HospitalInspections.org

Based on observation, record review and interview the facility failed to ensure staff follow the facility policy when a restraint was applied which was not ordered by the physician for one of five in-patients (Patient #7). The census was 22.

Findings included:

1. Record review of Patient #7's medical chart revealed the patient was admitted to the facility on 3/26/10 for ventilator weaning, ( a process of shifting the breathing function from the machine to the patient) nutrition, and therapy.

-Observation on 4/8/10 at 4:00 p.m. revealed the patient with bilateral ankle restraints.

-Record review revealed an order for bilateral soft wrist restraints and one ankle restraint.

-An interview on 4/8/10 at 4:30 p.m. Registered Nurse H stated he/she had applied the other ankle restraint to prevent the patient from getting hurt when she tried to get out of bed unassisted.

-Record review of the facility policy on Safety: Restraints revised January 2010 in part revealed the following information:

2. A physician's telephone, verbal or written order must be obtained utilizing the Physician's Order Sheet. The order is obtained from the patient's attending physician or the covering physician.

In an emergency (therapeutic use of restraint to prevent serious disruption of treatment), the qualified RN/LPN shall first restrain the patient with the least restrictive device, and then notify the physician immediately.

Based on observation, record review and interview the facility staff failed to obtain a physician's signature every 24 hours as required by the facility policy for patients (Patient #1, #8, #9) of five in-patients in restraints and for three (Patient #10, #11, #12) of six closed records. The census was 22.

Findings included:

1. Record review of Patient # 1's medical record revealed the patient was admitted to the facility on 3/17/10 for wound care, nutrition, and therapy.

-Record review of the Restraint Orders in part revealed the following:
-The restraint order dated 3/30/10 was timed 1:30 p.m., the restraint order dated 3/31/10 was timed 4:30 p.m.
-The restraint order dated 4/1/10 was timed 7:00 p.m., The restraint order dated 4/2/10 was timed 4:30 p.m.
-The restraint order dated 4/5/10 was timed 11:35 a.m., the restraint order for 4/6/10 was timed 3:00 p.m.
-The restraint order dated 4/7/10 was timed 6:00 p.m.

2. Record review of Patient # 8's medical chart revealed the patient was admitted to the facility on 3/26/10 for ventilator weaning ( a process of shifting the breathing function from the machine to the patient), nutrition, intravenous antibiotics ( given through a vein).

- Record review of the Restraint Orders in part revealed the following:
-The restraint order dated 3/14/10 was timed 3:00 p.m., the restraint order dated 3/31/10 was timed 4:30 p.m.
-The restraint order dated 3/15/10 was timed for 8:00 a.m., the restraint order dated 3/17/10 was timed 4:30 p.m.
-The restraint order dated 3/27/10 was timed for 7:00 a.m., the restraint order for 3/28/10 was timed 4:40 p.m.
-The restraint order dated for 3/31/10 was timed 8:00 a.m., the restraint order dated 4/1/10 was timed 6:50 p.m.
3. Record review of Patient # 9's medical chart revealed the patient was admitted to the facility on 2/12/10 for ventilator weaning, nutrition, and therapy.

-Record review of the Restraint Orders in part revealed the following:
- The restraint order dated 3/14/10 was timed for 8:00 a.m., the restraint order for 3/15/10 was timed 5:00 p.m.
- The restraint order dated 3/19/10 was timed for 8:00 a.m., the restraint order for 3/20/10 was timed 1:30 p.m.
- The restraint order dated 3/20/10 was timed for 12:15 p.m., the restraint order dated - The restraint order dated 3/26;/10 was timed for 8:00 a.m., the restraint order dated for 3/27/10 was timed 9:45 p.m.
- The restraint order dated 3/30/10 was timed for 8:00 a.m., the restraint order dated 3/31/10 was timed 1:30 p.m.
- The restraint order dated 4/2/10 was timed 8:00 a.m., the restraint order dated 4/3/10 was timed 1:30 p.m

4. Record review of Patient # 10's medical chart revealed the patient was admitted to the facility on 12/3/09 for ventilator weaning, nutrition and therapy.

-Record review of the Restrain Orders in part revealed the following:
- The restraint order dated 12/24/09 was timed 7:00 a.m., the restraint order dated 12/25/09 was timed 11:00 a.m.
- The restraint order dated 12/26/09 was timed 1:50 p.m.
- The restraint order dated 12/27/09 was timed 10:45 a.m., the restraint order dated 12/28/09 was timed 3:45 p.m.
- The restraint order dated 12/29/09 was timed 10:25 p.m.
- The restraint order dated 1/7/10 was timed 8:30 a.m., the restraint order dated 1/8/10 was timed 12:30 p.m.
- The restraint order dated 1/9/10 was timed 2:00 p.m.,
- The restraint order dated 1/10/10 was timed 1:30 p.m., the restraint order dated 1/11/10 was timed 4:30 p.m.

5. Record review of Patient #11's medical chart revealed the patient was admitted to the facility for ventilator weaning, intravenous antibiotics, nutrition and therapy.

-Record review of the Restraint Orders in part revealed the following:
-The restraint order dated 1/23/10 was timed 1:15 p.m., the restraint order dated 1/24 (no year) was timed 6:00 p.m.
-The restraint order dated 1/25/10 was timed 9:50 a.m., the restraint order dated 1/26/10 was timed 1:05 p.m.
-The restraint order dated 1/29/10 was timed 7:30 a.m., the restraint order dated 1/30/10 was timed 12:00 p.m.

6. Record review of Patient #12's medical chart revealed the patient was admitted to the facility on 12/16/09 for wound care and intravenous antibiotics.

Record review of the Restraint Orders in part revealed the following;
-The restraint order dated 12/26/09 was timed 7:00 a.m., the restraint order dated 12/27/09 was timed 4:20 p.m.

-Record review of the facilities policy on Safety: Restraints revision date January 2010 in part revealed the following information:
3. Restrain Orders (Attachment "A")
-Continued use of restraints is renewed every twenty-four (24) hours by written physician order, telephone order and or verbal order after face-to-face evaluation of the patient's physical and mental status. This order is written on the physician's order sheet.

-During an interview on 4/8/10 at 5:30 p.m. Nurse Manager A stated (after being shown by the surveyor) she saw several physician's orders which were not signed within the required twenty-four hours time period.

Based on observation, record review and interview the staff failed to follow the physicians order to apply bilateral wrist restraints for two in-patient (Patient #1, #8) of five patients who had restraints and staff did not follow the facility policy in not obtaining a new order after the wrist restraints had been off for more than 2 hours. The census was 22.

Findings included:

1. Record review of Patient #1's medical chart revealed the patient was admitted to the facility on 3/17/10 for wound care, nutrition and therapy.

-Observation on 4/8/10 at 3:30 p.m. revealed the patient lying in bed with the head of bed raised The patient did not have soft wrist restraints applied.

-Record review of the Restraint Orders dated 4/7/10 and timed at 6:00 p.m. revealed the physicians order was for bilateral wrist restraints was given because the patient had been picking/pulling at/reaching for lines/tubes/dressings and attempting to get out of bed/chair unassisted and unsteady gait.

-An interview on 4/8/10 at 3:30 p.m., Nurse Manager A stated the patient did not have bilateral wrist restraints on and she would need to check the chart to see if they were ordered. Nurse Manager A checked the chart and said the bilateral wrist restraints were ordered by the physician but were not on the patient.

2. Record review of Patient #8's medical chart revealed the patient had been admitted to the facility on 2/18/10 for ventilator weaning, nutrition and therapy

- Observation on 4/8/10 at 4:00 p.m. revealed the patient lying in bed with the head of bed raised. The patient's spouse was sitting in a chair by his/her side. The patient did not have bilateral soft wrist restraints on as ordered by the physician.
-Record review of the patients medical chart revealed no documentation which assessed the patient as not needing restraints or that they had been discontinued.

-Record review of the Restraint Orders in part revealed the following:
-The Restraint Orders were for bilateral wrist restraints.

-An interview on 4/9/10 at 10:00 a.m. Spouse I revealed the following information:
The spouse stated the restraints were removed whenever she or her family came to visit. She stated the patient did not need them when the family was there and they watched to see he would not pull any tubes out. The spouse stated it was sometimes many hours before the family would leave and then the restraints would be reapplied. Review of the medical record did not reveal new orders for restraints after the family visits.

-Record review of the facility policy on Safety: Restraints in part revealed the following information:
3. If the restraint is removed for care or while family or sitter is present, a new order is required when the device is reapplied if the restraint has been off more than 2 hours.

-The facility policy Safety: Restraints revised January 2010 in part revealed the following information:
4. The RN/LPN must determine the least restrictive device to be utilized. The RN/LPN is responsible for initiation and continued use of restraint on observation, record review and interview the facility failed to ensure the staff follow the facility's policy of obtaining a new order for restraints after the restraints had been removed for several hours while family was present.

-Record review of the patient's Restraint Orders did not reveal a physicians' order for restraints after the family left the bedside.

Based on observation and interview the facility failed to label a multi use container with the patients name, (Patient #1, #16) intended use and date initially opened. This would have the potential of affecting all patients. The census was 22.

Findings included:

Observation on 4/9/10 at 8:10 a.m. in Room 207 revealed the following multi dose supplies:
- 1 - Skin integrity wound cleaner 8 fluid ounces 236 milliliters
- 2 - Calamine skin protectant ( zinc oxide-based barrier)
- 1 - Hydrogen Peroxide ( disinfectant) 3 % Lot 29015 Expired 12/11 118 milliliters
- 1 - Combivent Inhaler Aerosol ( a combination of medications in a metered-dose aerosol inhaler)
- 1 - Chlorhexidine Gluconate) (a medication used in the treatment of gum disease) 12 % ( anti fungal) 3 ounces

Observation on 4/9/10 at 9:40 a.m. in Observation Room #3 revealed the following multi dose supplies:
- 1 - Sodium Chloride (salty water) 9% 10 cc
- 1 - Silvasorb Gel ( a mediation used to reduce the risk of infection)1.5 fluid ounces 44.4 milliliters
- 1- Santyl (a medication used to debride [removal of dead damaged or infected tissue) wounds) 15 grams

Based on observation and interview the facility failed to ensure the staff follow the facility policy for three in-patients (Patient #2, #3, #16) when staff did not use soap and water or hand cleanser when entering or leaving the room or between glove changes.
The facility census was 22.

Findings included:

1. Record review of Patient #2 medical chart revealed the patient was admitted to the facility on 4/3/10 for ventilator weaning.
-Observation on 4/8/10 at 2:52 p.m. revealed Speech Therapist (ST) M left the patient's room without using soap and water or hand cleanser. The ST was observed to be sitting on the patient's portable commode at bedside.

2. Record review of Patient # 3's medical chart revealed the patient was admitted to the facility on 4/6/10 for medically complex.
-Observation on 4/8/10 at 3:30 p.m. revealed Registered Nurse F entered the patient's room without using soap and water or hand cleanser.

3. Record review of Patient # 16 medical chart revealed the patient entered the facility on 3/3/10 for ventilator weaning.
-Observation on 4/9/10 at 8:07 a.m. revealed RN E enter the patient's room without washing hands or using hand cleanser. The RN donned non sterile gloves and suctioned the patient. He/She then removed the gloves and applied another pair of non sterile gloves. There was no hand washing with soap and water or hand cleanser between glove changes.

-An interview on 4/9/10 at 1:30 p.m. with the Director of Performance Improvement C stated the expectation would be the staff follow the policy by washing their hands with soap and water or hand cleanser before entering a patient's room and after leaving a patient's room and between glove changes.

Record review of the policy titled Hand Washing Policy Number IC.17 reviewed February 2010 in part revealed the following information:

Policy
It is the policy of this Hospital to emphasize that the single most important procedure for preventing nosocomial infections is hand washing.

Procedure:
1. When to wash hands:

b. 1) before performing invasive procedures
3) after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood, or body fluids, secretions, or excretions.
7) between contacts with different patients in high risk areas; and