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Based on observation, interview and a review of facility documentation, the facility failed to ensure that drugs in the form of pills were prepared in accordance with facility policies.

Findings:

During an observation of the medication cart in the 4 East medication room on 3/20/17 at 3:43 PM, the following was observed in the top drawer: an unlabeled paper cup with two red pills; and three paper cups with two white pills each. During an interview of the Pharmacy Director at the above stated time, she confirmed that this was an improper storage of the medications.

A review of facility policy "Medication Administration" read, "Nurses who prepare medications will administer medications. Pre-pouring of medications is not allowed." Thus, the facility was not in compliance with this policy.

During an interview of the Vice President of Risk Management on 3/21/17 at 2:55 PM, she confirmed the finding.

Based on interview and a review of facility documentation, the facility failed to ensure the adoption of policies which specified that the use of any verbal orders in the facility was to be infrequent.

Findings:

A review of facility documentation did not reveal any evidence of the adoption of policies which specified that the use of any verbal orders was to be infrequent.

During an interview of the Nurse manager on 3/21/17 at 2:25 PM, she confirmed the finding.

Based on interview, record review and review of facility policy, the facility failed to accurately complete 8 of 10 client medical records reviewed for express and informed consent, a mandatory examination required by the physician to determine the clients ability to consent to treatment (#1, 2, 3, 5, 7, 8, 9 & 10).

Findings:

Patient #1, #2, #3, #5, #7, #8, #9 and #10's records contained a preprinted State Baker Act form "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104". The form documented a statement in the first paragraph which read, "I have personally examined____, a person being served at____facility on____, 20__at__ AM PM (Date & Time of admission).

A bordered box at the bottom of the form contained instructional guidance which read, "Form shall be completed within 24 hours of a person's arrival at the receiving facility and filed in the clinical record of each person:
1. Admitted on a voluntary basis 2. Permitted to provide express and informed consent to his/her own treatment
3. Allowed to transfer to voluntary status 4. Prior to permitting a person to consent to his or her own treatment after having been previously found incompetent to consent to treatment."

Additionally, each reviewed certificate form CF-MH 3104 documented a different name of the facility, other then the current hospital name.

The following was observed on the reviewed patient's State Baker Act form entitled "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104":

1. Patient #1's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104 dated by a stamp at the bottom by the physician's stamped name dated 3/03/17, and a stamp placed on the bottom of the form with the patient's name with no admission date. The patient's last name was written in the top paragraph and no admission date in the required area by (Date & Time of admission). The patient was determined to be "Competent to provide express and informed consent...."

2. Patient #2's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104", dated 2/25/17 at 10 AM by the physician showed blank areas in the first paragraph with no completion of information. The patient was determined to be Incompetent to provide express and informed consent...."

3. Patient #3's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104 with no client identification information on the form anywhere and was determined "Competent to provide express and informed consent...." The form was dated 3/05/17 at 8:40 AM by the physician.

4. Patient #5's record showed 2 "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104. The first dated 3/16/17 at 8 am, which showed no date & Time of admission as required and documented the client as Competent to provide express and informed consent...." The second "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" was dated 3/20/17 at 2 PM by the physician. It did not document the client's date & time of admission, and showed the determination as "Incompetent to provide express and informed consent...."

5. Patient #7's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104 which had blank areas in the first paragraph and no completion of information. The client was determined to be Competent to provide express and informed consent....." The form was signed and dated by the physician 3/18/17 at 1 PM on the bottom of the form.

6. Patient #8's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" with a stamp on the first line with the client name and did not document a Date & Time of admission as required. The form documented "Competent to provide express and informed consent...." and was dated 3/06/17 at 6 PM, by the physician.

7. Patient #9's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" with blank areas in the first paragraph and no identifying client data on the form. The patient was determined to be Competent to provide express and informed consent...." A second "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" showed the first paragraph completely blank. The form documented a determination of "Refusing or unable (by virtue of legal hold status to provide and informed consent...." The form was signed by the physician and dated 3/02/17 at 12 PM.

8. Patient #10's record showed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" with blank areas in the first paragraph and no identifying client data or admission date. The form contained a patient sticker with the patient name and was signed by the physician and dated 3/14/17 at 11 AM.

In an interview with the Director of Nursing while reviewing records on 3/20/17 at 4:10 PM, he confirmed there was missing patient identification information on the competency forms.

In an interview with the Vice President of Risk Management on 3/22/17 at 10:30 AM, she related the competency form is usually identified with a patient sticker and sometimes the top is not completed with patient information, however a sticker had the patient name as identifying information.

Based on interview and record review, the facility failed to properly execute an informed consent form for a physician ordered psychotropic medication for 1 of 10 sampled patients (#2).

Findings:

Patient #2's record revealed a "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" which determined the client to be Incompetent to provide express and informed consent to voluntary admission and thus is incompetent to provide express and informed consent to treatment. The person must be transferred to involuntary status and a petition for a guardian advocate filed with the Circuit Court." The certificate was signed by the physician on 2/25/17. There were no additional "Certificate of Person's Competence To provide Express and Informed Consent, CF-MH 3104" found in the record.

A "Consent To Be Guardian Advocate" (GA) form dated 3/06/17 was observed on the record and documented the name of the client's GA which was witnessed by the court liaison.

Review of the physician progress notes dated 3/16/17 at 9:10 AM documented the patient's status as delusional, paranoid diagnosis of CPS (chronic paranoid schizophrenia).

Review of the nurse's progress note dated 3/16/17 at 9:27 PM read, "(Patient's name) is seen on the unit....is delusional and paranoid, disorganized thought process....."

Review of the physician orders dated 3/16/16 at 9 AM read, "D/C (discontinue) Seroquel. Start Seroquel XR 200 milligrams (mg.) PO (by mouth) HS (hour of sleep); D/C Haldol. Start Haldol Decanoate 100 mg. IM (intramuscular) on 3/16/17 Q (every) 2 weeks" for Psychosis.

Review of the patient's "Consent for Psychotropic Medication (Antipsychotics/Neuroleptics)" form revealed a consent dated 3/16/17 for Haldol Decanoate 100 mg. every 2 weeks, IM-3/16/17. The form documented a telephone consent for the medication was obtained by the GA and contained 2 nurse signatures as witnesses. Review of the patient's medication administration record (MAR) revealed Haldol Decanoate was given by the nurse as ordered on 3/16/17.

Review of the patient's "Consent for Psychotropic Medication (Antipsychotics/Neuroleptics") form revealed a consent dated 3/16/17 for Seroquel XR 200 mg. Q HS, PO. The line entitled "Signature of client or Legal Representative" documented an illegible and unrecognizable name on the form.

Review of patient #2's MAR revealed the Seroquel XR 200 mg. PO Q HS was given from 3/16/17 through 3/20/17 as ordered by the physician.

In an interview with the Nurse Manager and the Clinical Manager of Inpatient Social Work on 3/22/17 at 11:50 AM, they related they were unable to decipher the handwritten name on patient #2's Consent for Psychotropic Medication (Antipsychotics/Neuroleptics") form for Seroquel XR 200 mg. Q HS, PO. They also related patient #2 had an appointed GA and the form did not have the patient's GA signature. They also confirmed that the patient's MAR showed she had received the medication as ordered.

In an interview with the Medical Director on 3/22/17 at 12:05 PM, regarding the process for consent signatures for involuntary and voluntary capacity status on Psychotropic medication consent forms, he related if a patient had been determined incompetent to provide express and informed consent, a GA is appointed. He related if a patient was converted to voluntary status, a second competency exam would be completed showing the status of the patient. A second competency examination for patient #2 was not observed in the record.

In a follow-up interview on 3/22/17 at 3:30 PM with the Clinical Manager of Inpatient Social Work and the Nurse Manager, they related they had spoken to the nurse who was on duty and obtained the GA consent for the Haldol Decanoate on 3/16/17, and she was unable to explain who had signed patient #2's Seroquel XR consent form and it was not the patient's signature. They further related the nurse verbalized she did not complete the consent for the Seroquel XR on 3/16/17 and it was omitted.

Based on interview and a review of facility documentation, the facility failed to ensure the adoption of professional standards for Pharmaceutical Services which incorporated standards or recommendations by a nationally recognized professional organization.

Findings:

A review of facility documentation did not uncover any evidence that Pharmaceutical Services had adopted professional standards which incorporated standards or recommendations by a nationally recognized professional organization.

During an interview of the Pharmacy Director on 3/21/17 at approximately 11:06 AM, she confirmed the finding.

Based on observation, interview and a review of facility documentation, the facility failed to ensure that the expectations for specimen container expiration dates as stated in the description of services were followed.

Findings:

1. During a tour of the 3 West Laboratory room on 3/20/17 at approximately 4:32 PM, the following expired items were observed: 6 each BD Vacutainers (Buffered Sodium Chloride) collection tubes with expiration dates on their respective labels which read "2016-10." During an interview of the Risk Manager at this time, he confirmed that the storage of these expired items was improper.

2. During a tour of the 3 East Laboratory room on 3/20/17 at approximately 4:45 PM, the following expired items were observed: 3 each BD Vacutainers (culture & sensitivity preservative) collection tubes with expiration dates on their respective labels which read "7/2016." During an interview of the Risk Manager at this time, he confirmed that the storage of these expired items was improper.

A review of facility policy "Specimen Collection and Labeling" read, "On a monthly basis all speciment containers should be checked for expiration dates by the Phlebotamist. All expired tubes must be discarded." Thus, the facility was not in compliance with this policy.

During an interview of the Vice President of Risk Management on 3/21/17 at 3:05 PM, she confirmed the finding.

Based on observation, interview and a review of facility documentation, the facility failed to ensure compliance with recognized dietary practices concerning the integrity of food packaging.

Findings:

During a tour of the kitchen dry food storage area on 3/22/17 at 12:38 PM, a 25 pound paper bag of Italian Style Bread Crumbs was observed flat on a shelf. Further observation revealed that approximately 75% of the top surface of the bag was stained. During an interview of the Food Service Director at this time, he stated that the bag had been soiled by a food oil.

Since the bag had visibly absorbed the oil as reported by the Food Service Director, the integrity of the packaging had been compromised.

During an interview of the Dietician on 3/22/17 at approximately 2:10 PM, she indicated that they follow the "SafeStaff" program as a guide for various dietary practices. A review of the the manual for this program revealed the following: "Protect - all food while being ... stored ... must be protected against contamination." Thus, the facility was not in compliance with this expectation.

During an interview of the Dietician on 3/22/17 at 2:14 PM she confirmed the finding.

Based on observation, interview and a review of facility documentation, the facility failed to ensure the implementation of policies governing control of infections and communicable diseases through the improper storage of food items.

Findings:

During a tour of the 4 East Medication Room on 3/20/17 at 3:39 PM, a cabinet which held patient care items was observed. The contents included the following: insulin syringes, accucheck lancets; surgical masks; germicidal cloths and bandages. Also observed with these items was a previously opened six ounce bottle of "Crystal Hot Sauce". The bottle was half full. During an interview of the Pharmacy Director at this time, she confirmed that this storage of the hot sauce with the other items was improper.

A review of facility policy "Environmental Safety Walk" read, "Storage areas neat...." Thus, the facility was not in compliance with this policy.

During an interview of the Vice President of Risk Management on 3/21/17 at 4:24 PM, she confirmed the finding.

Based on interview and a review of facility documentation, the facility failed to ensure that the infection control officer or officer developed a system for identifying infections and communicable diseases of contract personnel in the dietary services department.

Findings:

A review of facility documentation did not reveal any evidence that the infection control officer or officer developed a system for identifying infections and communicable diseases of contract personnel in the dietary services department.

During an interview of the Vice President of Nursing on 3/22/17 at 11:55 PM, she stated that there were no protocols or policies in place through which any infections or communicable diseases which may arise among contract personnel in the dietary department. She stated that no infections or communicable disease which may have been experienced among contract dietary personnel have been reported to her in her position as the Infection Control officer. She stated that the Dietary Services department is contracted out to MMI Dining Systems and has nine employees.

During an interview of the Vice President of Nursing on 3/22/17 at 1:05 PM she confirmed the finding.