HospitalInspections.org

Based on review of medical records, incident reports, policies and procedures and interview with staff, it was determined the facility failed to:

1. Document care provided and problems/altercations involving consumers and staff.

2. Investigate incidents resulting in potential harm and discharge of a consumer with law enforcement.

This had the potential to affect all staff and consumers served by this facility.

Findings include:

Policy # RC 1.4
Subject: Medical Record Content/ Documentation

Policy: All documentation for each individual shall be assembled and located in one central record,unique to that consumer thereby constituting a unit record. Documentation within the consumer record shall be maintained in the standardized format and arranged in the standardized sequence.

The consumer record includes continuous documentation of the consumer's physical and emotional health status, beginning at admission as described on the Biopsychosocial and continuing throughout the treatment at AltaPointe Health Systems, through progress notes and finally at the time of discharge on the discharge summary.

A progress note is written by the service provider immediately after delivery of each direct service, but no later than 10 AM the day following services. In programs with electronic medical records, the documentation is completed immediately after services are rendered. Services provided are related to the individualized treatment plan and noted in the progress note. The progress note will contain the following:
Date
Amount of time
Setting/location
Signature to include credentials or job title
Description of services/interventions provided
Consumer's response to services/interventions.

Information of an unusual nature such as treatment complications, accidents or injuries to the consumer...will be included in the consumer record using the ... progress note as appropriate.

Policy # HS 1.1/ PI 1.9
Subject: Incident Reporting

Policy: AltaPointe Health Systems, Inc. provides a method of documentation and tracking Incidents, Accidents, or Events that occur during the organization's business

Procedure:

1. When an incident happens or is identified, the staff member who has first hand knowledge of the event, or who has discovered the incident or occurrence shall notify his/her program coordinator and complete a Confidential Incident Report within 24 hours.

4. If a consumer is involved relevant information should be documented in the medical record.

6. If a staff member is injured, this must be reported immediately to a Human Resources Department staff member who will provide guidance regarding further steps to be taken.

10. Incident Reports are written objectively and include only essential information.

11. Details, not commentary, trace the steps that led up to the event, including who, what, when, where, why and how. Facts are aligned in chronological order. Full names, dates, times and all other pertinent facts are required.

13. The Performance Improvement Department will be responsible for ensuring that a Root Cause analysis is completed as appropriate to determine the causes of the incident and to develop a risk reduction strategy.

Medical Record (MR) findings;

1. MR # 1 was admitted to the facility 4/17/13 with diagnoses of Schizoaffective Disorder Bipolar Type, Polysubstance Dependence and Antisocial Personality Disorder.

The Nursing Progress Note dated 4/23/13 at 8:00 PM, documented, "Walking around on unit loud and aggressive communication with peers and staff. Observed consumer talking loud, shouting and cursing at person on the phone, aggressive gestures toward person on the phone...consumer asked for medication from RN (Registered Nurse)...took medication by mouth without difficulty..."

The Nursing Progress Note dated 4/23/13 at 9:00 PM, documented, "Consumer crying, requested Benadryl and Desyrel for agitation and sleep aid, consumer refused offer to talk with RN..."

The Nursing Progress Note dated 4/24/13 at 6:40 AM, documented, " Slept 6 hours through the night. Consumer pacing in the halls, singing loudly, and cursing. Aggressive gestures toward staff. Consumer demanding Benadryl 50 mg (milligrams) by mouth for agitation. Consumer coming up to nurse station threatening staff...will continue to follow plan of care."

The Nursing Progress Note dated 4/24/13 at 9:00 AM, documented, " Patient making various threats on how he is going to kill this writer and other staff members. Pt (patient) was assessed and upon assessment he stated for this writer to go away...was then confrontational while this writer was assessing another consumer. Pt is currently pacing the halls and coming up to the nursing station pulling up his shirt sleeves showing his arms and saying ' I don't need a weapon, I'll break your neck write that down. I'll get you when I get out of here.' Will give pt PRN (as needed) Haldol and Benadryl. When offered pt these medications he said ' they ain't gonna slow me down, they ain't gonna do nothin."

The Nursing Progress Note dated 4/24/13 at 3:15 PM, documented, " Pt strangled a RN. Was put in restraints. Pt was then escorted to seclusion room after given Haldol 5 mg IM (intramuscular) and Benadryl 50 mg IM. Pt was threatening staff with verbal and violent. Pt d/ced(discharged) to Daphne Police department."

There was an order for seclusion dated 4/24/13 to start at 1:40 PM and stop at 5:39 PM. At the time of the survey 10/3/13 at 10:30 AM, the facility was unable to locate any seclusion paperwork related to the placement of the patient in seclusion. There was no documentation of how long the patient was in seclusion or when the patient was transferred to the Daphne Police department.

An incident report completed 4/24/13 at 12:45 PM, documented," Attempting to get consumer to go to his room to give injection due to shouting and cussing and acting out. Consumer lunged at me and wrapped hands around my throat and begin choking me. Security were able to break hold on my neck and secure him on floor so injection could be given."

The report was completed by the RN involved and witnessed by two staff from security. The nurse was examined at 12:46 PM and law enforcement was notified at 1:00 PM. There was no documentation of any investigation into the incident. The form was signed off by the nurse coordinator on 4/24/13.

The only two entries documented by the RN on 4/24/13 were made at 9:00 AM and 3:15 PM. There was no documentation of the escalating of the consumer, no interventions or treatments provided, no documentation of the consumer's response to the injection, the seclusion or the transfer to the Daphne Police department.

In an interview with EI (Employee Identifier) # 1, Director of Nursing, on 10/3/13 at 9:35 AM, she confirmed the facility was unable to locate the seclusion and restraint packet but were continuing to look for it in medical records. EI # 1 explained the reason there was no documentation of the incident in the medical record was, "Documentation requirements on first of shift and prior to end of shift was the requirement."

Based on medical record (MR) reviews, review of policy and procedures and interviews, it was determined the nurse failed to:

1. Document wound care as provided.

2. Follow their own policy for wound assessment and documentation on 1 of 1 consumers with wounds.


This affected medical record # 3 had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: # TX: 3.3.7
Subject: Wound Management and Dressing Changes

Policy: Medical staff including physicians, CRNP (certified registered nurse practitioner), PA (physician assistant) and nursing staff assess consumer's skin integrity as indicated. Consumers requiring extensive treatment for wounds will be referred for treatment to an agency specializing in wound care.

Assessment and documentation of a wound include but is not limited to the following information:
Location of wound
Length/width/depth of wound
Wound base (pink, red, yellow, black or green)
Exudate (serous, bloody, purulent)
Odor
Sensation and pain.

Dressing changes are done for the following reasons:
To protect wound from mechanical injury
To splint or immobilize a wound
To absorb drainage or fluid wastes
To prevent contamination from bodily discharges or outside environment
To provide physical as well as psychological comfort
To inhibit or kill organisms when using dressings that contain antiseptic medicine.

Wound Care Interventions:
1. Each consumer will be assessed for skin integrity at the time of admission.
2. A plan of care will be initiated as indicated.
3. Referrals will be made to appropriate facilities for wound care protocol.
4. The medical staff will address and manage underlying cause of wounds.
5. The medical staff will promote and adhere to infection control practices/isolation protocol if necessary.

Dressing Change Protocol:
1. Removal of old dressing ( always follow Standard Precaution procedure).
e. While dressing is off, note any changes in the wound and any unusual discharge or color change. Notify Medical Staff of any changes in the wound.
2. Putting on New Dressing
d. Dressing tape must include nurse's initials, date and time of dressing change.

Medical record findings:

1. MR # 3 was admitted 9/18/13 to the facility with a diagnosis of Schizophrenia.

On admission the consumer had a wound to right lower leg. The wound was not assessed on admission as the patient refused to allow the nurse to unwrap the dressing 9/18/13.

The physician ordered 9/18/13 to clean wound with normal saline and apply nonadherent dressing daily.

The physician ordered 9/19/13 to continue to do dressing changes daily as ordered if consumer refuses or takes dressing off or picks at wound and to please document accordingly.

The nurse documented on the electronic medication administration record (eMAR) the following wound care:
Clean wound with normal saline and apply nonadherent dressing daily-9/19/13.

There was no documented assessment, measurement or description of the wound or drainage on 9/19/13.

The physician ordered 9/20/13 medical consult leg wound.

The physician ordered 9/20/13 please clean with normal saline if needed and then cover with Telfa and Coban. Can do daily when convenient.

The nurse documented on the electronic medication administration record (eMAR) the following wound care:
Please clean with normal saline if needed and then cover with Telfa and Coban- 9/20/13, 9/21/13, 9/22/13, 9/23/13, 9/24/13, 9/26/13 and 9/27/13.

There was no documented assessment, measurement or description of the wound or drainage on 9/22/13 and 9/23/13 on the nurses progress note.

The nurses progress note dated 9/24/13 documented the wound base was pink and drainage noted to be bloody but scant. There was no measurement of the wound.

The nurses progress note dated 9/25/13 documented wound noted to be nickel size, wound base yellow with small amount of serosanguineous drainage. The eMAR failed to document wound care was completed on 9/25/13.

The nurses progress note dated 9/26/13 documented wound noted to be nickel size with a scant amount of serosanguineous drainage.

The physician ordered 9/27/13 to please make an appt (appointment) with wound care at MIMC (Mobile Infirmary Medical Center).

The physician ordered 9/27/13 to please have wound care nurse see patient for recommendations until wound care appt can be made.

On 9/27/13 at 4:00 PM the consumer was assessed by the PT (physical therapist) for wounds right lower leg. "Telfa removed with minimal yellow drainage, appears chronic and over scar tissue. Recommend daily saline wet to dry with 2 x 2 gauze secured with Coban. Small fluid filled raised area proximal to this wound with skin intact but erythema wound periphery. Discussed with CRNP appt with wound center recommended."

The nurses progress note dated 9/27/13, at 8:00 PM," Dime sized fluid filled area present on right lower leg, just above bandaged wound on lower right leg."

The nurse documented on the electronic medication administration record (eMAR) the following wound care:
Please clean with normal saline if needed and then cover with Telfa and Coban- 9/28/13, 9/29/13 and 9/30/13.

The nurses progress note dated 9/28/13 documented the dressing was intact to right lower extremity with raised fluid filled area above dressing approximately dime size with surrounding tissue red.

The nurses progress note dated 9/29/13 documented right lower leg dressing clean and intact with dime size, fluid filled pustule.

There was no documented assessment, measurement or description of the wound or drainage on 9/28/13 and 9/29/13 on the nurses progress note.

In an interview 10/3/13 at 10:05 AM with Employee Identifier # 1, the Director of Nursing, she confirmed the nurses failed to follow the wound care policy and the documentation was incomplete.