HospitalInspections.org

Based on policy and procedure review, closed medical record review, and staff interview, the nursing staff failed to obtain a physician order for restraints for 1 of 4 (#22) patients restrained.

The findings include:

Review of hospital policy, H-PC 05-010 PRO, PHYSICAL RESTRAINTS (VIOLENT AND NON-VIOLENT BEHAVIOR) AND SECLUSION, release date 10/2014 revealed, "Initial restraint order from the attending physician or other licensed independent practitioner (LIP) is required immediately or within a few minutes from initiating restraints. Maximum duration: 7 days..."

Open medical record review of Patient #22 revealed a 51 year old female admitted to the facility on 12/01/2014. Record review revealed documentation on a "RESTRAINT INITIATION.ORDER (NON-VIOLENT NON-SELF DESTRUCTIVE BEHAVIOR) signed by a RN (Registered Nurse) and dated 12/22/14 at 0800 that restraints were applied. Further review revealed the telephone order was blank. Review of the document revealed, "Physician/LIP (LICENSED INDEPENDENT PRACTITIONER)/AHP (ALLIED HEALTH PRACTITIONER)/Restraint Order confirmation (to be completed within 1 calendar day from initiation of the restraint)." Review of the document revealed no signature of a MD, LIP, or AHP. Medical record review revealed the restraints were removed on 12/28/14 at 0100 (6 days 17 hours later). Record review revealed no electronic order or written order for the restraints that were initiated on 12/22/2014 at 0800.

Interview with the Nurse Manager on 02/12/2015 at 1315 revealed the nurses are to reasess the need for restraints every shift. Interview revealed there was no electronic documentation or written documentation for the restraint order initiated 12/22/2014 at 0800.

Based on hospital policy review, observation, terminal cleaning log review, staff interviews and personnel file reviews, the hospital's Infection Control Preventionist failed to ensure the operating room was cleaned according to hospital policy for 1 of 1 operating room (OR #1).

The findings include:

Hospital administrative staff presented the Association of periOperative Registered Nurses (AORN) "Perioperative Standards and Recommended Practices 2014 Edition" as the guidelines used as policies for environmental cleaning in the operating room. Review of the AORN Environmental Cleaning guidelines revealed "floors should be mopped with damp or wet mops. Dry methods of environmental cleaning (i.e. dusting, sweeping) should not be used in semirestricted and restricted areas. ... Perioperative and environmental services personnel should receive initial and ongoing education and competency verification on their understanding of the principles and the performance of the processes for environmental cleaning in the perioperative areas. ... Competency assessment measures individual performance, provides a mechanism for documentation, and verifies that perioperative personnel have an understanding of facilities policies and potential environmental hazards to patients and personnel. ... "

Observation during tour of the operating room (OR #1) on 02/12/2015 at 1430 revealed dust particles that rolled up into balls located around the outside glass window frame of the supply cabinet in the operating room. Interview during tour with the operating room director revealed the operating room had been used earlier in the day and had been cleaned and was ready for a new surgical case. Interview revealed the operating room staff clean the operating room between cases and provide a deeper cleaning at the end of each day. Interview revealed cleaning included wiping down of all surfaces, walls, floors and equipment at the end of the day. Interview revealed the balls of dust should not be present. The director stated environmental services staff conduct a terminal cleaning in the operating room once a week.

Interview with EVS staff #1 on 02/12/2015 at 1410 revealed he was responsible for cleaning duties in the operating room every other weekend. Interview revealed the order of cleaning was to dust, sweep, then mop the floor. Interview revealed EVS staff #1 used a broom to remove the debris then swept the debris into a dustpan. Interview revealed EVS staff #1 wet mopped the floor after sweeping. Interview revealed EVS staff #1 received training from a former employee who cleaned the OR.

Review of the operating room terminal cleaning log revealed two environmental services staff members that conducted terminal cleaning in the operating room over the past six months (EVS staff #1 and EVS staff #2). Review of EVS staff #1's personnel file revealed the staff member was released from orientation on 03/01/2012. Review of the personnel file revealed no evidence of training or education related to terminal cleaning in the operating room setting. Review of EVS staff #2 revealed the staff member was released from orientation on 09/10/2014. Review of the personnel file revealed no evidence of training or education related to terminal cleaning in the operating room setting.

Interview on 02/12/2015 at 1505 with the Director of Environmental Services revealed surgical procedures are scheduled in the operating room on Tuesdays and Thursdays. Interview revealed the surgical staff clean the operating room between cases and at the end of each surgical day. Interview revealed environmental services staff clean the operating room weekly. Interview revealed the weekly cleaning includes dry sweeping the operating room floor. Interview with the director revealed the terminal cleaning check list that includes sweeping the floors was a list that was created with a former operating room director. Interview revealed the director or his staff have not received any infection control training related to environmental cleaning of an operating room. The staff member stated he was not aware of AORN guidelines.

Interview on 02/12/2015 at 1535 with the Infection Control Preventionist revealed she did not provide infection control oversite of the operating room. The staff member stated the operating room was treated as an "independent entity" and she was not involved in monitoring the cleaning in the operating room.

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