HospitalInspections.org

Based on a review of facility documents, medical record (MR), and interview with facility staff (EMP), it was determined that the facility failed to provide care in a safe setting in one of one medical record reviewed. (MR1).

Findings Include:

Review of Memorial Medical Center Patient Bill of Rights revealed, " ... You have a right to be treated with dignity and respect ... 5. You have the right to participate in the development and review of your Treatment Plan ... 8. You have the right not to be subjected to any harsh or unusual treatment ... ."

Review of facility policy Patient Rights. Department: Behavioral Medicine, revised July 2011, revealed, "Purpose: To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights, and involvement of patient. Policy: It is the policy of each Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while a patient is on the Unit ... H. The following patient rights are adhered to at all times on the Unit. 1. A patient is provided with care and services in the least restrictive environment. ... ."

Review of Assessment of the Patient, Nursing Database/Admission History-Documentation in Care Manager, dated May 2014, revealed, "... Points of Emphasis/Requirements: ... Patient care interventions complement the patient's Plan of Care. The patient is provided with a safe, comfortable environment. The patient's physical needs are met through appropriate care interventions. The patient's psychological stress is minimized and coping abilities enhanced. ... The patient's rights are respected and assured. ... . "

1. Review of MR1 dated November 7, 2014, revealed, "BEHAVIORAL RESTRAINT DOCUMENTATION ... Behavior Intervention Codes: (Note all that apply below in Behavior/Intervention codes column) 1. Reorientation. 2. Consistent limits set. 3. Stayed with patient for support/comfort. ... 12. Other: (describe) DAWN [hand written in], 13. Restraint removed ... BEHAVIORAL RESTRAINT DOCUMENTATION ... 1050 ... aggressive with staff, 1115 ... biting self ... 1130 ... Patient biting self, aggressive with staff ... 1145 ... used Dawn for deterrent to biting ... 1230 ... biting self ... 1300 ... laying down, pulling at restraints ... 1315 Biting at knees banging head [arrow up and arrow down] on pillow ... 1330 ... Biting at knees, pulling at restraints ... 1345 ... Pulling at restraints, banging head on pillow ... 1400 ... 1350 D/C Restraint ... ."

Continued review of MR1 "Inpatient Psych Daily Summary" nursing documentation dated November 7, 2014, revealed, "... 11/10/14, 17:43 Comments ... Late entry from 11/7/2014, 07-1500 shift. Staff applied dishwashing liquid to patient's arms and legs in an attempt to prevent self injurious behavior. Once patient stopped biting self, restraints were removed and patient showered. Patient did not ... have any noted skin reaction. ... ."

2. An interview was conducted with EMP3 on December 3, 2014, at 11:45 AM. "... I mentioned soap because it was non-toxic. EMP13 put Dawn on the patient's hands. ... Then the patient tried to bite their shoulder, so some Dawn was placed on the patient's shoulder. ... In hindsight, we shouldn't have used it. ... ."

Based on a review of facility documentation, medical record (MR), and interview with facility staff (EMP), it was determined that the facility failed to document an intervention in the patient's Treatment Plan in one of one record reviewed (MR1).

Findings Include:

Review of Assessment of the Patient Nursing Database/Admission History-Documentation in Care Manager, dated May 2014, revealed, "... Statement of Policy: ... Assessment is extremely important because it provides the scientific basis for a complete Nursing Care Plan. ... Documentation of the ... Plan of Care ... all need to be clearly documented. ... Points of Emphasis/Requirements ... Reassessment frequency (time lapsed assessment) is based on changes in patient condition, instability of the patient's condition, treatments being performed, Lab work, and patient symptoms. Reassessment must include date and time with focus on the physiological system involved. Include the description of the problem and detailed description of events. Document physician notification of problems and interventions. Document for interventions and outcomes that require notification of family and the name of family member notified. All patients require a re-assessment and documentation of systems at a minimum of once every 8 hours. Early in the shift for assessment is best practice. ... Orders include blood work, treatments, medications ordered, x-ray and other examinations. ... Patient care plans (IPOC) are outcome expectations of the patients care (refer to Provisions of Care-Organizational manual) include: Early recognition of patient condition and changes in condition will promote identification of the patient care needs. Patient care interventions complement the patient's plan of care. ... . "

Review of Overview of the Interdisciplinary Treatment Planning Process, dated July 2011, revealed, "... 1.0 Purpose: To ensure plans of care, treatment, and service are individualized to meet the patient's unique needs and circumstances. ... 2.0 Policy: ... C. Treatment planning is the structured process by which identified patient problems are resolved via specific goal-oriented treatment interventions. Continued care needs are identified as part of the Treatment Planning process. ... D. Key elements essential to all stages of Treatment Planning include the following: ... 5. Treatment Plans specify the frequency of each treatment intervention/procedure and name the disciplines and persons responsible for the interventions. ... 5.0 Procedure for Completing Interdisciplinary Treatment Plan ... P. Define specific interventions which comprise the treatment that will be utilized to help patient achieve short- and long- term goals on the individual Treatment Plans. ... 7.0 Interventions. A. Interventions are the actions each discipline will take to assist the patient in meeting the short-term goals. Each discipline lists interventions related to the problem and the short-term goals. 1. Interventions are discipline specific. 2. Interventions are specific and should be concise and clearly defined. 3. Interventions list the frequency, the action/focus, and the person responsible for completion. ... ."

1. Review of MR1 "Inpatient Psych Daily Summary" nursing documentation dated November 7, 2014, revealed, "... 11/10/14, 17:43 Comments ... Late entry from 11/7/2014, 07-1500 shift. Staff applied dishwashing liquid to patient's arms and legs in an attempt to prevent self injurious behavior. Once patient stopped biting self, restraints were removed and patient showered. Patient did not ... have any noted skin reaction. ... ."

Review of MR1 Treatment Plan failed to reveal any documented evidence for the use of Dawn dishsoap as an intervention for the patient's self biting behavior.

2. A group interview was conducted with EMP1, EMP6, and EMP7 on December 1, 2014, at 10:00 AM, and revealed, "... We would absolutely need an Order to use the Dawn. There is no Order in the medical record, it was not on the Treatment Plan as an intervention. It is a problem that we all have to address."

Based on a review of facility documents, medical record (MR), and interview with facility staff (EMP) it was determined that the facility failed to obtain a Physician Order for a treatment prior to the administration of that treatment in one of one medical record (MR1) reviewed.

Findings Include:

A review of RULES & REGULATIONS OF THE MEDICAL STAFF OF MEMORIAL MEDICAL CENTER dated September 24, 2014, revealed, "... RULE 2. MEDICAL RECORDS: ... II. CONTENT OF RECORDS: ... c) Diagnostic and Therapeutic Orders. 1) Diagnostic and Therapeutic Orders are written, dated and timed by Medical Staff members, by physicians in training status and by other individuals within the authority of their clinical privileges. ... ."

Review of Assessment of the Patient Nursing Database/Admission History-Documentation in Care Manager dated May 2014, revealed, "... Points of Emphasis/Requirements: ... Physician Orders (patient chart and CPOE) are based on patient's medical needs. Physician Orders are obtained (dated, timed, and signed) and then carried out as ordered or as designated by Physician or the Physician covering or Physician's Resident /PA/CRNP (ie: emergent /stat). Orders include blood work, treatments, medications ordered, x-ray and other examinations. ... . "

1. Review of MR1 dated November 7, 2014, revealed, "BEHAVIORAL RESTRAINT DOCUMENTATION ... Behavior Intervention Codes: (Note all that apply below in Behavior/Intervention codes column) 1. Reorientation. 2. Consistent limits set. 3. Stayed with patient for support/comfort. ... 12. Other: (describe) DAWN [hand written in]. 13. Restraint removed ... BEHAVIORAL RESTRAINT DOCUMENTATION ... 1050 ... aggressive with staff, 1115 ... biting self ... 1130 ... Patient biting self, aggressive with staff ...1145 ... used Dawn for deterrent to biting ... ."

Review of MR1 Inpatient Psych Daily Summary, nursing documentation dated November 7, 2014, revealed, "... 11/10/14, 17:43 Comments: ... Late entry from 11/7/2014, 07-1500 shift. Staff applied dishwashing liquid to patient's arms and legs in an attempt to prevent self injurious behavior. Once patient stopped biting self, restraints were removed and patient showered. Patient did not ... have any noted skin reaction. ... ."

Further review MR1 failed to reveal documented evidence of a Physician's Order for the use of dishsoap to deter the patient from biting self.

2. A group interview was conducted with EMP1, EMP6, and EMP7 on December 1, 2014, at 10:00 AM, and revealed, "... There was no Order to use Dawn on the patient. We would absolutely need an Order to use the Dawn. There is no Order in the medical record, it was not on the Treatment Plan as an intervention. It is a problem that we all have to address."