Bringing transparency to federal inspections
Tag No.: A0154
Surveyor: Hauke, Christina
Based on medical record review and staff interview, the hospital failed to demonstrate the least restrictive means for restraint when the patient became increasing agitated due to the involuntary admission and failed to document the time of involuntary admission and termination of restraints. This affected one of ten medical records reviewed, (Patient #9). The census at the time of survey was 140.
Findings included;
A medical record review was conducted for Patient #9 on 04/21/10. This patient presented to the emergency department (ED) on 03/24/10 at 6:42 PM for insomnia. The patient was triaged at 6:43 PM and seen by a physician at that same time. According to medical record documentation, the patient's family stated the patient had been acting differently, and has not been able to sleep. The patient stated at he/she needed something to relax and was very jittery, but alert and oriented to person, place, and time at the time of triage.
A psychiatric/social assessment at 6:56 PM by a registered nurse documented Patient #9 was restless and agitated, not abusive, and did not have thoughts of physically harming themselves or have thoughts they were better off dead. The medical record stated at 6:55 PM the patient was agitated, refused to change into a gown, and could not provide a urine sample. At 7:15 PM another nurse took over care for the patient. The patient agreed at that time to get into a gown, stating he/she didn't mean to be uncooperative earlier. At 8:30 PM the record stated the patient requested this nurse to come into the room. The patient was wanting to sign out against medical advice (AMA). This nurse stated that a behavior health nurse was in the department reviewing Patient #9's chart and would be in to see the patient. The patient had his/her gown off and was holding it to their chest. The patient stomped out of the room to the squad chairs at the side of the nurses' station and turned around and began yelling "I want to go home now!" The patient grabbed the nurse by the right upper arm and was told by the nurse to not grab this employee. The patient went back into the ED room and continued yelling "I want to go home and I'll sign out AMA". The ED physician was notified and stated the patient can't go home because the patient told this physician the patient was suicidal. However, the patient did not tell this nurse they were suicidal. The ED physician stated he/she will pink slip (involuntary admission) the patient if need be. (Refer to ED physician's note dated 03/24/10 at 7:10 PM which documented the patient denied having suicidal thoughts since a week ago.)
At 8:39 PM the patient asked the nurse "Can I have my clothes back?" The nurse told the patient "No". The patient asked why, and this nurse told the patient he/she made statements to the physician that he/she wanted to hurt self. This patient denied telling the physician they wanted to hurt themselves, stating they did not want to hurt self. The patient asked the nurse to tell them how the nurse can help them get out of here. The nurse stated the patient needed to see the behavior health nurse first. The patient was okay with this and requested a sandwich. The medical record was silent to whether the patient received a sandwich or food to eat.
There was no additional nursing documentation until 9:47 P.M. This documentation stated a patient care coordinator (staff) came to the nurse and stated "Patient left through the back door and security is on their way". This nurse went out to the waiting room and security had the patient and was bringing him/her back to the room. The nurse had verbal orders for medications which were administered intramuscularly at 9:57 PM (an antipsychotic medication, an anti-anxiety medication, and an antihistamine medication).
The security report dated 03/24/10 at 9:50 PM stated 1A (behavior health unit) pink slipped Patient (#9); attempted to run out of ED. Six additional staff responded, stopped patient from leaving, patient's child and spouse assisted staff in getting the patient from the lobby to ER room 7 where the patient was placed in 4 point soft restraints and medicated. The medical record was silent to the disposition of the 4 point soft restraints after being applied.
A review of the behavior health nurse's report (from unit 1A) documented this employee began an emergency psychiatric assessment: mental status exam on 03/24/10 at 7:39 PM for a total time of 2 hours. This report was silent to a time when this employee actually spoke to the patient, and stated the patient is agitated, trying to bite staff, has not slept for 3 days, and brought in a fake pop gun which was given to security. The patient is currently in restraints. This nurse rated the patient as high risk for suicide and psychiatric risk assessment at which time staff should initiate inpatient hospitalization and suicide precautions. This report lacked a time of when this finding was documented (the patient was not placed in physical restraints until attempted to leave at 9:50 PM).
A dictated note by a psychiatrist was dated 03/25/10 at 6:58 PM and stated a mental health staff member was called to evaluate the patient, who became very labile and agitated and ran the nurse off the first time. This documentation stated staff needed to do a more thorough examination and probably needed to admit the patient. The medical record was silent to what time the mental health nurse communicated their assessment to this psychiatrist.
The ED physician's note dated 03/24/10 at 7:10 PM stated the patient is in an abusive relationship, left spouse 3 days ago, is anxious, has occasional nausea when upset, was feeling suicidal one week ago, and has impulse control problems. At the time of this documentation, the patient was diagnosed with depression and drug abuse. A revised physician's report with addendum dictated 03/24/10 at 7:48 PM and 10:10 PM stated the following: Patient states about a week ago patient felt suicidal and felt at that time he/she had some impulse control problems but was able to actually control the thought of feeling suicidal and no longer feels that way. Patient describes just being very upset. States he/she has a safe place to go and identifies a sibling as somebody who can help them through this difficult time. Patient also identifies his/her child as a strong factor in their desire to live. Emergency department course: The patient appears to be having acute grief reaction, perhaps exacerbated by depression and marijuana abuse. Patient may well be a good candidate for contract for safety and outpatient management. Physician will consult with 1A (behavior health unit) for further evaluation to determine the final disposition.
An addendum by this physician stated (no time listed): The patient was being evaluated by 1A psychiatry. During the course of his/her ED stay, he/she became increasingly combative, manic and showing evidence of acute psychosis. Psychiatry, 1A, has determined that he/she requires inpatient hospitalization. The patient became increasingly combative. He/she started demonstrating destructive behavior and therefore was eminent danger to self and others, was not refractable with verbal redirections and therefore required mechanical followed by chemical restraining. Pink slip was written to restrain him/her for this process. Diagnosis: Suicidal ideation with psychosis.
Although there is documentation of a pink slip (application for emergency admission) written by the ED physician, this documentation was silent to the time the order was given.
Suicide precautions were implemented on 03/24/10 at 8:28 PM per verbal order of the ED physician.
An interview conducted with Staff B (ED nursing manager) on 04/22/10 at 2:35 PM verified the aforementioned concerns regarding Patient #9's medical record being silent to disposition of the 4 point soft restraints, the time of the pink slip was ordered, or of the patient voicing suicidal ideations in the ED.
Tag No.: A1111
Based on medical record review and staff interview, the hospital failed to ensure medications were administered as ordered, failed to provide appropriate discharge instructions and failed to ensure patients were assessed after administration of narcotic pain medications. This affected two of ten medical records reviewed, (Patient #6, and #8). The census at the time of the survey was 140.
Findings included;
The medical record for Patient #6 was reviewed on 4/21/10 and 4/22/10. Patient #6 presented to the Emergency Department on 01/05/10 with complaints of abdominal pain. The medical record revealed the emergency department physician examined the patient then wrote orders for laboratory tests and medications including Phenergan (anti-nausea medication) 25mg. Review of the nursing notes revealed the patient was administered 12.5mg of Phenergan at 8:05 A.M. instead of the ordered dose. The medical record was silent to a change in the order for the medication, or notification to the physician regarding the failure to administer the medication according to the physician's order.
The record also indicated patient #6 was medicated with Dilaudid (narcotic pain medication) at 8:57 P.M. The medical record lacked any documentation regarding the patient's response to this medication prior to his/her discharge at 9:15 P.M. The physician's dictation revealed the discharge plan for the patient was; "He will be discharged home with diet modifications. Call local surgeons as instructed." The discharge note from the nurse stated, "...patient education completed, verbalizes understanding.", with no further details regarding what was included in the patient education. The surveyor requested information regarding the discharge instructions given to the patient, and was provided with a copy of the instructions provided to the patient, as printed from the computerized medical record. These instructions included a phone number for the Physician referral line as well as pre-printed instructions for abdominal pain. The discharge instructions lacked any information regarding the patient's need to call a surgeon or follow any dietary modifications.
A second medical record for Patient #6 was presented. The patient presented to the emergency department on 01/08/10 with the same complaints. The patient was subsequently admitted to the hospital and surgery was performed to remove the patient's gallbladder. The second medical record lacked any information regarding the patient's follow up with a surgeon. The medical record also lacked information regarding the patient's diet at home prior to the second admission to the emergency department.
These findings were reviewed with Employee A and B on 04/22/10 at 4:00 P.M. at the time of exit.
On 04/21/10, a medical record review was conducted for Patient # 8. This patient presented to the emergency department (ED) on 01/05/10 at 3:00 PM with a complaint of abdominal pain. The patient had previously been in the ED for the same complaint on 01/04/10 at which time an ultrasound was done and a diagnosis was made of an ovary cyst. During the ED visit on 01/05/10, the patient was triaged at 2:59 PM. According to the medical record, this patient received an intravenous narcotic pain medication at 3:14 PM. for a pain level of 10 out of 10, and an IV medication for nausea. The medical record was silent to any serial vital signs after the triage vital signs were conducted. The patient was discharged home at 4:52 PM this same date with a pain level of 2 out of 10. An interview was conducted with the ED Manager (Staff B) on 04/21/10 at 4:00 PM verified the lack of vital signs for this patient after triage. This employee stated the facility policy was not followed to obtain vital signs prior to discharge from the ED, especially after the patient was given the IV narcotic.
These findings substantiate complaint OH00053939.