HospitalInspections.org

Based on observation, interview, and record review, the hospital's pharmacy service failed to ensure that outdated drugs were not available for patient use in 1 of 1 drug storage areas.

Findings:

On 2/2/11 at 9:30 AM an inspection of the hospital's drug storage night locker was completed. The night locker served as a storage area for commonly ordered medications that can be accessed when the main pharmacy is not open, and are accessed by a nursing supervisor. The following partial random inspections of the various medications available for patient use were found to be expired:

1. Fluphenazine HCL 5 mg tablets - 3 of 7 tablets with expiration dates of June 2010.

2. Nifedipine 30 mg tablets - 5 of 8 tablets with expiration dates of 7/3/10, 9/23/10, and
11/16/10.

3. Premarin 0.625 mg tablets - 10 of 10 tablets with expiration dates of 3/16/10, 8/31/10, and 9/23/10.

4. Zyprexa 2.5 mg tablets - 1 of 7 tablets with expiration date of 2/10.

5. Penicillin VK 500 mg tablets -2 of 7 tablets with expiration dates of 1/4/11.

6. Paxil 20 mg tablets - 1 of 12 tablets with expiration date of 1/8/11.

7. Bethanechol 25 mg tablets - 9 of 11 tablets with expiration dates of 3/2/10, 6/3/10, 11/14/10, and 1/5/11.

8. Nicotine Transdermal Patch 7 mg - 1 patch with expiration date of 9/2010.

9. Catapres TTS -3 Transdermal Patch - 1 patch with expiration date of 1/11.

The medication storage inspection was done in the presence of RN E, and confirmed the dates of the medications to be consistent with the manufacturer ' s expiration dates.

Pharmacist 1 was interviewed on 2/2/11 at 1:10 PM related to the expired medications in the night locker storage area, and presented 3 months of records (November/December 2010/January 2011) that provided documentation of the medication area inspection for the unit that housed the night locker. Pharmacist 1 stated that the pharmacy technician was responsible for the inspection of the medication area on a monthly basis, and the checklist report was cosigned by the nursing unit supervisor and the pharmacist on duty for the day the report was generated. The reports titled MEDICATION AREA INSPECTION REPORT had 29 line listed items for inspection, but failed to include the night locker medication storage area.

The review of the pharmacy policy(s) titled Medication Management - Storage - Expiration and Beyond Use Dates (# 09-03) was reviewed during the survey. The availability of the expired medications was not consistent with the pharmacy policy. The pharmacy policy titled Medication Management - Storage - Inspections: Medication Areas (#09-06) does not address the night locker storage area in the description of areas to inspect.

Based on interview and record review, the facility leadership in infection control failed to demonstrate effective training related to the cleaning of the blood glucometers used in the facility. This resulted in two of three licensed nursing staff, sampled from two different nursing units, failed to demonstrate verbally current knowledge/practice related to the cleaning of blood glucometers.

Findings:

On 2/2/11 at 10:30 AM, an inspection of the medication room adjacent to the senior unit was conducted. Two licensed nurse were queried regarding the cleaning of the blood glucometer found in the medication room. Both RN D and RN W responded that the cleaning of the blood glucometer was done by wiping the blood glucometer with alcohol pads.


The facility policy was requested and reviewed on the same day. The document was undated and titled Cleaning Procedures Glucometers. The procedure required the glucometers to be cleaned first soap and water to remove any gross debris and then with a "EPA - registered detergent/germicide with a tuberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10." [ Centers for Disease Control for glucometer cleaning recommendations and American Journal of Infection Control 2010: 38]


Additionally, the facility procedure documented that "Alcohol is also not an EPA-registered detergent/disinfectant."


The use of alcohol as specified in the interviews with RN's D and W were not consistent with the cleaning procedures provided in the facility document.

Based on record reviews and staff interviews, it was determined that the Master Treatment Plans failed to identify physician interventions for 7 of 9 active sample patients (A1, A6, B1, C1, C5, D6 and E4). (Refer to B122), and the names of physicians, social work staff, or activity therapy staff responsible for the listed interventions for 5 of 9/sample patients (B1, C5, D1, D6 and E4). (Refer to B123). In addition, the treatment plans were developed by nurses before all assessments were completed and without collaboration of the multidisciplinary team. These failed practices result in inadequate written treatment plans and the necessity for staff to rely on oral communication for determining the treatment focus for each patient.

Findings include:

A. Record Review: (See B122 and B123)

B. Staff Interviews:

1. In an interview on 2/22/2011 at 9:15AM, RN#6 told the surveyor, who had asked about the process of setting up interventions for the various disciplines involved in patient care, that the forms (Master Treatment Plans) were done by the nursing staff before the actual meeting of the treatment team.

2. On 2/23/2011 at 9AM, RN#2 stated that the night shift nursing staff chooses the problems and goals for the treatment plans.

Based on record reviews and staff interviews, it was determined that for 7 of 9 active sample patients (A1, A6, B1, C1, C5, D6 and E4), there were no psychiatrist interventions on the Master Treatment Plans. This failure results in a lack of information about the psychiatrist's focus of treatment and the modalities to be utilized.

Findings include:

A. Record Review

1. Patient A1. The Master Treatment Plan dated 2/2/2011 had no interventions by the psychiatrist.

2. Patient A6. The Master Treatment Plan dated 2/15/2011 had no interventions by the psychiatrist.

3. Patient B1. The Master Treatment Plan dated 1/28/2011 had no interventions by the psychiatrist.

4. Patient C1. The Master Treatment Plan dated 1/29/2011 had no interventions by the psychiatrist.

5. Patient C5. The Master Treatment Plan dated 2/2/2011 had no interventions by the psychiatrist.

6. Patient D6. The Master Treatment Plan dated 2/18/2011 had no interventions by the psychiatrist.

7. Patient E4. The Master Treatment Plan dated 2/10/2011 had no interventions by the psychiatrist.

B. Staff Interviews

1. On 2/22/2011 at 1:45PM, the Master Treatment Plan for Patient B1 was reviewed with RN#5. She agreed that there were no specific interventions by the psychiatrist for any of the six problems identified for the patient.

2. On 2/22/2011 at 2:15PM, the Master Treatment Plan for Patient C5 was reviewed with RN#2. She agreed that none of the seven problems identified for this patient had interventions by the psychiatrist.

3. On 2/22/2011 at 3:50PM, the Director of Quality Improvement was asked to review the Master Treatment Plan for Patients A1 and A6. After reviewing the plan for A1, he stated, "I don't see anything in here that shows interventions by the psychiatrist." After reviewing the plan for Patient A6, he said "I see the same thing; no interventions by the doctor."

Based on record reviews and staff interviews, it was determined that for 5 of 9 active sample patients (B1, C5, D1, D6 and E4), the preprinted Master Treatment Plans and Treatment Plan updates were missing names of the physician, social services staff, or the activity therapy staff for the listed interventions. This failure results in lack of staff accountability to ensure that interventions are carried out or to document the patient's response to the treatment modalities.

Findings include:

A. Record Review:

1. Patient B1. The "Multidisciplinary Treatment Plan Update" dated 2/19/2011 had only a nurse's signature and the patient's signature.

2. Patient C5. The "Multidisciplinary Treatment Plan Update" dated 2/20/2011 lacked a physician's signature.

3. Patient D1. The "Interdisciplinary Treatment Plan" dated 2/22/2011 had only a nurse's signature.

4. Patient D6. The "Interdisciplinary Treatment Plan" dated 2/18/2011 did not have a physician's signature. The "Multidisciplinary Treatment Plan Update" dated 2/20/2011 had only a nurse and an activity staff member's signatures.

5. Patient E4. The "Multidisciplinary Treatment Plan Update" dated 2/21/2011 had only a nurse's signature.

B. Staff Interviews

1. On 2/23/2011 at 10:55AM, the Director of Clinical Services was interviewed. She explained that when either the preprinted "Multidisciplinary Treatment Plan" and/or the "Interdisciplinary Treatment Plan Update" state, for example "SS" (i.e. Social Services staff) or "RN" (i.e. Registered Nurse) to address identified problems, the person who signed the form is considered the responsible staff person to monitor whether the interventions are being done.

2. On 2/23/2011 at 12:30PM, the Director of Clinical Services was shown several of the sample patient's treatment plans. She acknowledged the absence of staff names and signatures for patients C5, D1 and D6.

Based on record review, document review and staff interviews, the facility failed to follow proper restraint procedures for 2 of 9 active sample patients (A1 and A2). Patient A1 was restrained by staff to have blood drawn for lab tests, and the one hour face-to-face assessment was completed by an unqualified RN. Patient A2 had two seclusion events. There were no documentations of the 1 hour physician assessments, progress or treatment notes, or nurse supervision/monitoring of the patient. The treatment plan for Patient A2 also was not updated for either seclusion event. These failed practices result in lack of active therapeutic efforts to ensure the patient's safety and protection while in seclusion/restraint. They also violate patients' rights to safe treatment in the least restrictive manner possible.

Findings include:

A. Specific patient findings

1. Patient A1

a. Patient A1 was restrained on 1/26/11 at 9:10a.m. A description of the restraint event stated, "Restrained at doctors request to have lab values drawn today." The documentation stated that the patient was not cooperative with the blood draw. The documentation for the episode of restraint for patient A1 included a face-to-face assessment of the patient by RN# 8, who according to the Director of Nursing, was not trained to do seclusion/restraint assessments.

b. Review of Policy #200.41.01, "Seclusion/Restraint of Patient," dated 07/09 revealed that the policy did not contain any information about holds (manual restraint) to have lab tests done. The facility also had no policy describing the qualifications for RNs conducting face to face assessments of patients in restraint or seclusion.

c. In an interview on 2/23/11 at 12p.m., the Clinical Services Director stated "There are only 2 RNs--our DON and the Supervisor who could conduct the one hour face to face assessment of a patient in restraints or seclusion; they get 5150 training." The 5051 was the policy on legal holds, not the one hour face-to-face assessments for patients in seclusion/restraint.

d. In an interview on 2/23/11 at 12:10p.m., when asked about the policy regarding the face-to face assessments, the Director of Nursing stated, "We do not have a policy for that." When the DON was asked about his own seclusion/restraint training, he replied, "I'm sure I was (trained); I've got lots of experience and training. I don't remember what it was, and I don't have any documentation. We don't have anything formal for the training."

In the same interview (2/23/11 at 12:10p.m.), the Director of Nursing stated that the nurse who documented the one-hour face-to-face assessment for patient A1 was not trained to do the assessments. The DON stated, "She should not have done it; she's new."

2. Patient A2

a. Patient A2 was secluded twice on 2/18/11 -- (3:50 p.m.- 4:30p.m.); (7:30p.m. to 8:30p.m.). The medical record did not include any documentations of a physician one hour face-to-face assessment or any progress notes regarding the patient's seclusion episodes. The medical record for patient A2 also did not include a treatment plan update for either seclusion event.

b. The facility policy # 200.41.12, "Seclusion/Restraint of Patient," dated 07/09, specifies the following: "Following an episode of seclusion or restraint, the treating physician should document his/her evaluation of the patient and the impact of the intervention on the patient in terms of the patient's psychosocial functioning and personal psychology."

c. The facility policy #200.41.12, "Seclusion/Restraint of Patient," dated 07/09, specifies, "A Treatment Plan for Seclusion and/or Restraint should be completed for all episodes of seclusion and/or restraint.

d. In an interview on 2/22/11 at 4:20p.m., the Health Information Director stated, "It's not done; unfortunately it's not there." (referring to the missing documentations for patient A2's seclusion events)

e. In an interview 2/23/11 at 8:50a.m., the Director of Nursing (DON) stated, "There is nothing there..." (referring to the missing documentations for patient A2's seclusion events)

f. In an interview with the DON on 2/23/11 at 12:10 p.m., when asked about the needed updates for patient A2's treatment plan, the DON stated "It should be done; perhaps it's somewhere else in the chart." After reviewing the patient's record, the DON stated, "There is none."

Based on record reviews, document and policy review, and staff interviews, it was determined that the Medical Director failed to provide adequate monitoring and oversight of medical care for patients. Specifically, the Medical Director failed to:

I. Assure that Master Treatment Plans were developed by the multidisciplinary team after assessments were completed. This failed practice results in lack of comprehensive treatment plans for patients. (Refer to B118)

II. Assure that for 7 of 9 active sample patients (A1, A6, B1, C1, C5, D6 and E4), there were specific physician interventions on the Master Treatment Plans. This failure results in a lack of information about the focus of treatment and the modalities to be utilized. (Refer to B122)

III. Assure that for 5 of 9 active sample patients (B1, C5, D1, D6 and E4), the preprinted Master Treatment Plans and Treatment Plan updates included the names of the physician, social services staff, or the activity therapy staff responsible for the listed interventions. This failure results in lack of staff accountability to ensure that interventions are carried out or to document the patient's response to the various treatment modalities. (Refer to B123)

IV. Assure that all required seclusion/restraint interventions and documentations were provided for 2 of 9 active sample patients (A1 and A2). A1 was placed in a hold for a lab draw, and the one hour face-to-face assessment was completed by an unqualified RN. Patient A2 had 2 seclusion events, and there was no documentation of the one hour face-to-face physician assessment, progress or treatment notes, or nurse monitoring of the patient for either event. These deficient practices potentially result in harm for patients who are put in seclusion/restraint, and it violates patients' rights to safe treatment in the least restrictive manner possible. (Refer to B125)

Based on record review and staff interview, the Director of Nursing failed to assure that proper seclusion/restraint procedures were followed to ensure safe, consistent nursing practice for restrictive behavior management for 2 of 9 active sample patients (A1 and A2). Patient A1 was restrained for a lab test blood draw, and the 1 hour face-to-face assessment was completed by an unqualified RN. Patient A2 was placed in seclusion two times without documentation of the one hour face-to-face assessment, patient monitoring, or revisions/updates of the treatment plan. These failed practices result in lack of patients' protection and safety while in seclusion or restraints, and they violate patients' rights to treatment in the least possible restrictive manner.

Findings include:

A. Patient A1

1. On 1/26/11, patient A1 was restrained. A description of the restraint event stated, "Restrained at doctors request to have lab values drawn today." The documentation for the episode of restraint for patient A1 included a face-to-face assessment of the patient by RN# 8, who according to the Director of Nursing, was not trained to do seclusion/restraint assessments.

2. Review of Policy #200.41.01, "Seclusion/Restraint of Patient," dated 07/09 revealed that the policy did not contain any information about holds (manual restraint) to have lab tests done.

3. The facility policy # 200.41.12, "Seclusion/Restraint of Patient," dated 07/09, specifies the following: "Following an episode of seclusion or restraint, the treating physician should document his/her evaluation of the patient and the impact of the intervention on the patient in terms of the patient's psychosocial functioning and personal psychology." The facility had no policy describing the qualifications for RNs conducting face to face assessments of patients in restraint or seclusion.

4. In an interview on 2/23/11 at 12p.m., the Clinical Services Director stated "There are only 2 RNs--our DON and the Supervisor who could conduct the one hour face to face assessment of a patient in restraints or seclusion; they get 5150 training" The 5150 was the policy for legal holds, not the one hour face-to-face assessments for seclusion/restraint.

5. In an interview on 2/23/11 at 12:10p.m., when asked about the policy regarding the face-to face assessments, the Director of Nursing stated, "We do not have a policy for that." When the DON was asked about his own seclusion/restraint training, he replied, "I'm sure I was (trained); I've got lots of experience and training. I don't remember what it was, and I don't have any documentation. We don't have anything formal for the training."

In the same interview (2/23/11 at 12:10p.m.), the Director of Nursing stated that the nurse who documented the one-hour face-to-face assessment for patient A1 was not trained to do the assessments. The DON stated, "She should not have done it; she's new."

B. Patient A2

1. Patient A2 was secluded twice on 2/18/11 - (3:50p.m. to 4:30p.m.); (7:30p.m. to 8:35p.m.). The medical record did not include any documentations of a one hour face-to-face assessment or any nursing notes regarding the patient's seclusion episodes. The medical record for patient A2 also did not include a treatment plan update for either seclusion event.

2. The facility policy #200.41.12, "Seclusion/Restraint of Patient," dated 07/09, specifies, "A Treatment Plan for Seclusion and/or Restraint should be completed for all episodes of seclusion and/or restraint."

3. In an interview on 2/22/11 at 4:20p.m., the Health Information Director stated, "It's not done; unfortunately it's not there." (referring to the missing documentations for patient A2's seclusion events)

4. In an interview 2/23/11 at 8:50a.m., the Director of Nursing (DON) stated, "There is nothing there..." (referring to the missing documentations for patient A2's seclusion events)

5. In an interview with the DON on 2/23/11 at 12:10p.m., when asked about the treatment plan updates needed after patient A2's seclusion events, the DON stated "It should be done; perhaps it's somewhere else in the chart." After reviewing the patient's record, the DON stated, "There is none" (referring to the needed treatment plan updates).

Based on record review and patient and staff interviews, the facility failed to provide adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care required for patients. This resulted in sample patient C1 not receiving needed education regarding seizures (as specified in the treatment plan), and patient A2 being placed in seclusion without adequate monitoring (or documentation of monitoring). Insufficient nursing staffing can result in potential safety issues and inability to provide needed care to meet individual patient needs.

Findings include:

A. Patient C1

1. Patient C-1 had sustained a seizure on 2/10/11. The Master Treatment Plan identified goal #1 as "Patient will verbalize understanding of medical recommendations," and goal #2 "patient will verbalize understanding of seizure process and ongoing treatment for seizures." These goals had a target date of 2/17/11. The intervention identified as a nursing responsibility was to "assess patient's condition and response to treatment via V/S checks seizure actions and patient's knowledge of disease process/medication."

2. During a Chemical Dependency Group held on 2/22/11 at 11a.m., the patient asked the group leader to explain "what seizures are, what type (of seizures) I have and what can happen to me in the future, will I have more?"

B. Patient A2

1. On 2/18/11, patient A2 was placed in seclusion. A review of the Clinical Indicators for Nursing Care Requirements, attached to policy #100.28.01 "Patient Classification/Nursing Care Hours Report," date reviewed 12/08, specifies that seclusion or restraint is categorized as a "Level IV: Intensive Care." A review of the medical record showed no documentations of staff monitoring of the patient during the seclusion. Documentation on the staffing "Acuity Report Form" for the Youth Unit where patient A2 was housed, for the pm shift on 2/18/11 failed to identify any patient at a Level IV; therefore the staff failed to identify the higher acuity needs of the unit when there was at least one patient in seclusion.

2. In an interview on 2/23/11 at 8:50a.m., the Director of Nursing acknowledged that the staffing needs reported on the "Patient Classification/Nursing Care Hours Report" did not reflect the level of staffing required for the acuity level of the patients. The "Acuity Report Form" for the Youth Unit, for the pm shift on 2/18/11 did not identify any patient at a Level IV.

C. Additional staff interviews

1. In an interview with RN #2 on 2/23/11 at 9a.m. regarding staffing for the 2/22/11 day shift for the 20 bed unit where she worked, RN #2 stated, "I had 20 patients. I had 1 other nurse with me, I also had a new RN orientee, and I was precepting a student; it was pretty hectic." A record review of the "Acuity Report Form" for the day shift on 2/22/11 for unit ASU 1 where this RN was working included 3 patients at a Level I, 7 patients at a Level II and 10 patients at a Level III. According to the policy #100.28.01 "Patient Classification/Nursing Care Hours Report," date reviewed 12/08, there should have been 4.55 staff; the unit was understaffed with 4 staff members.

2. In an interview on 2/23/11 at 9:20a.m., RN #3 stated, "Noc [night] shift only has 1 RN and 1MHW. We had 4 new admissions on that shift; we had to borrow nurses from the other units; we do not bring in additional nurses." The "Acuity Report Form" for the night shift referred to by RN #3 for the SCP Unit (Gero-Psychiatric) was not completed at all, failing to follow policy #100.28.01 "Patient Classification/Nursing Care Hours Report," and policy #100.24.01 "Assignment of Care" date reviewed 12/08. This failure hinders the staff in accurately determining the needs of the patients on the unit in order to make assignments of staff who are qualified to provide safe care.

3. In an interview on 2/23/11 at 9:40a.m., RN #4 stated, "I have 18 patients. I am responsible for patients on the PICU (Psychiatric Intensive Care Unit). I need to use my brain sheet (patient roster where nursing staff jot down notes during the day) to stay on top of them. When asked to describe the nursing care for patient D-1 on her unit, RN #4 replied, "I need to check his picture. I'm not sure who he is. I think he's in for detox, but I really shouldn't say anything because I'm not sure of who he is." When asked to describe the nursing care for patient D-6 on her unit, RN #4 replied, "I think he has major depression, so we want to get him to groups, I hope I'm not mixing him up with ____(different patients, I need my brain (sheet)., I have a lot of patients."

4. In an interview with the DON on 2/23/11 at 8:50a.m. regarding staffing, in response to a discussion about concern about the number of patients that each nurse is responsible for he stated, "I am too" referring to the number of patients for which each nurse is responsible.