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Based on staff interviews and review of medical records, hospital policies, grievance documentation, and personnel files, it was determined the hospital failed to protect and promote patients' rights. This prevented the hospital from processing all grievances, compromised the hospital's ability to keep patients safe, and prevented staff from utilizing restraints in a consistent manner. Findings include:

1. Refer to A118 as it relates to the facility's failure to ensure a process for prompt resolution of all patient grievances had been implemented.

2. Refer to A166 as it relates to the facility's failure to ensure the use of restraints was in accordance with a written modification to patients' plans of care.

3. Refer to A168 as it relates to the facility's failure to ensure restraints were used only in accordance with the order of a physician or LIP and LIPs ordering restraints were authorized to do so by hospital policy in accordance with State law.

4. Refer to A169 as it relates to the facility's failure to ensure restraint orders were not written as a standing order or on an as needed basis.

5. Refer to A171 as it relates to the facility's failure to ensure restraints, used for the management of violent or self-destructive behavior, were limited to 4 hours for adults.

6. Refer to A174 as it relates to the facility's failure to ensure restraints were discontinued at the earliest possible time.

7. Refer to A176 as it relates to the facility's failure to ensure physicians who ordered restraints received training regarding restraints.

8. Refer to A178 as it relates to the facility's failure to ensure patients, who had behavioral restraints applied, were seen face-to-face within 1-hour after the initiation of the intervention by a person authorized to conduct restraint evaluations.

The cumulative effect of these negative systemic practices seriously impeded the ability of the hospital to provide care of adequate quality.

Based on review of grievances and staff interview, it was determined the hospital failed to ensure a process for the prompt resolution of all patient grievances had been implemented. This affected the resolution of 1 of 1 grievance filed while the patient (Patient #25) was still an inpatient in the hospital and had the potential to impact all patients who wished to file grievances while still in the hospital. This resulted in a lack of follow through for current inpatients who wished to file a grievance. Findings include:

1. Patient #25's medical record documented a 74 year old female who presented to the ED on 4/28/11 for seizures. She was triaged at 9:23 AM. An "EMERGENCY FLOW SHEET RECORD," dated 4/28/11, indicated Patient #25 was placed on an automatic blood pressure machine at 9:30 AM and it continued to monitor her blood pressure at intervals through 4:02 PM that same day. The ED record documented Patient #25 was admitted to the cardiovascular unit at approximately 4:00 PM that same day. Patient #25 remained an inpatient until she was discharged on 4/30/11.

An incident report, dated 4/29/11 at 10:20 AM, read Patient #25's "Niece stated pt's arm was hurting in the ED with B/P cuff on. She notified ED nurse. By the time pt was admitted to the unit, 2 skin tears were noted on arm 1 inner arm at elbow and 1 outer arm at elbow area...Niece feels like her concerns were not validated and is frustrated with new skin tears, edema, and decreased mobility of hand this am." While an incident report had been generated based on the event, a grievance was not initiated.

The Chief Quality Officer was interviewed on 5/26/11 at 8:25 AM. She confirmed the incident had not been filed as a grievance. She stated she had spoken to the niece about the incident. She said the niece complained that the skin tears had been caused by the automatic blood pressure cuff in the ED. She stated the complaint had not been logged as a grievance and was not part of the hospital's grievance process. She stated a written response had not been sent to the complainant.

2. The Quality Improvement Adviser, who was responsible for processing grievances at the hospital, was interviewed on 5/18/11 beginning at 3:30 PM. She stated if current inpatients or their representative made a complaint, it was handled by staff on the floor. She said Unit Directors investigated and attempted to resolve complaints but she said they were not filed as a grievances. She stated she could not think of an instance in the past 2 years where a grievance had been generated while a patient was still being treated in the hospital.

3. The Director of Medical & Surgical Services was interviewed beginning at 10:10 AM on 5/14/11. She stated if a current patient made a complaint about their care, she would investigate the allegation. She stated she would not enter the allegation as a grievance. She said if a patient made a complaint after they were discharged from the hospital, then it was automatically entered as a grievance.

The hospital did not implement a consistent grievance process which provided inpatients and/or their representatives the opportunity to file a grievance. This prevented prompt resolution of the grievances.

Based on record review, staff interview, and policy review, it was determined the hospital failed to ensure the use of restraints were in accordance with a written modification to patients' plans of care for 6 of 10 restrained patients (#1, #13, #21,#30, #37, and #38) whose records were reviewed. This had the potential to interfere with coordination and consistency of patient care. Findings include:

1. Patient #1 was a 26 year old female who was admitted to BHS on 5/12/11. Mechanical restraints and chemical restraints were initiated on 5/15/11 at 10:25 PM, according to documentation on "Behavioral Health Services Restraint and Seclusion Physician Order/Evaluation Form." Mechanical restraints were released on 5/16/11 at 1:20 AM, according to documentation on a "BHS BEHAVIORAL SECLUSION AND RESTRAINT LOG." The "BHS Treatment Plan" (plan of care), dated 5/15/11, was reviewed on 5/19/11. The plan of care did not include the use of restraints.

A BHS policy, "Treatment Planning," updated November 2007, stated revisions to goals and interventions would be included in the treatment plan review section. Each time the treatment plan was revised, staff was to enter a date. If the treatment plan had been revised, staff was to indicate this and note any revisions in the appropriate area (goals, objectives, treatment, etc.).

During an interview on 5/20/11 at 9:25 AM, the Accreditation Officer reviewed Patient #1's plan and confirmed there was no documentation in the plan referencing the use of restraints. She stated she would talk to the Director of BHS and get back to surveyors with any additional information. At 10:00 AM on the same date, she stated she had spoken to the Director of BHS and he explained restraints were referenced on a restraint debriefing form. Copies of the forms were provided to surveyors via fax on 5/23/11. The form "BEHAVIORAL HEALTH SERVICES POST SECLUSION AND RESTRAINT PATIENT DEBRIEFING" included the following questions: 1) from the patient's point of view what happened? 2) Have the patient identify events that contributed to the incident. 3) Do these triggers occur often for this patient? 4) Have these triggers caused the same type of reaction for the patient in the past? 5) What other alternatives were discussed to the triggers identified above? The form did not include a treatment plan.

Patient #1's plan of care was not modified to reflect the use of restraints.

2. Patient #37 was a 76 year old male who was admitted to the hospital on 3/16/11 and transferred to the Rehabilitation Unit on 3/18/11 for care related to a stroke. Patient #37's record contained physician orders for a Vail bed restraint (not to exceed 24 hour periods) on the following dates:

3/23/11 at 7:15 PM
3/25/11 at 1:30 PM
3/26/11 at 1:00 PM
3/27/11 at 1:00 PM
3/28/11 at 1:00 PM
3/29/11 at 1:00 PM
3/30/11 at 1:00 PM
3/31/11 at 1:00 PM
4/01/11 (not timed)
4/03/11 (not timed)

Patient #37's "INPATIENT REHAB INTERDISCIPLINARY TREATMENT PLAN," initiated 3/21/11, was not updated to include the orders for a Vail bed restraint. A hospital policy, "INTERDISCIPLINARY PLAN OF CARE," revised July 2007, stated the plan of care included nursing interventions and treatments and medical treatments.

During an interview on 5/19/11 at 4:20 PM, the Accreditation Officer reviewed Patient #37's record and confirmed the plan of care did not include a Vail bed restraint.

Patient #37's written plan of care was not updated to include use of a Vail bed restraint.



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3. Patient #38 was an 89 year old male admitted to the medical unit of the hospital on 5/04/11 for care primarily related to altered mental status.

An order was written by a physician on 5/04/11 at 4:10 PM for "restraints PRN." On 5/05/11 at 2:40 AM, an LPN documented on the "Daily Focus Assessment Report" under "Restraints" the patient was placed in soft, bilateral wrist restraints. The mechanical restraints were discontinued on 5/05/11 at 5:00 AM. Patient #38's plan of care was not updated to show the use of mechanical restraints.

In an interview on 5/20/11 at 9:25 AM, the Accreditation Officer stated any change in a patient's condition needs to be updated on the plan of care. In an interview on 5/20/11 at 9:40 AM, the Director of Medical & Surgical Services reviewed Patient #38's chart and stated the plan of care was not updated to include the use of mechanical restraints. She further stated she expected the plan of care to be updated when any restraint was used.

Patient #38's plan of care was not updated to show the use of mechanical restraints.



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5. Patient #13 was a 55 year old male admitted to the critical care unit on 5/10/11 for care after a heart attack and subsequent cardiac catheterization. His medical record contained daily restraint orders (from 5/10/11 at 7:30 AM through 5/21/11 at 7:30 AM) for bilateral soft wrist restraints.

Patient #13's care plan did not include goals and interventions related to the use of soft wrist restraints.

A Clinical Lead from the critical care unit reviewed Patient #13's medical record. She confirmed Patient #13's care plan did not include the use of restraints.

The use of restraints was not incorporated into Patient #13's POC.

6. Patient #21 was a 78 year old male admitted to the hospital on 2/25/11 after suffering a femur fracture. The discharge summary, completed by the physician on 2/28/11, indicated Patient #21 suffered respiratory complications during surgery and required sustained intubation and mechanical ventilation. The medical record contained an initial restraint order for bilateral soft wrist restraints on 2/26/11 at 4:00 PM.

Patient #21's care plan did not include goals and interventions related to the use of the soft wrist restraints.

The Quality Improvement Advisor reviewed Patient #21's medical record. She confirmed the use of restraints was not incorporated into the care plan.

Patient #21's POC did not address restraint usage.



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4. Patient #30's medical record documented a 20 year old female who was admitted to the hospital on 2/07/11 and was discharged on 2/10/11. Her diagnoses included acute renal failure and lithium toxicity. She also had a history of bipolar disorder. Patient #30 was initially examined in the ED and was then admitted to the medical unit for further treatment. Nursing notes documented Patient #30 was restless and anxious on the night of 2/07/11 and through the early morning of 2/08/11. At 10:15 AM on 2/08/11, the nursing note stated Patient #30 "...became combative and also aggressive. Called code orange [a call to staff to assist in the restraint of a patient] and patient was put on four point restraints around this time." Subsequent nursing notes stated Patient #30 continued in restraints until 4:50 PM on 2/08/11.

Restraints were not incorporated into Patient #30's POC while she was restrained. Instead, the POC for restraints stated they were initiated on 2/08/11 at 8:38 PM, 3 hours and 45 minutes after Patient #30 was removed from restraints. This was corroborated on 5/18/11 at 9:25 AM, by the RN who cared for Patient #30 while she was restrained.

The hospital did not update Patient #30's POC to reflect that she was in restraints.

Based on record review, staff interview, and review of hospital policies and personnel records, it was determined the hospital failed to ensure restraints were used only in accordance with the order of a physician or LIP and LIPs ordering restraints were authorized to do so by hospital policy in accordance with State law. This impacted 5 of 10 restrained patients (#1, #8, #17, #28, and #38) whose records were reviewed and resulted in staff, instead of physicians or LIPs, determining the type and duration of restraints to be used. It also resulted PAs ordering restraints without demonstrated administrative approval. Findings include:

1. Incomplete Physician Orders:

a. Patient #38 was an 89 year old male admitted to the medical unit of the hospital on 5/04/11 for care primarily related to altered mental status.

An order was written by a physician on 5/04/11 at 4:10 PM for "Restraints PRN." The order did not include the type of restraint to be used, the length of time for the restraint, or the number of limbs to be restrained. On 5/05/11 at 2:40 AM, an LPN documented on the "Daily Focus Assessment Report" under "Restraints" that the patient was placed in soft, bilateral wrist restraints. The mechanical restraints were discontinued on 5/05/11 at 5:00 AM.

A medical unit RN was interviewed on 5/19/11 at 3:35 PM. She confirmed the restraint order was limited to "Restraints PRN."

The mechanical restraints used on Patient #38 were not in accordance with a complete physician order.

b. Patient #8 was an 18 year old male admitted to BHS on 4/22/11 for care primarily related to psychosis.

On 4/22/11 at 6:40 PM, an order was written by the attending physician for mechanical restraints to be applied. The order did not include the type of mechanical restraint to be used, the length of time for the restraint, or the number of limbs to be restrained. On the "PATIENT CHECKS-CODE AND INITIAL" form, the behavioral health technician documented Patient #8 was out of leg restraints at 6:53 PM and out of arm restraints at 7:00 PM.

During an interview on 5/16/11 at 3:55 PM, the Director of BHS stated they did not get specific orders for mechanical restraints, such as 4 limbs or 2 limbs.

The restraints used on Patient #8 were not in accordance with a complete physician order.



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c. Patient #1 was a 26 year old female who was admitted to BHS on 5/12/11. Her medical record indicated that physician orders for mechanical and chemical restraints were obtained via telephone on 5/15/11 at 11:05 PM. The order for mechanical restraints did not indicate the type of mechanical restraint and the limbs to be restrained. The order for chemical restraints did not indicate the specific medication orders to be used as chemical restraints. Telephone order documentation did not include the name of the RN who received the order.

A separate physician's order, dated 5/15/11 at 10:35 PM, included medication orders for Ativan 2 mg IM every 4 hours PRN and Geodon 10 mg every 4 hours PRN. According to documentation on a "Behavioral Health Services Restraint and Seclusion Physician Order/Evaluation Form," in Patient #1's record, mechanical restraints and chemical restraints were initiated on 5/15/11 at 10:25 PM. A "Behavioral Health Services Seclusion and Restraint Flowsheet" documented Patient #1 was placed in 4 point restraints at that time.

A BHS staff RN and the Director of BHS were interviewed on 5/16/11 at 3:55 PM. The staff RN was asked to look at Patient #1's restraint orders and explain them. She stated BHS staff used Velcro restraints and generally restrained 4 limbs when they received an order for mechanical restraints. She stated they generally released limbs one at a time depending on the patient's control. The Director of BHS stated they did not get specific orders for mechanical restraints, such as 4 limbs or 2 limbs.

The Psychiatrist who authorized restraints for Patient #1 on 5/15/11 was interviewed on 5/19/11 at 9:20 AM. When asked what chemical restraints he had ordered for Patient #1 on 5/15/11 at 11:05 PM, he replied Ativan and Geodon.

Restraint orders did not include the type of mechanical and chemical restraints ordered or the limbs to be restrained.

d. Patient #17 was a 21 year old female who came into the ED on 4/11/11 and transferred to BHS on 4/12/11. The following orders for restraints were incomplete:

> An MD order for seclusion, dated 4/13/11 9:10 AM, did not state for how long the seclusion was being ordered.
> An MD order for (unspecified) restraints, dated 4/13/11 1:40 PM, did not state the type of restraint that was being ordered.
> An MD order for seclusion and mechanical restraints, dated 4/13/11 at 4:30 PM, did not state the type of mechanical restraints ordered or the limbs to be restrained. The order for seclusion did not state a time frame for the seclusion.
> A PA order for mechanical restraints, dated 4/13/11 at 10:20 PM, did not state the type of mechanical restraints ordered or the limbs to be restrained.
> A PA order for mechanical restraints, dated 4/14/11 at 2:30 AM, did not state the type of mechanical restraints or the limbs to be restrained.
> An MD order for mechanical restraints, dated 4/14/11 8:15 AM, did not state the type of mechanical restraints ordered or the limbs to be restrained.
> An MD order for mechanical restraints, dated 4/14/11 12:00 PM, did not state the type of mechanical restraints ordered or the limbs to be restrained.

The Director of BHS was interviewed on 5/16/11 at 3:55 PM. He stated they did not get specific orders for mechanical restraints, such as 4 limbs or 2 limbs.

The restraint orders were insufficient to direct staff in the type of restraints to use and in the duration of seclusion.

2. Restraints Applied Without a Physician/LIP Order:

The hospital policy, "RESTRAINTS AND SECLUSION," revised 11/06/08, stated orders for medical restraints were to be obtained from the LIP within 12 hours of restraint initiation. The policy included a definition of a Medical/Surgical/Restraint as a restraint for "Non-behavioral use, for example, to protect lines from being pulled out by disoriented patients." The policy did not require an order from an LIP be obtained prior to, during, or immediately after, the initiation of a restraint, to ensure restraints were initiated only in accordance with the order of an LIP.

The hospital's policy allowed for the use of restraint for up to 12 hours without an order from an LIP.

3. Physician Assistants Ordering Restraints:

a. Patient #17 was a 21 year old female who came into the ED on 4/11/11 and transferred to BHS on 4/12/11. Mechanical restraints were ordered by a PA on 4/13/11 at 10:20 PM and 4/14/11 at 2:30 AM. During an interview on 5/17/11 at 10:30 AM, the Chief Quality Officer reviewed Patient #17's record and confirmed the findings.

Physician assistants are not LIPs in Idaho. The Idaho Rules for the Licensure of Physician Assistants, at IDAPA 22.01.03.010.07, indicate a physician assistant must render patient services under the direction of a supervising and alternate surpervising physician.

The hospital policy, "RESTRAINTS AND SECLUSION," revised 11/06/08, stated an order for medical restraints and behavioral restraints must be obtained from a physician or LIP. This policy did not reference exceptions for PAs who are not LIPs.

The "Allied Health Practitioner Professional Policy Bylaws Attachment B," dated 5/11/11, identified PA's as allied health practitioners and stated that all allied health practitioners "will provide services only under supervision of a member of the medical staff." During an interview on 5/19/11 at 9:20 AM, a staff Psychiatrist described PAs and NPs as "allied health care practitioners" rather than LIPs.


During an interview on 5/17/11 10:30 AM, the Chief Quality Officer confirmed PAs ordered restraints at the hospital. She explained the orders were co-signed by physicians.

The Chief Quality Officer and the Accreditation Officer were interviewed by telephone on 5/23/11 at 1:30 PM. They stated the bylaws were general and did not address PAs ordering restraints, which should be addressed in individual credentialing files for PAs. They confirmed the hospital's restraint policy did not specifically address PA's authorization to order restraints.

The hospital provided additional documents after the above referenced telephone call. These included "Clinical Privileges" and a "Delegation of Services Agreement" for one PA who had ordered restraints on Patient #17. Neither document specifically referenced authorization to order restraints. The "Clinical Privileges" document referenced the ability of the PA to order therapeutic modalities such as medications and treatments, but did not specify restraints.

Restraint orders were not in accordance with a physician or LIP. The hospital's bylaws, credentialing files, and restraint policy did not reflect an exception to allow PAs to order restraints.



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b. Patient #28's medical record documented a 24 year old male who was admitted to the hospital's BHS on 1/18/11 and was discharged on 2/01/11. His diagnosis was schizophrenia. A nursing note written at 7:00 PM on 1/18/11, stated "Pt became verbally paranoid about other pts talking about him and then began talking about wanting to die. Provided direct staff support and attempted to redirect the pt. Pt was near the Nurses Station. Pt began trying to hit his head against the wall and was physically restrained from 1805 [6:05 PM] until 1815 [6:15 PM]." The "Behavioral Health Services Restraint & Seclusion Physician Order/Evaluation Form," stated "Physical Restraints" were initiated on 1/18/11 at 6:05 PM. The telephone order for the restraints was written at 6:05 PM on 1/18/11 and stated a PA gave the order. The PA signed the order at 6:30 PM.

Also, nursing notes stated Patient #28 began kicking a door which again led to him being physically restrained for 10 minutes, beginning at 4:45 PM on 1/19/11. The order for the restraint was written at 5:35 PM on 1/19/11 by a PA.

Patient #28's medical record was reviewed with the Director of BHS beginning at 9:00 AM on 5/19/11. He confirmed the orders for restraint were written by a PA.

Restraints were not utilized in accordance with an order by a physician or LIP.

4. Physician Orders Not Followed:

Patient #28's medical record also contained a form labeled "Physician Orders," dated 1/20/11 at 10:10 AM, which ordered soft wrist and soft ankle restraints placed on Patient #28. It was signed by a physician at the time. A corresponding nursing note was not present in the medical record so it could not be determined when Patient #28 was placed in restraints and when they were released.

The policy "RESTRAINTS AND SECLUSION," dated 11/06/08, defined a "Rigid Restraint" as "Leather/all-Velcro/Velcro nylon." The policy did not define "soft restraints."

The Charge Nurse on the BHS was interviewed on 5/26/11 at 11:50 AM. He stated "soft restraints" were used on medical units but were not used on the Behavioral Health Unit. He said these were lighter and flimsier. He stated the Behavioral Health Unit only used sturdier more rigid Velcro/nylon restraints for behavioral interventions. He stated even though they were ordered, Patient #28 could not have been restrained using soft restraints because these were not available for use on the BHS.

The physician ordered the wrong type of restraints for Patient #28. He did not order the type of restraints used on the BHS. Nursing staff did not use restraints in accordance with the physician order because they used a different type of restraints that were available to them.

Based on record review, staff interview, and policy review, it was determined the hospital failed to ensure restraint orders were not written as a standing order or on an as needed basis for 4 of 10 restrained patients (#1, #17, #37, and #38) whose records were reviewed. This resulted in the use of restraints on a PRN basis. Findings include:

1. Patient Examples of Restraint Orders Written as PRN/As-Needed Orders

a. Patient #38 was an 89 year old male admitted to the medical unit of the hospital on 5/04/11 for care primarily related to altered mental status.

On 5/05/11 at 2:40 AM, an LPN documented Patient #38 was placed in soft, bilateral wrist restraints on a form titled "Daily Focus Assessment Report." An order was written by a physician on 5/04/11 at 4:10 PM for "Restraints PRN."

A medical unit RN was interviewed on 5/19/11 at 3:35 PM. She reviewed Patient #38's record and confirmed the PRN order for restraints.

The restraints used on Patient #38 were written as a PRN order.



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b. Patient #1 was a 26 year old female who was admitted to BHS on 5/12/11. The medical record documented receipt of a physician's telephone order for mechanical and chemical restraints on 5/15/11 at 11:05 PM. A separate physician's order, dated 5/15/11 at 10:35 PM, included medication orders for Ativan 2 mg IM every 4 hours PRN and Geodon 10 mg every 4 hours PRN. According to documentation on "Behavioral Health Services Restraint and Seclusion Physician Order/Evaluation Form," mechanical restraints and chemical restraints were initiated on 5/15/11 at 10:25 PM.

The Psychiatrist who authorized restraints for Patient #1 on 5/15/11 was interviewed on 5/19/11 at 9:20 AM. When asked what chemical restraints he had ordered for Patient #1 on 5/15/11 at 11:05 PM, he replied Ativan and Geodon. He explained he considered Ativan and Geodon restraints when used to manage a patient's behavior who was at imminent risk of hurting self or staff. At other times, he explained, the same medications could be considered standard symptomatic treatment. In the case of Patient #1, he acknowledged writing the order as PRN and explained his intentions were that the medication would be given one time as a chemical restraint and then be used PRN for symptomatic treatment.

The order for chemical restraints was written as a PRN order.

c. Patient #17 was a 21 year old female who came into the ED on 4/11/11 and transferred to BHS on 4/12/11. On 4/11/11 at 8:45 PM, an ED physician's order included "Restraints as needed." The type of restraints was not indicated.

During an interview on 5/17/11 at 10:00 AM, an RN reviewed Patient #17's record and confirmed the restraints were ordered on an as-needed basis.

An order for an unknown type of restraint was written as an as-needed order.

2. Restraint Orders Treated as PRN Orders:

a. The hospital policy, "RESTRAINTS AND SECLUSION," revised 11/06/08, stated when a trial removal of restraints was attempted and failed, the restraint could be re-applied within the 24 hour period.

When staff discontinued a restraint or seclusion and restarted the restraints under the same order, it constituted PRN use of the order.

The policy allowed for PRN use of restraints.

b. The Director of Critical Care was interviewed on 5/17/11 at 3:30 PM. She stated for patient's restrained for medical reasons, the order for restraints were appropriate for a 24 hour period of time. She stated if restraints were discontinued because they were no longer needed and then reapplied at a later time, as long as it was within the 24 hour time frame of the order, a new order for restraints was not required. She stated this was facility policy and the practice in her department.

c. Patient #37 was a 76 year old male who was admitted to the hospital on 3/16/11 and transferred to the Rehabilitation Unit on 3/18/11 for care related to a stroke. Patient #37's record contained physician orders for a Vail bed restraint (not to exceed 24 hour periods) on the following dates:

3/23/11 at 7:15 PM for safety, impulsive, fall risk, confusion
3/25/11 at 1:30 PM for fall risk, safety
3/26/11 at 1:00 PM for high fall risk, safety
3/27/11 at 1:00 PM for high fall risk, safety
3/28/11 at 1:00 PM for high fall risk, patient very impulsive
3/29/11 at 1:00 PM for high fall risk, impulsivity
3/30/11 at 1:00 PM for impulsivity, high fall risk
3/31/11 at 1:00 PM for impulsivity, high fall risk with history of falls
4/01/11 (not timed) for impulsivity, high fall risk with history of falls
4/03/11 (not timed) for impulsivity, high fall risk

Nursing documentation was not clear or consistent as to when Patient #37 was restrained in a zipped up Vail bed and when he was not. The hospital policy titled RESTRAINTS AND SECLUSION, revised 11/08, did not address the use of Vail bed restraints.

On 5/19/11 at 4:40 PM, an RN was interviewed, who worked on the Rehabilitation Unit where Patient #37 received care. The RN was asked how he would implement an order for "Vail bed restraints not to exceed 24 hours." He stated he would use the Vail bed on an as-needed basis, leave it open when he felt it appropriate and close it when he felt appropriate. He stated he would not have to get a new order within the 24 hour period because an order for 24 hours would cover the need to use the Vail bed. He stated it would "not be realistic" to get a new order every time a patient was put back in a Vail bed. He reviewed Patient #37's record and stated he agreed the nursing documentation was not clear as to when the restraints were on or off. He explained the hospital used to have a system where nursing staff would document hourly whether the restraints were on or off a patient. However, he stated, the new computer system did not allow ease of documentation of when restraints were on or off.

PRN restraints were initiated and ordered throughout the hospital.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure orders for restraint, used for the management of violent or self-destructive behavior, were limited to 4 hours for adults, for 1 of 6 adult patients reviewed (#30), who had behavioral restraints applied. This resulted in a lack of direction to staff regarding how long to continue the restraint. Findings include:

Patient #30's medical record documented a 20 year old female who was admitted to the hospital on 2/07/11 and was discharged on 2/10/11. Her diagnoses included acute renal failure and lithium toxicity. She also had a history of bipolar disorder. Patient #30 was initially examined in the ED and was then admitted to the medical floor for further treatment. Nursing notes documented Patient #30 was restless and anxious on the night of 2/07/11 and through the early morning of 2/08/11. At 10:15 AM on 2/08/11, the nursing note stated Patient #30 "...became combative and also aggressive. Called code orange and patient was put on four point restraints around this time." Nursing notes stated Patient #30 continued in restraints 5 hours and 35 minutes, until 4:50 PM on 2/08/11.

Patient #30's medical record had documented telephone orders for wrist and ankle restraints written at 10:15 AM on 2/08/11. The order stated it was a "Medical/Surgical" restraint order with a time limit of 24 hours. However, the order clearly constituted a behavioral restraint as the order stated Patient #30 was "biting, hitting, kicking, harm to self." The order was a form which contained boxes for "Medical/Surgical...24 hours, Adult Behavioral Health...4 hours, Age 9-17 Behavioral Health...2 hours, Age 9 & younger Behavioral Health...1 hour." The incorrect box was checked.

The RN who obtained the order for restraints was interviewed beginning at 9:25 AM on 5/18/11. He stated Patient #30 was violent, assaultive to staff, and a danger to herself. He confirmed the restraint order was written for 24 hours.

The restraint order for Patient #30 exceeded the 4 hour allowable time. This resulted in her being restrained for more than 4 hours without the physician reassessing the need for continued restraint.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure restraints were discontinued at the earliest possible time for 1 of 6 adult patients (#30) who had behavioral restraints applied and whose record was reviewed. This resulted in a patient being restrained longer than necessary. Findings include:

Patient #30's medical record documented a 20 year old female who was admitted to the hospital on 2/07/11 and was discharged on 2/10/11. Her diagnoses included acute renal failure and lithium toxicity. She also had a history of bipolar disorder. Patient #30 was initially examined in the ED and was then admitted to the medical floor for further treatment. Nursing notes documented Patient #30 was restless and anxious on the night of 2/07/11 and through the early morning of 2/08/11. At 10:15 AM on 2/08/11, the nursing note stated Patient #30 "...became combative and also aggressive. Called code orange and patient was put on four point restraints around this time." Nursing notes stated Patient #30 continued in restraints 5 hours and 35 minutes, until 4:50 PM on 2/08/11.

The nursing note at 11:00 AM on 2/08/11 noted Patient #30 was in 4 point restraints. Her behavior and mental/emotional status were not documented. Reasons for restraint listed "Could Roll or Fall out of Bed, Unsteady Gait or Balance, Pulling Out Invasive Lines, Harmful to Self, Harmful to Others." No details were documented. The nursing note at 12:00 noon on 2/08/11, stated the same exact information. Again, the note stated Patient #30 was in 4 point restraints. Her behavior and mental/emotional status were not documented. The nursing note at 1:00 PM was essentially the same except "Could Roll or Fall out of Bed" was not listed as a reason for restraint. The nursing note at 2:00 PM was essentially the same except 6 reasons for restraint were listed. Reasons listed also included "Attempts to Self-Transfer" and "Unable to Sit Upright." A separate nursing note at 2:00 PM, labeled "Patient Rounding," stated "Patient remains on need for four point restraints. Released patient's restraints and patient cont. to be aggressive and try to bite herself." No other details were documented. The nursing note at 3:00 PM was essentially the same as the note at 1:00 PM. No mention of current behavior was documented. The nursing note at 4:00 PM did not document any behaviors. The nursing note at 4:50 PM stated the restraints were discontinued. No assessment of Patient #30's emotional/behavioral state was documented. The next nursing note, at 6:00 PM, stated "Patient in room awake, Doing well without restraints."

The RN who cared for Patient #30 and who wrote the above notes, was interviewed beginning at 9:25 AM on 5/18/11. He stated Patient #30 was alternately restless and sleeping while she was restrained. He confirmed the documentation.

The hospital did not document the continued need to restrain Patient #30.

Based on staff interview and review of medical records and hospital policies, it was determined the hospital failed to ensure 1 of 2 physicians who ordered restraints and who were interviewed, had received training regarding restraints. This resulted in a lack of direction to the medical staff regarding the correct use of restraints. Findings include:

1. Patient #30's medical record documented a 20 year old female who was admitted to the hospital on 2/07/11 and was discharged on 2/10/11. Her diagnoses included acute renal failure and lithium toxicity. She also had a history of bipolar disorder. Patient #30 had telephone orders from her attending physician for wrist and ankle restraints, written at 10:15 AM on 2/08/11. The order was signed by the physician on 2/10/11 at 7:30 AM. The order stated it was a "Medical/Surgical" restraint order. However, the restraint order was clearly for behavioral restraints as it stated Patient #30 was "biting, hitting, kicking, harm to self." The order should have been limited to 4 hours per regulation 42 CFR Part 482.13(e)(11). However, it was written for 24 hours. Nursing notes stated Patient #30 continued in restraints for 5 hours and 35 minutes, until 4:50 PM on 2/08/11. Physician progress notes did not show evidence of assessment of the need for restraints. Physician notes did not document an examination of Patient #30 while she was restrained and they did not document an assessment of her need for restraint. A visit to Patient #30 was not conducted by the ordering physician until 2/09/11 at 7:00 AM. The visit note did not mention the restraint.

The physician who ordered the restraints for Patient #30 was interviewed on 2/18/11 at 8:55 AM. He confirmed the order and the lack of an assessment of the need for restraints. He stated he was not sure if Patient #30 needed 4 point restraints or not. He stated he had not received any training from the hospital regarding restraints. He also stated he was not familiar with the hospital's restraint policy.

2. The policy "RESTRAINTS AND SECLUSION," dated 11/06/08, was the comprehensive policy for all restraints utilized at the hospital. The policy did not address training requirements for physicians who ordered restraints or for staff who applied and monitored restraints. This was confirmed by the Chief Quality Officer who was interviewed on 5/26/11 beginning at 8:25 AM.

The hospital failed to train physicians in the use of restraints.

Based on staff interview and review of medical records, it was determined the hospital failed to ensure 1 of 6 adult patients (#30), who had behavioral restraints applied and whose records were reviewed, was seen face-to-face within 1-hour after the initiation of the intervention by a person authorized to conduct restraint evaluations. This resulted in the absence of a comprehensive evaluation of the patient to determine alternate causes for the behavior and whether non-coercive measures could be used to control behaviors. Findings include:

Patient #30's medical record documented a 20 year old female who was admitted to the hospital on 2/07/11 and was discharged on 2/10/11. Her diagnoses included acute renal failure and lithium toxicity. She also had a history of bipolar disorder. Patient #30 had a telephone order from her attending physician for wrist and ankle restraints, written at 10:15 AM on 2/08/11. The order stated Patient #30 was "biting, hitting, kicking, harm to self."

After Patient #30 was placed in restraints, she was not seen face to face by a physician or LIP in order to assess the need for restraint and possible alternative interventions. The only documented physician visit on 2/08/11, after the restraint was applied, was written by the nephrologist at 7:00 PM that evening. The note did not mention the use of restraints. Physician progress notes by a psychiatrist and by the attending physician were documented on 2/09/11 at 10:56 AM and 7:00 AM, respectively. Neither physician progress note mentioned the restraint.

The physician who ordered the restraints for Patient #30 was interviewed on 2/18/11 at 8:55 AM. He stated he did not visit Patient #30 after he ordered the restraints.

The Core Measures Resource Nurse reviewed the record and was interviewed beginning at 9:25 AM on 5/18/11. He confirmed a face to face visit to Patient #30, within 1 hour of the restraints being applied, was not documented.

The hospital did not provide a face to face visit by a physician or LIP after Patient #30 was placed in restraints to control her behavior.

Based on record review, policy review, and staff interview it was determined the hospital failed to ensure an RN evaluated and appropriately addressed abnormal findings during the admission assessment process of 2 of 14 ED patients (#22 and #25) whose records were reviewed. This resulted in Patient #25 sustaining skin tears and the potential for other negative patient outcomes. Findings include:

1. Patient #22 was a 60 year old male who was brought in to the ED by paramedics on 1/29/11. The paramedic report at 2:05 PM indicated Patient #22 had left sided weakness, left knee pain, slurred speech and a blood pressure of 150/110. The report indicated Patient #22 fell at his place of business and was found by a friend who contacted EMS.

The triage nurse performed an admission assessment at 2:10 PM, and the blood pressure at that time was 211/76. The narrative note by the triage nurse stated, "Pt here via EMS with c/o pain, inability to bear weight on left knee. Report also hinted at a possible problem with slurred speech, but wife states speech is normal and he just needs a drink of water."

A physician entry note at 3:11 PM included the diagnosis of acute left knee injury, as well as the patient disposition of home, condition stable.

The final nursing entry was at 3:25 PM, described as a "discharge note." The entry read "Patient discharged home, patient is in a wheelchair. Accompanied by spouse." The vital signs were taken and the blood pressure was 176/87.

An entry by the physician who assessed Patient #22 was dated 1/30/11 at 7:06 AM, and included as the chief complaint a fall with resulting left knee pain. The physician described Patient #22 as not able to bear weight or walk on his left leg. A review of systems was noted by the physician, with the statement: "Pt reports being at his otherwise baseline state of health, no other assoc. system complaints." A neurological assessment by the physician, dated 1/30/11 at 7:15 AM, stated "speech normal, symmetric strength."

The record included the result of x-rays of the left knee done on 1/29/11 at 2:28 PM.

Patient #22's vital signs were taken two times during the hour and 15 minutes he spent in the ED. The nurse did not assess the left sided weakness or further evaluate the slurred speech reported by the paramedics upon admission. The medical record did not contain documentation that the nurse notified the physician of the elevated blood pressure.

In an interview on 5/20/11 at 9:00 AM, the ED Director reviewed Patient #22's record and stated the admission blood pressure of 211/76 was outside of parameters. He stated the electronic medical records computer program would alert the nurse with a "V" on the computer when abnormal vital signs were entered into the system. The Director stated the "V" indicated further management would be required by the nurse, which included placing the patient on a monitor, taking and recording vital signs every 15 minutes, and alerting the physician of the abnormal result. The Director stated the abnormal blood pressure parameters were systolic greater than 180 or less than 75 and a diastolic of greater than 130 or less than 45. The Director stated the RN caring for Patient #22 should have placed him on a monitor and notified the physician of the elevated blood pressure. He confirmed the medical record did not contain additional vital signs or documentation that the physician was notified.

The record indicated Patient #22 was brought back to the ED at 6:17 PM that evening by his wife with complaints of left sided weakness, slurred speech, and confusion. The admitting RN noted Patient #22's blood pressure at that time was 197/96. Patient #22 was transported to a referral facility shortly after with a diagnosis of intracerebral hemorrhage (bleeding in the brain, also known as a stroke).

During an interview on 5/20/11 at 10:00 AM, the physician that assessed Patient #22 during his first visit to the ED reviewed the record and stated he had questioned the wife of Patient #22 regarding his slurred speech. The physician stated Patient #22 and his wife assured him his speech was okay, and his main complaint was left knee pain. The physician stated he had not documented his conversation with Patient #22 or his wife regarding the slurred speech. The physician stated pain could cause an increase in blood pressure. The physician explained Patient #22 had been his last patient for his shift, and he left the facility shortly after discharging Patient #22. The physician stated he returned on 1/30/11 and dictated notes for Patient #22, not knowing that Patient #22 had been readmitted that evening and then transported to another facility.

Nursing staff did not appropriately evaluate Patient #22's abnormal vital signs.



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2. Patient #25's medical record documented a 74 year old female who presented to the ED on 4/28/11 for seizures. She was triaged at 9:23 AM. An "EMERGENCY FLOW SHEET RECORD," dated 4/28/11, indicated Patient #25 was placed on an automatic blood pressure machine at 9:30 AM and it continued to monitor her blood pressure at intervals through 4:02 PM that same day. The ED record documented Patient #25 was admitted to the cardiovascular unit at approximately 4:00 PM that same day. Patient #25 remained an inpatient until she was discharged on 4/30/11. The ED record did not mention skin tears.

An incident report, dated 4/29/11 at 10:20 AM, read Patient #25's "Niece stated pt's arm was hurting in the ED with B/P cuff on. She notified ED nurse. By the time pt was admitted to the unit, 2 skin tears were noted on arm 1 inner arm at elbow and 1 outer arm at elbow area...Niece feels like her concerns were not validated and is frustrated with new skin tears, edema, and decreased mobility of hand this am." Two pictures of Patient #25's arm were present which noted 2 large skin tears.

The Chief Quality Officer was interviewed on 5/26/11 at 8:25 AM. She stated she had spoken to the niece about the incident. She said the niece complained that the skin tears had been caused by the automatic blood pressure cuff in the ED. She stated the skin tears were caused by the automatic blood pressure cuff.

The nurse who cared for Patient #25 failed to monitor her skin to prevent breakdown from the blood pressure cuff.

Based on medical record review, review of facility policies, and staff interview it was determined the facility failed to ensure thorough nursing care plans were developed for 3 of 30 patients (#7, #13, #30) whose inpatient records were reviewed. Lack of a complete care plan had the potential to result in unaddressed patient care needs and interfere with coordination of patient care among staff members. Findings include:

1. The facility's "INTERDISCIPLINARY PLAN OF CARE" policy, last revised July 2007, was reviewed. According to the policy, the plan of care was developed using the nursing processes of assessment, diagnosis, planning, and implementation, and evaluation. Documentation in the policy stated that actual or potential diagnoses to be addressed in the care plan were determined as a result of the patient assessment.

Complete care plans were not developed as follows:

a. Patient #13 was a 55 year old male admitted to the facility on 5/10/11 for care after a heart attack and subsequent cardiac catheterization. A physician consultation, dated 5/10/11, indicated Patient #13 was being treated for acute respiratory failure, acute renal failure, poorly controlled diabetes mellitus, and an acute myocardial infarction.

Patient #13's nursing care plan included interventions and goals related to mechanical ventilation, altered cardiac function, core measures (such as vaccinations, venous thromboembolism prophylaxis, etc.), a basic, age-appropriate care plan (which included shift assessments, vital signs, pain assessment, education, etc.), and anxiety. The care plan did not include the diagnoses related to diabetic managment or renal failure, and did not include interventions or goals related to these healthcare issues.

The Director of Critical Care was interviewed on 5/17/11 at 9:30 AM. She reviewed Patient #13's care plan and verified information related to diabetic management and renal failure were not included in the plan. She stated she would have expected these issues to be addressed in the nursing care plan.

Goals and interventions related to Patient #13's acute renal failure and poorly controlled diabetes mellitus were not incorporated into her POC.



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b. Patient #30's medical record documented a 20 year old female who was admitted to the hospital on 2/07/11 and was discharged on 2/10/11. Her diagnoses included acute renal failure and lithium toxicity. She also had a history of bipolar disorder. Patient #30 was initially examined in the ED and was then admitted to the medical unit for further treatment. An ED nursing note at 1:08 PM on 2/07/11, stated the nurse tried 3 times unsuccessfully to draw blood for testing. The note stated the attempt was successful by using Patient #30's foot to draw the blood. A nursing note at 8:45 AM on 2/08/11, stated the Life Flight nurse had been summoned to attempt to draw more blood for testing. The attempt was not successful. A physician order, dated 2/10/11 at 7:40 AM, stated "May use lower extremities for blood draw." As noted above, Patient #30 was very anxious. She became agitated and this led to her being restrained on 2/08/11 at 10:15 AM.

Patient #30's "Patient Care Plan Report," initiated at 3:00 PM on 2/07/11, and updated through out her stay, did not address problems obtaining blood samples for testing.

The RN, who cared for Patient #30 on 2/07/11 and 2/10/11, was interviewed on 5/18/11 beginning at 9:25 AM. He confirmed blood draws were not included in Patient #30's POC. He stated she underwent multiple unsuccessful attempts to draw blood by multiple staff and eventually blood was drawn from her foot.

Patient #30's POC was not complete.



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c. Patient #7 was a 7 week old male infant admitted to the facility on 5/15/11 for bronchiolitis. (According to the National Institutes of Health, bronchiolitis is swelling and mucus buildup in the smallest air passages in the lungs, usually due to a viral infection. It usually affects children under the age of 2 years.) The H&P, dictated by the admitting pediatrician on 5/15/11, indicated Patient #7 was on oxygen and had difficulty with breastfeeding and breathing due to nasal stuffiness.

Record review indicated Patient #7 had an NG tube placed on 5/16/11 at 5:30 PM, due to difficulty breastfeeding, in an attempt to increase fluids and avoid the need for IV fluids.

Patient #7's nursing care plan included interventions and goals related to pain, knowledge deficit, anxiety, and impaired gas exchange. The care plan did not include the diagnosis, goals, or interventions for impaired nutrition related to difficulty breathing while eating.

The Director of Women's and Children's Services was interviewed on 5/17/11 at 9:15 AM. She reviewed Patient #7's care plan and verified information related to nutrition and inadequate oral intake, as well as, the recent placement of an NG tube, were not included in the plan. She stated she would have expected that nutrition would have been included in the care plan.

Patient #7's POC was not revised to reflect his unique needs.

Based on record review, and staff interview, it was determined the hospital failed to ensure that complete, legal medical records were accurate, completed, accessible, and provided upon request for 5 of 14 ED patients (#22, #42, #47, #51, #52) whose complete, legal medical records were requested. Failure to obtain and provide the complete and accurate record had the potential to negatively impact coordination, quality, and safety of patient care. Findings include:

1. The complete, legal ED medical record for Patient #22's 1/29/11 ED admission was requested. The medical record received documented evaluation and treatment related to knee pain as a result of a fall. It further documented Patient #22 was discharged home at 3:25 PM on 1/29/11. The record contained a report of a head CT scan performed on 1/29/11 at 7:57 PM and sent to the ED. This was four hours and 32 minutes after the documented time of discharge. Patient #22's ED record did not include a physician order for the head CT scan.

On 5/18/11 at 12:05 PM, the HIM Manager was interviewed regarding the contents of Patient #22's record. The HIM Manager confirmed she had provided the entire legal medical record as requested, and demonstrated on her computer how she reviewed patient medical record information. The HIM Manager stated her computer program indicated Patient #22 had only one admission to the ED on 1/29/11. She was unable to explain the CT scan report found in the ED medical record.

The Director of HIM was interviewed on 5/18/11 at 12:30 PM. She determined Patient #22 had made two visits to the ED on 1/29/11. She stated Patient #22 had been discharged around 3:25 PM, but had returned to the ED shortly after 6:00 PM. She stated the ED staff appeared to continue documentation in the first admission record (from the admission at 2:10 PM on 1/29/11) as if Patient #22 had not been discharged. She stated both visits were under the same episode. She stated each time a patient was seen in the ED it was to be considered a new episode. The Director of HIM explained the facility used one software program in the ED which was merged with the software program used by the HIM Department for storing medical records. She stated the records generated from the program used by the ED were not considered legal medical records. She stated every night around midnight the information from ED records was merged into the HIM software program and was then considered the legal medical record. The Director of HIM stated the ED Director had access to the ED software program, and potentially to additional patient information.

In an interview on 5/18/11 at 3:45 PM, the ED Director was able to obtain more information about Patient #22's admissions to the ED on 1/29/11. The ED Director stated Patient #22 had returned to the ED at 6:17 PM, and the staff pulled his previous visit from the archives. The ED Director then provided documentation from the second ED admission. The ED Director stated Patient #22 had two records in the ED software system, but not in the HIM system. The Director was able to print two separate ED visits for Patient #22 for 1/29/11 on the software program specific to the ED. The ED Director stated the two software programs did not always communicate with one another.

Patient #22's legal medical record provided by HIM was not complete.




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2. Patient #52's medical record documented a 24 year old female who presented to the ED on 3/21/11 at 1:43 PM. She complained of drainage from her suture line following caesarean section surgery. No vital signs, including temperature, pulse, respiration, blood pressure, and oxygen saturation levels, were documented in her medical record.

The Director of HIM was interviewed on 5/19/11 at 11:25 AM. She reviewed the medical record and confirmed vital signs were not documented. She stated she did not know why the record was not complete but she said the vital signs were not part of the medical record. She stated the ED sometimes used another system to document vital signs that did not interface with the hospital's medical record and speculated this could be the reason for the missing information.

Patient #52's medical record was not complete.

3. Patient #51's medical record documented a 69 year old male who presented to the ED on 3/17/11 at 2:36 PM. He complained of swollen genitals. Fore skin reduction was performed in the ED utilizing Propofol, an anesthetic. A nursing note at 3:50 PM on 3/17/11, stated the Propofol was administered by an RN. Another nursing note at 4:12 PM on 3/17/11, stated the Propofol was administered by a physician.

The Core Measures Resource Nurse reviewed the medical record on 5/19/11 at 11:00 AM. He stated the physician actually administered the Propofol.

Patient #51's medical record was not accurate.

4. Patient #42's medical record documented a 5 year old male who presented to the ED on 5/13/11 at 8:22 PM with a depressed skull fracture. He was transferred to another acute care hospital for specialized neurosurgical care at approximately 10:21 PM on 5/13/11. Transfer forms, including physician certification that the benefits of the transfer outweighed the risks and parental consent for the transfer were not included in the medical record.

The Core Measures Resource Nurse reviewed the medical record on 5/19/11 at 11:00 AM. He contacted HIM personnel and stated the transfer forms could not be found. He stated he believed the transfer forms had been completed but had not been saved in the medical record.

Patient #42's medical record was not complete.

5. Patient #47's medical record documented a 59 year old male who presented to the ED on 5/08/11 at 9:43 AM complaining of chest pain. He was diagnosed with a myocardial infarction. He was transferred to another acute care hospital for specialized care at approximately 10:16 AM on 5/08/11. A nursing note at 10:16 AM on 2/08/11, stated "Transfer-[receiving hospital], Disposition Transport: Taxi/Public Transport." A physician note at 10:17 PM on 5/08/11, stated Patient #47 was actually transported by ambulance to the receiving hospital.

The Core Measures Resource Nurse reviewed the medical record on 5/19/11 at 11:00 AM. He confirmed the contradictions in the medical record.

Patient #47's medical record was not accurate.

Based on staff interview and review of patient records, it was determined the hospital failed to ensure medical record documentation was complete with properly authenticated physician orders for 1 of 6 outpatients (#31) whose records were reviewed from the outpatient imaging center. This had the potential to interfere with coordination of patient care, result in misinterpretation of information, or cause a medical error. Findings include:

Patient #31 was a 43 year old male who had an outpatient MRI scan performed on 5/18/11 at 9:00 AM. His record contained a pre-printed form from the referring physician practice group. The form listed the name of the practice and three office addresses. The form had not been dated or timed, however Patient #31's name and date of birth were hand-written in. The individual who filled out the form indicated which test was to be done (an MRI of the cervical spine) and documented Patient #31 had a history of neck pain.

The lower portion of the form provided three options for imaging centers, one of which was the imaging center surveyed. Additional information on the form addressed pre-authorization of the imaging study and served as a notice to the patient that a pre-authorization was done as a courtesy with instructions for patients to verify individual coverage with their insurance.

At the very bottom of the form were the signatures of five physicians and two PAs. One physician's signature had been circled. It was unclear if the form was an order form for the imaging center or an informational document for the patient.

In an interview on 5/18/11 at 9:10 AM, the technician performing the MRI reviewed the form for Patient #31 and stated the ordering physician was the signature with the circle around it.

In an interview on 5/18/11 at 9:15 AM, the Manager of Outpatient Imaging reviewed the form described above. He could not verify who had circled the physician name or completed the form. He stated this form was considered a physician order.

The facility accepted physician orders that were not properly authenticated.

Based on observation, review of kitchen logs and hospital policies, and staff interviews, it was determined the hospital failed to ensure 1 of 1 kitchen evaluated for environmental issues was maintained in such a manner as to ensure the safety and well-being of patients. Failure to maintain a clean food storage and preparation environment directly impacted the well-being of all patients receiving care in the hospital. Failure to stay current on repairs had the potential to impact patient health and safety. Findings include:

1. During a tour of the hospital's kitchen, on 5/19/11 from 3:30 PM to 4:45 PM, accompanied by the Dietary Manager and the Chef, the following concerns were noted:

a. The following food was observed to be undated and/or expired:

i. In a refrigerated cart storing sandwich items, the container of cheese slices was undated.

ii. The deli refrigerator had a container of cherry topping dated 5/11/11. At the time of the observation the Dietary Manager stated food which was prepared and then stored in the refrigerator was good for seven days. She discarded the cherry topping as it had expired.

iii. A refrigerator in the "Grill" section of the cafeteria had four undated containers of brownies.

The Dietary Manager discarded the brownies as they were identified.

b. The walk-in freezer unit had condensation leaking onto food storage racks. Four boxes of frozen meat were directly under the leak. One box of meat had areas of ice where condensation from the freezer had dripped and refrozen. Water dripping from the leaking freezing unit had the potential to compromise the integrity of the frozen foods below.

There were also metal food storage racks with hanging ice from the dripping freezer unit. The floor under the freezer unit and food storage racks had multiple areas of pooled condensation which had refrozen. This posed a safety hazard for kitchen staff.

During the tour the Chef stated the leak in the walk-in freezer had been noted on Monday, 5/16/11. He said the refrigeration company workers had been in on 5/19/11, but were not able to replace a part for the freezer unit. He stated a plastic bucket would be collecting the condensation until the freezer unit was fixed.

c. The dishwashing area floor was wet due pooled water under the sink which extended beyond the rubber mats used for staff while working at the sink.

The Dietary Manager and the Chef confirmed the presence of pooled water in this location during the tour on 5/19/11.

d. The deep fryer had thick amounts of floating fried food particles in the corners. There was no log to indicate when the oil had last been replaced.

During the tour on 5/19/11 the Chef stated the deep fryer had an auto filtration system that filtered the oil daily. He stated he personally changed the oil weekly but did not maintain a log to record the dates this was done.

e. The dishwasher had a sign on it which indicated the water was to be replaced every two hours. There was no log to indicate when the water had last been changed.

During the tour on 5/19/11 neither the Dietary Manager nor the Chef were able to state when the water had last been changed, and when it was due to be changed again. The Chef also confirmed there was no log to record the dishwasher water replacement activities.

f. The ventilation hood above the grill and stove had panels with a thick amount of grease and dust.

The Dietary Manager was present during the tour of the department of 5/19/11, and stated the panels above the grill were cleaned on a rotation basis. She described how one panel would be removed daily and cleaned in the dishwasher. The Dietary Manager stated she would make sure all the panels would be cleaned that night.

A second tour of the kitchen was done on 5/20/11 at 8:40 AM. The thick layer of dust and grease was still present on the panels. The Dietary Manager confirmed the panels had not been cleaned.

g. Sections of the kitchen floor were stained from previous spills of food and liquids. Small pieces of food littered the floor behind the grill and oven unit.

During the tour on 5/19/11, the Dietary Manager stated housekeeping was responsible for cleaning the department after the kitchen was closed. The nightly cleaning included scrubbing and hosing down the floors and behind the equipment.

A second tour to of the kitchen was done on 5/20/11 at 8:40 AM. The floors behind the grills and oven unit contained dust and food items that had been noted on the previous day.
During the tour the presence of the food and debris were verified by the Dietary Manager. She stated she spoke with the Housekeeping Supervisor on the evening of 5/19/11 about cleaning.

A policy titled "INFECTION CONTROL/FOOD SERVICE," dated October 1979, and reviewed January 2001, addressed food storage and staff responsibilities. The policy stated the nutritional services department would develop and maintain clean and sanitary work areas, equipment, and storage areas.

The physical environment of the dietary department was not adequately maintained to ensure the safety and well-being of patients.

Based on staff interview, observation, and review of facility policy and procedures, it was determined the Infection Control Coordinator failed to develop a surveillance program for 2 of 2 non-patient care areas (Laboratory and Nutritional Services) surveyed to identify and evaluate infection control practices. The failure to develop a program to monitor the non-patient care areas had the potential to expose hospital patients and staff to infection. Findings include:

1. During a tour of the Laboratory with the Lab Director and the Director of Support Services on 5/19/11 from 9:00 AM to 9:30 AM, the following infection control concerns were noted:

a. The Blood Bank area had one sink, which had tubing from equipment draining into it. On the left corner of the sink were two containers of commercial hand lotion. On the right corner of the sink was an antibacterial skin moisturizer, which was provided by the hospital.

At the time of the tour, the Lab Director stated the sink was a designated "dirty" sink, and the commercial hand lotions were against hospital policy and would be removed. He stated the sink was not to be used as a hand washing area. The Lab Director stated there was no clean sink in the blood bank area of the lab.

b. The main lab area had four sinks, three of which were designated as "dirty" sinks with tubing from equipment draining into them, or urine specimens to be discarded piled in the sink. The fourth sink was full of crushed ice to the point it could not be used to wash hands.

During the tour, the Lab Director stated the three "dirty" sinks were not to be used by staff for hand washing, and stated the only designated "clean" sink to be used by staff for hand washing was the sink that had the ice in it. The Lab Director stated there was a sink in the staff break room, as well as, in the restroom which was adjacent to the break room. The access to the break room was behind a door. The restroom was through the breakroom behind another door.

A policy, "Hand Hygiene," dated May 2008, detailed when hand washing was to be done rather than the use of alcohol hand sanitizing rub. The policy stated hand washing was to be done at the start of the work shift, before eating or drinking, after using the restroom, and after coughing or sneezing.

During the tour on 5/19/11 at 9:00 AM, a lab employee stated it was difficult to wash hands as a result of the lack of available "clean sinks." She stated she utilized hand sanitizers.

The lab lacked sufficient access to designated "clean" sinks for staff to perform appropriate hand hygiene.

2. During a tour of the hospital's kitchen with the Dietary Manager and Chef, on 5/19/11 from 3:30 PM to 4:45 PM, the following infection control concerns were noted in the kitchen:

a. The walk-in freezer unit had condensation leaking onto food storage racks. Four boxes of frozen meat were directly under the leak. One box of meat had areas of ice where condensation from the freezer had dripped and refrozen. Water dripping from the leaking freezing unit had the potential to compromise the integrity of the frozen foods below.

During the tour on 5/19/11 beginning at 3:30 PM, the Chef stated the leak in the walk-in freezer had been noted on Monday, 5/16/11. He said the refrigeration company workers had been in on 5/19/11, but were not able to replace a part for the freezer unit. He stated a plastic bucket would be collecting the condensation until the freezer unit was fixed.

b. The dishwasher had a sign which indicated the water was to be replaced every two hours. There was no log to indicate when the water was changed.

On 5/19/11 at 3:30 PM, neither the Dietary Manager nor the Chef were able to state when the water had last been changed, and when it was due to be changed again. The Chef also confirmed there was no log to record the dishwasher water replacement activities.

c. At 4:30 PM on 5/19/11, a kitchen staff member was observed assembling food on the tray line and was noted to be wearing one glove. He was observed to scratch his forehead and hair with his ungloved hand. He continued to assemble the patient food tray without pausing to wash his hands or to use hand sanitizer.

The staff member was questioned immediately after the observation regarding the use of one glove. He stated he "did not want to cross contaminate." He was asked about the touching of his face and hair and failure to perform hand hygiene. He stated, "You caught me." The staff member indicated he was aware that hand sanitizer was within reach of his work area.

d. During a second tour of the kitchen area with the Dietary Manager, on 5/20/11 at 8:40 AM, a clipboard with a form titled "Assembler Cold Food Temperature Log" was noted in the food tray line assembly area. It was dated 5/19/11 and listed scheduled times foods were checked for temperatures. The pre-printed times on the form were 10:00 AM, 1:30 PM, 4:00 PM, and 6:30 PM. The 4:00 PM and 6:30 PM times slots were blank.

On 5/20/11 at 8:40 AM, the Assistant Director of Dietary reviewed the log and confirmed no temperatures had been taken for foods at 4:00 PM and 6:30 PM on 5/19/11.

In a phone interview on 5/23/11 at 1:30 PM, the Infection Control Coordinator stated she had no formal surveillance program for non-patient care areas such as laboratory and dietary. She stated she tried to perform an informal rounding of ancillary departments once a month.

The Infection Control Coordinator did not have an active surveillance program with the Laboratory and Nutritional Services Departments.