HospitalInspections.org

Based on medical record review, document review, and staff interview, in 10 of 20 medical records reviewed, the facility failed to appropriately document every 30 minutes observation of patients in the Psychiatric Emergency Department to ensure their safety (Patient #s 1, 5, 6, 7, 8, 15, 6, 17, 18, 19).

Findings Include:

Review of medical record for Patient #1 identified: A 28-year-old male, who was triaged in the Psychiatric Emergency Department (ED) on 1/12/19. The patient remained in the ED and was to be admitted.

Staff G, ED/ RN/ Nurse Manager, notes that on 1/13/19 at 8:45 AM, at breakfast time, a Patient Care Associate (PCA) went to wake the patient up for breakfast and found the patient unresponsive.

Staff H, Medical ED Physician who responded to the emergency code, noted that upon arrival, she found the patient cold, mottled, stiff tone throughout, pupils were unreactive. The patient was declared dead at 9:23 AM.

Review of the Facility's "Q 30 minutes Checklist" revealed the patient was on every 30 minutes observation and was noted to be in the bedroom from 1/12/19 at 11:30 PM to 8:30 AM on 1/13/19.

As per interview with Staff A, RN, on 1/30/19 at 12:30 PM, he worked on 1/12/19 from 7:00 PM to 7:30 AM on 1/13/19. The patient was stable all night during rounds. He stood by the door and observed the patient was lying on his side facing the window and was asleep.

On 1/24/19 at 10:24 AM, during interview with Staff E, RN, she stated that at the beginning of her shift on 1/13/19 at around 7:00 AM, "I just eye balled the patient." The patient was sleeping and lying on his side.

As per interview with Staff J, PCA, he stated that he arrived on the unit on 1/13/19 at 7:00 AM. He conducted an environmental round, and did the routine 30 minutes rounding. The rounding consists of identifying each patient and documenting their location and activity (meaning what the patient doing) on the "Q 30 minutes Checklist". He went to the door of Patient #1, he looked in and saw the patient in bed sleeping. He indicated on the rounding sheet that the patient was in the bedroom.

There was no documented evidence that the patient's activities were documented from the time he was admitted on 1/12/19 at 6:15 AM to when he was found unresponsive on 1/13/19 at 8:45 AM.

Similar findings regarding the lack of documentation of patients' activities were noted for Patient #s 5, 6, 7, 8, 15, 6, 17, 18, 19 who were on Q 30 minutes observation in the Psychiatric ED.

Review of the Facility policy titled, "Close Observation of Patients" last reviewed on 8/2017, stated that Psych ED patients and newly admitted patients in the Extended Observation Unit (EOB), and inpatients Psychiatric Units are placed on Routine Observation, unless risk assessment of the patient indicates a different level of observation.

The Q 30 minutes Checklist was not integrated into the Close Observation policy. In addition, the policy did not provide guidance to staff on how Q 30 minutes checks should be conducted.

On 1/25/19 at 10:00 AM, during interviews with Staff L, Director of Regulatory Affairs, Staff M, Director of Operations, and Staff S, Director of Risk Management they acknowledged findings.

Based on medical record review, observation, and interview, in one (1) of eight (8) medical records, Nursing Staff failed to evaluate the care of a patient to ensure a timely treatment of the patient's medical condition (Patient #1).

Findings include:

Review of medical record for Patient #1 identified a patient who was evaluated in the Psychiatric Emergency Department on 1/12/19 at 6:51 AM for paranoid ideation. The initial "Comprehensive Psychiatric Assessment" at 8:54 AM, revealed the patient did not endorse any suicidal and homicidal ideation. The patient's prognosis was guarded and the plan was to admit him to inpatient psychiatry for further evaluation and treatment.

The patient's observation records indicated he was placed on every 30 minutes monitoring.

On 1/13/19 at 6:32 AM, Staff A, ED RN noted, "client asked medication to help him sleep, Risperdal 1mg PO (oral) and Benadryl IM (Intramuscular) was ordered and administered. Client currently asleep, breathing well."

At 7:40 AM, Staff E, RN noted "Received patient lying in bed asleep, easily aroused in stable condition. No shortness of breath or acute distress noted. Safe and effective environment maintained."

A nurse noted that at approximately 8:50 AM, a Patient Care Associate (PCA) went to wake the patient up for breakfast and found him unresponsive. The patient was lying in a prone position with a bed sheet tied around his neck.

Staff H, Medical ED physician who responded to the code noted that she found the patient cold, mottled, with arms above head, stiff tone throughout. Initial cardiac rhythm: asystole (cardiac arrest - a flatline on the heart monitor). The patient could not be ventilated as he was stiff with rigor mortis (stiffening of the joints and muscles of a body a few hours after death). Pupils were unreactive. The physician pronounced the patient dead at 9:23 AM.

As per telephone interview with Staff A on 1/30/19 at 12:30 PM, he reported that he conducted rounds on 1/13/19, between 5:45 AM and 6:15 AM and documented his observation at 6:32 AM. The patient (Patient #1) was in Room 104, a two -bedded room. He did not enter the room, he stood by the door when he conducted the assessment. The client was asleep, lying on his side, and facing the window. He saw the patient's chest move up and down.

As per interview with Staff E, ED RN on 1/24/19 at approximately 11:00 AM, she stated that she did not enter the patient's room, she stood at the door and "eyeballed" the patient. She reported that she did not arouse the patient and she did not assess the patient's respirations as indicated in her notes on 1/13/19 at 7:40 AM. When asked why she documented an assessment she did not perform, she replied that her documentation was "Just a standard statement" and was not based on the assessment of the patient.

During interview on 1/25/19 at 10:00 AM, Staff L, Director of Regulatory Affairs and Staff M, Director of Operations, they acknowledged that the patient's assessments documented by Staff A and Staff E were not consistent with the condition the patient was found on 1/13/19.

Based on observation, document review and interview, the facility failed to maintain a safe temperature for the nourishment refrigerator in accordance with prevailing standards.
This finding was noted in one (1) of two (2) refrigerators inspected.

Findings include:

During a tour of the Emergency Department (ED) on 1/23/19 at approximately 10:30 AM, the food thermometer in the nourishment refrigerator was found at the bottom of the refrigerator, underneath milk cartons, near the refrigerator door.

Inappropriate placement of a thermometer in a refrigerator can result in an inaccurate temperature reading.

Review of the "Daily Refrigerator Temperature Log" for January 2019, noted that the required temperature range for the nourishment refrigerator was noted as 36 to 46-degree Fahrenheit and that the refrigerator temperature should be measured twice a day; in AM and PM. On 1/20/ 19 through 1/24/19, the food refrigerator temperature in the mornings (AM) were above 40 degrees Fahrenheit (F). The Evening/Night (PM) temperatures were not documented for 16 out of the 23 days on the log.

The 2015 Food Code recommends that refrigerator temperature is to be kept at or below 40° F (4° C), and the freezer temperature at 0° F (-18° C).

Review of the facility's policy titled "Nourishment Floor Supplies," last revised 11/2018, lacked guidance on a safe temperature range for food stored in the refrigerator, and on the proper placement of food thermometer for accurate temperature readings.

On 1/25/19 at approximately 11:00 AM, during interview with Staff N, Assistant Director of Nursing ED, staff acknowledged findings.