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Based on document review and interview, it was determined, for 4 of 30 patients (Pts. #1, 11, 13, & 21) receiving psychotropic medication, the Hospital failed to ensure patients or their representatives were notified of psychotropic medication purpose, effects, benefits, and side effects, before medication administration.

Findings include:

1. Hospital policy No. 704.12, revised 3/13, titled, "Patient Informed Consent for Psychotropic Medication" was reviewed on 7/9/13 at 9:00 AM. The policy required, "Action steps: 1. The physician and/or nurse discusses with the patient and/or patient/guardian, the proposed medications, purpose, desired effects, benefits and side effects of the medications... 4. RN/Physician ensures that patient/parent and/or guardian sign the Patient Consent for Psychotropic Medications form prior to medication administration."

2. On 7/8/13 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 61 year old male, admitted on 6/27/13, with diagnoses of schizoaffective disorder, dementia, and hypertension. A patient consent for psychotropic medication was dated 7/3/13 and included, Amantadine, Depakote, Exelon, Namenda, Seroquel, and Haldol. No prior psychotropic consent was found. Pt. #1's medication administration record included administration of amantadine, Depakote, and exelon, on 6/28, 6/29, 6/30, 7/1, & 7/2, five days before the consent was documented.

3. An interview was conducted with the Chief Nursing Officer (CNO) on 7/8/13 at 11:00 AM. The CNO reviewed Pt. 1's clinical record and did not find an earlier consent for psychotropic medications.

4. The clinical record for Pt #11 was reviewed on 7/9/13 and included that Pt #11 was a 42 year old female who was admitted to the Hospital on 6/17/13 with a diagnosis of bipolar disorder. The Patient Consent for Psychotropic Medication form lacked the required second witness signature for verbal consent for Zyprexa and Ativan.

5. An interview was conducted with the CNO on 7/9/13 at 2:00 PM. The CNO reviewed Pt. 11's clinical record and agreed the second witness signature was missing.

6. The clinical record for Pt. #13 was reviewed on 7/9/13. Pt. #13 was a 19 year old female, admitted on 6/19/13 with a diagnosis of suicidal ideation. The "Patient Consent for Psychotropic Medications" record included documentation indicating the guardian consented. However, the form lacked the patient's or guardian's signature.

7. The clinical record for Pt #21 was reviewed on 7/9/13 and included that Pt #21 was a 40 year old male who was admitted to the Hospital on 6/5/13 with a diagnosis of bipolar disorder. The Patient Consent for Psychotropic Medications form included the patient's signature, but lacked a physician or nurse witnessing signature and date for the following medications: Seroquel, Celexa, Thorazine, and Depakote.

8. An interview was conducted with the Clinical Manager on 7/9/13 at 11:30 AM. The Manager stated Pt. #13's mother should have signed the consent form as a witness and confirmed Pt. #21's consent lacked a witness's signature.



19843




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A. Based on document review and interview, it was determined, for 5 of 30 clinical records reviewed (Pts. #1, 9, 10, 12, & 13), the Hospital failed to ensure patient reassessment was completed each day/shift, as required by policy.

Findings include:

1. On 7/10/13 at 11:00 AM, policy no. 703.102, revised 6/12, titled, Initial Assessments of Patients" was reviewed. The policy required, "Action steps... 12. Unit RN... reassesses patient needs, status, effectiveness of interventions and precautions daily..."

2. On 7/10/13 at 11:10 AM, policy no. 706.08, revised 3/13, titled, "Precautions and Observations" was reviewed. The policy required, "... For any 1:1 [one staff to one patient monitoring]... the RN will complete a nursing assessment every shift..."

3. On 7/8/13 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 61 year old male, admitted on 6/27/13, with diagnoses of schizoaffective disorder, dementia, and hypertension. A physician's order dated 6/28/13, required one to one observation. Between the date of admission and day of review, reassessment for each shift (3 shifts per day) was missing on 4 days (6/29, 7/1, 7/4, & 7/7).

4. On 7/9/13 at 10:10 AM, the clinical record of Pt. #9 was reviewed. Pt. #9 was a 28 year old male, admitted on 6/21/13, with a diagnosis of schizoaffective disorder. A nursing reassessment for 6/24/13 was not found.

5. On 7/9/13 at 10:30 AM, the clinical record of Pt. #10 was reviewed. Pt. #10 was a 27 year old male, admitted on 5/31/13, with diagnoses of severe depression, bipolar disorder, autism, unspecified intellectual disabilities, and hypertension. A physician's order dated 5/31/13, required one to one observation. Between the date of the order and date of discharge, 6/10/13, reassessment for each shift was missing for 6 days, (June 1, 5, 6, 7, 8, & 9). On 6/6/13, reassessments for all 3 shifts were missing.

6. On 7/9/13 at 1:55 PM, an interview was conducted with the Director of Clinical Services. The Director stated she checked in the medical records office for Pts. #9 & 10's missing reassessment sheets, but could not find any.

7. The clinical record of Pt. #12 was reviewed on 7/9/13. Pt. #12 was a 26 year old male admitted on 6/20/13 with diagnoses of recurrent psychosis, bipolar disorder, mental retardation and head banging. The physician's order dated 7/4/13 included 1:1 observation while awake. The every 8 hour nursing assessment for patients on 1:1 was lacking for the 3-11 shift on 7/4/13.

8. The clinical record for Pt. #13 was reviewed on 7/9/13. Pt. #13 was a 19 year old female admitted on 6/19/13 with diagnoses of suicidal ideation. The physician's order dated 7/1/13 included 1:1 observations. The every 8 hour nursing assessment for patients on 1:1 was lacking for the 7-3 PM shift on 7/4/13.

9. An interview was conducted with the Clinical Manager on 7/9/13 at 11:30 AM. The Manager reviewed Pts. #12 & 13's clinical records and confirmed the findings.

B. Based on document review and interview, it was determined, for 1 of 3 diabetic patient's clinical records reviewed (Pt. #23), the Hospital failed to ensure physician's orders were followed.

1. On 7/10/13 at 9:00 AM, the clinical record of Pt. # 23 was reviewed. Pt. #23 was a 19 year old male, admitted on 5/26/13, with diagnoses of bipolar disorder, cannabis abuse, and diabetes mellitus type II. A physician's order dated 5/26/13 at 8:30 AM, required, "Accucheck BID [measure blood glucose twice a day] Metformin 500 mg PO [by mouth] BID, hold [Metformin] if accucheck is equal to or less than 100." Between the date of the order and date of discharge (6/19/13) Metformin was administered 19 times when Pt. #23's accucheck was less than 100.

2. An interview was conducted with the Chief Nursing Officer (CNO) on 7/10/13 at 10:00 AM. The CNO reviewed Pt. 23's clinical record and stated the findings were accurate.


19843

Based on document review and interview, it was determined that for one of one medical records department, the Hospital failed to ensure that medical records were completed within 30 days after discharge.

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (adopted 4/25/13) required, "...All discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge. Incomplete records exceeding 30 days following discharge will be considered delinquent..."

2. On 7/10/13 at approximately 1:30 pm, the Chief Nursing Officer (CNO) presented the surveyor with a letter of attestation which documented, "There are 52 delinquent records at...[Hospital]...as of 7/10/13."

3. The above findings were confirmed with the CNO on 7/10/13 at approximately 2:00 pm.

Based on document review and interview, it was determined that for 2 of 2 food service tray lines, the Hospital failed to ensure that trayline temperatures were monitored 3 times throughout meal service per policy, which potentially affected 89 patients on census on 7/10/13.

Findings include:

1. The Hospital's Dietary Department's policy entitled "Holding and Service" (revised 6/20/12) required, "Holding- Hot foods will be held at a minimum temperature of 135 degrees Farenheit for a maximum of 4 hours..."

2. The "Trayline Temperature Record" form required, "Temperatures should be checked for hot foods 3 times throughout meal service: before serving, middle of meal service and end of meal service."

3. The "Daily Cafe Temperature Log" (1/1/13-7/10/13) for the cafeteria's front trayline was reviewed on 7/10/13 and included only the food temperatures at the start of the trayline. Every daily log sheet lacked initials of the employee who checked the temperature, the actual start time of the trayline, and temperatures for the middle and end of the tray line. Therefore, it would not be possible to determine the maintenance of the minimum temperature throughout holding; and the total holding time is not documented.

4. During a tour of the Hospital's Dietary Department during the "back" lunch trayline on 7/10/13 between approximately 11:15 am and 11:30 am, the trayline was set up, and trays were being prepared for the meals to be delivered to the patient units. At 11:30 am, the Trayline Temperature Record for 7/10/13 was reviewed at the trayline site and included documentation of ending temperatures for foods on the trayline that was still active, rendering this information inaccurate.

5. The above information was confirmed during an interview with the Chief Nursing Officer on 7/10/13 at approximately 2:00 PM.