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Based on observation, medical record review, review of policy and staff interview it was determined the registered nurse (RN) failed to notify the physician regarding suicidal attempts and failed to follow orders for monitoring and assessment of patients. This failed practice involved six (6) of ten (10) patients reviewed (patients #1, 4, 7, 8, 9 and 10) and has the potential to adversely impact the care and condition of all patients.

Findings include:

1. Review of the medical record for patient #1 revealed the nurse documented in part at 2100 on 4/19/12: "Patient became angry at fresh air because staff attempted to redirect her. She continued to escalate. Health Service Worker found her with towel tied around her neck and she said she wanted to kill herself..." Review of this record revealed no documentation the physician was notified regarding this incident.

2. Review of the medical record for patient #1 revealed the nurse documented in part at 1750 on 5/15/12: "1750 roommate running to desk reporting patient choking herself. Patient sitting in bed with a muscle shirt around her neck pulling, face dusky some petechiae along the lines of her jaw...." Review of this record revealed no documentation the physician was notified regarding this incident.

Interview was conducted with the A3 Nurse Manager at 1500 on 6/25/12. This record was reviewed and discussed at this time. After reviewing the record the Nurse Manager acknowledged the nurses's charting, on both 4/19/12 and 5/15/12, was incomplete.

The policy "Nursing Care of the at Risk Suicidal Patient," last reviewed 7/6/10, was provided for review. It states in part: "In a case where a patient presents a high suicide risk or an acute emergency, the Nursing Supervisor, Nurse Manager and the Physician shall be notified immediately for appropriate precautionary orders and intervention."

3. Review of the medical record for patient #4 revealed the following orders written by the Nurse Practitioner on 4/11/12: "Please obtain abdominal girths every three days and document the results in the nurses progress notes" and "Weigh patient twice a week, Thursday and Monday. Preferably in the morning, after voiding and before breakfast in the same type of clothing."

Review of the medical record for patient #4 revealed no record of abdominal girth being measured since it was ordered, Review of the weights revealed no record the patient was weighed twice a week, Thursday and Monday as ordered. During the month of June the patient was weighed twice. These weights were obtained on 6/2/12 and 6/16/12 which were both Saturdays.

4. Observation on the A5 Unit at 0900 on 6/26/12 revealed patient #7 was being prepared for transfer to an outside hospital. Review of the 6/26/12 nurses note documented by the nurse at 1036 revealed: "Writer went to check pt vital signs this morning prior to med pass. Patient Blood Pressure very low noted at 98/24, pulse 110, Respiration 16. Patient was pale and clammy. Informed charge nurse who also took patient's vital signs. Findings were 100/40, Respiration 22, Pulse 88, Temperature 100.3, SPO2 92%. Doctor notified, pt sent out on Medical Trial Visit to Cabell Huntington at 0920 per order."

Review of physician orders for patient #7 revealed an order written on 6/25/12 at 11:11 for "Temperature Pulse Respiration and Blood Pressure every shift." Review of the vital sign record for this patient revealed the following:

6/25 Dayshift, No Blood Pressure or Pulse was recorded.
6/25 Eveningshift, No Respiration or Temperature was recorded.
6/25 Nightshift, No Temperature, Pulse, Respiration or Blood Pressure was recorded.

5. These records were reviewed and discussed with the A3 Nurse Manager at 0930 on 6/27/12. She agreed with these findings.

6. Review of the medical record for patient #8 revealed an 11/21/11 order, written at 1154, for "Temperature, Pulse, Respiration and Blood Pressure daily." Review of the vital sign record revealed Temperature, Pulse, Respiration and Blood Pressure was not recorded 6/23 and 6/24/12.

7. Review of the medical record for patient #9 revealed an order written on 5/26/11 "Temperature, Pulse, Respiration and Blood Pressure daily" and an order written on 12/30/11 "Weigh every Saturday." Review of the vital sign record revealed: no vitals signs for 6/2 and 6/9, no Temperature on 6/17, no Temperature, Pulse or Respiration for 6/20, no vital signs for 6/24/12. Review of the record revealed the patient was last weighed on 6/2/12.

7. Review of the medical record for patient #10 revealed the patient had a history of Congestive Heart Failure, Hypertension and Cardiomyopathy. On 6/20/12 the physician ordered: "Temperature, Pulse, Respiration and Blood Pressure daily" and "Weigh every Saturday." Review of the vital sign record revealed no vitals signs were recorded on 6/23, 6/24 or 6/25/12. The patient's last weight was recorded on 6/13/12.

8. These records were reviewed and discussed with the A 3 Nurse Manager at 1125 on 6/27/12. She agreed with these findings.


31230

Based on observation, review of policy and staff interview it was determined the hospital failed to ensure medications were administered per policy and acceptable practice. This failed practice involved one of one medication passes observed on the A 3 Unit and has the potential to adversely impact the condition of all patients.

Findings include:

1. The 0900 medication pass on the A3 unit was observed on 6/26/12. The 0900 medication pass was not completed until 1130. At 1000 Registered Nurse (RN) #1 acknowledged many of the 0900 medications were being administered late.

2. During the medication pass RN #1 was observed to pull the medication cart out of the medication room and place it against the counter behind the nurses station. On two (2) occasions, at 0925 and 0952, RN #1 removed oral medications from the drawer and placed them on top of the cart, then went into the medication room to retrieve an item. On both occasions the medications on top of the medication cart were accessible to patients who were standing at the counter waiting.

3. When this observation was shared with the RN she turned the medication cart against the wall in the nurses station with her back to the patients. This prevented patients from reaching the medication cart but for the rest of the medication pass RN#1 could not observe patients to ensure the medications were actually swallowed. This was discussed with her and she agreed with this observation.

4. At approximately 1030 RN #1 took a short break during the medication pass. While she was gone the medication cart was left against the wall behind the nurses station. The cart was locked but a bottom drawer which contained multiple bottles of laxatives and inhalers was left open (unlocked). After returning the RN acknowledged all drawers should be closed prior to leaving and locking cart.

5. During the course of the one hundred fifty (150) minute medication pass no handwashing was observed. RN#1 was observed to use alcohol sanitizer three (3) times. A total of twenty-six (26) patients were observed to receive medications. This lack of consistent hand cleaning was shared with the RN and she agreed.

6. During the medication pass the left end of the medication cart was noted to be streaked and dirty from top to bottom. RN #1 agreed with this observation.

7 At 1114 (during the medication pass) the house keeper was observed to empty the trash and sweep the medication room floor. The surveyor observed two (2) kinds of pretzels and popcorn being swept up off the medication room floor. The floor was still visibly dirty and the housekeeper was asked how frequently the medication room was mopped. She stated it was mopped whenever the housekeeper could be given access to the medication room. She then mopped the floor.

8. At approximately 1300 on 6/26/12 an observation in the medication room was made with the A3 Nurse Manager. After examining the medication cart she acknowledged the cart was "filthy." Observation at this time revealed the cabinets in the medication room were covered with multiple sheets of paper, many of which were splashed and soiled. The fronts of two (2) cabinets were noted to be splashed and soiled with an unknown substance. The Nurse Manager agreed with this observation.

9. At 1350 on 6/26/12 the surveyor was reviewing medical records in the charting room behind the nurse's station, which was close to the medication room. The surveyor heard RN#1 ask the ward clerk to watch the medication room. The surveyor then went out into the nurses' station to observe the medication room. RN #1 was not present. The medication room door was propped open. Multiple bags of medication were observed lying on top of the medication cart. This observation was then shared with RN#2 who was in the charting room behind the nurses' station. She acknowledged she heard RN#1 ask the ward clerk to watch the medication room. RN #2 then went into the medication room until RN #1 returned. RN #2 agreed the medication room should have been locked when RN #1 left.

10. The policy "Medication Administration," last revision 6/2012, was provided for review. The policy states in part: "The Medication Room is to be kept locked at all times...It is the responsibility of each medication nurse to keep the Medication Room clean, organized and stocked with needed supplies. The Medication Cart, counter, sink, desk, etc., should be cleaned at the end of each shift...The Medication Cart is to remain locked at all times when not in use...Non-Time Critical Scheduled Medications administered more frequently than daily but not more frequently than every 4 hours may be given sixty (60) minutes before or sixty (60) minutes after the designated time...Never leave the Medication Cart unattended. Do not turn your back to the cart...The Medication Nurse is to remain with the patient until the Nurse is confident that the patient has swallowed the medication...Nurse is expected to wash hands before and after administering any medications. During med pass of p. o. meds, Nurse should utilize alcohol hand rinse between patients."

11. These observations were shared with the Director of Nursing (DON) at 0800 on 6/27/12. She indicated she was aware of ongoing issues with the A3 Medication Room. The DON acknowledged the practices observed were not acceptable and indicated these issues were being addressed.