HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure registered nurses re-evaluated and/or re-assessed the nursing care for 7 of 7 patients (Patient #22, #19, #32, #10, #18, #13, and #15) whose medical conditions were not re-evaluated according to the patients' needs.

1) Patient #22 developed EPS (Extrapyramidal Symptoms) drug induced movement disorder during the inpatient stay. Nursing personnel failed to re-evaluate Patient #22 (minor patient) and document EPS status after being administered emergent Cogentin (medication used to control side-effects of certain psychotropic medications) on 04/06/17 at 1635.

2) Patient #19's blood pressure was elevated on 02/25/17 and 02/26/17 with no re-assessment.

3) Patient #32's hypertensive-crisis-level blood pressure was not re-assessed for three hours and fifteen minutes.

4) Patient #10 was noted on admission to have a medical history that included Hypertension (high blood pressure). The patient had an elevated blood pressure on admission. Patient #10's blood pressure was not re-evaluated by registered nursing staff for twelve hours and 41 minutes following the patient's initial assessment.

5) Although Patient #18 was admitted a pediatric advanced hypertensive stage, the patient's blood pressure was not followed up and re-assessed by nursing staff for 8 hours and 25 minutes.

6) Patient #13's admission medical diagnoses included high blood pressure. Three days into his hospitalization, the patient was noted to have an AHA (American Heart Association) stage 2 elevated blood pressure. The blood pressure was not re-assessed until 24 hours and 14 minutes later.

7) Patient #15 was noted to be hypertensive upon admission. Two days into her hospital stay, the patient's elevated blood pressure was not followed up for fourteen hours.

Findings included:

1) Patient #22's Intake Assessment dated 03/27/17 timed at 1700 reflected, "8 year old...CPS [Child Protective Services]...attention deficit disorder...picked up chair and tried to hit someone with it...trashing home...angers easily..."

Patient #22's physician order dated 04/04/17 timed at 1620 reflected, "Discontinue seroquel...risperdal 0.5 mg [milligrams] po TID [three times a day]...aggression...increase depakote 250 mg po BID [twice daily]..."

The physician order dated 04/06/17 timed at 1635 reflected, "cogentin 2 ml [milliliters] IM [Intramuscular] times one for EPS..."

Patient #22's daily nursing assessment note dated 04/06/17 timed at 1700 reflected, "Patient is irritable and impulsive will continue to redirect...patient went to cafeteria...and had EPS, muscle spasms and stiffness...MD notified...administered medications ordered..."

The MAR (medication administration record) dated 04/06/17 timed at 1635 reflected, "Cogentin 2 ml IM times one administered at 1635..."

The daily nursing assessment notes dated 04/07/17 timed at 0215 through 04/13/17 revealed no further follow-up assessment for Patient #22's EPS prior to discharge. The discharge note dated 04/13/17 timed at 1145 reflected, "Patient is ready for discharge...given all personal items and copies of all discharge documents...being transported to foster home by caseworker..."

The physician discharge orders dated 04/13/17 timed at 0830 reflected, "Cogentin 0.5 mg po BID..."

On 04/21/17 at approximately 1424 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #22's medical record. Personnel #1 verified that the patient's EPS symptoms were not re-assessed from 04/07/17 through 04/13/17, the day of discharge. Personnel #1 verified there was no further documentation regarding an EPS assessment.

2) Patient #19's Nursing Assessment dated 02/21/17 timed at 2130 reflected, "72 year old with unsteady gait...mood disorder...unstable blood pressure...history of two strokes on Christmas...confused, anxiety depression and pain..."

The Vital Signs Report Sheet dated 02/25/17 timed at 1720 reflected, "Blood Pressure 168/87, pulse 57..." The document revealed no further blood pressure check.

The Vital Signs Report Sheet dated 02/26/17 timed at 0838 reflected, "B/P 177/81..." No follow-up and/or re-assessment for Patient #19's elevated B/P was noted.

On 04/20/17 at approximately 1425 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #19's medical record. Personnel #1 verified Patient #19's elevated blood pressure was not reassessed.

3) Patient #32 was observed on 04/21/17 at 1405. The patient was crying and stating she was depressed and had been admitted for drinking.

Patient #32's Physician Pre-Admission Exam and Certification dated 04/04/17 at 1100 reflected Patient #32's chief complaint of Depression and "Detox" [detoxification procedure]. The patient was noted to be drunk on admission. Patient #32 was noted to be depressed and had previously shot herself with a pellet gun. Patient #32's blood pressure was assessed to be 150/98 mmHg.

Patient #32's Inpatient Admission Orders dated 04/04/17 at 1103 ordered Patient #32 to receive a Librium Detoxification Treatment.

Patient #32's Nursing Assessment dated 04/04/17, untimed, reflected the patient's elevated blood pressure of 165/90 mmHg.

Patient #32's Vital Sign Report Sheet dated 04/06/17 at 0845 reflected a blood pressure of 181/110 mmHg. There was no evidence that the crisis stage level blood pressure reading was rechecked until three hours and 15 minutes later, on 04/06/17 at 1200, as documented on Patient #32's Withdrawal Flow Sheet.

Patient #32's Withdrawal Flow Sheet dated 04/06/17 at 1600 and 2000, and dated 04/07/17 at 0000 and 0400 did not reflect any vital signs.

Personnel #1 acknowledged the above findings on 04/21/17 at 1415.

The American Heart Association noted that a systolic blood pressure greater than 160 mmHg to be Stage 2 Hypertension; a blood pressure of 180/110 mmHg was a hypertensive crisis (https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/GettheFactsAboutHighBloodPressure/The-Facts-About-High-Blood-Pressure_UCM_002050_Article.jsp)

4) Patient #10's Nursing Assessment dated 04/11/17 at 1930 noted the patient's blood pressure of 146/80 mmHg. The document identified the patient's medical problems to include Hypertension (high blood pressure).

Record review of Patient #10's nursing documentation dated 04/11/17 did not reflect a follow-up blood pressure assessment.

Patient #10's Vital Sign Report Sheet dated 04/12/17 at 0811 reflected the patient's blood pressure of 142/81 mmHg.

During an interview on 04/20/17 at 1315, Personnel #1 acknowledged that the patient's blood pressure had not been rechecked for more than 12 hours after the initial assessment.

According to the American Heart Association (2016), a systolic blood pressure reading of 140 mmHg or higher was considered Stage 1 Hypertension (high blood pressure) and was noted to cause multiple health threats including Heart Attack, Stroke, Heart Failure, Kidney Damage, and Vision Loss (https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/LearnHowHBPHarmsYourHealth/Health-Threats-From-High-Blood-Pressure_UCM_002051_Article.jsp).


5) Patient #18 (a minor) was observed in his room on 04/20/17 at 1225. The patient stated he was "bored" in his room during quiet time.

Record review of Patient #18's Nursing Assessment dated 04/19/17 at 2315 reflected the patient's blood pressure of 142/79 mmHg.

Record review of the patient's vital signs report sheet dated "04/20[17]" timed at 0740 reflected a blood pressure of 139/88 mmHg.

During an interview on 04/20/17 at 1230, Personnel #26 stated Patient #18's...[family member] had informed staff of Patient #18's elevated blood pressure.

During an interview on 04/20/17 at 1230, Personnel #1 denied that a blood pressure recheck was completed on Patient #18 between the initial assessment on 04/19/17 at 2315 and the routine vital sign check approximately eight hours later on 04/20/17 at 0740.

The National Heart, Lung, and Blood Institute of the National Institute of Health (2004) noted that a blood pressure of 142/79 in children and adolescents was considered Stage 2 Hypertension https://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/hbp-ch.pdf).


6) Patient #13's Psychiatric Evaluation dated 04/15/17 reflected the patient's medical diagnoses included Hypertension and COPD (Chronic Obstructive Pulmonary Disease).

Patient # 13's Vital Signs Report Sheet dated 04/17/17 at 1614 reflected an elevated blood pressure of 165/91 mmHg. Twenty-four hours and 14 minutes later, on 04/18/17 at 1625, the Vital Signs Report Sheet reflected a still elevated follow up blood pressure reading of 142/92 mmHg.

Personnel #1 was interviewed on 04/21/17 at 1135 and agreed that there was no follow-up blood pressure check for Patient #13's (04/17/17) elevated blood pressure assessment.


7) Patient #15's Intake Assessment dated 04/13/17 at 0320 reflected a blood pressure of 144/83 mmHg. The patient's medical problems included Hypertension.

Patient #15's Physician Psychiatric Evaluation dated 04/13/17 at 1130 reflected the medical diagnosis of Hypertension.

The Vital Signs Report Sheet dated 04/15.17 at 1800 reflected the patient had an elevated blood pressure of 161/94 mmHg. The document reflected a still elevated follow-up blood pressure of 143/82 mmHg fourteen hours later, on 04/16/17 at 0800. The patient's blood pressure was not rechecked for another eight hours until 04/16/17 at 1600 and noted to be elevated again at 154/71 mmHg.

Personnel #1 was asked about additional vital sign documentation in Patient #15's chart during an interview on 04/21/17 at 1140. Personnel #1 denied additional vital signs were noted.


Hospital Policy titled "Assessment and Reassessment of Patients" dated 01/10/14 reflected, "A head to toe assessment is performed every 24 hours and more often as needed...routine vital signs are done on day and evening shift unless ordered more frequently...any abnormal findings are reported and verified by the Registered Nurse and documented...more frequents assessments of patients may be needed when the patient is having a physical problem...."

Based on interview and record review the hospital failed to ensure a nursing plan of care was kept current for 1 of 1 patient [Patient #22] who developed EPS [Extrapyramidal Symptoms] drug induced movement disorders during his inpatient stay.

Findings included:

1) Patient #22's Intake Assessment dated 03/27/17 timed at 1700 reflected, "8 year old...CPS [child protective services]...attention deficit disorder...picked up chair and tried to hit someone with it...trashing home...angers easily..."

The physician order dated 04/04/17 timed at 1620 reflected, "Discontinue seroquel...risperdal 0.5 mg [milligrams] po [by mouth] TID [three times a day]...aggression...increase depakote 250 mg po BID [twice daily]..."

The physician order dated 04/06/17 timed at 1635 reflected, "cogentin 2 ml [milliliters] IM [Intramuscular] times one for EPS..."

The daily nursing assessment note dated 04/06/17 timed at 1700 reflected, "Patient is irritable and impulsive will continue to redirect...patient went to cafeteria...and had EPS, muscle spasms and stiffness...MD notified...administered medication ordered..."

The MAR [medication administration record] dated 04/06/17 timed at 1635 reflected, "Cogentin 2 ml IM times one administered at 1635..."

The Master Treatment Plan Review short and long-term goals dated 04/04/17 timed at 0900 reflected, "Danger to others...medications increased for mood and prn [as needed] for agitation....CPS seeking placement..." No documentation was found in the Treatment Plan which addressed the EPS Patient #22 experienced during his hospitalization.

The physician discharge orders dated 04/13/17 timed at 0830 reflected, "Cogentin 0.5 mg po BID..."

On 04/21/17 at approximately 1424 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #22's medical record. Personnel #1 stated the treatment plan did not address the EPS symptoms and care provided.

Hospital Policy titled, "Treatment Plans" with a revision date of 01/13/14 reflected, "Each patient will have an individualized master treatment plan...the care of each patient is designed, implemented, assessed and updated in an orderly and clinically sound manner..."

Based on record review and interview, the treating physician failed to complete a discharge summary within 30 days of the patient's discharge for 1 of 1 (Patient #28). Patient #28's discharge summary was not completed within 30 days following discharge.

Findings included:

Patient #28's medical record reflected an admission date of 03/01/17 with a diagnosis of Major Depressive Disorder. A discharge order was written on 03/04/17. There was no evidence of a discharge summary in the file as of 04/26/17.

During an interview on 04/26/17 at 1455 Personnel #1 agreed there was not a discharge summary in the chart.

The policy titled, "Discharge Summary" dated 01/10/14 reflected, "A discharge summary shall be a part of every patient's medical record..."

Based on observation, interview, and record review, the hospital's designated infection control officer failed to ensure that staff members adhere to infection control practices for 1 of 1 kitchen.

1. There was food without time and temperature control left sitting out in the kitchen.

2. There was dust and grime on the ice machine, on utensils in the kitchen, and dust and food particles on the flour bins in the dry storage area.

3. There was unlabeled and undated food in the walk in refrigerator.

Findings included:

During a tour of the hospital kitchen on 04/21/17 between 0925 and 1025 the following was observed:

1. A hotel pan of uncooked chicken was observed sitting beside the stove on a shelf.

2. A hotel pan with pieces of cooked sausage was sitting out on a prep table.

3. A hotel pan of green beans was sitting on the stove cool to the touch.

4. A rolling cart with a hotel pan of sliced turkey, a hotel pan of a meat patty, a hotel pan of mixed vegetables, and a hotel pan with corn was sitting out in the kitchen.

5. The ice machine had dust on the flat surfaces, there was a dusty and greasy ice bucket on a shelf under the ice machine.

6. There were 4 ladles hanging on a wire rack next to a prep table with dust and grime in them.

7. There was an undated hotel pan of red Jello in the walk-in refrigerator.

8. There was an undated serving container of a pink colored liquid labeled Out Patient in the walk in refrigerator.

9. In the dry goods storage area the bin containing the flour, sugar, and cornmeal had flour on the outside surfaces of the bins.

10. The outside of the freezer door had a large area of condensation.

11. The ice machine in the kitchen had last been cleaned on 09/09/16.

During a tour of the kitchen on 4/21/17 at 0925 until 1025 Personnel #4 was advised of the above findings and agreed with findings.

During an interview on 04/21/17 with Personnel #25 stated the manufacture's recommendation for cleaning the ice machine was every 6 months. The invoice for the last cleaning of the ice machine was dated 09/09/16. Personnel #25 agreed this was 6 weeks late.

The policy titled, "Proper Food Handling" dated 01/10/14 reflected, "Keep all perishable foods 41 degrees F or lower..."

The policy titled Infection "Prevention for Dietary" dated 02/18/17 reflected, "Dietary Manager...assures that the kitchen is cleaned properly and that all equipment is in proper maintenance...sanitation of utensils...all equipment is to be cleaned in accordance with State Health Regulations and recommendations of the manufacturer...food preparation and storage...all items are dated with date opened and use by date..."

Based on interview and record review the hospital failed to ensure 1 of 1 patient [Patient #22] had and individual treatment plan which addressed Patient #22's development of EPS (Extrapyramidal symptoms) drug induced movement disorders during his inpatient stay.

Findings included:

1) Patient #22's Intake Assessment dated 03/27/17 timed at 1700 reflected, "8 year old...CPS [child protective services]...attention deficit disorder...picked up chair and tried to hit someone with it...trashing home...angers easily..."

The physician order dated 04/04/17 timed at 1620 reflected, "Discontinue seroquel...risperdal 0.5 mg [milligrams] po [by mouth] TID [three times a day]...aggression...increase depakote 250 mg po BID [twice daily]..."

The physician order dated 04/06/17 timed at 1635 reflected, "cogentin 2 ml [milliliters] IM [Intramuscular] times one for EPS..."

The daily nursing assessment note dated 04/06/17 timed at 1700 reflected, "Patient is irritable and impulsive will continue to redirect...patient went to cafeteria...and had EPS, muscle spasms and stiffness...MD notified...administered medication ordered..."

The MAR [medication administration record] dated 04/06/17 timed at 1635 reflected, "Cogentin 2 ml IM times one administered at 1635..."

The Master Treatment Plan Review short and long-term goals dated 04/04/17 timed at 0900 reflected, "Danger to others...medications increased for mood and prn [as needed] for agitation....CPS seeking placement..." No documentation was found in the Treatment plan which addressed the EPS Patient #22 sustained while inpatient.

The physician discharge orders dated 04/13/17 timed at 0830 reflected, "Cogentin 0.5 mg po BID..."

On 04/21/17 at approximately 1424 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #22's medical record. Personnel #1 stated the treatment plan did not address the EPS symptoms and care provided.

The policy and procedure titled, "Treatment Plans" with a revision date of 01/13/14 reflected, "Each patient will have an individualized master treatment plan...the care of each patient is designed, implemented, assessed and updated in an orderly and clinically sound manner..."