HospitalInspections.org

Based on staff interview and record review, the hospital failed to assure each patient's right to receive care in a safe setting by failing to initiate advanced mouth checks when indicated and by not appropriately assessing the potential safety precautions for the use of a heat wrap for 1 applicable patient. (Patient #12) Findings include:

Per record review, when Patient #12 was admitted on 11/10/15, the hospital was informed of the patient's previous attempts of self harm to include self strangulation, toxic ingestion of lethal amounts of medications and chemical ingestion to include flea spray, hand sanitizer and burn relief cream. Patient #12 also reported "cheeking" medications and confirmed upon admission s/he remained suicidal. Per review of hospital policy Administration and Scheduled Time of Medication, last reviewed 01/2015, states: IV. Mouth Checks--Standard & Advanced : "Mouth check - the act of visually inspecting the inside of the patient's mouth after a medication has been administered". The Treatment Team and assigned physician have the option of maintaining Standard Mouth Checks or Advanced Mouth Checks. With Advanced Mouth Checks the patient is monitored more closely by nursing staff and is initiated "For patients considered at high risk for cheeking/ palming/not taking meds according to policy". A Nursing Progress note states on 11/13/15 during the evening shift Patient #12 reported s/he "....planned to overdose. Pt handed staff a cup with dissolved pills in it with some water. Pt. stated that this was three nights worth of medication. Pt stated s/he took pills and spit them into water as s/he took them". Despite Patient's #12 previous history of cheeking medications, Advanced Mouth Checks were not ordered by the physician until after this incident had occurred. Per interview on 11/18/15 at 2:40 PM, the attending physician confirmed s/he should have placed Patient #12 on Advanced Mouth Checks at the time of admission.

In addition, there was also a failure of the Treatment team to assess if Patient #12 met criteria for the safe use of a ThermaCare heat wrap (a disposable over-the-counter wrap used for treatment associated with muscle & joint pain). Despite Patient #12's recent history of toxic ingestion, on 11/14/15 a ThermaCare wrap was ordered to treat the patient's complaints of back pain. Upon being informed on the evening of 11/14/15 s/he would continue to be assigned to ALSA (low stimulation area) due to the patient's ongoing expressions of depression and thoughts of wanting to die, Patient #12 went into her/his bedroom and broke open the ThremaCare wrap and ingested part of the contents which contains iron. Hospital staff followed up with Poison Control, and the ingestion was not lethal. Per interview on the afternoon of 11/17/15, the Chief Medical Officer confirmed the use of ThermaCare wraps requires a more comprehensive safety assessment for each individual patient prior to application.

Based on staff interview and record review nursing failed to revise the care plan to reflect goals and interventions identified to meet the needs of 1 patient who was diagnosed with a new medical condition. (Patient #32). Findings include:


Per record review Patient #32 was admitted on 10/9/15 for evaluation and treatment of a psychiatric disorder. On 11/10/15 the patient, who was preparing for upcoming discharge, was identified with an elevated fasting blood sugar level requiring use of insulin by injection to help lower the level. Although the patient's discharge was delayed and s/he remained hospitalized for an additional 6 days to stabilize the newly diagnosed diabetes, his/her care plan had not been revised to reflect goals and interventions to address this identified issue. The Nurse Manager of the unit on which the patient resided confirmed, during interview on the morning of 11/19/15, that the care plan had not been revised to reflect the patient's current status and needs.

Based on observation, and staff interview, the Director of Food Services failed to assure the hospital food services were effectively managed in regards to kitchen sanitation and infection control measures. Findings include:

Per observation during an initial tour of the kitchen accompanied by the Director of Food Services on 11/16/2015 at 10:30 AM, a bag of cooked bacon was stored unlabled and undated in the freezer and a vat of yellow foodstuff was stored undated and unlabeled in the refridgerator. Per interview, The Director of Food Services confirmed that open containers of food should be labeled and dated when stored.

Per observation at 3:45 PM on 11/18/15, accompanied by the Director of Infection Control, a Dietary Aide was observed assembling a sandwich wrap without wearing gloves. When asked if s/he should be wearing gloves, the staff person state that s/he knew that s/he should be wearing gloves and usually does wear gloves. Per interview, the Director of Infection Control and a Registered Dietitian who was present confirmed all staff should wear gloves when preparing food.