HospitalInspections.org

Based on observations, staff interviews, medical record review, and review of hospital policy and procedures, the hospital failed to protect patients' rights; to a safe environment, confidentiality of patients' medical record information, and from unauthorized use of restraints due to lack of physician orders for the restraint usage. This could affect all patients in the hospital. The total census during this visit was 40.

Findings include:

The hospital failed to ensure each patient received care in a safe setting. This affected one patient (#6); however there is a potential to affect the total patient census of 40. Please refer to A144 regarding care in a safe setting.

The hospital failed to ensure the confidentiality of clinical records and patient information by keeping medical records secure from unauthorized access of medical records. Please refer to A147 regarding unsecured medical records.

The hospital failed to ensure patients were restrained only when a physician had ordered the use of the restraint. This affected five (Patients #s 6, 7, 8, 9, and 10) of five patients observed in restraints during the survey. Please refer to A168 regarding the lack of physician orders for restraints.

Based on direct observation, staff interview, medical record review, and review of the hospital's policy and procedures, the hospital did not follow the established written infection control policies. The lack infection control practices could affect all patients, visitors and staff. The patient census was 40.

Findings include:

During an observation period on the A East Unit on 12/11/2012, at room AE07, patient #11's open record and the nurse's report sheet/notes of other patients was observed on a shelf in the hallway. Staff B, who was accompanying the surveyor, closed up the shelf. The nurse (staff H) called out and said don't mess with my papers. Staff B told the surveyor that the papers were left out because the patient was in isolation. No precautionary signage was present on the door to indicate that the patient required specific infection control measures.

The above observation was verified by Staff B on 12/11/2012 at 11:40 PM.

Staff H, who was responsible for patient #11's care, was questioned regarding the lack of infection control signage placed on the door of patients in need of contact precautions. Staff H stated there used to be signs on the door and a hanging isolation unit containing the appropriate personnel protective equipment. Staff T, who was cleaning the room during the observation period, stated there should be a sign.

During observational tours of the hospital on 12/11/12, and 12/12/12, four patient rooms were identified by hospital staff as having patients in isolation. The surveyor checked the rooms of the patients who had been identified to require contact precautions. The four (patients #13, #14, #15, and 16) patients' room doors lacked the required precautionary signage.

These rooms were again checked on 12/13/12 at 10:00AM and the identified rooms continued to lack the precautionary signage.

Review of the medical records of Patient #13, Patient #14, Patient #15, and Patient #16 was completed on 12/13/12 and revealed the following;

Patient #13 was diagnosed with C-Difficile,

Patient #14 with VRE ( Vancomycin Resistant Staphylococcus Aureus,

Patient #15 with MDR (multi--resistant organisms and e-coli and

Patient #16 with C-Difficile.

These infections are associated with an increased length of stay and mortality in healthcare settings. The prevention and control of these infections is a national priority.

The policy and procedure entitled, "Contact Precautions " (#IC.1630), was reviewed on 12/13/12 and revealed, "Utilize the hanging isolation units containing appropriate PPE". The policy continued, "place the contact precautions sign under the patient's room number identification outside of the patient's room".

During interviews of nursing staff regarding their patients on 12/11/12 at 10:26 AM on the 1 East Unit, two staff members were observed dragging soiled linen through the hall and then the staff member was observed putting linen in the linen room. Dirty linen was observed on the floor in room E 108. Linen was noted on the floor in room AE 06.

On 12/11/12 at 11:00 AM, during direct observations in the therapy room, staff F was observed providing speech therapy to patient #10. Staff F touched patient #10 and then went over and was touching patient #12. Staff F then continued working with patient #10 using an I Pad. Staff F gloved his/her hands without washing his/her hands and wiped off the I Pad after use. Staff F then ungloved and threw the wash cloth, used to wash off the table and the I pad, in the dirty linen hamper. Still staff F did not wash his/her hands. Staff F patted the patient on the back and continued down the hall.

The hospital's policy entitled, "Hand Hygiene (#IC.1560) was reviewed and revealed, "Responsibility of all hospital staff is to wash hands after touching patient surroundings, between contact with different patients, and after removing gloves.

The above infection control breaches were verified by staff B on 12/13/2012 at 3:50 PM and again with the administrative staff at the exit conference.

Based on medical record review, staff interview, and observation of the patient/staff interactions on both floors of the hospital, the hospital failed to ensure each patient received care in a safe setting. This affected one patient (#6); however there is a potential to affect the total patient census of 40.

Findings include:

On 12/12/2012, during direct observation of staff/patient interactions on the A East Unit, during the morning hours, the surveyor heard a nurse call out for help in room AE14. When the surveyor entered the room at the same time as four hospital staff members, it was noted Patient #6 was locked in the bathroom. The nurse stated that the patient had fallen in the bathroom and he/she (the nurse) could not get the door open. None of the four staff members who had responded had a key to the bathroom door.

The physical therapist (one of the four staff members), ran up the hall to see if someone had a key. The physical therapist returned with two (2) keys on a stick. However, the four staff members were unsure how to use the keys or which key to use.

The administrative staff member (Staff B), who had been accompanying the surveyor, took the keys and opened the door. Staff B stated that both keys were the same. When the door was opened (after five minutes had passed), the patient was observed on the floor with his/her pelvic restraint partially attached. The patient was located on the floor, under the sink next to the toilet, and between the sink and the wheelchair, which was pushed up against the door.

The staff members lifted the patient back into the wheelchair and helped the patient to the toilet. Vital signs were taken and the patient denied any pain. The patient stated that he/she was using the bathroom. It was not clear whether the patient was aware of what had happen as the patient had answered yes and no to the same question; Did someone help you into the bathroom?

Patient #6's medical record was reviewed during the afternoon of 12/12/2012, and revealed the patient had an order from the physician dated 12/6/2012 which stated to toilet the patient at 6:00AM, 9:00 AM, 12:00 Noon, 3:00 PM, 6:00 PM, and 9:00 PM.

When the nurse responsible for the patient was interviewed, during the afternoon of 12/12/2012, the nurse stated he/she did not know when the patient got into the bathroom. The patient was to be assisted by 1 or 2 staff members, according to the nursing assessment, as the patient had an unsteady gait. The medical record indicated that the patient was confused and disoriented.


The medical record review for patient #6 was completed on 12/12/2012. The medical record indicated that the patient's was admitted on 11/27/2012 with diagnoses of traumatic brain injury and polytrauma from a motor vehicle crash which had occurred on 10/29/12. When the the patient was medically stable the patient had been transferred from an area hospital to HealthSouth Rehabilitation Hospital for in-patient rehabilitation services.
The patient was observed after the fall to be up in the wheelchair, in the hallway.

Interview of the administrative staff member (Staff B) on 12/12/2012 at 11:00 AM., regarding the incident (fall) revealed the following : That a key to the bathroom is kept at each nurse's station. Staff B was unaware that the four staff that responded did not know that the key was at the nurse's station or how to use the key. The surveyor questioned what happens if the key is misplaced. Staff D stated that a key is also kept in the in his/her office in administration, however on the evening and night shift that key would not be available.

There was no documentation available for review to support that each staff member had been trained in what to do if a patient was locked in the bathroom or where the key to unlock the patients' bathrooms was kept. Nor was there any documentation that security was notified of the Incident.

Staff S (security) was interviewed regarding the locking bathroom doors on 12/12/2012 at 12:00 PM, Staff S stated that each nurse should have a key to open bathroom doors.

When interviewed, on 12/12/2012, Staff S was asked how many patients are cognitively impaired on the A East Unit on 12/12/2012, Staff S reported 17 of the 40 patients currently residing on the unit were cognitively impaired.

The above incident was verified and confirmed by the administrative staff on 12/14/2012 at the exit conference.

Based on direct observations and patient interview, the hospital did not ensure the confidentiality of clinical records and patient information was protected.

Findings include:

During an observation period on the A East Unit on 12/11/2012, at room AE07, patient #11's open record and the nurse's report sheet/notes of other patients was observed on a shelf in the hallway. Staff B, who was accompanying the surveyor, closed up the shelf. The nurse (staff H) called out and said don't mess with my papers. Staff B told the surveyor that the papers were left out because the patient was in isolation. No signage was present on the door to indicate that the patient was isolation.

The above observation was verified by Staff B on 12/11/2012 at 11:40 PM.

Based on medical record review, staff interview, and hospital policy and procedure review, the hospital failed to ensure patients observed with restraints in use during the survey had physician orders for the continued use of the restraints were renewed within 24 hours as required by the hospital's policy. This affected five (Patient #s 6, 7, 8, 9, and 10) of five patients observed in restraints during the survey. The patient census was 40.

Findings include:

Review of the medical record of patient #6 was completed on 12/12/12. The patient had an order for the use of pelvic restraints and a bed enclosure. On 12/2/12 the order for the restraints was not dated. The restraint order, dated 12/4/12, indicated the time the order was written and it was determined the order greater than five hours past 24 hours as required. A physician's order, dated 12/6/12, for the use of the restraint indicated the time the order was written and it was determined to be one hour greater than 24 hours. The physician's order for the restraint dated 12/10/12, also indicated the time of the order and the order was determined to be four and a half hours greater than 24 hours.

Review of the medical record of patient #7 was completed on 12/13/12. The patient had a physician's order for full side rails and a lap buddy. The order dated 12/10/12 indicated the time of the order and it was determined to be four hours greater than 24 hours.

Review of the medical record of patient #8 was completed on 12/13/12. The patient had an order for pelvic restraint and an bed enclosed. The restraint order dated 11/25/12 indicated the time the order was written and it was determined the order was one hour greater than 24 hours. The restraint orders dated 11/26/12 and 11/27/12 had no time indicated. The restraint order dated 11/29/12, did indicate the time the order was given and it was determined the order was three hours greater than 24 hours.
On 11/30/12 there was no order written for the use of the restraints. The restraint order, dated 12/4/12, was determined to be greater than five hours and fifteen minutes than 24 hours. The restraint order, dated 12/7/12, was determined to be five hours greater than 24 hours.

Review of the medical record of patient #9 was completed on 12/13/12. The patient had an order for a pelvic restraint. The order dated 11/29/12, was determined to be five hours over 24 hours. From 11/29/12 thru 12/4/12 there were no orders for the Pelvic restraint usage during that time frame. The next signed order for the pelvic restraint was dated 12/5/12 ( this was verified with staff B on 12/13/12 at 3:00 pm).

The next signed physician order for restraint usage was dated 12/7/12, which was five and a half hours greater than 24 hours. The order dated 12/11/12 was determined to be three hours greater than 24 hours.

Review of the medical record of patient #10 was completed on 12/13/12. The patient had a physician order for the use of a pelvic restraint. The order, dated 11/29/12, indicated the time the order was written and it was determined the order was five and one half hours greater than 24 hours. The order, written on 11/30/12, was not dated by the physician as to when the order was signed. The order dated 12/4/12 was written but was not signed or timed by the physician. The next restraint order was written on 12/5/12 at 11:00 am. The 12/6/12 order was determined to be two hours and 15 minutes greater than 24 hours.

The hospital restraint policy and procedure entitled "Use of Restraints in Non Psychiatric Hospital or Unit" was reviewed on 12/14/12 at 10:00 am. The policy indicated restraints would only be used with a physician's order and renewed within 24 hours. The policy stated the documentation of the monitoring of the restraints will be done and the monitoring of the patients in restraints will be incorporated into the Plan of Care.


These findings were confirmed with the administrative staff on 12/14/12 at 3:09 pm.

Based on record review and staff interview the hospital failed to ensure five (Patients # 6, 7, 8, 9, and 10) of five patients observed with restraints in use during the survey had been assessed for possible discontinuation of the restraint usage. The hospital census was 40

Findings include:

The medical records of five ( #6, #7, #8, #9, #10), of five patients observed during the survey with restraints in place lacked documentation these patients had been assessed for possible discontinuation of the restraints.
All five records were reviewed on 12/13/12 and lacked documentation that indicated the restraints usage was monitored and/or assessed on an ongoing basis for each patient restrained.

Based on medical record review, and staff interview, the hospital failed to ensure staff documented a description of the alternatives or other less restrictive interventions attempted prior to the use of restraints for five (Patients #6, 7, 8 9, and 10) of 5 patients observed to have restrains in use during the survey. The hospital census was 40.

Findings include:

The review of the medical records for patients #6, #7, #8, #9, and #10 was completed on 12/13/12 and revealed these patients were restrained. The patients' medical records lacked documentation of specific alternatives and/or less restrictive interventions the hospital staff had attempted prior to restraining these patients.

Staff B reviewed the medical records of these patients with the surveyor and verified these omissions in the medical records on 12/13/12.

Based on medical record review, and staff interview, the hospital failed to ensure the staff documented the patients' response to the interventions used, including the rational for the continued of of the restraint for the 5 patients restrained. The hospital census was 40.

Findings include:

Patients #6, #7, #8, #9, and 10 medical records were reviewed on 12/13/12 and the medical records indicated that these patients were restrained. The patients medical records were silent to the specific patient's response to any interventions tried and/or the rationale to continue the use of a restraint. There was no care plans developed for these 5 patients restrained.

Staff B reviewed the patients in restraints records with the surveyor and verified the omissions in the records on 12/13/12.