HospitalInspections.org

Based on observation, the facility failed to protect patient's rights to privacy by placing patient names in public view. This failure affected all 32 patients on the on the Medical/Surgical Unit. The facility census was 66.

Findings included:

Observation on 1/5/11 at 10:07 AM, on the first floor Medical/Surgical unit showed patient charts lying on the desk at the nursing station and visible within a circular chart rack. Patients' first and last names were affixed to the charts and the names were clearly visible from the public hallway and visitor's side of the nursing station.

Based on observation and interview the facility failed to provide a safe environment for 15 of 15 patients on the Behavioral Health Unit by allowing:
-Non-suicide resistant water control knobs on the sinks in two of four patient shower rooms
-Non-suicide resistant water control knobs on the sinks in ten of ten patient rooms
-Non-suicide resistant faucet on sink in one of four patient shower rooms
The configuration of the water control knobs and faucet on sinks creates a looping hazard for all patients on the unit. The unit census was 15 and the facility census was 66.

Findings included:
Record review showed all 15 patients were on every 15-minute checks for suicide precautions.

Observation on 1/3/11 at 2:55 PM, on the Adult Unit showed the following patient safety issues:
-Both shower rooms had a sink with turn grips on the water control knobs that protruded out horizontally approximately two inches from the top of the knobs.
-The sink in one shower room had a gooseneck faucet extending up about nine inches and curved down towards the sink.
-All five patient rooms had sinks with turn grips on the water control knobs that protruded out horizontally approximately two inches from the top of the knobs.

Observation on 1/3/11 at 2:45 PM, on the Geriatric Unit showed the following patient safety issues:
-All five patient rooms had sinks with turn grips on the water control knobs that protruded out horizontally approximately two inches from the top of the knobs.

Observation on both Adult and Geriatric units on 1/3/11 at 3:00 PM, showed all ten patient rooms were unlocked and the patients had access to their rooms.
During an interview on 1/4/11 at 3:15 PM, Staff G, Behavioral Health Director, stated that patients with suicidal ideations are admitted to both the Adult and Geriatric Units. Staff G stated that patients on the Adult Unit are allowed to use the shower rooms without direct observation by staff. Patients on the Geriatric Unit are always assisted by staff while using the shower room. Staff G confirmed that the configuration of the one sink faucet and all sink handles were unsafe and posed a safety risk to patients.
During an interview on 1/5/11 at 11:15 AM, Staff L, Plant Operations Director stated that the facility would continue to change out the water control knobs in the shower areas and all patient rooms.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed by the facility. Personnel record review of five (Staff R, S, T, U and V) of five facility staff reviewed revealed the facility failed to compare the names of staff upon hire and on a periodic basis against the EDL. The facility census was 66.

Findings included:

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

2. Review of Staff R's personnel file showed Staff R had been employed in the facility since 04/95 and had no verification that he/she was not on the EDL.

3. Review of Staff S's personnel file showed Staff S had been employed in the facility since 4/10 and had no verification that he/she was not on the EDL.

4. Review of Staff T's personnel record showed Staff T had been employed in the facility since 10/90 and had no verification that he/she was not on the EDL.

5. Review of Staff U's personnel record showed Staff U had been employed in the facility since 5/10 and had no verification that he/she was not on the EDL.

6. Record review of Staff V's personnel record showed Staff V had been employed in the facility since 5/88 and had no verification that he/she was not on the EDL.

7. During an interview on 1/5/11 at 1:50 PM, Staff M, Director of Human Resources stated that the facility had not been using EDL as part of their initial or ongoing employment screening process.

Based on facility policy review, record review, and interview, the facility failed to document justification for restraint use for one patient (#3) of seven restraint patients reviewed. The facility census was 66.

Findings included:

1. Review of the facility policy titled, "Restraint Management," revised Jan. 2011, gave the following direction (in part):
- Indications: Restraint shall only be used for the protection of the patient, staff members or others. Such indications shall be present and documented at the initiation of and throughout the episode of restraint.

2. Review of the medical record for current Patient #3 on 1/3/11 at 2:20 PM, showed the following (in part):
- Restraint Order Form, dated 1/2/11 at 3:00 PM, did not indicate justification, location, or type of restraint for the use of soft wrist restraints. There was no indication of whether the order was a telephone/verbal order, and there was no nurse signature. The order was signed by the physician on 1/3/11 at 9:00 AM. Review of nursing documentation showed bilateral soft wrist restraints were used during the period in question for "Pulling at or reaching for IV lines, monitor devices, tubes, dressings."

3. During an interview on 1/4/11 at 3:45 PM, Staff E, Intensive Care Unit Department Director, confirmed staff failed to obtain appropriate written orders for physical restraints for Patient #3.

Based on facility policy review, record review, and interview, the facility failed to obtain an order for the use of restraints for two patients (#3 and #11) of seven restraint patients reviewed. The facility census was 66.

Findings included:

1. Review of the facility policy titled, "Restraint Management," revised Jan. 2011, gave the following direction (in part):
- Orders: Restraints shall be ordered by a physician member of the medical staff.

2. Review of the medical record for current Patient #3 on 1/3/11 at 2:20 PM, showed the following (in part):
- Restraint Order Form dated 12/31/10 at 4:30 PM, for bilateral soft wrist restraints to keep Patient #3 from pulling at tubes was signed by a nurse, but did not indicate whether the order was a telephone/verbal order. Review of nursing documentation confirmed the patient was in restraints. The physician did not sign the Restraint Order Form until 8:00 AM, the following day, indicating the patient was restrained for 15 ? hours without a physician order.
- Restraint Order Form dated 1/1/11 at 3:00 PM, for bilateral soft wrist restraints to keep Patient #3 from pulling at tubes was signed by a nurse, but did not indicate whether the order was a telephone/verbal order. Review of nursing documentation confirmed the patient was in restraints. The physician did not sign the Restraint Order Form until 8:30 AM, the following day, indicating the patient was restrained for 17 ? hours without a physician order.
- Restraint Order Form dated 1/2/11 at 3:00 PM, for bilateral soft wrist restraints to keep Patient #3 from pulling at tubes was not signed by a nurse, and did not indicate whether the order was a telephone/verbal order. Review of nursing documentation confirmed the patient was in restraints. The physician did not sign the Restraint Order Form until 9:00 AM, the following day, indicating the patient was restrained for 24 ? hours without a physician order.

3. Review of the closed medical record for Patient #11 on 1/4/11 at 1:05 PM, showed the following (in part):
- Restraint Order Form dated 12/22/10 for initiation of bilateral soft wrist restraints to keep Patient #11 from pulling at tubes was signed by a physician at 9:30 PM.
- Restraint Order Form dated 12/23/10 at 10:00 PM, for bilateral soft wrist restraints to keep Patient #11 from pulling at tubes was not signed by a nurse, and did not indicate whether the order was a telephone/verbal order. Review of nursing documentation confirmed the patient was in restraints. The Restraint Order Form was not signed, dated, or timed by the physician.
- Restraint Order Form dated 12/24/10 at 10:00 PM, for bilateral soft wrist restraints to keep Patient #11 from pulling at tubes was not signed by a nurse, and did not indicate whether the order was a telephone/verbal order. Review of nursing documentation confirmed the patient was in restraints until a breathing tube was removed on 12/25/10. The Restraint Order Form was not signed, dated, or timed by the physician, indicating the patient was restrained for approximately 60 hours without a physician order.

4. During an interview on 1/4/11 at 3:45 PM, Staff E, Intensive Care Unit Department Director, confirmed staff failed to obtain appropriate written orders for physical restraints for patients #3 and #11.

Based on interview and record review the facility failed to have a policy documenting the training requirements for physicians in the use of restraints and/or seclusion. The facility census was 66.

Findings included:

Review of the facility policies revealed no policy addressing restraint and/or seclusion training requirements for physicians.

During an interview on 1/5/11 at 9:20 AM, Staff D, Chief Nursing Office stated that the facility does not have a policy addressing the training requirements for physicians regarding the use of restraints/seclusion.

During an interview on 1/5/11 at 10:20 AM, Staff P, Medical Staff Coordinator stated the facility developed a training packet in 2009 for the new physicians and it included the restraint policy. Staff P stated the facility did not have a policy for the training packet or a policy addressing restraint training requirements. Staff P stated the facility has 54 physicians that could order restraints and only 13 of those have received training on the restraint/seclusion policy.

Based on interview and record review the facility failed to ensure staff providing care for patients in restraints received basic first aid training related to restraint use. This failure has the potential to affect all patients placed in restraints. The facility census was 66.

Findings included:

Review of the facility restraint training showed no training in the use of first aid related to restraint use.

During an interview on 1/5/11 at 9:50 AM, Staff H, Director of Education stated the restraint training for staff is related to applying and discontinuing restraints and the restraint policy but does not include first aid related to restraint use.

Review of five personnel records showed no first aid training related to restraint use.