HospitalInspections.org

Based on observation, clinical record review and interviews for one sampled patient (patient #21), the clinical record lacked a comprehensive assessment for the utilization of a restraint. The findings include:

Patient #21's diagnoses included acquired brain injury, and subarachnoid hemorrhage. A review of the history and physical dated 8/25/10 identified that the patient was able to follow simple commands, and was able to stand for transfer and intermittent ambulation and utilized a wheelchair which is modified for the patient's body position. A care plan dated 4/18/11 identified alteration in mobility related to disease process with interventions that included stand pivot for transfer with assistance of two staff members and blue soft safety belt when in wheelchair with slip knot. Observations on 6/6/11 at 2:15PM identified Patient #21 in the common area of the nursing unit seated in a wheelchair with a waist restraint in place tied in a slip knot on the right side of the wheelchair. Interview and review of the clinical record with the Nurse Manger and the Patient Care Coordinator of the Transitional Unit on 6/7/11 at 8:30AM identified that although a clip seat belt is attached to the wheelchair and is intended to be utilized to maintain pelvic alignment, the waist restraint has been utilized as the patient preferred a softer device. The Patient Care Coordinator further identified that this device was not utilized as a restraint as the patient is able to release the belt, however the clinical record lacked documentation of an assessment for the utilization of this device and/or evidence that the patient was able to release the device. A review of the Hospital Optimal Therapeutic Environment (OTE) policy identified that prior to the application of any device, the patient will receive an appropriate assessment. Interview with the Physical Therapist on 6/8/11 at 9:00AM identified that he/she was not aware of the use of the waist belt. The Physical therapist further identified that if the patient was not able to tolerate the use of the clip belt in the wheelchair, therapy should have been notified to evaluate the patient and other alternatives would have been attempted to maintain proper pelvic positioning in the wheelchair according to the plan of care.

Based on observation and interview with staff for 1 of 2 patients (Patient #14) who utilized humidified air via a tracheostomy, the hospital failed to ensure that the humidified air remained attached to the patient's tracheostomy. The findings include:

a. Observation with the Nurse Manager and LPN #10 on 6/7/11 at 9:15 AM identified that Patient #14 ' s humidified air tubing was lying on the floor under the patient ' s bed, actively running. LPN #10 identified that the tubing should have been connected to the tracheostomy.

Based on clinical record review, observations, interviews with staff, and review of hospital documentation for 3 of 3 patients with histories of acquired brain injuries and/or a history of suicide attempts (Patients #1, #8, and #33), the hospital failed to ensure that patient safety risk assessments were completed, and/or included suicidality with mode and means, and/or failed to include environmental risk assessments appropriate to meet the safety needs of each patient. The findings include:


a. Patient #1 was admitted on 10/12/10 with an acquired brain injury. A psychological consultation dated 3/9/11 identified Patient #1 as a moderate risk for suicide due to the brain injury, and history of major depression, past suicide attempts, and impulsivity. Patient #1 ' s clinical record was reviewed with the VP of Quality and Safety on 6/8/11 at 8:50 AM. Although the patient ' s behavioral management and safety plans identified that the patient tampered with safety devices, including cords and alarms, the clinical record failed to include a safety assessment of the patient ' s environment specific to suicidality and safety. The VP of Quality and Safety identified as of August 2010, all psychology assessments would include a patient suicide assessment. The hospital policy for management of the patient with potential for suicide identified that patients would be assessed as low, medium, or high risk. However, the policy failed to identify parameters for low, medium or high risk for suicide, or what types of precautions should be instituted based on the suicide risk assessment. Observation of Patient #1 ' s room on 6/6/11 at 9:40 AM identified that the patient had an electric bed cord and a call bell cord that were not secured to prevent the patient from utilizing them as a means of hanging.

b. Patient #8 was admitted on 4/15/09 with diagnoses of acquired brain injury, dementia, and behavioral disturbances. The clinical record identified that the patient had problems with aggressive and assaultive behaviors, and a behavior management plan identified for staff to change the patient ' s supervision if the patient made suicidal statements/ideations. The clinical record failed to identify that a suicide/safety risk assessment was conducted. Patient #8 ' s clinical record was reviewed with the VP of Quality and Safety on 6/8/11 at 8:50 AM, who identified that the behavior management plan was a guide for the nursing staff and did not necessarily indicate that the patient was suicidal. Observation of Patient #8 ' s room on 6/6/11 at 1 PM identified that the patient had an electric bed cord and a call bell cord that were not secured to prevent the patient from utilizing them as a means of hanging.

c. Patient #33 was admitted from 5/16/11 to 6/5/11 with a fractured leg and open wounds sustained in a motor vehicle accident. The patient had a history of a suicide attempt by overdosing on medications. Patient #8 ' s clinical record was reviewed with the VP of Quality and Safety on 6/8/11 at 8:50 AM. The clinical record failed to identify that a suicide/safety risk assessment was conducted, per policy.

Based on a tour of the dietary department, review of facility policies, review of hospital documentation, observations and interviews dietary staff failed to consistently monitor milk temperatures and/or ensure safe milk temperatures. The findings include:
A tour of the dietary department was conducted on 6/7/11 with the Dietary Manager. Observation of the tray service line on 6/7/11 at 11:20 AM identified that milk was taken from a nearby refrigeration unit, placed on patient trays and the trays were placed on delivery carts. Interview and observation with the Dietary Manager at this time noted that two of the carts were newer and had a separate hot and cold side to help maintain food temperatures. Review of the food temperature logs on 6/7/11 from 6/3/11 to 6/7/11 identified that the temperature of cold liquids was not monitored at each meal. Interview with the Dietary Manager on 6/7/11 at 11:30 AM indicated that temperatures of cold liquids, to include milk, were monitored three times a week during test tray audits. Review of the test tray audits from 6/3/11 to 6/6/11 noted that milk temperatures taken on the tray line were 40 to 50 degrees Fahrenheit (F), had risen as high as 55 degrees upon arrival to a unit and were recorded between 50 and 62 degrees when the last tray was removed from the cart. Interview with the Dietary Manager on 6/7/11 at 11: 30 AM indicated that milk temperatures should not be greater than 50 degrees. The hospital policy for temperature checks identified, in part, that milk from the point of origin should be at 34-48 degrees (F). The hospital food handling and preparation policy noted that all cold potentially hazardous foods will be maintained at a product temperature of 40 degrees (F) or below at the warmest part of the mass. According to the State of Connecticut Public Health Code Section 19-13-B42 (d), all potentially hazardous food which consists in whole or in part of milk or milk products, eggs, meat, poultry, fish, shellfish, or other ingredients capable of supporting the rapid and progressive growth of infectious or toxigenic microorganisms, shall be maintained at safe temperatures at 45 degrees F. or below, or 140 degrees F. or above, except during necessary periods of preparation.