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30526

Based on record review and staff interviews, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to failure to follow their policy for safe and supportive observation of patients for 13 of 18 sample patients (ID #1, 3, 7, 8, 24, 25, 26, 27, 30, 31,32,33 & 34) who were not observed according to their prescribed level of observation, and failure to follow their policy for 2 of 2 sample patients (ID's # 7 & 10), who were administered medications via a G-tube at the Zambarano Unit. The hospital also failed to follow their policy for hyperthermia/hypothermia machine for 3 of 3 sample patient's (ID #'s 7, 30 & 32) who had physicians orders for hyper-hypothermia machine.

Findings are as follows:

1. The facility has failed to provide nursing care for patients in accordance with the hospital policy for safe and supportive observation of patients who are to be observed in one of the following categories. "A specific level of observation will be ordered for every patient by the Licensed Independent Practitioner (LIP)". The facility has failed to provide nursing care for each patient in accordance to the LIP's orders for 5-minute close or 30-minute routine observation. The hospital has a system failure relative to implementation of the above policy, by lack of ensuring that the physicians were educated to the new requirements for writing orders on all patients for observation status, and durations for time allowed off the units. The hospital also lacked a system to ensure the new 15-minute check daily flow sheets were being completed, and there was no evidence of follow up by the Supervising RN, when the flow sheets were not completed. (refer to A 395).

2. The hospital has failed to provide nursing care in accordance with the facility policy for medication administration via enteral tubes for two patients who received enteral medications. (refer to A 395).

3. The hospital has failed to provide nursing care in accordance with the facility policy for use of the hyper-hypothermia machine and monitoring patient's temperatures. The hospital lacks a system for monitoring compliance to the above policy relative to how to set the machine, when to take temperatures, when to document temperatures and what was "stable" relative to patient's temperatures. (refer to A 395).

Based on record review and staff interviews, it has been determined that the hospital has failed to provide nursing care for patients in accordance with the hospital policy for "SAFE AND SUPPORTIVE OBSERVATION OF PATIENTS" for 13 of 18 sample patients (Patient's ID #'s 1, 3, 7, 8, 24, 25, 26, 27, 30, 31, 32, 33 & 34) who were not observed according to a prescribed level of observation at the Zambarano Unit and the Regan building.

The facility has also failed to provide nursing care in accordance with the hospital policy for "MEDICATION ADMINISTRATION VIA ENTERAL TUBE" and "ADMINISTERING ENTERAL TUBE FEEDINGS" for 2 of 2 sample patients (Patient ID #'s 7 & 10), who were administered medication via G-tubes at the north campus.

The facility has also failed to provide nursing care in accordance with the hospital policy for "HYPERTHERMIA/HYPOTHERMIA MACHINE, for 3 of 3 patient's ( ID #'s 7, 30 & 32) who had physician's order for the machine for temperature monitoring and maintaining temperature levels.

Findings are as follows:

The hospital policy and procedure for "SAFE AND SUPPORTIVE OBSERVATION OF PATIENTS", revised on 4/2018, states in part:

"I. PURPOSE: To provide a framework for the safe and supportive observation for all patients and those who are at risk to harm to self and others...

II. POLICY:

It is the policy of Eleanor Slater Hospital to provide safe and supportive care and treatment for all patients throughout their hospital stay. Determining appropriate levels of observation is necessary to ensure a safe environment and...

1. Eleanor Slater Hospital (ESH) will provide safe and supportive observation of all patients throughout hospitalization. 2. A specific category/level of observation will be ordered for every patient by the Licensed Independent Practitioner (LIP). The order must state the category/level of observation based on assessment of the patient's physical, psychological, cognitive and behavioral condition. The ordered interval will be written as 1:1 Continuous, 15-minute Close, 5-minute Close or 30-minute Routine...9. Staff will receive orientation and annual training focusing on the responsibilities of observation including patient safety, de-escalation techniques, debriefing, hand off communication and documentation...

V. DEFINITIONS:

Observation Category/levels-Defined as the frequency or observation assigned to a patient determined by a risk assessment.... The purpose of observation is to ensure the safe and sensitive monitoring of the individual's behavior and mental well-being, enabling a rapid response to change while at the same time fostering relationships between staff and the patient being observed...

D. 30-Minute Observation-... This level of observation is specific to all medical patients at Zambarano and Regan 5...

IV. PROCEDURES:

A. PROCEDURES FOR ALL LEVELS OF OBSERVATION;

6. The CNA/MHW (Certified Nursing assistant/Mental Health Worker) psychiatric Tech will document patient observations on the appropriate forms...

D. Routine 30-Minute Observation: ...

2. The CNA will perform 30-minute checks (observations) while the patient is on the unit and will record these on the Routine Observation of All Patients Form; ...

3. If the patient with Routine Observation is off the unit for an activity or procedure, the CNA will record this on the Routine Observation of All Patient Form. The CNA is responsible to ensure that the patient returns to the unit when required. If the patient does not return to the unit within the agreed upon time, the CNA will notify the RN...

5. Patients who have privileges may leave the unit unattended for specified lengths of time, (by LIP order) however their location must be known to staff. (Refer to Off Unit Leave Monitoring Form ESH-217).

6. Patients assigned Routine Observation that are allowed off the unit independently will sign out on the Off-Unit Leave Monitoring Sheet; the patient will initial, and staff will sign the form signature confirming the patient is off the unit.

7. If permitted by LIP order, patients may use the bathroom and shower room independently...


1. Record review for Patient ID #1, during a complaint investigation revealed that s/he is a 59-year-old, who was admitted to the hospital on 6/22/2006. Upon admission the patient had the following diagnoses, Autoimmune Disease, Hepatitis B, Cystic/Bullous disease right upper lobe, anemia, and cognitive development disability.

Review of the record reveals that on 8/21/2019 the patient's physicians' orders dated 8/2/2019 stated "privileges: community supervised; grounds unsupervised."

Review of the hospitals observation policy states "30-minute routine observation- is considered the least restrictive and minimal acceptable level of observation for all patients".
Review of the record for patient ID #1, failed to reveal a 30-minute observation was completed.

Review of the units four-hour check list on 8/21/2019, list Patient ID #1 as being checked at 7:00 AM, 11:00 AM, 3:00 PM LOA, 7:00 PM LOA, 11:00 PM & 3:00 AM checked as being observed, when it is documented in the progress notes that the patient was transferred to the ER at 12:45 PM and did not return to the hospital until 9/3/2019.

Review of a physician note dated 8/21/2019 at 12:35 PM, states in part; "found on floor in shower ... patient had apparently been showering when shower door closed due to electrical interruption". "fall with possible right hip fracture, will refer to acute care hospital ER for assessment."

Review of the nurses note date 8/21/2019 at 1:50 PM states, "found on the floor in shower room. MD called to floor to evaluate, was lying on right side, no bleeding. Patient denies hitting head, small scrape noted on right knee. Patient lifted to wheelchair and transported to bed. When in bed right leg externally rotated ...patient very diaphoretic. Transfer to acute care hospital ER, Lorazepam 0.5 mg x 1 now for anxiety."

Review of the record of the hospital course, reveals that the patient was admitted after a fall and being found down for an unknown duration of time. Patient was found to be in Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) which was further complicated by (ATN) Acute tubular necrosis (death of epithelial cells). The patient's kidney function declined markedly, and urine output was decreased, and nephrology was consulted. S/he was treated with IV fluids and transferred to the ICU. Dialysis was initiated, a Permacath was placed during the admission due to the necessity of outpatient dialysis. The patient remained in the hospital until 9/3/2019 when s/he was discharged back to the Long-Term Care (LTC) hospital.

On 9/4/2019 the patient went for his/her dialysis treatment and was sent back to the hospital from the dialysis unit and admitted for pneumonia. S/he remained hospitalized until 9/10/2019 when s/he returned to the LTC hospital and continues outpatient dialysis three times a week.

During surveyor interview on 9/18/2019 at approximately 11:00 AM with the charge nurse, Staff A, who was on duty on 8/21/2019. She informed the surveyor that on 8/21/2019 patient ID #1, was being seen by the behavioral therapist (Staff B) and he would take the patient out of the building in the morning and walk with him/her on the grounds as part of his/her therapy.
She stated that the hospital generators were being tested on 8/21/2019 and that every time there was an interruption in power that the fire doors automatically close. She stated that the door to the shower room, (room 33) is a fire door, and that the doors were shutting all day.
She stated that the patient eats his/her meals in his/her room and that around lunch time, 11:00- 11:15 AM, they looked for the patient who was not in his/her room, so they overhead paged the patient. When s/he did not return to the unit, they again overhead paged the patient.

A while later they overhead paged Staff B, who also did not return to the unit. One of the CNA's (Staff C) went down to the therapy department and spoke with staff B who stated that he returned the patient to his/her room after his/her walk, gave him/her a bottle of water and set out his/her clothes for him/her to take a shower. He stated that he left the patient at 10:30 AM and s/he was going to take a shower before lunch.
The CNA went back upstairs to the unit and at 12:10 PM opened the door to the shower room (which had shut during the generator testing) and found the patient lying on the floor.

The surveyor asked the nurse Staff A, for evidence that the patient was being observed for 30-minute checks as required by policy, and she was unable to produce evidence that the 30-minute observations were being conducted. The surveyor also asked the nurse for evidence that the patient was signed out or in when s/he was off the unit with the therapist, and she stated that the therapist had not signed the patient out nor had he communicated with the nurse. The nurse acknowledged that the staff did not know when the patient was off the unit with the therapist, or when s/he returned to the unit or entered the shower room.

Review of the patient's physicians ordered dated 8/2/2019 failed to reveal a prescribed observation level of care, or an order stating that the patient can use the bathroom and shower independently which is required by policy.

During surveyor interview with the patient's physician on 9/19/2019 at 10:45 AM, she stated that on the order sheet it states "privileges; and she completes if the patient can be independent or if they need supervision for community and grounds. When the surveyor showed her the policy which was revised and implemented in April 2018, she stated that she was unaware of the policy, requiring minimum 30- minute observation nor was she aware of the requirement for writing an order if the patient could use the bathroom or shower independently.

During surveyor interview with the Director of Quality on 9/18/2019 at approximately 2:30 PM, when asked about the policy on patient observation that was revised and implemented in April 2018, she stated that all staff had been in-serviced on the policy which requires a minimum observation of 30 minutes on all medical patient.

She was unable to explain why Patient ID #1's physician's orders did not contain a level of care for observation, or an order that s/he was allowed to independently use the bathroom and shower.

She was not able to produce evidence that the patient had been observed every 30 minutes, or that the staff was aware of the ware about's of the patient between when Staff B left him at 10:30 AM, until s/he was discovered on the floor of the shower at 12:10 PM.

Additionally, she was unable to explain how the 4-hour check list could have been checked for 7:00 PM and 3:00 AM (8/22/2019) when the patient was still in the acute care hospital.

2. Record review for Patient ID #3 revealed the patient has diagnoses which include but are not limited to Developmental Disability, Behavioral Dyscontrol/ impulsivity/aggressiveness and a history of falls.

Record review lacked an order for a specific category/level of observation by LIP for this patient. There is also no evidence that this patient has been observed at least every 30-minute for safety according to the hospital policy before 8/23/2019.

3. Record review for Patient ID #7 revealed the patient has a G-tube and a Foley catheter. The patient has a physician's order dated 9/11/2019 for 15-minute check when in bed.

Review of the observation sheets revealed no evidence that the 15-minute checks were done between 9:15 PM to 10:45 PM on 9/18/2019.

Additionally, review of the observation sheets revealed the 30-minute check for safety according to the hospital policy were not done on the following days:

- 8/15/2019 between 9:30 AM to 3:15 PM
- 8/16/2019 between 8:45 AM to 3:15 PM
- 8/17/2019 between 9:30 AM and 2:45 PM and 3:15 PM to 5:45 PM
- 8/19/2019 between 10:15 AM to 2:45 PM
- 8/21/2019 between 9:00 AM to 1:45 PM, and 9:00 PM to 11:15 PM,
- 8/22/2019 between 9:45 AM to 1:30 PM
- 9/18/2019 between 10:00 AM to 2:45 PM and between 9:15 PM to 10:45 PM
- 9/20/2019 between 9:15 AM to 2:45 PM

During an interview with the Nurse Manager on 9/20/2019 at 9:30 AM, she revealed the resident has an order for 15 minutes check due to pulling on the G-tube and the Foley catheter. The Nurse Manager could not provide evidence that the patient was observed on the above dates and times according to the physician's and/or hospital policy.

4. Record review for Patient ID #8 revealed a physician's order dated 9/4/2019 for "activity; supervised community/ground privileges, 15-minute checks OOB (out of bed). Review of the observation record for 15-minute checks dated 9/10/2019 for 7:00 AM through 3:15 PM, reveals that it is completed from 7:00 AM through 12:15 PM, and is not completed from 12:15 PM through 3:15 PM. However, the observation sheet is signed off as being completed by the CNA, the RN, and the (SRN) supervising RN.

The surveyor interviewed the SRN, in the presence of the Nurse Manager, on 9/19/2019 at 2:15 PM, about signing off on the observation sheet when it was not completed, and she was unable to explain why she signed off the sheet when it was not completed.

Review of the observation sheet for 9/12/2019 is completed from 7:00 AM through 1:15 PM, where it is noted off unit, the record lacks documentation of the patient returning to the unit and again is signed off by the CNA, RN, and SRN.

Review of the observation sheet for 9/19/2019 is completed from 7:00 AM through 2:00 PM, not completed from 2:00 PM through 3:15 PM, and is signed off by the CNA and RN.
Review of the observation sheet for 9/20/2019 was observed by the surveyor at 9:30 AM at the nurse's station, the record was signed as the 15-minute observation was only completed at 7:30 AM, 7:45 & 8:00 AM. The surveyor showed the observation sheet to the charge nurse at this time and she was unable to explain why it was not completed.

5. Review of the "1st SHIFT ROUTINE OBSERVATION OF ALL UNIT PATIENTS" revealed Patient ID #24 was "out" on 9/23/2019 from 9:00 AM to 9:25 AM, 10:05 AM to 11:25 AM, 11:40 AM to 12:20 PM and 2:05 PM to 3:05 PM.

Record review revealed the order lacked a specific length of time that the patient is allowed off unit unattended.

Additionally, the "Off-Unit Leave Monitoring Sheet" is documented as the patient is off the unit on 9/23/2019 at 2:10 PM, with no return time noted.

6. Review of the "1st SHIFT ROUTINE OBSERVATION OF ALL UNIT PATIENTS" revealed Patient ID #25 was "out" on 9/20/2019 at 10:30 AM.

Record review revealed the order lacks a specifies length of time that the patient is allowed off the unit unattended.

Additionally, there is no evidence that the patient has initialed, and staff signed the Off-Unit Leave Monitoring Sheet signature confirming the "TIME LEFT" or "TIME RETURNED" to the unit.

During the interview with the Nurse Coordinator (Staff D) on 9/24/2019 at approximately 12:00 PM, she revealed the patient usually returns to the unit around 9:00 PM. The Nurse Coordinator acknowledged that they do not have Off-Unit Leave Monitoring sheet.

7. Review of the "OFF UNIT SIGN IN/OUT SHEET" for Patient ID #26 revealed the patient signed out of the unit on 9/20/2019 between 9:33 AM and 9:55 AM, however, review of the "1st SHIFT EVERY 5 MINUTE OBSERVATIONS OF ALL UNIT PATIENTS" revealed
the patient was observed on the unit every 5 minutes during this time.

During an interview with the Nurse Manager on 9/24/2019 at approximately 12:10 PM, she was unable to explain how the five-minute checks were completed when the patient was signed out of the unit.

8. Record review for Patient ID #27 revealed the 5-minute observation sheet dated 9/23/2019 is completed every 5-minutes from 11:05 AM through 3:05 PM, except from 1:35 PM through 2:00 PM where it is circled. Review of the 9/23/2019 unit sign out sheet reveals that the patient signed off the unit at 2:20 PM and the time returned is not completed, however the 5-minute checks are completed through 3:05 PM.

During an interview with the nurse manager on 9/24/2019 at approximately 12:10 PM, she was unable to explain how the five-minute checks were completed when the patient was signed out of the unit.

9. Record review for Patient ID #'s 30, 31, 32, 33, & 34 current monthly physicians orders all lacked an order for a specific level of observation.

During a surveyor interview with the Risk Manager on 10/2/2019 at approximately 2:15 PM she was unable to produce evidence of a physician's order for an observation level of care as required by hospital policy.

During a surveyor interview with the Director of Quality on 9/18/2019 at approximately 2:30 PM, when asked about the policy on patient observation that was revised and implemented on April 2018, she stated that all staff had been in-serviced on the policy which requires a minimum observation of 30 minutes on all medical patient.

She was unable to explain why physician's orders did not contain a level of care for observation, or an order that patients were allowed to independently use the bathroom and shower. She was also unable to explain why the flow sheet for 30-minute observation that was attached to the policy dated 4/2018 was not in use on the nursing units.

She was not able to produce evidence that all patients have been observed every 30 minutes, or that the staff is aware when patients are off the units as the sign in and out logs are not completed. Additionally, she was unable to explain how the daily record for 15-minute checks which are to be completed if ordered by a physician are being signed off as completed by the nursing assistant, the charge nurse and the supervising RN, when they are not completed.

She acknowledged that the hospital did not have a system to ensure that the physicians were made aware of the changes in the observation policy that was effective in April 2018 requiring them to write an order for a level of care, orders for the patients to leave the unit with a specific duration documented and orders for patients to use the bathroom and or shower independently. She also acknowledged that by patient's not being signed out of the unit the staff had no system to locate these patients, nor information as to where they were or what time they were expected to return to the unit.

Additionally, she acknowledged the hospital lacked a system to monitor or audit the 15-minute checks were being completed, or that there was any follow up by the charge nurse or Supervising RN who were signing off the sheets that were not completed.

The hospital policy and procedure for "MEDICATION ADMINISTRATION VIA ENTERAL TUBE" revised on 8/2017, states in part,

"GENERAL GUIDELINES: ...
Flush with tap water before and after medications..."

The hospital policy and procedure for "ADMINISTERING ENTERAL TUBE FEEDINGS" revised on 3/10/2017, states in part;

"PROCEDURE: ...
6. Elevate the head of the bed 30-45 degrees unless contraindicated.
Special Consideration:
a. to prevent aspiration; keep the head elevated at all times for continuous feeding. For intermittent feeding keep the head elevated during the feeding and one hour afterward.

MOST COMMON COMPLICATIONS;
1. Clogged tubes: Recommendation/guidelines; ...
b. Flush the tube before and after administering medications"...

1. Record review for Patient ID #7 revealed the patient has a physician's order dated 9/11/2019 for KCL (potassium) 20 mEq (milliequivalent) by mouth or via G-tube (gastrostomy tube), twice daily for low levels of potassium and Miralax 17 grams in 100 cc (cubic centimeter) of water by mouth or via G-tube, twice daily for constipation.

Surveyor observation on 9/20/2019 at 9:05 AM, revealed the head of the bed was not elevated 30-45 degrees but was only elevated to 5-10 degrees.

Additionally, the nurse (Staff F) did not flush the G-tube with tap water before administering the above medications (crushed and mixed with approximately 50 cc of water).

2. Record review for Patient ID #10 revealed the patient has a current physician's order for September 2019 for Tylenol 650 mg via G-tube, three times daily for discomfort.

Surveyor observation on 9/20/2019 at 1:40 PM revealed a unit nurse (Staff E) did not flush the G-tube with tap water before administering the above medication.

During an interview with the Chief Nursing Officer present, on 9/24/2019 at approximately 2:20 PM, the Nurse Educator stated staff should have flushed the G-tubes with water before administering medications. She also stated that the head of the bed should have been elevated at least 30 degrees during the medication administration.

The hospital policy "HYPERTHERMIA/HYPOTHERMIA MACHINE" dated 8/6/77, revised /02, reviewed 3/17, states in part:

POLICY

"1. A physician's order is required for use of the hyper/hypothermia machine. The order should include the date, the purpose of the blanket and set point of the machine and patient temperature for parameters.... 7. Monitor and record the patient's vital signs every 15 minutes until stable and at least every 2 hours while on the machine and until stable when removed or according to physician's orders...8. The nurse will document on the Treatment Record...

PROCEDURE
5. For machine operation, insert the rectal probe and tape in place. The patient's temperature must be monitored every 15 minutes....7. Be sure to turn machine off or switch to monitor mode when desired body temperature is reached...

1. Record review for patient ID #7, reveals a current monthly physicians order dated 9/11/2019 which states' " Warming blanket for T<95 w/ patient set point 96. Daily temp".

Review of the patient's September 2019 Treatment Record, revealed the warming blanket was documented as;

- 11-7 shift the blanket was off from September 1st through the 21st and on from September 22nd through the 30th

- 7-3 shift the blanket was off for 24 days (all days except September 1st, 3rd 17th ,19th ,28th & 29th ) when the blanket is documented as on

- 3-11 shift the blanket was off on September 7th and 8th, and on the other 26 days in September except for September 22nd where there is no documentation noted

Review of the Physiological Data Sheet (vital signs) for September 2019, fails to document the patient's temperature for five of the thirty days; September 8th, 21st, 23rd, 25th and 27th .

Review of the Nurses Flow Sheet for September 8, 2019 on the 7-3 shift, states "Temp 92.4 on warming blanket".

The surveyor interviewed the Nurse Education on 10/2/2019 at approximately 2:00 PM, about the machine and she stated that the machines were purchased in 2013 and have been in use since that time. She was unable to provide evidence that the staff had been in-serviced on use of the new machines, and she was unaware that some of the staff were not using the machine on automatic cooling /heating based on the physician's set temperature order. Additionally, she was unable to provide evidence that she or staff were aware of the policy requiring the patient's temperature to be taken every 15 minutes when on the blanket until stable and at least every 2 hours while on the machine.

2. Record review for patient ID #30, reveals a current monthly physicians order dated 9/11/2019 which states' "Cooling blanket prn temps greater than 99.8 set to 98"..."Vital signs weekly".

Review of the patient's September 2019 Treatment Record, revealed the cooling blanket was documented as;

The blanket was on all three shifts for all days in September, from the 1st through the 29th when the patient was sent to the acute hospital ER for evaluation and treatment.

Review of the Physiological Data Sheet (vital signs) for September 2019, fails to document the patient's temperature for 7 of 29 days; September 11th ,17th, 21st , 24th , 26th , 27th & 28th.

Review of the Nurses Flow Sheets for September 28, 2019 on the 3-11 shift, states "Temp 100.7 R (rectal) cooling blanket on.

Review of the patients Care Plan dated 8/29/2019, list problem as, "a risk for alteration in comfort due to hypo/hyperthalamic thermal deregulation dysfunction due to brain stem injury". Goal; "body temps will be controlled with use of warming/cooling blanket". Approaches; "Maintain cooling blanket for temp >98.8 set point 98 degree, maintain warming blanket for temp <97 set point 98 degree.

During surveyor interview with the staff nurse, (Staff G), on 10/2/2019 at approximately 10:00 AM, she informed the surveyor that the order for the cooling blanket said prn, therefore she did not have it on automatic but had placed it on monitor only. When asked by the surveyor if she had been in-serviced about the use of the blanket for control of the patient's temperature she stated she could not recall.

The surveyor interviewed the charge nurse on the unit on 10/2/2019 at approximately 11:35 AM, who stated that the machines should be set on automatic in accordance with the physician's orders for the patient's temperature. She also informed the surveyor that she was aware that "some of the staff set the machine to monitor only". She was unaware of the hospital's policy relative to monitoring the patient's temperature "every 15 minutes until stable" and every 2 hours while on the machine.

Additionally, she was unaware that the physician's order stated, " vital signs weekly".

3. Record review for patient ID # 32, reveals current monthly physicians' orders which states' " Warming blanket for rectal T<95; set point 99; DC (discontinue) for temp >98 degree." "Vital signs ...monthly".

Review of the patient's September 2019 Treatment Record, revealed the warming blanket was documented as;

- 11-7 shift the blanket was off from the September 1st through the 25th and on from the 26th through the 30th.

- 7-3 shift the blanket was off for 24 days, all days except for September 1st, 3rd, 16th, 19th, 23rd & 29th when it is documented that the blanket was on.

- 3-11 shift the blanket was off on September 15th, 19th, 20th, & 21st and on the 26 other days in September, except on the 22nd where there is no documentation.

Review of the Physiological Data Sheet (vital signs) for September 2019, fails to document the patient's temperature for four of the thirty days, September 21st, 22nd, 23rd and 26th.

Review of the Nurses Flow Sheet for September 22nd, 23rd, 24th, & 25th lack documentation relative to the machine being on or off.

Review of the patient's record fails to identify if the machine is being used on automatic temperature control or if it is being used on monitor only. During interview with the charge nurse, 10/2/2019 at approximately 11:35 AM, she was unable to produce evidence that the machine was being used in accordance with the physician's orders or that the staff were following hospital policy relative to monitoring and documenting the patient's temperatures while on the machine.

During interview with the risk manager on 10/2/2019, at approximately 1:30 PM, she was unable to explain why the patient's temperatures were not recorded every 15 minutes until stable, and at least every 2 hours while on the machine, according to the policy. Additionally, she was unable to explain why some of the staff were setting the "Blanketrol III" machine on automatic, and why some were setting it on monitor only. She was unable to provide evidence that the hospital had a system for monitoring compliance to the above policy relative to how to set the machine, when to take temperatures, when to document temperatures and what was "stable" relative to patient's temperatures.