HospitalInspections.org

33456

Based on staff interview, medical record review, and facility Policy and Procedure review, the facility failed to ensure 21 of 26 sampled Patients (Patients 1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25) had completed informed consents for psychotherapeutic medications (drugs that are prescribed for their effects in relieving symptoms of anxiety, depression, or other mental disorders).

These failures had the potential for Patients or their representative to make uninformed decisions regarding the administration of medication for mental health conditions.

Findings:

Review of the medical records indicated 21 of 26 sampled Patient's did not have a completed "Medication Consent Form" for psychotherapeutic medication. The "Medication Consent Form" lacked the following information:

1. Patient's name at the top of the form for 17 of 26 consents reviewed: Patients 1, 3, 5, 6, 7, 9, 11, 12, 13, 15, 16, 17, 18, 19, 20, 24 and 25;

2. Admission date at the top of the form for 20 of 26 consents reviewed: Patients 1, 3, 5, 6, 7, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 23, 24 and 25;

3. Physician's name who prescribed the medication for five (5) of 26 consents reviewed: Patients 1, 3, 9, 10 and 16;

4. Dosage, route of administration, frequency, and duration of the psychotherapeutic medication for 21 of 26 consents reviewed: Patients 1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 23 and 24;

5. Written information on medication was to be either "given to the patient by MD" or " requested by the MD to be given by staff". Neither box had been checked for 13 of 26 consents reviewed: Patients 3, 7, 10, 11, 12, 13, 15, 16, 18, 19, 21, and 23;

6. Date and time of Patient or Guardian signature was missing on 13 of 26 consents reviewed: Patients 9, 11, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23 and 24.

Review of the facility Policy and Procedure titled, "Informed Consent for Psychotherapeutic Medication", dated 1/16, indicated the following: "All patients who are to be treated with psychotherapeutic medications...The type, range frequency and amount [dosage] (including use of PRN, as needed, orders)...Method (oral, injection, etc.)...Duration of taking medications...Such consent shall be documented by the prescribing physician".

During an interview on 6/8/16 at 11 a.m., the Medical Director (MD) acknowledged the consents were not completed according to the facility policy, or the Plan of Correction submitted to California Department of Public Health. MD acknowledged that the consent needs to have the dosage/frequency, method of administration and length of treatment.

31321

Based on observation, interview and hospital record review, the facility failed to:

1. Prevent physical abuse and neglect to 2 of 26 sampled Patients (Patients 20, 26);

2. Report the abuse to a State Agency;

3. Have a Policy and Procedure for the investigation of abuse or neglect related to patient abuse.

These failures had potential to allow for patient abuse/injuries and patient neglect to be unrecognized, uninvestigated and subsequently untreated.

Findings:

Patient 26 was admitted to the hospital on 5/23/16.

During a re-visit survey to the hospital on 6/9/16 at 1:01 p.m., an interview with Patient 26 was conducted on Unit H. Patient 26 said she had been in the hospital for "about 2 weeks" and her "biggest complaint is the staff forgets that I am hard of hearing. They want me to go to the group therapy and when I do I can't hear anything the speaker is saying." Patient 26 also said she lost her eye glasses before she was admitted to the hospital and now she is unable to read the literature they give her. Also, Patient 26 said she wanted to call her mom to let her know she was alright, but she cannot hear on the payphone on the unit. She said she told "a couple of nurses and her psychiatrist" about this but nothing was done about it. Patient 26 said she told her Case Worker that she couldn't read the forms she was given by her and the hospital but the Case Worker was "unsympathetic" and did not offer any assistance with this issue.

During an interview on 6/9/16 at 2:40 p.m., with the Charge Nurse (CN) for Unit H, she said she was not informed about Patient 26 losing her eye glasses. CN said she didn't know Patient 26 could not use the payphone. She said there is a relay system for the patient to call through for the hard of hearing patients. When asked if Patient 26 had been instructed on the relay system for patients that are hearing impaired, when using the phone, she did not know if Patient 26 had been instructed to use the relay system.

Patient 20 was admitted on 5/20/16.

In a review of Patient 20's medical record dated 5/16/16 at 2:46 p.m., it revealed Patient 20 was in a physical altercation with a male peer...another patient put her in a headlock after he threw food on her and then he hit her...the staff came in when both patients were biting each other. There was a bite mark and broken skin on Patients 20's right hand and her lip was bloody. Patient 20 stated she wanted to press charges and was provided information and phone number to call to file a report.

In a review of Patients 20's medical record dated 5/19/16 at 9:05 a.m., the interdisciplinary progress notes said Patient 20 was walking down the hallway by herself and was provoked by a peer calling her "crazy"...Patient 20 instantly escalated and wrapped her palms around his neck yelling "call me crazy again see what happens!"...Patient 20 and peer were separated by staff.

In an interview with the Performance Improvement Director (PID) on 6/8/16 at 1:15 p.m., he said the hospital did not have an abuse policy in place for abuse between patients or staff to patient abuse, and abuse is only reported when the patients "choose to file charges" against the abuser. He said, the hospital does not call the police unless the patient wants to "press charges." The hospital does not report abuse to the Department of Public Health. The PID said, abuse is written in the "medical consult book" on each unit. In a concurrent interview and record review of the hospital's "Incident Report" titled "Healthcare Peer Review Report", the PID stated this process is an "internal process" and copies of these internal reports would not be available/provided.

There was no evidence of an investigation for these incidents. No reports were filed with the Department of Public Health or the Police Department.

Based on staff interview, medical record review, and facility Policy and Procedure review, the facility failed to obtain a Physician's order within the specified time frames for restraint or seclusion (R/S) for eight (8) out of 19 patients reviewed for R/S (Patients 6, 17, 20, 7, 12, 14, 21 and 18).

These failures placed patients at risk for, or have led to unwarranted R/S.

Findings:

Review of the eight medical records indicated the following:
1. Patient 6 had R/S ordered on 5/22/16 at 9:02 a.m. by a QRN (Qualified Registered Nurse). The Physician authenticated the order on 5/28/16 at 2:20 p.m.;

2. Patient 17 had R/S ordered on 5/17/16 at 8 p.m. by a QRN. The physician authenticated the order on 5/20/16, at 7:05 a.m.;

3. Patient 20 had R/S ordered on 5/20/16 at 11:12 p.m. by a QRN. No authentication by the Physician never authenticated the R/S order was documented;

4. Patient 7 had R/S ordered on 5/27/16 at 12:50 p.m. by a QRN. The physician authenticated the order on 5/30/16 at 12:30 p.m.;

5. Patient 12 had R/S ordered on 5/18/16 at 10:08 a.m. by a QRN. The physician authenticated the order on 5/20/16 at 12:15 p.m.;

6. Patient 14 had R/S ordered on 5/4/16 at 5:50 p.m. by a QRN. The physician authenticated the order on 5/7/16 at 8 a.m.;

7. Patient 18 had R/S ordered on 5/13/16 at 5:30 a.m. by a QRN. The physician authenticated the order on 5/18/16 at 9 a.m.; and

8. Patient 21 had two (2) restraint documents which indicated the same R/S episode. One had a QRN order for 9 a.m., the other one had a QRN order for 10 a.m.

Review of the facility Policy and Procedure titled, "Seclusion/Restraint/Physical Hold" dated 5/16, indicated the following for R/S orders:
1. "Physician Authentication: Must be done within 24 hours of order given".

In an interview with the Medical Director (MD) on 6/8/16, at 11 a.m., the MD acknowledged and confirmed the R/S orders had not been authenticated by the physician within 24 hours, as Policy and Procedure dictated.

Based on staff interview, medical record review, and facility Policy and Procedure review, the facility failed to ensure a face to face evaluation was reviewed by an Attending Physician within 1 hour of the evaluation for seven (7) out of 19 Patient records reviewed for restraint/seclusion (R/S). (Patients 20, 7, 12, 19, 14, 18 and 21) .

These failures had the potential for R/S to be extended without cause.

Findings:

Review of the seven (7) medical records indicated the following:

1. Patient 20 had a face to face evaluation completed 5/20/16 at 12:05 p.m. There was no documented evidence a review of the face to face was performed with the physician. The physician authenticated the review 5/27/16 at 1 p.m.;

2. Patient 7 had a face to face evaluation on 5/27/16 at 1 p.m. The physician authenticated the face to face evaluation on 5/30/16 at 12:30 p.m.;

3. Patient 12 had a face to face evaluation on 5/18/16 at 11:08 a.m. The physician authenticated the face to face evaluation on 5/20/16 at 12:30 p.m.;

4. Patient 19 had a face to face evaluation at 1:45 p.m., there was no date documented. The physician authenticated the face to face evaluation on 6/6/16 at 1 p.m.;

5. Patient 14 had a face to face evaluation on 5/4/16 at 5:43 p.m. The physician authenticated the face to face evaluation on 5/24/16 at 7:30 p.m.;

6. Patient 18 had a face to face evaluation on 5/13/16 at 5:30 a.m. The face to face evaluation review with the physician was documented at 4:30 a.m., one (1) hour prior to when the face to face evaluation had been completed. The physician authenticated the face to face evaluation on 5/18/16 at 9 a.m.;

7. Patient 21 had two (2) face to face evaluations for the same episode of R/S on 5/30/16: one at 9:15 a.m. and one at 10 a.m. There was no date documented; and

7a. Two different QRN's signatures were on one (1) of the face to face evaluation forms, and one QRN signature was on the other form.


Review of the Policy and Procedure titled, "Restraint/Seclusion/Physical Hold", dated 5/16 indicated the following:
1. "...conducts an in-person, face to face assessment of the patient within 1 hour of initiation and documents findings on the face to face evaluation form (Evaluation must be completed within 1 hour)".

In an interview with the Chief Nurse Officer (CNO) on 6/9/16 at 2:07 p.m., the CNO stated the physicians are supposed to authenticate the face to face evaluation performed by a QRN within 24 hours. The CNO confirmed the patients mentioned above did not have authenticated face to face evaluations by the physician within 24 hours. The CNO stated the physicians were supposed to authenticate the face to face evaluation at the same time as the R/S orders were signed.