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Based on review of medical records and interview, it was determined that the facility failed to follow facility policy concerning restraint of a patient.

Findings were:

Facility policy entitled "Restraint and Seclusion" stated in part "'Restraint' means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely ...Restraint is initiated only upon the order of a physician or other licensed independent practitioner ...Restraint orders must be dated and timed when signed by the physician and include: 1) criteria for release; 2) type of restraint used; 3) reason for restraint; 4) and specify duration of restraint order."

Facility policy entitled "Patient Rights and Responsibilities" stated in part that the patient has "The right to be free from restraints, of any form, that are not medically necessary or used as a means of coercion, discipline, convenience or retaliation by staff."

Facility policy entitled "Care of the Combative Patient" stated in part "It is the responsibility of this facility to promote safety and protection of in the care of a combative patient/hostile person and the staff and/or individuals at risk for harming themselves or others.
Procedure Steps:
Combative Patient/Person
1. Protect involved person from harm
2. Attempt to calm and reassure patient/person
3. Call for help. DO NOT LEAVE PATIENT/PERSON. CALL CODE STRONG 3333.
4. Contact physician if involving a patient
5. Document pertinent information.

Facility policy entitled "SPHN Emergency Codes" stated in part "Providence Memorial Hospital has established policies and procedures for a variety of potential disasters and emergencies. To expedite staff notification and response, the notification of external authorities, and to minimize public panic, emergency codes have been developed ...
Code Strong -Activates notification of staff and response personnel to a violent situation."

Patient # B1 was restrained on 12/02/14 @ 5:07 am. Nursing narrative note by Staff Member # B17 stated in part, "Pt.'s left arm grabbed by ****(Security Guard) and the right arm by ****(PCT), and his left leg by myself (RN)." While a Code "Strong" was called, patient's doctor was not alerted, nor was an order received for a personal hold/restraint.

In an interview with the Chief Nursing Officer on 12/2/14, it was confirmed that Patient # B1 was put in a brief personal hold/restraint. It was also acknowledged that the nursing staff failed to follow facility policy in regard to restraint of a patient.

Based on a review of medical records in the Post-Operative Care Unit (PACU) revealed that documentation was not completed for an updated history and physical examination prior to surgery for 2 out of 4 PACU patients.

Findings included:

Review of the medical records of 2 out of 4 patients, Patient #E6 and Patient #E7 in the PACU on 12/2/14, accompanied by Staff #2, Director of Surgical Services, and Staff #6, Risk Manager/Patient Safety Officer, the following was observed. For Patients #E6 and E7, the History and Physical examination was documented on 12/1/2014. The form entitled, "History & Physical Update" which stated, "Attach original H&P to this form" for documentation that the history and physical" (completed within the past 30 days) has been reviewed and the patient has been re-examined." was left blank. There was no documented evidence from the medical record provided to the surveyor to indicate the physician had reviewed and re-examined the patient prior to surgery.

Review of the Providence Memorial Hospital Rules & Regulations of Medical and Dental Staff, last revised 8/25/14, stated, in part, "2. A complete history and physical examination, performed by a practitioner member of or approved by the medical staff ...must be recorded in the medical record of all inpatients within 24 hours, and for all elective surgical inpatients and ambulatory (same-day) surgery patients at the time of admission and prior to the procedure ...a ... Inpatient H&P ....A physical examination and medical history must be done no more than 30 days before, with an appropriate up-dated assessment, or 24 hours after an admission for each patient by a doctor ...The H&P must be performed within 30 days prior to the hospital admission; and an appropriate assessment, which should include a physical examination of the patient to update any components of the patient's current medical status that may have changed since the prior H&P was performed or to address any area where more current data is needed."

The above findings were confirmed in an interview in the Pre-op area during the tour on 12/2/14 with Staff #E2 and Staff #E6.

Based on a review of documentation and interview, it was determined that the facility failed ensure that food and dietetic services organization requirements were met, as evidence by failing to ensure that thermometers utilized in food preparation areas were appropriately calibrated per policy. The failure to calibrate thermometers used to measure the temperatures of food prior to serving could led to inaccurate temperature readings, increasing the potential for food borne illness.

Findings were:

Facility based policy and procedure entitled, "Thermometer Calibration" stated in part, "Temperatures of food shall be monitored using accurate thermometers. Thermometers should be accurate to +/-2 ? F ....
PROCEDURES:
To verify accuracy of thermometers: ...
? Complete Thermometer Calibration Sheet. If the Thermometer is recalibrated, the corrective actions column must also be completed; initial the entry."

A form in the Food and Nutrition Policy and Procedure Manual entitled, "Thermometer Calibration Sheet" stated, "All thermometers used in the department are calibrated weekly and documented on this form. The forms are kept on file for 3 months." The bottom of the form stated, "***Calibration of every thermometer is to take place once a week every week and form must be signed."

Review of facility documentation revealed the following:
? The facility based form entitled "Trayline Temperature Monitoring Form" is utilized to document meal temperatures three times a day. At the bottom of the form a line stated, "WEDNESDAY ONLY: THERMOMETER CALIBRATION: place in ice water cup STD=32? F = ____?F."
? A review of the "Trayline Temperature Monitoring Form" for the main kitchen from January through May 2014, and October 2104 revealed no documentation of thermometer calibration. Review of the "Trayline Temperature Monitoring Form" for (the facility retail cafeteria) for October and November 2014 revealed no documentation of thermometer calibration.

In an interview with Staff member D #2, Food Services Director, on the afternoon of 12/02/14 in the facility conference room, she was asked if there was a form other than the "Trayline Temperature Monitoring Form" used to document the calibration of thermometers used for measuring food tray temperatures. Staff member D #2 stated, "No, this is the form on which we'd have the opportunity to document that. That ' s an area needing improvement."

Staff member D #2, they stated that the calibration of thermometers is not documented weekly per policy. Staff member D #2 stated that thermometer calibrations were not recorded consistently. They stated, "That's an opportunity for us to record that information. There are probably sporadic recordings of the thermometer calibration. That's an opportunity for improvement in this department."

The above findings were confirmed in an interview with staff member D #2 on 12/02/14.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that dietary changes were ordered by a practitioner responsible for the care of the patient as required by facility policy for 1 of 3 patients with special diets.

Findings were:

A review of 3 records of patients on special diets revealed that the tube feedings for Patient #D6 were discontinued without a physician's order. Physician orders showed the following order:
"12/2/14 10:56:00 MST, Formula: Nephro, 10 mL/hr, Start Meal: Next Meal, Continuous..."
The Intake and Output form noted the patient received a tube feeding at 12:00 noon on 12/3/14 and then no further feedings. There was no order to stop tube feedings. A nursing progress note on 12/3/14 at 1:00 p.m. MST stated, in part, "TF (tube feedings) DC'ed (discontinued) by Dr. Fernandez. Orders received to connect OG to low continuous suction."

In an interview with Staff #D16, Unit Director, on the morning of 12/4/14 in the nurse's station of the ICU, she stated, "There should have been a verbal order to stop tube feedings. He [the physician] should have put them [the orders] in. Maybe he documented it in his progress note." When asked if the progress note would be considered a physician order, she stated, "Well, no. And a verbal order should only be given in an emergency. "

In an interview with Staff #D15, ICU RN, in review of the chart of Patient #D6 on the morning of 12/4/14 in the nurse's station of the ICU, she stated "Sometimes the physicians don't enter orders about resuming a patient's diet after a procedure. There's no order to stop the tube feedings here [indicating the physician orders contained in the electronic health record] so there was probably a verbal order." When asked if that meant the non-electronic patient chart contained a handwritten verbal order noted by the nurse, she stated, "Well, no. It's a problem. And if we enter the order in the system [as nurses] they'll [the physicians] get mad at us." When asked if this issue sometimes resulted in patients' diets not being stopped or resumed as necessary, she stated, "Yes."

Facility policy #O1, entitled "Physician Orders: Receiving, Transcribing," last revised 10/14, stated in part:
"RECEIVING ORDERS - TELEPHONE/VERBAL
1. Telephone orders are to be taken by licensed/registered personnel only. Verbal orders should be taken only in emergency situations...
4. Transcribe to the physician order sheet each order as received. Include the date and time.
5. Readback to the physician all telephone orders to verify accuracy and place nurse initials in the readback column for each order..."

Facility Patient Food Services policy #C002 entitled "Diet Orders," last revised 1/14, stated in part:
"Diets are ordered in Cerner by the responsible physician prior to the service of the diet ...
Physician
Writes/enters diet order in medical record/information system...
Writes a diet order for "NPO" when a patient is not allowed oral intake.
Writes new diet order to resume oral intake for patients who have been NPO..."

The above findings were again confirmed in an interview with the Interim Chief Operating Officer on the morning of 12/4/14 in the facility conference room.

Based on tour and interview it was determined the facility failed to ensure that alcohol based hand sanitizer rub dispensers were install in a safe manner, as evident by the presence of such dispenser near active electrical outlets, creating a fire hazard.

Findings were:

Tour of the facility revealed that multiple alcohol based hand sanitizer dispensers were observed to be placed in close proximity to electrical outlets and plugs.

During a tour of the facility on 12/02/14, the following observations were made:
? In the Pre-Operative Holding area, patient bays 1 through 4 were observed to have alcohol based hand sanitizer dispensers beside or above electrical outlets and plugs. These hand sanitizer dispensers were observed within 2-4 inches of the electrical outlets.
? In a secondary Pre-Operative Area, one alcohol based hand sanitizer dispenser was observed 3 inches from an electrical outlet that was active with electric medical devices plugged in.

Staff E #2, Director of Surgical Services, confirmed the hazard presented by the location of the hand sanitizers.

During a tour of the facility on 12/03/14 the following observations were made:
? On the Medical Oncology Floor in the hallway between the exit door and room 401, an alcohol based hand sanitizer dispenser was observed located beside an electrical outlet.

In an interview on 12/03/14, staff member D #7 stated that the placement of the alcohol based hand sanitizer dispensed near electrical outlet was a result in miscommunication between various departments. Staff Member D #7 stated, "There was a breakdown. Now my guys are trained, now they know not to place them over outlets." Staff member D #7 stated the alcohol based hand sanitizer dispensers are supplied by housekeepers. "I think some units were just installing them themselves." The staff member also stated that, "The previous infection control nurse would put blue dots on the wall where she wanted them installed and my guys would go and place them without question."

Staff member D #7 confirmed that as of 12/03/14 alcohol based hand sanitizer dispensers throughout the facility remained in close proximity to electrical outlets, creating a fire hazard. Staff member D #7 stated the maintenance department was currently working to move them to appropriate and safe locations.

Based on review of medical records, staff interviews, patient interviews, and tour of the perioperative area of the hospital, the hospital failed to ensure that surgical standards of practice were followed as there were consent forms improperly documented, a patient without an emergency call light in reach, processes for disinfection not followed, and lack of proper labeling of IV fluids.

Findings included:

During a tour of the pre-operative the morning of 12/2/14, accompanied by Staff #E2, Director of Surgical Services, the following was observed:
? Review of the clinical record for Patient #1 at 8:55 am with Staff #E5, Pre-op RN, revealed the "Consent for Anesthesia Services" had not been signed by the patient (the line for "Patient's Signature/Other Legally Responsible Person" was blank), however the date, "12/2/14", and the time, "0905" was already handwritten on the form in the designated areas. The "Witness Signature" blank had already been signed by Staff #E5, despite there being no patient signature to witness. This was confirmed in an interview while reviewing the record with Staff #E5 and Staff #E2.
? During an interview with Patient #1 in the pre-op patient room, upon entering the patient room, the television was on and the volume was too high to converse. It was observed that the call light device, which also included the television controls, was inaccessible to the patient as it was hung out of reach on a hook on the wall above the patient's bed. Patient #E1 stated, "I can't even reach the call light or turn down the television." This was reviewed in an interview with Staff #E5 and Staff #E2 during the tour.
? In pre-op area, the surveyor noted children's activity toys mounted on the wall in the patient. In an interview with Staff #E16, Pre-op RN during the tour, she was asked by the surveyor how the children's activity toys were disinfected between patients. Staff #E16 stated, "I'm not aware that it happens ...I've never had the opportunity to do this." This presents a risk for cross contamination without performing thorough disinfection in the pre-op holding bays between patients.
? In the pre-op area, in the supply alcove IV solutions warmer, there was a sign posted on the front of the warmer which stated, "SOLUTION WARMING GUIDELINES IV SOLUTIONS WARMED TO 104 F (40 C) ARE GOOD FOR 30 DAYS PLEASE DATE ALL BAGS AND ROTATE SOLUTIONS APPROPRIATELY" Observation of the interior of the IV solution warmer revealed 16 one liter bags of IV solution in the warmer with labels which read, "in warmer Dec 07 2014, remove on Jan 2014". The "in warmer" date of 12/7/14 was observed during the tour on 12/2/14. There was no means of accurately determining when the IV solution had been placed in the warmer and the accurate 30 day removal or use by date of the solutions.
The above findings were confirmed in an interview with Staff #E2.