HospitalInspections.org

Based on medical record review, hospital policy review, hospital quality data review, and administrative staff review, the hospital failed to ensure physician orders for non-violent restraints were reordered per hospital policy for 3 of 3 patient's receiving restraint interventions for safety (#4, 7, and 8).

Findings include:

Hospital policy review on 07/29/2015 revealed "Restraints for Non-Violent or Non-Self Destructive Behavior" approved 05/2015 which stated ". . . 3. Orders for nonviolent or non-self-destructive behavior must specify a defined length of time but may not exceed 7 consecutive days. Orders must be entered into the computer. 4. The physician progress notes must include the need for restraint. . . "

Review of the hospital's "Medical Record Review Report" for April through June 2015 revealed "Restraint Documentation" "Renewal of order q [every] 7 days" was 33.3 percent. Continued review revealed 12 records were reviewed.

1. Open record review for Patient #4 revealed a hospital admission on 07/09/2015 for anoxic encephalopathy (brain swelling as a result from lack of oxygen) and pancreatitis. Review of the physician's progress notes revealed the patient required all four bedside rails to be up while in bed, due to the patient's forgetfullness to call for assistance to get out of bed. Continued review revealed the patient also required a reverse seatbelt while sitting in a chair for the same reason. Review of physician's orders for 07/09/2015 through 07/29/2015 revealed an order for non-violent restraint bed side-rails up times four while the patient was in bed unattended. The non-violent restraint orders were dated 07/10/2015 and 07/21/2015 (due 07/17/2015). Continued review revealed no physician's order for use of the reverse seatbelt. Review of nursing progress notes for 07/09/2015 through 07/29/2015 revealed documentation, per hospital policy, of use of non-violent restraints every shift.

Observation and interview with Patient #4 on 07/29/2015 at 0900 revealed the patient was out of bed in a chair with reverse seatbelt intact. The interview revealed "Sometimes I forget to use the call bell."

Interview on 07/29/2015 at 1210 with the Director of Nursing revealed hospital administration was aware of the results of the "Medical Record Review Report" for April through June 2015, however, the leadership team had not addressed the findings as of the end of the survey on 07/30/2015.

2. Open record review for Patient #7 revealed a hospital admission on 07/17/2015 for debility following abdominal pain from an unknown cause. Review of physician's progress notes for 07/27/2015 revealed documentation stating Patient #7 had a continued need for side rails up times four when the patient was in bed for patient safety. Review of physician's orders revealed an order for non-violent restraints of four side rails on 07/21/2015. Continued review of physician's orders revealed no 7-day renewal order for non-violent restraints for patient safety. Review of nursing progress notes for 07/17/2015 through 07/29/2015 revealed documentation, per hospital policy, of use of non-violent restraints every shift.

Interview on 07/29/2015 at 1210 with the Director of Nursing revealed hospital administration was aware of the results of the "Medical Record Review Report" for April through June 2015, however, the leadership team had not addressed the findings as of the end of the survey on 07/30/2015.

3. Closed record review for Patient #8 revealed a hospital admission on 06/11/2015 for herpes simplex encephalitis (swelling of the brain due to herpes). The patient was discharged on 07/14/2015. Review of physician's progress notes from 06/11/2015 through 07/14/2015 revealed a need for non-violent restraint of bed side-rails up times four while the patient was in bed for patient safety. Review of physician's orders revealed an order for non-violent restraint of side-rails up times four for patient safety on 06/11/2015, 06/15/2015, 06/30/2015 (8 days late), 07/07/2015 and 07/14/2015.

Interview on 07/29/2015 at 1210 with the Director of Nursing revealed hospital administration was aware of the results of the "Medical Record Review Report" for April through June 2015, however, the leadership team had not addressed the findings as of the end of the survey on 07/30/2015.

Based on review of hospital policy, observation, and administrative staff interviews, the hospital staff failed to ensure a clean and sanitary environment for 2 of 3 rooms observed for cleanliness.

Findings include:

Review of hospital policy, provided by environmental services supervisor (EVS), for daily cleaning of patient rooms revealed a daily sweeping and mopping of each patient room.

Observation of three patient rooms, indicated as being ready for a patient admission, revealed 2 of 3 rooms with visible debris on floors, floors were sticky and appeared soiled with removable stains. 2 of 3 patient rooms had visible high dust above television stand arm and window sills. 1 of 3 rooms had sticky substance on nightstand and drawers

Interview with the EVS supervisor on 07/30/2015 at 1045 revealed the EVS department had an employee opening for a floor scrubber that had not been filled. The interview revealed the floors are to be scrubbed every 90 days using a special machine to deep clean the floors. The interview revealed "it has been awhile since they were scrubbed." The interview revealed the EVS supervisor had contacted a company to send someone to scrub the floors using a machine that deep cleans the floors. The interview revealed the high dust and sticky substance from the night stand should have been removed.

Interview with the director of nursing on 07/29/2015 at 1600 revealed no knowledge of the floors being deep cleaned in the past 90 days.