HospitalInspections.org

Based on record review and interview the hospital failed to implement restraints in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy. This deficient practice is evidenced by failure of the hospital to ensure a patient (#27) in restraints for non-violent/non-self-destructive behavior was assessed and monitored according to hospital policy for 1(#27) of 2 (#27, #28) sampled patient records reviewed for restraint use from a total patient sample of 32 (#1-#32).

Findings:

Review of the hospital policy titled, "Initiating and Monitoring Restraints," revealed, in part: A patient in restraint for non-violent or non-self-destructive behavior must be monitored at least every two hours or sooner according to patient need. At least every two hours, the following will be monitored, assessed and documented in the medical record as indicated: safety checks, circulation and range of motion in the extremities, nutrition and hydration, hygiene and elimination, physical and psychological status and comfort, readiness for discontinuation .... At least every four hours, the following will be monitored, assessed and documented in the medical record: temperature, pulse, respirations, blood pressure, oxygen saturation (SaO2).

Review of the electronic medical record for Patient #27, navigated by S5Nav, revealed on 02/28/2021 at 8:30 a.m. the patient was noted to be pulling at his lines and tracheostomy and the licensed practitioner was notified.

Review of orders for Patient #27 revealed a new order on 02/28/2021 at 8:37 a.m. for non-violent/non-self-destructive behavior restraints. Further review revealed an order for discontinuation of the restraints 03/01/2021 at 7:50 p.m.

Review of Patient #27's restraint record for 03/01/2021 revealed there was no documented evidence the patient had been monitored, per hospital restraint policy, from 2:36 a.m. to 8:51 a.m. (6 hours and 13 minutes), while in restraints.

In an interview on 07/20/2021 at 1:10 p.m., S1Adm reviewed the record and verified Patient #27 was not monitored per policy.

Based on record review and interview the hospital failed to ensure medication administration errors and the actions taken were documented in the patients' medical record. This deficient practice is evidenced by failure of nursing staff to document medication errors in the medical record for 2 (#2, #21) of 2 sampled patient records reviewed for medication errors from a total patient sample of 32 (#1- #32)

Findings:

Review of the hospital policy titled, "Medication Variance," policy number 9-4. 15.0, revealed in part: The drug administered in error/omitted in error and the action taken should be documented in the patient's medical record.

Patient #2
Review of Quarterly Incident Report Summary for January 1, 2021 to June 30, 2021, revealed Patient #2 had a medication event. The brief factual description revealed on 01/14/2021 nursing staff "administered 15 units of short acting insulin and promptly realized she had given incorrect medication ...RN held midnight dose of short acting insulin."

Review of orders for Patient #2, navigated by S5Nav, revealed on 01/05/2021 at 9:16 a.m. an order was placed for insulin aspart U-100 - 6 units every 6 hours with a start time of 12:00 p.m.

Review of medication administration record for Patient #2 revealed on 01/14/2021 at 6:00 p.m. the patient was administered insulin aspart U-100 - 6 units and at 10:05 p.m. the patient was administered 15 units of detemir insulin. There is no documentation of accidental administration of 15 units short acting (aspart) insulin in the medication administration record, nurses' notes, or critical communication and no documentation of why the midnight short acting insulin was not given.

In an interview on 7/20/2021 at 12:00 p.m., S1Adm and S2DON verified the medication error had occurred and was not documented in Patient #2's medical record.

Patient #21
Review of Quarterly Incident Report Summary for January 1, 2021 to June 30, 2021 revealed Patient #21 had a medication event. The brief factual description revealed a precedex drip was started on 01/13/2021 at 12:15 p.m. and on 02/14/2021 at 10:00 a.m. the weight setting for the drip was noted to be wrong and corrected.

Review of orders for Patient #21, navigated by S5Nav, revealed an order dated 01/13/2021 at 12:15 p.m. for dexmedetomidine 400 mcg in sodium chloride 0.9% 100 ml continuous at 32.4 ml/hr.

Review of Patient #21's medication administration record for 01/14/2021 revealed the infusion rate at 06:16 a.m. was 30.1 ml/hr and the infusion rate at 10:01 a.m. was 32.4 ml/hr. There was no documentation in the medication administration record, nurses' notes, or critical communications that an error was recognized and corrected.

In an interview 07/20/2021 at 12:05 p.m., S1Adm and S2DON verified the medication error had occurred and was not documented in the patient's medical record.

Based on record review and interview, the hospital failed to ensure the content of the medical record included a discharge summary that accurately reflected the disposition of care. This deficient practice is evidenced by failure to ensure the discharge summary included documentation of a Code Blue and transfer to another hospital as part of the summary of dispostion of care for 1 (#27) of 11 (#4, #5#, #6, #7, #21, #27, #28, #29, #30, #31, #32) sampled discharged patient records reviewed.

Findings:

Review of the Medical Staff By-laws and Rules/Regulations revealed in part: A Discharge Summary shall be recorded at the time of discharge unless awaiting results. Any inpatient that dies in the hospital shall have a recorded death summary. In all instances, the content of the medical record shall be sufficient to justify diagnosis and warrant the treatment and end result.

Review of the electronic medical record for Patient #27, navigated by S5Nav, revealed on 01/16/2021 at 9:08 p.m. the patient was found unresponsive and a Code Blue (medical code) was initiated. The patient was subsequently transferred to another facility and returned on 01/20/2021.

Review of the discharge summary for Patient #27, navigated by S5Nav, revealed no mention of the Code Blue or transfer to another facility.

In an interview on 07/20/2021 at 1:00 p.m., with S1Adm and S2DON, they both verified the discharge summary documentation did not include the Code Blue and transfer to another facility. They verified the discharge summary failed to provide an accurate summary of the disposition of care provided to Patient #27 during the patient's hospitalization.

Based on policy review, observations, and interviews, the hospital failed to ensure methods were employed for preventing and controlling the transmission of infections within the hospital. This deficient practice was evidenced by the hospital failing to ensure staff (S3RN) providing contracted Company A's dialysis services followed infection prevention and control policies for 1 (#8) of 4 (#8, #9, #10, #11) sampled hemodialysis patients from a total patient sample of 32 (#1-#32).

Findings:

Review of contracted dialysis Company A's Hospital Services Policy & Procedure #1, Policy: 7-03-01, Title: Infection Control in the Hospital Dialysis Setting revealed, in part: Purpose: To promote a safe, clean environment for all patients and teammates of the dialysis unit and to reduce the risk of spreading infections or bloodborne pathogens in a hospital dialysis setting.

Teammate Personal Protective Equipment (PPE): 10. Gloves should be worn when:
Touching the blood lines, dialyzer or dialysis delivery system during or after a dialysis treatment.

Review of contracted dialysis Company A's Hospital Services Policy & Procedure #1, Policy: 7-03-02, Title: Hand Hygiene revealed, in part: Purpose: To prevent the spread of microorganisms and cross-contamination between teammates, patients and equipment.
Policy: 1. Hands will be washed prior to gloving, after removal of gloves.

Observations of Patient #8's hemodialysis treatment provided by S3RN were conducted on 07/19/2021 from 1:20 p.m. to 2:16 p.m. Observations revealed S3RN touched the hemodialysis machine with an ungloved hand on two occasions. Observations revealed S3RN did not perform hand hygiene prior to gloving and after removal of gloves on five occasions.

In an interview on 07/19/2021 at 2:13 p.m., S3RN indicated gloves should be worn when touching the dialysis machine. S3RN indicated hand hygiene should be done prior to gloving and after removal of gloves.

In an interview on 07/20/2021 at 11:34 a.m., S2DON confirmed S3RN should follow dialysis service Company A's infection control policies and procedures.