/29/13 for the entire 24 hour day.

On 10/02/13 at approximately 1400 during an interview with Staff C, it was determined that the patients # 7 & # 9 had completed physician orders for restraints while the patients were not restrained.

On 10/02/13 at approximately 1500 during review of the policy titled " Restraints and Seclusion" dated 06/2012 it was determined under the heading "Orders to Initiate Restraint" that "The order for a restraint may never be written as a standing order or on an as needed bases (PRN)."

Based on document review and interview, it was determined that the facility failed to ensure that 4 of 5 sampled patients in restraints (Patient #3, #4, #7 and #9), had timely physician evaluations and the renewal of continued restraint use orders as required by hospital policy. Findings include:

On 10/01/13 at approximately 1500 during record review, it was determined that 4 of 5 sampled patients in restraints ( Patient #3, #4, #7 and #9) did not have timely evaluations by physicians for the renewal or continuation of the use of restraints as required. All patients identified had patterns of physicians failing to reevaluate the patients beyond the 24 hours required per policy.

On 10/02/13 at approximately 1445 during an interview with Staff C, it was determined that the patients #3, #4, #7 and # 9 did not have timely physician evaluations (within 24 hours) and the renewal of continued restraints.

On 10/02/13 at approximately 1500 during review of the policy titled " Restraints and Seclusion" dated 06/2012 it was determined under the heading "Orders to Initiate Restraint or Seclusion for Control of behavior" #6 states "The original order may only be renewed for up to 24 hours, and thereafter, a physician or licensed independent practitioner must see and assess the patient before issuing a new order."

Based on medical record review, interview and policy and procedure review, the facility failed to ensure that an individualized plan of care was developed and updated in 4 out of 9 (#1, #4, #6,and #9) patient medical records reviewed. Failure to develop and update an individualized care plan has the potential for poor patient outcomes.
Findings include:

On 10/1/13 at approximately 1200 during medical record review of patient #4, revealed the patient was admitted on 9/4/13 and was currently still an inpatient. The admitting diagnosis was respiratory failure and antibiotic therapy. On the document titled, "Pressure Ulcer Data Collection Tool", dated 9/6/13 it was documented that the patient had "no pressure ulcers" on admission to the facility. On the document titled, "Interdisciplinary plan of care discharge and barrier update", dated 9/12/13, it was documented that the patient had "an abrasion that was healing", remained on the ventilator and was receiving dialysis." It was signed by all team members and all of the sections were completed. The following week on 9/19/13 the "Interdisciplinary plan of care discharge and barrier update", there was no documentation on "pharmacy, wound care, dialysis or respiratory therapy". The "case manager, wound care nurse, respiratory therapist and pharmacy" failed to update the plan of care for this patient and didn't sign the document as being present for the meeting. Review of the document titled, "Interdisciplinary plan of care discharge and barrier update", for the week of 9/26/13 revealed that no documentation for wound care, dialysis or respiratory therapy had been completed. The wound care nurse and respiratory therapy failed to update this patient's plan of care and attend the meeting. During review of the document titled, "Pressure Ulcer Data Collection Tool", dated 9/26/13, it was documented that the patient had acquired "5 pressure ulcers; sacrum, right and left heel, right and left lateral leg." The sacrum was the largest with a "length of 7.5 cm., width of 13 cm. and depth of 0.1 cm." A photo of this pressure ulcer dated 9/26/13 was viewed with documentation of "a small amount of serosanguineous exudate and a wound bed of black/brown eschar and pink/beefy red tissue."

On 10/2/13 at approximately 1300 when staff B was queried if there was any other type of care plan documentation for this patient in which the response was, "no." When asked to confirm the findings of incomplete care plans she concurred with the findings.

On 10/2/13 at approximately 1330 during policy and procedure review of the document titled, "Interdisciplinary Team Management of Patient Care", states under the section, "Policy, The Case Manager is the designated team leader with the responsibility of overseeing and directing the total plan of care for each patient. He/she ascertains that appropriate disciplines have an established plan of care that is comprehensive and addresses the needs of the patient. All care must meet with the approval of the physician in charge of the patient." The section titled, "Procedure", states, "Each team member reports on the status, problems and/or goals the patient has accomplished..."


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On 10/01/13 at approximately 1100 during medical record review of patient #1, revealed the patient was admitted on 06/21/13 and was currently still an inpatient. During review of the document titled, "Wound Documentation" it was documented that the patient had acquired a "posterior inferior/superior scrotum" wound. The physician ordered on 06/21/13 for the wound to "be cleansed and (dressing) changed on a daily basis." The wound dressing was documented changed on 06/25, 06/28, 06/29, 07/01, and 07/03. During medical record review with Staff C on 10/02/13 at approximately 1215 it was confirmed that nursing staff failed to follow the physician's order to "change the scrotum dressing on a daily basis."

On 10/01/13 at approximately 1300 during medical record review of patient #6, revealed that the patient was admitted on 08/06/13 and was currently still an inpatient. During review of the document titled, "Wound Documentation" it was documented that the patient had acquired a "R (right) & L (left) Ischium" wound. The physician ordered on 08/06/13 for the wound to "be cleansed and changed on a daily basis." It was documented that the wound dressing was changed on 08/07, 08/10, 08/13, 08/14, and 08/17. During review with Staff C on 10/02/13 at approximately 1245 it was confirmed that nursing staff failed to follow the physician's order to "change the R & L ischium dressings on a daily basis."

On 10/01/13 at approximately 1330 during medical record review of patient #9, revealed that the patient was admitted on 07/25/13 and was currently still an inpatient. During review of the document titled, "Wound Documentation" it was documented that the patient had acquired "Broken Blisters / Entire Body". The physician ordered on 07/25/13 for the "blisters to be cleansed and (dressings) changed on a daily basis." It was documented that the blister dressings were changed on 07/29, 07/31, 08/02, 08/07,08/08, 08/09, and 08/12. During review with Staff C on 10/02/13 at approximately 1330 it was determined that nursing staff failed to follow the physician's order for "blisters to be cleansed and (dressings) changed on a daily basis."

Based on observation, interview and policy and procedure review the facility failed to ensure that the infection control officer had a system for monitoring compliance of isolation precautions in the care of patients with communicable disease and taking action for remediation as needed. This has the potential for the increased spread of infections resulting in poor patient outcomes. Findings include:

On 10/1/13 at approximately 0945 during observations of the unit, the following breaches in procedure for contact precautions was observed: The patient in room 759 was in "Contact Precautions", staff J was observed in the room with the patient, doing patient care, with no gown or gloves on. Staff J was asked if she was aware of the hospital's "Contact Precautions" procedure and responded, "yes, I was rushing to get to the patient."
The patient in room 758 was in "Contact Precautions", observed staff K coming out of the patient's room with gloves on and came into the nursing station, to return the blood glucose machine, wearing contaminated gloves. Staff B confirmed this observation at the time of occurrence.
The patient in room 757 was in "Contact Precautions" and observed staff L, having gloves on, preparing medications for administration at the computer right outside the patient's room, then going into the patient's room and returning to use the computer with the same (contaminated) gloves. When staff L was queried regarding the observations, she replied, "I didn't touch anything in the patient's room, I just went to scan the barcode for the patient's medication."

On 10/2/13 at approximately 1030 during an interview with the infection preventionist, staff B, she was queried as to if the staff has infection control training for contact precautions, she stated, "Yes, annual competencies and ongoing training throughout the year at staff meetings."

On 10/2/13 at approximately 0930 during review of the policy and procedure for contact precautions it was found in the policy IC III-5, titled, "Contact/Contact Enteric Precautions", states under the section B, specific procedures, #3, "Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur", #6, "Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room", and #9, "All equipment that needs to be "shared" will be disinfected between patients."