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SAMARITAN HOSPITAL-ST MARY'S CAMPUS
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0169
Based on medical record review and interview, it was determined the facility did not ensure that there was an individualized physician order for the use of restraints.
Findings:
Review of 4 of 4 medical records from the Intensive Care Unit (ICU) revealed they did not contain the required physician order for the use of restraints.
Interview on 11/17/10 with Nursing Administration revealed that in the ICU, standing are used for the use of restraints on intubated patients.
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on medical record review and interview the facility failed to ensure that medical record entries are dated and timed.
Findings:
9 out of 29 medical records reviewed revealed that doctors' orders and progress notes were not dated and timed.
This was confirmed with the AVP of Quality/Risk Management and Patient Safety on 11/17/10 at 1300 hours.
MAINTENANCE OF PHYSICAL PLANT
Tag No.: A0701
Based on observation and interview with the Facilities Director during the tour of the facility on 11/15/10, houskeeping staff failed to ensure that the floors of the staff bathrooms on the 5th and 6th floor were maintained in a clean condition.
Based on observation and interview with the Food Service Director and Facilities Director during a tour of the facility kitchen, the facility failed to ensure that the kitchen was maintained in a manner that the safety and well-being of patients is assured.
Specifically:
On 11/17/10 at 10:45 am the following was noted in the kitchen:
1.) A light shield in one of the walk-in refrigerators was broken.
2.) The vacuum breaker at the 3 compartment sink appeared not to be functioning properly in that it was leaking.
3.) The cutting board at the cafeteria line was deeply scored and uncleanable.
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observation during a tour of the facility with the Facilities Director, the facility failed to ensure that adequate infection control practices were maintained. Specifically:
On 11/15/10 at 11:00am, the 5th and 6th floor soiled utility room handwashing sinks were found to have equipment stored in them, rendering them unusable for staff to wash their hands after handling soiled equipment and/or linens.