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The facility failed to ensure that alternatives and/or least restrictive devices were attempted prior to the application of restraints. The finding is based on review of the clinical record, interview and review of facility policy and include the following:

Patient #22 presented to the ED on 1/1/10 at 2:28 AM with suicidal ideation. Review of the clinical record with the VP of Nursing indicated that on 1/1/10 at approximately 2:35 AM the patient attempted to elope and was placed in four point restraints. Review of the physician's restraint orders dated 1/1/10 failed to identify alternative measures attempted, behaviors requiring the use of restraints and/or the type of restraint ordered. Review of the facility policy indicated the Licensed Independent Practitioner is responsible to ensure that the order included the type of restraint, rationale/behaviors and alternatives attempted.

Based on review of the clinical record and review of facility polices, the facility failed to ensure that pain reassessments were completed in a timely manner for one of three patients, Patient #8. The findings include:

Patient #8 had diagnoses that included a cervical fusion, neurogenic bladder with urinary retention. Patient #8 was admitted to the facility on 4/27/09 to undergo a transurethral resection of the prostate (TURP). Review of the clinical record dated 4/28/09 at 9:30 AM identified that Patient #8 was medicated for back pain rated as a five out of ten (zero being no pain and ten being the worst pain) and was medicated with Vicodin one tablet. The clinical record lacked documentation to reflect that Patient #8's pain was reassessed in accordance with facility policies after administration of the Vicodin. Facility policy directed that pain reassessments be completed within one hour after administration of pain medication.




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Based on clinical record reviews and interviews with facility personnel for one of one sampled patients (Patient #14), the facility failed to ensure that a physician's order was followed.

The findings include:

Patient #14 was admitted to the hospital on 1/20/10 with Mental Status Changes, Renal Failure and a Urinary Tract Infection. Review of physician orders dated 1/20/10 identified that the patient was to have neurological checks completed every two hours. Review of nursing flowsheets dated 1/20/10-1/21/10 identified that neurological checks were completed on 1/21/10 only 3 times since physician ' s order was written. Review of hospital policy identified that the frequency of neurlogical assessments are per physician order. Interview with the Nurse Manager on 1/21/10 identified that the patient's neurological checks were not completed per physician order.

Based on review of the clinical record and review of facility policies, the facility failed to ensure that all entries by physicians into the clinical record of one patient, Patient #8, were timed. The findings include:

Patient #8 had diagnoses that included a cervical fusion, neurogenic bladder with urinary retention. Patient #8 was admitted to the facility on 4/27/09 to undergo a transurethral resection of the prostate (TURP). Review of physician progress notes identified that six out of eleven entries by physicians were untimed. Review of the Medical Staff By-Laws directed that all entries into the clinical record be dated and timed.

The facility failed to ensure that infection control measures were accurate and implemented appropriately. The findings are based on observation, policy review, and staff interviews and include the following:

Review of the clinical record of Patient #33 identified that the patient was admitted on 1/14/10 with diarrhea and on 1/15/10 was confirmed positive for Clostridium Difficile (C-DIF). During a tour of M2W on 1/22/10, Patient # 33 was observed on precautions. A green contact isolation sign was posted that directed, wash hands with soap and water or alcohol based hand gel. Review of the facility C-DIF policy indicated that hands should be washed with soap and warm water before and after treating each patient, removing gloves and after touching surfaces. The policy indicated that alcohol based hand gels may not be effective in destroying C-DIF spores. Interview with the Nurse Manager on 1/22/10 indicated that the facility had two contact signs and that they were interchangeable. Interview with the Infection Control Practitioner on 1/25/10 indicated that the green precaution sign should be utilized in conjunction with a precaution sign that is specific for C-DIF and/or patients with diarrhea.

Based on observations and interviews with facility personnel, the facility failed to ensure
that infection control practices were followed.

The findings include:


1. During tour of South 3 unit on 1/21/10 identified that multiple bags of soiled linen were located on the floor in the soiled utility room. In addition, multiple (10) clean flower vases were located in a cabinet in the soiled utility room. Interview with the Clinical Manager on 1/21/10 identified that the soiled linen should not be on the floor but in a receptacle and clean equipment needed to be removed from the soiled utility room.

2. During tour of the M3W unit on 1/21/10 identified that multiple geri chair trays and equipment were located on the floor of the equipment room. Interview with the Nurse Manager on 1/21/10 identified that the geri chair equipment needed to be removed from the floor.