HospitalInspections.org

The facility failed to protect and promote the rights of it's patients as evidenced by:
failed to ensure that the patient's family or representative are notified promptly of hospital admissions (A 133); they failed to provide a safe setting for the patients (A 144).

Based on record review, interview and policy review the facility failed to ensure that the patient's family or representative are notified promptly of hospital admissions. Findings include:

Review of patient #4's record on 01-06-10 revealed that on 2 different occasions ( 06-18-09 & 6-28-09) the patient was transferred to the hospital. Review of nursing documentation for 06-18-09 & 06-19-09, revealed that there was no entry documented for notification of patients's family regarding the patient's transfer. On 06-28-09 patient was transferred to the hospital and admitted per nursing documentation at 8:00 AM. There is no entry documenting notification of family.

Interview with the Director of Nursing on 01-07-10 at 10:00 AM, confirmed that when a patient is sent to the hospital the family is supposed to be notified of the transfer unless the patient requests otherwise.

Facility policies were not followed in regards to making the family aware of a patient's transfer to the hospital. Policy 2.10 "Emergencies arising within the hospital" states: "When a patient requires emergency medical treatment, the Nurse/Attending Psychiatrist, will contact the patient's family as soon as possible, but no more than 24 hours. ....the nurse will document actions in the patient's medical record".

Based on observation, interview and record review the nursing staff failed to monitor and assess the patients to ensure a safe environment for that patient in 11 of 31 charts reviewed (#4, #5, #6, #14,#17,#19, #21, #24, #25, #26 and #31.) Findings include:

On 1/6/10 at 9:30 am patient #4,#5,#6, #14,#17, #19, #21,#24,#25,#26,#31, records were reviewed.

Patient #4:
The patient was admitted on 5/27/09. Patient #4's record revealed a physicians's order dated 5/27/09 to check vital signs per protocol (every shift for three days). Review of the document titled "Flowsheet-Vital Signs & Meals" indicated that admission vital signs were taken on 5/27/09 at 5:30 a.m. Vital signs were documented only one time each day on 5/29/09, 5/30/09, 6/02/09. The patient was started on a new blood pressure medication on 6/14/09. Vital signs were not monitored and the patient started falling on 6/14/09 x 2 in one half an hour. Then again on 6-19-09 that resulted in a facial injury. These findings were verified by the Director of Nursing.

Also for Patient #4, it was determined during record review that on 06-16-09 @ 4:00 PM, Social Worker #1 was informed by the patient ' s sister during a family session that the patient has had allergic reactions to Haldol in the past. Despite this notification, Patient #4 continued to receive Haldol until 06-19-09 2:00 PM, when Social Worker #2 reported the notation of allergy to the Psychiatrist and Director of Nursing.


Patient #5:
The patient was admitted on 6/30/09. Patient #5's record revealed a physicians's order dated 6/30/09 to check vital signs daily. Review of the document titled "Flowsheet-Vital Signs & Meals" indicated that admission vital signs were taken on 6/30/09 at 4:20 A.M No other vital signs were documented for the patient until 7/2/09 on the afternoon shift. This was the last set of vitals taken. The patient was discharged on 7/03/09 at 1.34 p.m.. These findings were verified by the Director of Nursing.

Patient #6:
The patient was admitted on 6/13/09. Patient #6's record revealed a physicians's order dated 6/13/09 to check vital signs per protocol. Review of the document titled "Flowsheet-Vitals & Meals" indicated documentation of admission blood pressure and pulse taken on 6/13/09 at 5:30 p.m. and no other vital signs were documented again until 6/25/09. These findings were verified by the Director of Nursing.

Patient# 14:
The patient was admitted on 6/13/09. Patient #6's record revealed a physicians's order dated 6/13/09 to check vital signs per protocol (every shift for three days). Review of the document titled "Flowsheet-Vitals & Meals" indicated documentation of admission blood pressure and pulse taken on 6/13/09 at 5:30 p.m. and no other vital signs were documented again until 6/25/09. These findings were verified by the Director of Nursing.

Patient #17 had an order for Diazide 37.5/25 mg once daily, with the direction to hold the medication for a systolic blood pressure reading below 110. Nursing did not document patient #17's blood pressure on 12/28/09, 12/29/09, 12/30/09 or 12/31/09. Nurse #4 verified these findings.

Patient #19 did not receive any medications on 1/1/10 except for a 2 mg. injection of Ativan The first documentation of any attempt to obtain a list of the patient's pre-admission medications was noted at 1/1/10 at 9:10 PM. These findings were verified by RN #3. The facility "Vital Signs and Meals Flowsheet" was completed only once on 1/1/10 and Nursing notes for 1/1/10 contained no documentation of vital signs.

Patient# 21:
The patient was admitted on 6/02/09. Patient #21's record revealed a physicians's order dated 6/02/09 to check vital signs per protocol. Review of the document titled "Flowsheet-Vitals & Meals" indicated documentation of admission vital signs taken on 6/03/09 at 12:00 a.m. Vital signs were not documented for each shift for three days after admission per policy. These findings were verified by the Director of Nursing.

Patient# 24:
The patient was admitted on 7/30/09. Patient #24's record revealed a physicians's order dated 7/30/09 revealed "CNO (Close Nursing Observation) for a recent abdominal surgery due to a peptic ulcer. Review of the document titled "Flowsheet-Vitals & Meals" indicated that there was no documentation on the amount of caloric intake, how the post surgical site looked, signs or symptoms of another bowel obstruction, no assessment of determination if the wound was well approximated, & were there any signs or symptoms of infection. The documentation did not reflect "Close Nursing Monitoring for Stomach ulcer". The patient was discharged on 8/1/09. These findings were verified by the Director of Nursing.

Patient #25:
The patient was admitted on 7/12/09. Patient #25's record revealed a physicians's order dated 7/13/09 to check vital signs per protocol. Review of the document titled "Flowsheet-Vitals & Meals" indicated documentation of admission vital signs taken at 1:15 p.m. The next set of vitals were taken on 7/17/09 at 9:12 a.m. five days after admission. No other vital signs were documented and the patient was discharged on 7/20/09 at 2:00 p.m.. These findings were verified by the Director of Nursing.

Patient #26:
The patient was admitted on 7/10/09. Patient #26's record revealed a physicians's order dated 7/10/09 to check vital signs per protocol (every shift for three days). Review of the document titled "Flowsheet-Vitals & Meals" indicated documentation of admission vitals were taken on 7/10/09 at 1:00 p.m. There was only one more set of vitals taken on 7/15/09 and the patient was discharged on 7/17/09 at 1:22 p.m.. These findings were verified by the Director of Nursing.

Patient #31:
The patient was admitted on 7/12/09. Patient #31's record revealed a physicians's order dated 7/12/09 was to check vital signs per protocol (every shift for three days). Review of the document titled "Flowsheet-Vitals & Meals" indicated documentation of admission vital signs taken on the afternoon shift, but not dated or timed. Vital signs were taken only three more additional times during the patients hospitalization. The patient was discharged on 7/17/09 at 1:22 p.m. These findings were verified by the Director of Nursing.

Facility policies were not followed in providing patient care. Policy 2.10 states: "Every patient who is admitted to BCA StoneCrest Center with a known diagnosis of diabetes will have their blood sugar tested by glucometer upon admission to the unit." It also states that the facility will: "Monitor glucose level as ordered by the physician." Policy 2.24 states: "A physical examination will be done within 24-hours of admission as an inpatient." Policy 2.18 states: "Vital signs are obtained and recorded for three consecutive days on all shifts admission to BCA and documented on the flow sheet."

It was determined the facility failed to assess and monitor the patients according to the physicians orders and hospital policies (see A-392); failed to ensure that the nursing staff develops and keeps current nursing care plans (see A-396) and failed to ensure that contract nurse's were oriented to hospital policies and procedures (see A-398).

Based on observation, interview and record review the facility failed to assess and monitor patients to provide for the nursing care setting for 11 of 31 patients reviewed (#4, #5, #6, #7, #17,#19, #21, #24, #25, #26 and #31.) Findings include:

On 1/7/10 at 9:30 am patient #17's record was reviewed with Registered Nurse (RN) #4. The patient was admitted on 12/26/09 with diagnoses of diabetes mellitus and hypertension. Review of patient #17's record revealed a physician's order dated 12/27/09 to check blood sugars twice daily. Review of the Medication Administration Record (MAR) indicated that there was no documentation to show that the blood sugars were completed according to the physicians orders on 12/29/09 and 12/30/09 and only one documented blood sugar check was done on 12/31/09, 1/2/10, 1/3/10, and 1/4/10. These findings were verified with Nurse #4.

Patient #17 had an order for Diazide 37.5/25 mg once daily to be taken by mouth,, with the direction to hold the medication for a systolic blood pressure reading below 110. Nursing did not document patient #17's blood pressure on 12/28/09, 12/29/09, 12/30/09 or 12/31/09. Nurse #4 verified that that blood pressures were not documented by nursing on these dates.

On 1/6/10 at approximately 10 am, review of patient #19's record revealed that the patient was admitted on 12/31/09 with diagnoses of diabetes mellitus, obesity, asthma, sleep apnea, hypertension and pacemaker insertion. Documentation of a pre-admission blood sugar was not included in the medical record. The first blood sugar check was done on 1/1/10 at 6:16 pm. Patient #19's History and Physical was completed on 1/2/10 at 11 am, 36 hours after admission.

The first documentation of any attempt to obtain a list of the patient's pre-admission medications was noted at 1/1/10 at 9:10 pm. Patient #19 did not receive any medications on 1/1/10 except for a 2 mg. injection of Ativan. The facility "Vital Signs and Meals Flowsheet" was completed only once on 1/1/10 and nursing notes 1/1/10 contained no documentation of vital signs. These findings were verified by RN #3.

Facility policies were not followed in providing patient care. Policy 2.10 states: "Every patient who is admitted to BCA StoneCrest Center with a known diagnosis of diabetes will have their blood sugar tested by glucometer upon admission to the unit." It also states that the facility will: "Monitor glucose level as ordered by the physician." Policy 2.24 states: "A physical examination will be done within 24-hours of admission as an inpatient." Policy 2.18 states: "Vital signs are obtained and recorded for three consecutive days on all shifts admission to BCA and documented on the flow sheet."

Based on record review, policy review and interview the facility failed to ensure that the nursing staff develops and keeps current nursing care plans. Findings include:

On 1/7/10 at 9:30 am patient #17's record was reviewed with Registered Nurse (RN) #4. The patient was admitted on 12/26/09 with a diagnoses of diabetes mellitus. Further review of patient #17's record revealed a physicians's order dated 12/27/09 to check blood sugars twice daily but the "Master Treatment Plan" did not contain a care plan for monitoring blood sugar. These findings were verified with Nurse #4.

On 1/7/10 at approximately 1 pm patient #30's closed record was reviewed. The Nursing Comprehensive Assessment completed upon admission (7/10/09) revealed that the patient rated his pain as moderate- severe, "hurts a whole lot." He described the pain as "sharp, burning" and present all the time. The assessment included a history of 3 knee surgeries. The patient's History and Physical included diagnoses of herniated discs and Diverticulitis. His Medication Administration Record (MAR) documented the use of Lorcet, Vicodin, Norco and Tylenol for pain. The record contained no plan of care for pain control. On 1/7/10 at approximately 1:15 pm the Director of Nursing verified that the record did not contain a pain care plan and stated, "he should have had a care plan for pain." Facility policy 2.08 states: "When pain is identified on the pain assessment, the RN/Physician must include this as a problem on the patients Master Treatment Plan." The policy does not state whether a care plan with patient specific interventions will be completed or if the problem will simply be listed.

Facility policy 2.01 states that Registered Nurses will "Develop a nursing care plan with specific goals and interventions delineating nursing actions unique to each client's physical and emotional needs."


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During record reviews on 01-06-10 and 01-07-10, 3 closed records that were reviewed (#s 4, 29 and 30) and 2 open records that were reviewed (#s 11 and 17) all contained incomplete nursing care plans. Additionaly:

1) Patient #4's care plan did not address patient's diagnosis of hypertension and the care plan for falls added 06/19/09 and did not contain any information in the intervention section about the use of the 1:1 staff that was assigned to the patient.

2) Review of patient #11's chart, who was admitted on 01-05-10 had a care plan started on 01-05-10 addressing "Potential for Injury to others R/T Threatening/Aggressive Behavior" however, the patient was admitted per record documentation for attempting to harm self.

3) Review of patient #29's care plan did not address the diagnosis' of hypertension or asthma that were noted on the admission assessment.

Interview with the Director of nursing took place on 01-07-10 at 2:00 PM. The Director confirmed that the nursing care plans should contain care plans for medical conditions as well as psychiatric conditions and that they should be accurate, complete and kept current.

Based on interview and record review the facility failed to ensure that contract nurse's were oriented to hospital policies and procedures or evaluated for 2 of 2 contract nurses reviewed. Findings include:

On 1/7/10 at 10:35 am, employee records of 2 contract (agency) nurses (Nurse #1 and Nurse #2) were reviewed with the Human Resources Assistant. No documentation of any orientation to the facility was contained in their files. The Director of Nursing was unable to locate any documentation either. The Director of Nursing stated, "They should be oriented and evaluated."