HospitalInspections.org

Based on medical record review, observations, staff interviews and facility policy review, the facility failed to ensure the documentation by physicians for the use of restraints was complete and accurate for 1 of 5 current patients, Patient #2.

The Findings Include:

Patient #2 was a 67 year old admitted on 1/27/12 with the diagnoses of Dysphasia, Chronic Respiratory Failure, CVA (Cerebral Vascular Accident (Stroke)), Diabetes MRSA (Methicillin-resistant Staphylococcus aureus) and Seizure Disorder. Patient #2 was in soft wrist and or mitten restraints almost daily since admission.

Patient #2's medical record was reviewed on 2/29/12. Eleven "Restraint Orders for Medical-Surgical Management" forms were reviewed from 2/17/12 to 2/27/12. The above mentioned form had 5 areas to be completed by the physician and they are:
1. Restrain for Medical reasons to promote healing Patient Behavior(s) and Rationale for Restraint Use
2. Alternatives
3. Duration of Restraint (Choose either a or b) a. Restrain (initial order is for 24 hours only) b. Restrain for _______ hours (less than 24 hours)
4. Type of Restraint
5. Face to Face evaluation (completed by MD), Assessment, Plan

Five (5) of the eleven (11) orders were not timed, Alternatives were not addressed in 11 of 11 orders; 1 order had section "B" of part 3 checked but had no amount of hours for the restraint, and the Face to Face section was not filled out for 4 of the 11 orders and was only partial completed for 4 of the 11 orders.

The facility Administrator stated, "This form is to be filled out by the physician. They receive education and training on completing this form when they submit their application to be credentialed and with each re-credentialing."

Based on medical record review, staff interview, contract staff interview and facility contract review, the facility staff failed to ensure the contracted dialysis staff accurately and completely documented the information related to dialysis for 1 of 5 patients, Patient #1.

The Findings Include:

Patient #1 was a 47 year old admitted to the facility on 2/16/12 with the diagnoses of Acute Renal Failure, Hypertension, Status Post Spinal Fusion of C5 to C7, MRSA and epidural abscess.

Patient #1 began physician's ordered renal dialysis on 2/20/12 for 3 days per week (MWF). The physician's order was for a BFR (blood flow rate) of 350 and a DFR (dialysate flow rate) of 600 and a dialyzer F180. There was also a physician's order for daily weights.

Patient #1 was observed able to ambulate without assistance.

Patient #1's medical record was reviewed on 2/28 and 29/12 and the following was noted:
1. Documented on the Hemodialysis forms completed by the dialysis staff were the following:
On 2/20/12
Dialyzer: F160
BFR: AS TOL (The dialysis staff explained this was "As tolerated.)
DFR: A1.5
Pre Weight in kg: ___ (was blank)
(Patient #1's weight on the graphic record was 179.3 lbs. (81.3 kg).)
Post Weight in kg: 82.8
Dry weight: TBD (The dialysis staff explained this was "To be Determined".)
Previous Post Weight: ___ (was blank)
Net Fluid Removed: 5.3 L's
Comments: Goal 3-3.5 L's per Dr. (Name of nephrologist)
Treatment Report: ...."Removed 3.5 L's w/o diff."

On 2/22/12
Dialyzer: F180
BFR: AS TOL
DFR: A1.5
Pre Weight in kg: UTD (The dialysis staff explained this meant Unable to determine.)
(Patient #1's weight on the graphic record was 164.4 lbs.(76.38 kg).)
Post Weight in kg: UTD
Dry Weight: TBD
Net Fluid Removed: 3.5 L
Comments: ..."UTW pt bed scale isn't functioning."

On 2/24/12
Dialyzer: F180
BFR: As Tol
DFR: A1.5
Pre Weight in kg: UTD
(Patient #1's weight on the graphic record was not recorded.)
Post Weight in kg: UTD
Dry Weight: TBD (malfunctioning bed)
Net Fluid Removed: 3.2 L

On 2/27/12
Dialyzer: F180
BFR: As Tol
DFR: ____ (blank)
Pre Weight in kg: UTD
(Patient #1's weight on the graphic record was 170.5 lbs. (76.38 kg).)
Post Weight in kg: UTD
Dry Weight: TBD (malfunctioning bed)
Previous Post Weight: UTD
Net Fluid Removed: 3.1.Ls

On 2/29/12
Dialyzer: F180
BFR: As Tol
DFR: A1.5
Pre Weight in kg: 76.2
(Patient #1's weight on the graphic record was 76.2 kg.)
Post Weight in kg: 73.5
Dry Weight: TBD
Previous Post Weight: UTD
Net Fluid Removed: 2.3 L's
Treatment Report: ? Goal during tx.

The dialysis treatment staff stated, "We receive verbal orders from the doctor (nephrologist) and make changes per his order."

There were no verbal orders written by any staff member on Patient #1's medical record.

The DON (Director of Nursing) stated, "TBD, As Tol and blanks are not acceptable forms of documentation. We strongly recommended our nursing staff do not take verbal orders except in an emergency. The dialysis staff are not allowed to write orders in our medical records. Besides they have the medical record when the physician makes rounds all they have to do is give it (medical record) to the physician and let him write the order. I will be discussing all of these problems with them."

Based on observations, staff interviews and review of facility policies, the facility failed to ensure the active surveillance of the environment was maintained to help prevent the spread of infections.

The Finding Include:

During the initial tour of the facility on 2/28/12 two unoccupied rooms that were reportedly ready to receive new expectant patients were viewed. Room 784 had a dusty sprinkler head that was immediately over the patient bed. The bed had crusty cords at the head and foot of the bed. The air conditioning/heating vent contained dust, dirt and parts of plastic and the pump for tube feeding administration had dirty cords. The Director of Nursing (DON) stated, "That is unacceptable. That is dried tube feeding ingredients." A respiratory ventilator was in the room with a plastic cover (similar to a light weight plastic bag) laying over it. The plastic tubing for patient use was attached. The plastic tubing was partially lying on the floor uncovered. There was no date indicating when the machine was cleaned and ready for use or when the tubing was attached.

Room 788 was also tour and was ready to receive a new admission. The bed cords were crusty with dust and the overbed table was dirty. The air conditioning/heating vent contained dust and dirt.

The vent in the clean utility room was coated in dust.

Pod 2 was used at the time of the survey to store items in at least 2 of the room. One room contained an extra respiratory ventilator with a light weight plastic cover laying over it. Plastic tubing for patient use was attached. The plastic tubing was partially rubbing the wheel of a cart next to it. There was no date indicating when the machine was cleaned and ready for use or when the tubing was attached. The respiratory therapist stated, "The machine is set up and ready for use."

A second room in Pod 2 was used to store linen. The air conditioning/heating vent contained dust and dirt.

Also in Pod 2 was a room used for dialyzing patients; in this room the following was noted:
1. On a cart in this room was a box of what was described as dialysis transducers but the box was labeled as "Biopatch". The box had no top and the dialysis transducers were uncovered. There was a reddish brown substance dried on the box.
2. A bottle labeled as Betadine Multi use was dated as opened on 1/13/12 was available for use.
3. A 20 ml opened wet syringe was in the clean supply drawer.
4. There were 6 expired fistula needles mixed in a box of 25 unexpired fistula needles available for use.


The ice machine was observed in the nourishment room. The ice machine failed to have an "air gap" where the drain tube from the ice machine comes in contact with the floor drain. The DON stated, "I contacted maintenance and when they saw the drain they said there was no air gap."

The policy for Environment of Care was reviewed on 2/29/12. The policy states "C" Cleaning (Complete Cleaning) (Terminal Cleaning) (Discharge Cleaning) Involves the complete cleaning on an area using a solution of bleach/water or Center for Disease Control (CDC) approved disinfectant.... including furniture and fixtures before another patient is admitted or another procedure is performed."