HospitalInspections.org

Based on observation, interview and review of patient hospital policy for "Patient Rights" the hospital failed to ensure a patient's right for privacy by having a door open during a counseling session with the psychiatrist for 1 of 1 random patient. Findings:

Observation on 04/19/10 at 12:30pm revealed S3, MD Psychiatrist visiting with a random patient in the Group Therapy room with the door open to the patients in chairs waiting for their session with the psychiatrist. Other patients were in the dining room for a meal. Staff were also observed outside the group therapy room assisting patients. The surveyor could hear the conversation between the psychiatrist and the patient.

S3, MD was interviewed face to face on 04/19/20 at 12:50pm. S3 indicated the door should have been shut.

Review of the hospital policy RTS-01 entitled "Patient Rights" presented as the hospital's current policy revealed in part, "Individual Client Rights" 6. Each patient's confidentiality, privacy, and security shall be assured and protected within treatment services provided and the environment of care."

Based on observation and interview the hospital failed to ensure the patient's right to receive care in a safe setting was maintained by having bed alarms with a 59 inch cord wrapped around the frame of the bed. This practice had the potential to affect 10 of 10 patients with bed alarms. Findings:

Observation on 04/19/10 at 12:20pm revealed a bed alarm on a patient's bed with the alarm attached to a 59 inch cord wrapped around the lower bed frame. S1 Director of Nurses (DON) verified these alarms were implemented as part of the fall prevention protocol because of the high number of geri-psych admissions with high risk for falls. Further she indicated when patient's are suicidal they have a 1:1 Mental Health Technician observing them and the cords would not be an unsafe issue.

S2, Administrator was interviewed face to face on 04/20/10 at 10:30am. He indicated the census was 10 and all 10 beds had alarms with the cord. Further he indicated the cords were unsafe and this would be corrected.

Based on record review and interview the hospital failed to ensure the Registered Nurse (RN) supervise and evaluate the nursing care of each patient by failing to do ongoing assessments of a patient after a fall (Patient #2) resulting in a delay of 13 hours and 50 minutes before transferring the patient, with a fracture of the right proximal femur, to an acute care hospital for 1 of 1 patients with a fall out of a total sample of 7 patients and failing too establish a policy and procedure for assessing patients after a fall. Findings:

The hospital medical record for Patient #2 was reviewed. Patient #2 was admitted on 03/08/10 and discharged to Hospital A on 03/11/10 at 1820 (6:20pm). Review of the Psychiatric Evaluation with an evaluation date of 03/09/10 revealed, " Impression: Dementia late onset, Alzheimer's type with depressed mood and hallucinations. Review of the "At Risk For Falls (ARF) Score Sheet" revealed a score of 34 (high risk).
Documentation in the Multi-Disciplinary Note revealed in part the following:
03/11/10 0310 (3:10am) "Pt. found sitting on floor in room by MHT (Mental Health Technician). Bed alarm in place on bed but not alarming. Pt. states she fell. Pt confused and disoriented. Pt. assisted back to bed. C/O R leg pain but points to L leg. V/S stable. Bed alarm changed out. Will monitor closely."
03/11/10 0325 (3:25am) "Darvocet N 100 1 PO administered for C/O pain." (location of pain not identified) "Will monitor closely."
03/11/10 0330 (3:30am) Notified (name of S1, DON) and (name of S3, MD Psychiatrist) of pt fall. New order received from (name of S3, MD Psychiatrist for neurochecks. O2 for 24 hours. Pt stable at this time. No change in mental status noted. Will continue to monitor."
03/11/10 0500 (5am) "MHT's assisting pt with ADL's. Pt denies pain at this time. Voices 0 C/O at thi time. Monitoring closely."

Further documentation in the Multi-Disciplinary Note revealed in part:
03/11/10 1700 (5pm) (13 hours 50 minutes after Patient #2's fall) Dr. visit with pt. x-ray stat ordered. pt. con't to denies pain. Staff noted facial grimacing & moaning during transferral to bed from chair. Pt refuse pain meds. staff con't to monitor."
03/11/10 1825( 6:25pm) (14 hours 15 minutes after Patient #2's fall) New order per Dr. to transfer pt to (name of Hospital A) due to result of X-ray. 1755 Dr. notified about X-ray report
1758 DON notified. 18:00 Name of Dr. S4, notified. 1800 call family. 1807, retried family. spoke with Sister Kathleen-notified pt was being transferred to (Name of Hospital A) 1820 (6:60pm) EMS departed to (Name of Hospital A) with pt."

There was no documented evidence in the record of a full range of motion assessment or skin assessment for bruising after Patient #2's fall at 3:10am until 5pm when the physician visited and assessed Patient #2.

Review of the Progress Note for "patient complaint or follow-up" for Patient #2, dated 03/11/10 but not timed by the physician, (multidisciplinary note documentation revealed the Dr. visited with patient on 03/11/10 at 1700 (5pm) revealed in part, "Objective, L hip mildly tender. R hip very tender to palpitation, decreased R leg length." Impression: R/O fx R hip. Plan: R hip x-ray."

Review of the x-ray for Patient #2 dated 03/11/2010 time 5:37pm revealed in part, "Comminuted intertrochanteric fracture involving the proximal right femur."

S1, DON was interviewed face to face on 04/19/10 at 11:30am. S1 reviewed the record for Patient #2 and confirmed there was no documented evidence of a full range of motion assessment or skin assessment for bruising or skin lacerations after the patient's fall. Further she indicated there was no hospital policy for nursing assessment after a patient's fall.

S5, RN was interviewed per telephone on 04/19/10 at 2:45pm. S5 indicated she had done Psychiatric Nursing since 2007 and worked the 7a to 7p shift as needed. S5 indicated she was told by the 7p to 7a shift nurse at the 7am report Patient #2 had fallen during the night shift. Further S5 indicated she had assessed Patient #2 by "touching her and moving her around" (not documented) and when Patient #2 moved she would grimace. S5 indicated this should have been documented. S5 further indicated she could not remember if Patient #2 had bruising.

S6, RN was interviewed per telephone on 04/19/10 at 3pm. S6 indicated she had been employed since 08/2009. She verified she remembered the fall of Patient #2 and had taken vital signs, done range of motion of the hips, (not documented) and checked the skin and head. S6 further indicated the assessment should have been documented in Patient #2's record.

S4, MD Director of Psychiatric Services was interviewed on 04/20/10 at 11:10am. S4 indicated he remembered Patient #2 and she was assessed but was not expressing any pain.

Based on record review and interview the hospital failed to develop a care plan for a patient with a high risk for excessive bleeding, who was taking Coumadin, a blood thinner, for 1 of 1 patients on Coumadin out of a total of 7 sampled patients. (Patient #2) Findings:

The hospital medical record for Patient #2 was reviewed. Patient #2 was admitted on 03/08/10 and discharged to Hospital A on 03/11/10 at 1820 (6:20pm). Review of the Psychiatric Evaluation dated 03/10/10 revealed, "Impression: Dementia late onset, Alzheimer's type with depressed mood and hallucinations. Review of the "At Risk For Falls (ARF) Score Sheet" revealed a score of 34 (high risk). Review of the Physician Order, signed by the nurse and physician, dated 03/08/10 and timed 1500 (3pm) revealed , "15. Coumadin 4mg PO Q day at 5pm." Review of the "Multidisciplinary Integrated Treatment Plan" revealed no documented evidence the patient's risk for excessive bleeding was identified.

S1, Director of Nurses was interviewed face to face on 04/19/10 at 1:30pm. S1 reviewed the record for Patient #2 and confirmed the patient was on Coumadin daily but the risk for excessive bleeding was not identified as a problem and care-planned.

Review of the hospital policy TX-Gen-02 entitled "Treatment Planning/Integrated/Multidisciplinary" date adopted March 2008, revealed in part," Admitting RN: This preliminary plan of care addresses presenting needs. Initiates individualized treatment problem/nursing diagnosis list as identified in the assessment. Nurse Revises and develops nursing and medical components of the treatment plan based on additional findings from patient, assessments, problem, needs strengths and limitations, and physician's orders. Includes all physician orders in the Treatment Plan."

Based on record review (patient records and Medical Staff Rules and Regulations) and interview the hospital failed to ensure 1) all entries entered into the medical record were timed for 3 of 7 sampled patients #1, #2, #4, ) and failed to ensure all entries entered into the medical record were legible for 2 of 7 sampled patients. (#1, #2) Findings:

1) failed to ensure all entries entered into the medical record were timed
Patient #2
Medical record review revealed physician progress notes dated 03/09/10, 03/10/10 and 03/11/10 were not timed.

Patient #4
Medical record review revealed physician progress notes dated 02/26/10, 02/27/10, 02/28/10, 03/04/10 and 03/05/10 were not timed.

Patient #1
Medical record review revealed physician progress notes dated 12/10/09, 12/11/09, 12/15/09, 12/16/09, 12/17/09, 12/23/09, 12/24/09, 2/16/10 and 2/18/10 were not timed.


2) failed to ensure all entries entered into the medical record were legible
Patient #2
Medical record review revealed progress notes dated 03/09/10 and 03/11/10 were not legible.

Patient #1
Medical record review revealed progress notes dated 12/10/10, 12/15/09, 12/16/09, 12/17/09, 12/23/09, 2/14/10, 2/16/10 and 2/18/10 were not legible.

Interview with S4 Director of Psychiatry on 4/13/10 at approximately 12:00 p.m. revealed that all progress notes should be timed and legible.

Review of the "Medical Staff Rules and Regulations" revealed in part, "Medical Records and Orders" 7. All clinical entries and summaries in the patient's medical record shell be accurately dated, timed and authenticated."

Based on observation, interview and review of the alarm and sensor pad instructions the hospital failed to ensure the manufacturing recommendations for use of the Secure alarm system were followed by failing to test the bed alarm each time it was used to ensure it was functioning properly for 1 of 1 patient with a fall who had a bed alarm. (Patient #2) This practice had the potential to affect 10 of 10 patients with bed alarms. Findings:

The hospital record for Patient #2 was reviewed. Documentation in the Multi-Disciplinary Note 03/11/10 at 0310 (3:10am) revealed in part, "Pt. found sitting on floor in room by MHT (Mental Health Technician) Bed alarm in place on bed but not alarming. Pt. states she fell. Pt confused and disoriented. Pt. assisted back to bed. C/O R leg pain but points to L leg. V/S stable. Bed alarm changed out."

The Secure P.A.D.S Bed Sensor alarm instructions were reviewed. Documentation revealed in part, "1. The alarm and sensor pad should be checked prior to each use for proper functioning. The Test/Resent button also functions as a battery tester."

Further review of Patient# 2's record revealed no documented evidence the alarm was tested prior to use.

S1, Director of Nurses was interviewed face to face on 04/19/10 at 11:30am. She indicated she tests the alarms daily but this was not documented.

S6, RN was interviewed per telephone on 04/19/10 at 3pm. S6 indicated she was assigned to Patient #2 the night she fell and had put the alarm on that night. S6 indicated the alarm had been tested prior to Patient #2 going to bed but it was not documented. Further she did not know the exact policy for use of the bed alarm.

S7, Human Resource Director was interviewed face to face on 04/20/10 at 8:50am. S7 indicated she could not find documented evidence of employee training for use of the bed alarm system