HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the care of each patient as evidenced by: 1) failure to perform physical assessments of patients after the RN received reports of a physical altercation between peers on 3 separate occasions for 2 of 7 sampled patients (#FF1, #FF5); 2) failure to assess the intake and output (I&O) for 3 of 3 patients reviewed with orders for I&O from a total sample of 7 patients (#FF1, #FF2, #FF3); and 3) failure to perform a complete physical assessment with a complaint by the patient of not feeling well for 1 of 1 patients reviewed with complaints of not feeling well from a total sample of 7 patients (#FF5). Findings:

1) Failure of the RN to perform physical assessments of patients who had been involved in physical altercations with peers:
Patient #FF1
Review of Patient #FF1's "Physician's Admit Orders" revealed she was admitted on 02/23/11 at 1814 (6:14pm) with a provisional diagnosis of psychosis. Review of the "Psychiatric Evaluation" performed by Physician FFS9 on 02/24/11 revealed diagnoses of psychotic disorder, impulse control disorder, oppositional defiant disorder, and a history of traumatic brain injury.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by RN Charge Nurse FFS11 for Patient #FF1 on 02/26/11 at 1400 (2:00pm) revealed "Pt (patient) returned from gym. MHT (mental health tech) reports she was in altercation with pt # FF5. She was hit with the basketball & (and) threw the ball back at peer & hit L (left) side of her face. Pt's then began slapping one another & were separated by MHT. On assessment no injury noted. Medical Director FFS10 notified...".

Review of the "narrative summary" of the "Tech Notes/Observation Sheet" written by MHT FFS12 on 02/26/11, with no documented evidence of the time the note was written, revealed, in part, "Pt observed in the gym at CRH (Crossroads Regional Hospital). Pt was hit in the upper body with a basketball thrown by a peer. Both pt and peer were redirected and separated. Pt and peer began hitting and slapping each other. Pt and peer were separated and taken to the unit. RN was notified...".

Review of the entire medical record revealed no documented evidence that a complete physical assessment had been performed by RN Charge Nurse FFS11 to include Patient # FF1's vital signs, neurological status, and areas of the body assessed for injury.

In a face-to-face interview on 02/28/11 at 4:20pm, DON (director of nursing) FFS2 confirmed there was no documented evidence that RN Charge Nurse FFS11 had performed a complete physical assessment after the altercation with a peer on 02/26/11.

Patient #FF5
Review of Patient #FF5's medical record revealed she was admitted on 02/18/11 at 2025 (8:25pm) with a diagnosis of Intermittent Explosive Disorder. Review of the "Psychiatric Evaluation" performed on 02/19/11 by Physician FFS9 revealed diagnoses of mood disorder and oppositional defiant disorder.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by FFS13 RN on 02/20/11 at 1800 (6:00pm) revealed "Pt hit in face with ball by another pt. States was hurting for a few minutes but not hurting at this time. Will continue to monitor for safety". Further review revealed no documented evidence FFS13 had performed a complete physical assessment to assess for injury. Review of the "Quality/Risk Management Report of Event" completed by FFS13 on 02/20/11 revealed no documented evidence that the incident report had been reviewed by someone in leadership.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by FFS14 LPN (licensed practical nurse) on 02/26/11 at 1400 (2:00pm) revealed "returned to unit tearful holding left side of face. Stated a peer had hit her with basketball. Reported by staff that an altercation involving slapping started shortly afterwards. Returned to unit. Ice pack applied to affected area @ (at) this time". Further review revealed no documented evidence FFS14 had reported the injury to the RN in charge and that a RN had performed a complete physical assessment.

In a face-to-face interview on 02/28/11 at 4:20pm, FFS2 DON confirmed a complete physical assessment of Patient #FF5 had not been performed by a RN after the physical altercation between peers on 02/20/11 and 02/26/11.

In a face-to-face interview on 02/28/11 at 4:55pm, FFS2 DON confirmed the incident report had no evidence that it had been reviewed by leadership.

In a face to face interview on 02/28/11 at 4:00pm S1 Administrator indicated the assessment policy needed revisions to include physical assessment and had not been approved as yet by the Medical Executive Committee. Further S1 added that the meeting was scheduled for 7:00pm tonight (02/28/11).

In a face-to-face interview on 03/01/11 at 10:50am, FFS1 Administrator indicated he and FFS2 DON were responsible for reviewing the incident reports at the operational meeting that was held each morning. He could offer no explanation for the incident report from the altercation between peers on 02/20/11 not having been reviewed by himself or FFS2.

Review of the hospital policy titled "Reporting and Analysis of Events", revised 11/09/10, revealed, in part, "...In order to accurately document information relative to possible variations in patient care or untoward events, a Risk Management/Quality management Confidential Report of Event is to be completed. ...Reports on all unusual events/occurrences involving patients will be reviewed and investigated by the Charge Nurse and Director of Nursing/designee. The Risk management/Quality Management Confidential Report of Event Forms are to be dated and timed by the persons completing the form. ... Procedure: ... D. The appropriate department manager or Director of Nursing should review the QM/RM (quality manager/risk manager) Report of Event. If the event occurs after hours or on weekends or holidays the Charge Nurse should complete the review. E. The QM/RM Report of Event form will be forwarded to the office of the Quality/Risk Management Coordinator within 24 hours of the occurrence or event (Reports from patient care units may be placed in the designated QM/RM box on the unit). Reports completed on weekends and holidays will be picked up by QM/RM staff on the next business day. ...All QM/RM forms involving patients will be forwarded to the Quality/Risk Management Coordinator and the original report or a copy will be forwarded to the Director of Nursing by a Risk Management staff member, for review and documentation of corrective action plan as indicated ...".

2) Failure to assess the I&O of patients as ordered by the physician:
Patient #FF1
Review of Patient #FF1's "Physician's Admit Orders" revealed she was admitted on 02/23/11 at 1814 (6:14pm) with a provisional diagnosis of psychosis. Review of the "Psychiatric Evaluation" performed by Physician FFS9 on 02/24/11 revealed diagnoses of psychotic disorder, impulse control disorder, oppositional defiant disorder, and a history of traumatic brain injury.

Review of Patient #FF1's "Physician's Orders" revealed an order on 02/24/11 at 0955 (9:55am) for nursing to monitor intake and output and help with ADL (activities of daily living) skills. Further review revealed an order on 02/28/11 at 10:20am to discontinue I&Os.

Review of the "Daily Intake/Output Record" revealed the following:
02/24/11 - 7am to 3pm shift: 120 cc (cubic centimeters) juice, 360 cc juice, 360 cc juice, 240 cc ensure; no documented evidence of the total intake for the shift and no documented evidence of output;
02/24/11 - 3pm to 11pm shift: no documented evidence of intake or output;
02/24/11 - 11pm to 7am shift: no documented evidence of intake; 100 cc output;
02/25/11 - 7am to 3pm shift: no documented evidence of totals for intake and output;
02/25/11 - 3pm to 11pm shift: no documented evidence of any recorded intake and output;
02/25/11 - 11pm to 7am shift: no documented evidence of any recorded intake and output;
02/26/11 - 7am to 3pm shift: no documented evidence of totals for intake and output;
02/26/11 - 3pm to 11pm shift: no documented evidence of any recorded output;
02/26/11 - 11pm to 7am: 120 water (no means of measurement documented), unmeasured at 6:20am; voided x (times) 1 at 6:15am "(not measured)";
02/27/11 - 7am to 3pm shift: no documented evidence of totals for intake and output;
02/27/11 - 3pm to 11pm shift: no documented evidence of totals for intake and output;
02/27/11 - 11pm to 7am shift: no measured voiding at 6:00am;
02/28/11 - 7am to 3pm shift: no documented evidence of intake or output from 7:00am to 10:20am when order was given to discontinue I&Os.
Further review revealed no documented evidence the totals of the intake per shift and/or per 24-hour period had been calculated.

Patient #FF2
Review of the medical record for Patient #FF2 revealed a 17 year old female admitted to the Child/Adolescent Unit of the hospital via Physician's Emergency Certificate on 02/14/11 for psychotic disorder with bizarre behavior.

Review of the Physician's Orders for Patient #FF2 dated/timed 02/19/11 at 0800 (8:00am) revealed an order for, "Strict I&Os (Intake and Output) and chart".

Review of the "Daily Intake/Output Record" dated 02/19/11 through 02/27/11 revealed no documented evidence the totals of the intake or output per shift and/or per 24-hour period had been calculated.

Review of the "Interdisciplinary Progress Notes" (utilized by the nursing staff for assessment and documentation of the patient) dated 02/19/11 through 02/27/11 revealed no documented evidence the intake and output for Patient #FF2 had been assessed and charted as ordered by the physician.

Patient #FF3
Review of the medical record for Patient #FF3 revealed a 22 year old female admitted to the Adult Unit of the hospital via Physician's Emergency Certificate on 01/18/11 for psychotic disorder and to rule out Schizophreniform Disorder and Cannabis Disorder.

Review of the Physicians' Orders dated/timed 01/29/11 at 1445 (2:45pm) for Patient #FF3 revealed an order to, "make sure patient is eating well, monitor food and fluid intake" .

Review of the "Daily Intake/Output Record" dated -1/29/11 through 02/27/11 revealed no documented evidence the fluid intake had been monitored for the following dates and shifts: 01/30/11 11p-7a; 02/02/11 11p-7a; 02/05/11 11p-7a; 02/06/11 11p-7a; 02/07/11 11p-7a; 02/08/11 11p-7a; 02/10/11 11p-7a; 02/11/11 11p-7a; 02/12/11 11p-7a; 02/13/11 11p-7a; 02/14/11 11p-7a; 02/15/11 11p-7a; 02/21/11 7a-3p, 3p-11p, and 11p-7a; 02/22/11 11p-7a; 02/23/11 11p-7a; 02/24/11 11p-7a; 02/25/11 11p-7a; 02/26/11 11p-7a; and 02/27/11 11p-7a. Further review revealed no documented evidence the totals of the intake per shift and/or per 24-hour period had been calculated.

In a face-to-face interview on 02/28/11 at 3:10pm, FF1 Administrator, FF2 DON, FF15, Staff Development RN, and FFS16, ADON (assistant director of nursing) could offer no explanation for I&Os not being assessed by the RN as ordered by the physician. FF1 Administrator indicated the hospital did not have an I&O policy prior to the start of this survey.

3) Failure to perform a complete physical assessment with a complaint by the patient of not feeling well:
Review of Patient #FF5's medical record revealed she was admitted on 02/18/11 at 2025 (8:25pm) with a diagnosis of Intermittent Explosive Disorder. Review of the "Psychiatric Evaluation" performed on 02/19/11 by Physician FFS9 revealed diagnoses of mood disorder and oppositional defiant disorder.

Review of the narrative portion of the "Interdisciplinary Progress Note" written by FFS11 RN on 02/21/11 at 1345 (1:45pm) revealed, in part, "HR (heart rate) 112. Pt states "I don't feel good". Call placed to Physician FFS9...". Further review revealed no documented evidence FFS11 performed a complete physical assessment to include blood pressure, respirations, temperature, auscultation of breath sounds, and neurological status.

In a face-to-face interview on 02/28/11 at 4:55pm, FFS2 DON confirmed the assessment of Patient #FF5 by FFS11 did not include all elements of a physical assessment.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 06/03/10 and submitted by Consultant FFS7 as the hospital's current policy for assessment and reassessment, revealed, in part, "...Nursing Reassessment Post admission re-assessment of a patient's physical status will be accomplished by the RN charge nurse in the event of an injury, return form therapeutic assignment (pass), at the time of discharge or any other time physical impairments may be identified by staff...".

In a face to face interview on 02/28/11 at 4:00pm FFS1 Administrator indicated the assessment policy needed revisions to include physical assessment and had not been approved as yet by the Medical Executive Committee. Further FFS1 added that the meeting was scheduled for 7:00pm tonight (02/28/11).

In a face-to-face interview on 03/01/11 at 12:25pm with FFS18 Physician owner and member of the governing body and FFS1 Administrator present, FFS18 confirmed FFS7 former DON/QAPI told him she could not report to FFS3 Consultant, but she (FFS7) could report to FFS1 Administrator. FFS1 indicated at the time he (FFS1) would accept FFS7 reporting directly to him. FFS1 Administrator indicated he was responsible to follow-up on FFS7 to ensure she was implementing the action plan to correct the identified problems with nursing services. FFS1 further indicated he relied on the expectation that FFS7 was doing what she was directed to do, and he did not check to see what was being done. FFS1 Administrator indicated he had no evidence to provide the surveyors that the in-services that were supposed to be held with the nursing staff on January 28, 29, 30, and 31, 2011 had been conducted. FFS1 further could offer no explanation for the continued practice of the failure of the RN to physically assess patients for injury following physical altercations, to assess the intake and output of patients as ordered by the physician, and to assess patients who report a change in condition other than it was his responsibility to follow-up and he didn't do it.



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