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Based on interview, record review, and facility policy review it was determined the facility failed to ensure an effective process was established for the patient or patient's representative/guardian to make informed decisions regarding medical interventions for one (1) of ten (10) sampled patients (Patient #1). Psychotropic medications (mood altering drugs that affect mental activity, behavior, and/or perception) were ordered and/or altered for Patient #1 without the consent of the patient's representative/guardian.

The findings include:

Review of the facility policy entitled "Psychotropic Medications," revised January 2014, revealed the purpose of the policy was for the protection and promotion of each patient's rights and to provide a procedure for informing patients about psychotropic medications. The policy revealed the patient and or patient representative/guardian had the right to be informed regarding their care in order to make informed decisions regarding their care planning and treatment, including requesting and/or refusing treatment. Further review of the policy revealed patients or patient representatives/guardians must be informed about actions and side effects of psychotropic medications before they could be administered and documentation of consent would be noted within the patient chart. The policy revealed the psychotropic drug consent form would be utilized for documentation and the appropriate medication/education sheet would be provided to the patient or patient's representative/guardian.

A review of Patient #1's medical record revealed the facility admitted Patient #1 on 02/28/14 with a diagnosis of Dementia with Behavioral Disturbances. Further review of the record revealed on 03/03/14, 2 milligrams (mg) of Valium (a benzodiazepine drug used to treat anxiety disorders) were ordered for Patient #1, two times a day (10:00 AM and 10:00 PM); on 03/11/14, the dosage was increased to 5 mg two times a day (10:00 AM and 10:00 PM). There was no evidence Patient #1's representative/guardian was informed about the order for Valium and no evidence consent for treatment was obtained for this medication prior to administering the medication to Patient #1.

Further review of Patient #1's medical record revealed on 03/11/14, 30 mg of Remeron (an antidepressant medication used to treat major depressive disorder) were administered to Patient #1 without consent from the patient's representative/guardian or evidence that the patient's representative/guardian was informed about actions and side effects of the drug. In addition, 100 mg of Seroquel (a short-acting atypical antipsychotic drug approved for the treatment of schizophrenia and bipolar disorder) were administered to Patient #1 on 03/11/12 and 200 mg were administered on 03/12/14 without consent from the patient's representative/guardian or evidence the patient's representative/guardian was informed about the actions and side effects of the medication.

Interview with Clinical Manager #1 on 03/19/14 at 12:30 PM revealed facility staff was required to also notify patients' representatives or guardians of changes in medications/treatments.

However, further review of Patient #1's medical record revealed increases/changes were made in the dosage of psychotropic medications without notifying Patient #1's representative/guardian. On 03/01/14, consent was obtained from Patient #1's representative/guardian to administer Amitriptyline (a tricyclic antidepressant medication used to treat symptoms of depression). Although the dosage was not included on the consent form, staff administered 25 mg of Amitriptyline. However, on 03/06/14 the physician's order for Amitriptyline was changed to 100 mg at 2:00 PM and 150 mg at 10:00 PM; on 03/07/14 the Amitriptyline dosage was increased to 200 mg at 10:00 PM, and the AM dose discontinued; on 03/08/14, the Amitriptyline order was changed to 100 mg at 10:00 PM, and the AM dose discontinued on 03/10/14. There was no evidence Patient #1's representative/guardian was notified of the changes in the dosages of Amitriptyline that had been administered to Patient #1.

On 03/01/14, consent was obtained from Patient #1's representative/guardian to administer Risperdal (an atypical antipsychotic drug that is mainly used to treat schizophrenia). The consent form did not identify the dosage or frequency of the medication; however, a review of Patient #1's physician orders revealed 0.25 mg of Risperdal, two times a day, was ordered for Patient #1. On 03/03/14 the order was increased to 0.5 mg of Risperdal, two times a day (10:00 AM and 10:00 PM); on 03/06/14 the dosage of Risperdal was increased to 1 mg two times a day (10:00 AM and 10:00 PM); on 03/11/14 the order was changed to 0.5 mg of Risperdal, two times a day (10:00 AM and 10:00 PM) and then discontinued at 10:02 PM on 03/11/14. There was no evidence Patient #1's representative/guardian was notified of the changes in the antipsychotic medication.

Interview with Patient #1's representative/guardian on 03/18/14 at 7:30 PM revealed the facility had changed Patient #1's medications and provided medical treatment without obtaining prior consent.

Further interview with Clinical Manager #1 on 03/19/14 at 12:30 PM revealed facility staff was required to notify patients' representatives/guardians of changes in condition or changes in medications/treatment. The interview further revealed the clinical manager was aware that on numerous occasions during Patient #1's course of treatment, facility staff failed to obtain appropriate consent from Patient #1's representative before changes were made in psychotropic medications. Clinical Manager #1 gave no explanation why the consents had not been completed.

Based on interview and record review it was determined the facility failed to ensure a Registered Nurse supervised and/or evaluated the nursing care and implemented interventions identified on a care plan for one (1) of ten (10) sampled patients (Patient #1).

Review of documentation revealed the facility admitted Patient #1 on 02/28/14 with diagnoses that included Dementia with Behavioral Disturbance and Depressed/Anxious Mood. A review of a nursing assessment conducted on the day of Patient #1's admission revealed the patient was continent of bowel and bladder. In addition, the assessment revealed the patient's skin was "within normal limits." Review of documentation revealed staff developed a Nursing Care Plan on 03/01/14 to address the patient's needs and assessed Patient #1 to have the potential for skin breakdown due to "altered tissue depletion." Review of interventions included on the care plan revealed staff was to inspect and document an assessment of the patient's skin upon admission and daily; implement measures to maintain urinary incontinence, e.g., to offer a bedpan, urinal, or assist the patient to the commode every two (2) to three (3) hours; and implement measures to decrease skin irritation resulting from incontinence or diarrhea. A review of a treatment plan dated 03/03/14 revealed Patient #1 had "good mobility." However, nursing staff failed to provide supervision to ensure the interventions identified on the Nursing Care Plan were implemented. Documentation revealed staff failed to assist Patient #1 to the commode every two (2) to three (3) hours to maintain urinary continence and failed to provide assistance with turning, repositioning, and incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown.

In addition, review of facility policy titled "Special Precautions Level II-Impulsive Behavior Precautions" revealed a procedure had been developed for patients who were viewed as a risk for "impulsive acts." According to the procedure, "rounding for a purpose" would be made in the patient's chart every two (2) hours; and staff assigned to monitor were to make an entry on the "Special Precautions, Patient Observation Record every fifteen (15) minutes." In addition, the procedure revealed the RN supervisor was to make an entry in the progress notes every twelve (12) hours. However, nursing staff failed to provide supervision to ensure the patient was monitored every fifteen (15) minutes in accordance with the established procedure. Staff failed to document Patient #1 had been monitored every fifteen (15) minutes in accordance with the procedure between the hours of 1:45 PM and 3:55 PM on 03/12/14.

Continued review of documentation revealed on the evening of 03/11/14 and the morning of 03/12/14 facility staff administered numerous medications to Patient #1 that included antipsychotics, antidepressants, and antianxiety medications. On the morning of 03/12/14, staff crushed the medications and placed the medications in applesauce when administered due to the patient's unresponsive behavior. On 03/12/14, the patient was observed to be unresponsive and at approximately 3:45 PM, the patient vomited brown emesis and was transferred to the Critical Care Unit (CCU). Documentation revealed at the time the patient was admitted to the CCU, staff documented Patient #1 had a Stage II pressure sore to the buttock area.

Refer to A0395 and A0396.

Based on interview and record review it was determined the facility failed to ensure a Registered Nurse (RN) supervised and/or evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #1). Review of documentation and interviews revealed Patient #1 was continent of bowel and bladder, ambulatory, oriented to person and place, and his/her skin was intact at the time of admission. Interviews and documentation revealed on 03/12/14, staff assisted Patient #1 up to a chair in the day area at 9:30 AM and the patient remained in the chair until 3:55 PM and was unresponsive. A review of nurse's notes and documentation on the facility's observation sheets revealed Registered Nurses failed to ensure staff offered the patient fluids; provided assistance to the bathroom; provided assistance with turning and repositioning; or provided incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown. Based on documentation, on 03/12/14 at approximately 3:45 PM, the patient vomited brown stool and coffee ground material on the floor and walls of the Behavioral Unit and was transferred to the CCU. Documentation at the time the resident was admitted to the CCU revealed Patient #1 had a Stage II pressure sore to the buttock area.

The findings include:

Review of facility's policy titled "Hourly Rounding for a Purpose," revised 01/21/14, revealed nursing staff was to conduct "hourly" rounds and address each of the "four P's" (pain, position, potty, and problems) on all patients. Nursing personnel were to specifically address the four P's and document in the medical record that the four P's had been addressed.

Review of facility policy titled "Patient Observation Category: Special Precautions," revised January 2014, revealed the purpose of the policy was to ensure the patient was treated in the least restrictive environment that was clinically permitted and provided a means of monitoring to prevent the patient from harming themselves or others. Procedure II of the policy, "Special Precautions Level II-Impulsive Behavior Precautions" revealed the procedure was designed for patients who were viewed as a risk for "impulsive acts." According to the procedure, "rounding for a purpose will be made in the patient's chart every two (2) hours"; and staff assigned to monitor were to make an entry on the "Special Precautions, Patient Observation Record" every fifteen (15) minutes. In addition, the procedure revealed the RN supervisor was to make an entry in the progress notes every twelve (12) hours.

A review of the medical record revealed the facility admitted Patient #1 on 02/28/14 with diagnoses of Dementia with behavioral disturbances, Adjustment Disorder with depressed/anxious mood, Chronic Obstructive Pulmonary Disease, Diabetes, Anemia, and Hypertension. A review of Patient #1's admission nursing assessment, dated 02/28/14, revealed the patient had no skin breakdown, was continent of bowel and bladder, was ambulatory, and oriented to person and place. Review of the Medication Administration Record (MAR) with the facility pharmacist revealed on the evening of 03/11/14, staff administered medications to Patient #1 that included the following: 0.5 milligrams (mg) of Cogentin (anticholinergic used in the treatment of Parkinson's) at 5:25 PM and 9:13 PM; 0.5 mg of Risperdal (an atypical antipsychotic drug which is mainly used to treat schizophrenia), 10 mg of Namenda (used to treat moderate to severe dementia of the Alzheimer's type), 300 mg of Neurontin (used with other medication to treat seizures and to treat nerve pain), 30 mg of Remeron (an antidepressant medication used to treat major depressive disorders), and 5 mg of Valium (a benzodiazepine drug used to treat anxiety disorders) at 9:59 PM. Continued review revealed on 03/12/14, facility staff administered 0.5 mg of Risperdal at 7:21 AM; and at 9:13 AM, staff administered 10 mg of Namenda, 300 mg of Neurontin, 0.5 mg of Cogentin, 5 mg of Valium, and 100 mg of Seroquel (a short-acting atypical antipsychotic drug for the treatment of schizophrenia and bipolar disease) to Patient #1. In addition, review of the "Hourly Nurse Rounding for a Purpose," sheets revealed on 03/12/14 at 9:30 AM, Patient #1 was assisted up to a chair and placed in the day area, and remained in the chair until 3:55 PM with no documented movement. Further review revealed no documentation the patient was monitored or checked every fifteen (15) minutes between the hours of 1:45 PM and 3:55 PM. On 03/12/14 at approximately 4:00 PM, Patient #1 was transferred to the Critical Care Unit (CCU) after the resident vomited brown emesis, and was determined to have aspiration pneumonia and unresponsiveness. Review of the medical physician's consultation report dated 03/13/14 revealed staff had observed Patient #1 and the patient had "acutely decompensated" and had "projectile and feculent" vomiting that was all over the floor and walls. The physician noted upon the patient's arrival to CCU, Patient #1 was "hypoxic" and "hypotensive," and had two (2) episodes of brown stool and coffee ground material in his vomitus. The nursing assessment for Patient #1 in the CCU conducted on 03/12/14 at 4:42 PM also revealed a Stage II pressure ulcer with deep tissue injury noted to the patient's buttocks.

Interview with Certified Nursing Assistant (CNA) #1 on 03/18/14 at 4:40 PM revealed the CNA had provided care for Patient #1 on 03/12/14. CNA #1 stated she had monitored Patient #1 every 5 minutes, but had not documented past 1:45 PM because the unit was "so busy" and she was the only CNA on the floor. The interview further revealed she and RN #1 woke Patient #1 around 9:00 AM on 03/12/14 and cleaned stool from the patient from a small bowel movement. CNA #1 stated RN #1 crushed up and fed Patient #1 the morning medications because Patient #1 could not swallow them. CNA #1 stated that when they changed Patient #1's adult brief, the patient was noted to have a reddened area on both buttocks, and they placed a "gel cushion" in the patient's chair. CNA #1 stated she could not remember if she offered fluids and/or toileting every two hours to Patient #1 throughout the day. CNA #1 stated she and RN #1 assisted Patient #1 back to bed around 4:00 PM with a "Hoyer Lift" (mechanical lift) because the patient was unable to walk, stand, or pivot independently. CNA #1 stated when they positioned Patient #1 onto his/her side in the bed to place a "lift" under the patient, a "brown liquid" came out of the patient's mouth. According to CNA #1, at that time, RN #1 instructed her to take the patient's vital signs. She stated the patient's vital signs were "not good" and RN #1 requested assistance from the facility's Rapid Response Team.

Interview with RN #1 on 03/18/14 at 3:15 PM and on 03/19/14 at 4:30 PM revealed she was Patient #1's assigned nurse on 03/12/14. RN #1 stated when she began her shift at 7:00 AM on 03/12/14, Patient #1 was still asleep in bed. RN #1 stated between 8:30 AM and 9:00 AM, she and CNA #1 went to the patient's room to assist him/her out of bed and the patient was "sedated" and had been incontinent of stool. RN #1 stated Patient #1 had a red blanchable area on the buttocks with no broken area, and she placed a "gel cushion" in the chair when she transported the patient to the day room. RN #1 stated that she administered the patient's medications the morning of 03/12/14 and had to crush the medications and place them in applesauce because the patient was too sedated to swallow them intact. RN #1 stated staff fed the patient his/her breakfast and he/she ate approximately 50 percent of the meal, but could not recall if staff had offered the patient fluids or toileting every two hours during her shift on 03/12/14. RN #1 stated at approximately 4:00 PM, she and CNA #1 assisted Patient #1 back to the bedroom in the chair and used a mechanical lift to transfer the patient because the patient was unable to assist with the transfer. RN #1 stated that when they positioned Patient #1 to his/her side to position the mechanical lift in place, a brown liquid came out of the patient's mouth. At that time, according to RN #1, she thought the patient was "bleeding out" and instructed CNA #1 to monitor the patient's vital signs. RN #1 stated the patient's "vital signs" were "not good" and she requested assistance from the Rapid Response Team.

Interview with Patient #1's medical physician on 03/18/14 at 4:30 PM revealed facility staff had not informed him of "any issues" and stated he was not aware of the pressure sore to the patient's buttocks prior to the patient's admission to the CCU. According to the physician, the decline in Patient #1's medical condition happened "suddenly."

Interview with the attending Psychiatrist on 03/18/14 at 3:45 PM revealed Patient #1 was admitted to the Behavioral Health Unit from a local nursing home due to inappropriate sexual behavior and aggressiveness. According to the Psychiatrist, the patient's diagnoses included dementia with behavioral disturbances. The Psychiatrist stated he had adjusted the patient's medications to help with the patient's behaviors and difficulty sleeping. The interview further revealed that nursing staff never informed him of any concerns regarding Patient #1 being over sedated or any reported decompensation in the patient's condition. The Psychiatrist stated on 03/12/14, during morning rounds, he observed Patient #1 asleep while sitting in a chair in the common area of the Behavioral Unit. The Psychiatrist stated he touched the patient to awaken him/her and stated he/she mumbled something and went back to sleep. He stated he wasn't surprised by the presentation of the patient because of the medication changes, and stated, "Sometimes I over shoot the medicine; when patients come in walking, I want them to go out walking."

Interview with the Clinical Manager for the Behavioral Health Unit on 03/18/14 at 11:50 AM revealed Patient #1 had been ambulatory, confused, and sexually inappropriate (verbally) upon the patient's admission to the Behavioral Unit on 02/28/14. The interview further revealed the Psychiatrist adjusted Patient #1's medications numerous times due to the patient's sexually inappropriate behaviors. The Clinical Manager stated Patient #1's representative contacted him by telephone on 03/17/14 and voiced a complaint about the care Patient #1 received from staff on the Behavioral Unit and had asked the Clinical Manager how Patient #1 "ended up with poop in [his/her] lungs?" The Clinical Manager stated upon receipt of the complaint, he began an internal investigation, met with the Risk Manager, and also completed an incident report and placed the incident report in the facility's "system" per facility protocol. According to the Clinical Manager and documentation provided, the facility implemented a plan of correction on 03/17/14 that included re-education of facility staff related to monitoring the time a nonambulatory patient remained in a chair, policies on nursing rounds and skin assessments, patient observation categories, hourly rounding for a purpose, and patient rights. The Clinical Manager also stated that after the reported incident on 03/17/14 he began to monitor to ensure patients on the unit were not left in chairs for more than two (2) hours at a time and nurses followed facility protocol to prevent skin breakdown.

Interview with the Risk Manager on 03/20/14 at 1:30 PM revealed that she became aware of the incident when Patient #1 was admitted to the CCU with a Stage II pressure ulcer and she began an internal investigation. The interview further revealed the Clinical Manager informed her of a complaint received from Patient #1's representative/guardian. She stated she reviewed the medical record for Patient #1 and identified concerns with staff's lack of communication, documentation, and that nursing staff had not followed facility protocol regarding skin integrity and monitoring of patients.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement nursing care plans/interventions for one (1) of ten (10) sampled patients (Patient #1). A review of Patient #1's nursing assessment conducted on the day of admission, 02/28/14, revealed the patient was continent of bowel and bladder and the patient's skin was within normal limits with no skin breakdown noted. On 03/01/14, nursing staff developed a care plan and noted the patient had the potential for skin breakdown related to his/her "altered tissue depletion." Review of interventions on the care plan revealed staff was to inspect and document an assessment of the patient's skin upon admission and daily; implement measures to maintain urinary continence, e.g., to offer a bedpan, urinal, or assist the patient to the commode every two (2) to three (3) hours; and implement measures to decrease skin irritation resulting from incontinence or diarrhea. However, review of nursing documentation and interview with nursing staff revealed the facility failed to assist Patient #1 to the commode every two (2) to three (3) hours on 03/12/14 to maintain urinary continence and failed to provide assistance with turning, repositioning, and incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown. In addition, review of facility policy titled "Special Precautions Level II-Impulsive Behavior Precautions" revealed a procedure for staff to monitor patients for impulsive behaviors and to make entries on the "Special Precautions, Patient Observation Record" every fifteen (15) minutes of the observations. The procedure revealed the RN supervisor was to make an entry in the progress notes every twelve (12) hours. However, staff failed to document Patient #1 had been monitored every fifteen (15) minutes in accordance with the procedure between the hours of 1:45 PM and 3:55 PM on 03/12/14.

Continued review of documentation revealed Patient #1 was unresponsive during the day on 03/12/14, vomited, and his/her medical condition declined. Staff transferred the patient to the Critical Care Unit (CCU) at 4:00 PM. Documentation revealed at the time the patient was admitted to the CCU staff implemented emergency measures that included mechanical ventilation of Patient #1. In addition, staff documented Patient #1 had a Stage II pressure sore to the buttock area.

The findings include:

A review of facility policy titled "Nursing Care Plans," revised January 2014, revealed each patient had an individualized plan of care based on his/her needs and problems and initiated by the registered nurse. The plan would be evaluated and revised as indicated by the patient's response.

Review of facility policy titled "Special Precautions Level II-Impulsive Behavior Precautions" revealed a procedure had been developed for patients who were viewed as a risk for "impulsive acts." According to the procedure, "rounding for a purpose" would be made in the patient's chart every two (2) hours; and staff assigned to monitor was to make an entry on the "Special Precautions, Patient Observation Record every fifteen (15) minutes." In addition, the procedure revealed the RN supervisor was to make an entry in the progress notes every twelve (12) hours.

Review of Patient #1's medical record revealed the facility admitted the patient on 02/28/14 with diagnoses of Dementia with behavioral disturbances, Adjustment Disorder with depressed/anxious mood, Chronic Obstructive Pulmonary Disease, Diabetes, Anemia, and Hypertension. A review of Patient #1's admission nursing assessment dated 02/28/14 revealed the patient had no skin breakdown, was continent of bowel and bladder, ambulatory, and oriented to person and place. Further review revealed staff developed a nursing care plan on 03/01/14 and noted the patient had the potential for skin breakdown related to his/her "altered tissue depletion." Interventions on the care plan revealed staff was to inspect and document an assessment of the patient's skin upon admission and daily. In addition, staff was to implement measures to maintain the patient's urinary continence that included offering the patient a bedpan, urinal, or to assist the patient to the commode, every two (2) to three (3) hours; and to implement measures to decrease irritation of the patient's skin that could be the result of incontinence or diarrhea. However, review of nursing documentation and interview with nursing staff revealed the facility failed to implement the interventions identified on the patient's care plan. Staff failed to assist Patient #1 to the commode every two (2) to three (3) hours on 03/12/14 in an effort to maintain the patient's urinary continence, and failed to provide the patient assistance with turning, repositioning, and incontinence care in an effort to prevent the development of pressure sores and/or skin breakdown. In addition, a review of documentation revealed staff failed to document Patient #1 had been monitored every fifteen (15) minutes between the hours of 1:45 PM and 3:55 PM on 03/12/14 in accordance with the facility's established "Special Precautions Level II-Impulsive Behavior Precautions" procedure.

In addition, interviews and documentation revealed Patient #1 was unresponsive during the day on 03/12/14 and at approximately 3:45 PM, the patient vomited brown, coffee ground like material and was transferred to the Critical Care Unit (CCU) at 4:00 PM. Based on documentation, staff implemented emergency measures in the CCU that included mechanical ventilation of Patient #1. In addition, staff documented Patient #1 had a Stage II pressure sore to the buttock area.

Certified Nursing Assistant (CNA) #1 stated in interview conducted on 03/18/14 at 4:40 PM she had provided care for Patient #1 on 03/12/14. CNA #1 stated she had monitored Patient #1 every fifteen (15) minutes on 03/12/14 but failed to document her observations past 1:45 PM because the unit was "so busy" and she was the only CNA on the floor. The CNA also stated that she did not recall if she offered fluids or bathroom to the patient every two hours as required on 03/12/14 as planned.

Registered Nurse (RN) #1 stated in interview on 03/18/14 at 3:15 PM and on 03/19/14 at 4:30 PM that she had been assigned to provide care and supervision of Patient #1 on 03/12/14. RN #1 stated between 8:30 AM and 9:00 AM on 03/12/14, she and CNA #1 assisted Patient #1 out of bed and noted the patient had a red, blanchable area on the buttocks and placed a "gel cushion" in the chair when she transported the patient to the day room. RN #1 stated that she could not recall if staff had offered fluids or had offered to take the patient to the toilet every two hours as identified in the patient's care plan.

Interview with the Clinical Manager for the Behavioral Health Unit on 03/18/14 at 11:50 AM revealed that based on documentation staff had not always implemented the interventions identified on the patient's care plan during the patient's admission to the facility. The Clinical Manager stated there had been a breakdown of communication and documentation and could offer no explanation why staff had failed to ensure Patient #1's care plan was implemented.