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Based on observation, medical record review, and staff interview it was determined the facility failed to ensure patient's placed in isolation were done so under a physician's order. This affected one (Patient #2) of ten patients reviewed. The active census was 84.


Findings include:


Tour of the Victorian Village site was conducted on 11/28/16 at 2:30 PM. At 3:09 PM the patient in room one of the high observation unit was interviewed. Outside the patient's room was a sign reading, "contact isolation". Staff B who accompanied the surveyor on tour instructed the surveyor to don a gown and gloves prior to entry into the patient's room. The patient reported that he/she was not infected and isolation was not necessary. After exit of the patient's room, Staff B reported that the physician who was on site was consulted regarding the patient's lab results and decided the patient's isolation was no longer necessary.


The medical record for Patient #2 was reviewed on 11/28/16. The medical record review revealed the patient was admitted to the facility on 11/25/16. Review of the admission orders did not reveal an order for isolation.


Interview on 11/29/16 at 7:30 AM with Staff B and C, confirmed the patient was admitted on 11/25/16 with a pending Staphaureous laboratory culture from his/her previous admission. Staff C reported the nurse called the physician for the order for contact isolation but forgot to document it. The order was never written nor signed but the patient remained in isolation until 11/28/16 at 3:20 PM.

Based on medical record review, staff interview, and policy review it was determined nursing documentation was not available in the medical record on review. This affected one ( Patient #3) of ten medical records reviewed. The active census was 84.

Findings include:


Review of the Policy and Procedure for Documentation Standards D05-G ( revised 10/01/16) states documentation should be done throughout the shift and not left until the end of the shift. If information needs to be entered for an occurrence from a previous day or hour ,enter the necessary information, starting the entry with "Late Entry" including the date and time of the actual occurrence.


Review of the medical record for Patient #3 on 11/28/16 at 4:30 PM revealed a physician's order at 6:19 AM for freedom splint restraints to be applied. The restraint was due to interference with medical treatment and poor safety awareness as the patient disconnected self from mechanical ventilator. The medical record lacked evidence nursing staff provided care every two hours as per policy for patients in physical restraints.

This finding was confirmed with Staff D on 11/28/16 at 5:12 PM.


Staff B provided nursing documentation on 11/29/16 at 1:47 PM that revealed the patient was removed from the restraints on 11/28/16 at 8:00 AM. Two hour nursing documentation was not required as the patient was in restraints for an hour and a half. Review of the nursing documentation revealed the note was created at 6:15 PM on 11/28/16 after surveyor had left.

Staff B confirmed on 11/29/16 at 4:40 PM the nurse failed to document the note as a late entry as per facility policy.