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Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure patients requiring restraints had the restraints implemented according to the hospital's policy and procedure for 3 of 14 concurrent patient records review for restraints (Patient 7, 11, and 12) and for 1 of 6 closed patient records reviewed for restraints. (Patient 2)


The findings are:


Review of the closed record for Patient 2 revealed the restraints were ordered and implemented for 4 episodes without documentation being fully completed.

1. On 04/18/17, a verbal physician restraint order was obtained for soft limb wrist restraints. The physician order was signed and dated by a registered nurse, but the time was not recorded.

2. On 04/17/17, the physician ordered soft limb wrist restraints, but the physician failed to record the time that the physician order for the restraint was written.

3. On 04/16/17, the physician ordered soft limb wrist restraints, but the physician failed to document the time that the physician order for the restraint was recorded.

4. On 04/15/17, the physician ordered soft limb wrist restraints, but the physician failed to document the time that the order for restraints was written.

In an interview on 08/02/17 at 4:12 p.m., the Chief Nursing Officer confirmed the soft limb restraints ordered by the physician for Patient 2 had no time that the physician orders were written.





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Observations on 8/1/17 at 11:15 a.m. revealed Patient 7 in bilateral soft limb wrist restraints. Review of Patient 7's record revealed an admission date of 6/27/17. Review of a Restraint Use Order Form dated 7/27/17 in the patient's chart showed the physician order was signed and dated by the nurse, but had no time written on the order or the type of intervention ordered. Review of the patient's 7/31/17 restraint episode revealed restraints were ordered, but there was no documentation of the clinical justification for the use of the restraints.

Observations on 8/1/17 at 11:17 revealed Patient 11 in bilateral soft limb wrist restraints. Review of Patient 11's record revealed an admission date of 7/10/17. Review of a Restraint Use Order Form dated 7/12/17 in the patient's chart revealed there was no documentation for the clinical justification for the use of the restraints or the type of intervention ordered. Review of the patient's 7/20/17 and 7/21/17 restraint episodes revealed physician restraint orders for bilateral soft wrist restraints due to the patient attempting to pull out tubes, drains, or other lines/devices medically necessary for treatment. There was no documentation on the physician order form of the physician's signature, date, or time. Review of the patient's restraint episode dated 7/30/17 revealed physician restraint orders that had no documentation of the clinical justification for the use of the soft wrist restraints.

Observations on 8/1/17 at 11:18 revealed Patient 12 in bilateral soft limb wrist restraints. Review of Patient 12's record revealed an admission date of 7/25/17. Review of a Restraint Use Order Form dated 7/27/17 in the patient's chart revealed a physician order for bilateral soft wrist restraints and bilateral mittens with a clinical justification that Patient 12 attempted to pull out tubes, drains, or other lines/devices medically necessary for treatment and was unable to comply with safety instructions. Review of the physician order revealed the physician order was not signed, dated, or timed.

In an interview on 8/1/17 at 3:46 p.m., the Chief Nursing Officer (CNO) verified clinical justification for the use of restraints and the type of intervention ordered should be documented on restraint orders. The CNO verified restraint orders should have a signature, date, and time on the physician orders for restraints.

Hospital policy, titled, "03.6022.01 Restraint of Patients" approved on 09/2016, states, "The reason for the use of the restraint must be documented and the restraint is in effect for one calendar day. In an interview on 08/02/17 at 4:15 p.m., the Chief Nursing Officer confirmed that if physician orders are not dated and timed, one can not determine how long the restraint has been in effect.

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure the patient's consent to treat, and the patient's rights and responsibilities form was signed by the patient or patient representative, and failed to ensure the health care surrogate information was signed and accurate for 3 of 14 concurrent inpatient records reviewed. (Patient 3, 6 and 8)


The findings are:


Review of Patient 6's record revealed an admission date of 7/27/17. Review of a copy of the Patient Rights and Responsibilities form revealed the form was not signed by the patient or patient's representative, the date of representative/family notification, and the name of employee who notified and the employee's signature was blank. Review of the Designation For Health Care Surrogate form revealed the patient's signature, and the box was checked, "I do not wish to designate a Health Care Surrogate at this time", and the form was signed by Patient 6's son. The Identification of Surrogate or Identification/Notification of Proxy form noted the patient's name with the box checked with "No health care surrogate designation is known to exist for the above named patient." Review of the other forms in the patient's record revealed the patient's son signed as the patient representative. In an interview on 8/2/17 at 2:15 p.m., the Admissions Coordinator verified the Patient Rights and Responsibilities form was not signed by the patient or patient's representative. The Admissions Coordinator verified the information on the Designation For Health Care Surrogate form and the Identification of Surrogate or Identification/Notification of Proxy form was not accurate. Review of a copy of the Conditions of Treatment and Admission in the patient's chart revealed a document that included consent to hospital care and treatment, consent to release information, personal effects and valuables that had no signature by Patient 6 or the patient's representative. In an interview on 8/2/17 at 2:15 p.m., the Admissions Coordinator verified the Conditions of Treatment and Admission form in the patient's chart was not signed by the patient or the patient's representative.


On 8/2/17 at 1:45 p.m., review of Patient 8's chart revealed the patient was admitted on 5/19/17 for respiratory management and there was no signed consent to treat and no Patient Rights information provided to and/or documented in the patient's chart. On 8/2/17 at 2:10 p.m., the Admissions Coordinator verified the blank consent to treat form, blank advanced directives, and blank Patient Rights forms, and revealed, "I am here from 7:30 a.m. to 3:30 p.m., and I will have the forms signed. If not, I will pass it on to the rn(registered nurse). Case management addresses Advanced Directives."

Review of the hospital's policy and procedure, titled, "01.0500.01 "Patient Rights and Responsibilities" effective 09-2016, reads on page 1, ".....Admissions personnel will review these rights with the patient and caregiver at the time of admission and document in the medical record."

Hospital policy and procedure, titled, "Consent for Treatment -01.0512.01", reads, "....Except for emergency situations, a general consent form must be completed by the individual (or authorized person) seeking/requiring care prior to admission and/or institution of treatment....".

Based on observations, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure medications were kept secure at all times for 1 of 2 medication carts observed.


The findings are:


On 8/1/17 at 2:55 p.m., observations in the William's nursing station revealed a medication cart that was unlocked and unsecured by nursing staff. The cart was located next to a hallway with easy access to patients and visitors. The findings were verified with the Directory of Respiratory at the time of the observation on 8/1/17 who stated, "This cart should be locked."

Hospital policy and procedure, titled, "Medication Storage- 08.005.001.001", reads, "....the storage of medications in the pharmacy, medication room, or automated Dispensing cabinets shall be considered secured....".

Based on observations, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure expired patient supplies were removed from the patient care areas and biologicals were marked with correct labeling.


The findings are:


On 8/1/17 at 10:37 a.m., random observations in the inpatient pharmacy revealed an opened unsealed vial of Vancomycin 750 mgs(milligrams) on the shelf. The finding was verified by the Infection Control Officer and the Pharmacist on duty on 8/1/17 at 10:38, and Pharmacist 1 revealed," I didn't know that was there. It shouldn't be."

On 8/1/17 at 11:00 a.m., observations in the Long Nursing Station's medication refrigerator revealed a multidose vial of Acetylcysteine thirty (30) milliliter (ml) labeled as opened on 5/22/17; a multidose vial of Acetylcysteine 30 mls labeled as opened on 6/4/17; and a multidose vial of Acetylcysteine 30 mls that was not labeled when opened. On 8/1/17 at 11:02 a.m., observations in the Long Nursing Station's medication area revealed an unlabeled container of Accuchek Inform II glucometer strips. The findings were verified by the Infection Control Officer at the time of the observation at 11: 02 a.m. on 8/1/17 .

On 8/1/17 at 2:56 p.m., observations in the Williams Nursing Station's medication area revealed an unlabeled container of Accuchek Inform II glucometer strips. The findings were verified with the Directory of Respiratory at the time of the observation at 2:56 p.m. on 8/1/17.

Hospital policy and procedure, titled, "Medication Storage- 08.005.001.001", reads, "....Multidose Vials: Multi-dose vials may only be dispensed for single patient use. Once opened, a 28-day beyond use expiration should be noted on the vial....".
Hospital policy and procedure, titled, "Blood Glucose Monitoring- 03.0100.00", reads, "....date...upon opening the bottle for the first time....".

Based on observations, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that food products were stored under appropriate conditions to include labeling, removal after use by date, and temperature for 1 of 1 kitchen observed.


The findings are

Observations in the kitchen on 7/31/17 at 3:00 p.m. revealed a refrigerator with a pan of sliced mushrooms that was not labeled. A pan of ground ham labeled 7/14/17 with a use by date of 7/19/17 was in the refrigerator. A freezer revealed an opened bag of chicken tenders and 2 packages of hamburger patties that were not labeled. In an interview on 7/31/17 at 3:30 p.m., the Director of Food Services verified the lack of labels on the foods and removal of out of date food from the refrigerator/freezer. Observations in the kitchen on 8/1/17 at 10:35 a.m. revealed proper food temperatures for the hot and cold foods except the milk. Three cartoons of milk were tested with temperatures greater than 40 degrees Fahrenheit. In an interview on 8/1/17 at 10:45 a.m., the Executive Chef verified milk temperatures were to be between 38-40 degrees Fahrenheit.

Review of hospital policy 1.2.5.2, titled, "Food Safety policies Food Safety Labeling and Dating Guide" issued 1/27/12 and revised 7/29/14, reads, "Storing Prepared Food Labels Required section: Product storage label: Name of product (unless clearly identifiable), date of preparation and/or "use-by" date....".

Review of the Operational Standard:, titled, "Food Storage", effective January 2017, reads, "Refer to the table and procedures below for the proper storage and use method for a variety of food items and other supplies." The table indicated perishable foods .....dairy products was to be stored at 38-40 degrees Fahrenheit.