HospitalInspections.org

20638

Based on record review and interview the hospital failed to ensure patients received care in a safe setting by:
1) failing to ensure a patient under a Physician's Emergency Certificate for suicidal ideation, identified as a "flight risk (elopement risk)", was provided with enough staff to safely escort the patient from the hospital to the transport vehicle for transfer to a recipient hospital for psychiatric treatment, which resulted in the patient's elopement from the sending hospital (Our Lady of the Lake) for 1 of 10 Emergency Department psychiatric patients reviewed out of a total sample of 31 (#12).
2) failing to ensure a patient presenting to the Emergency Department with command hallucinations instructing him to harm himself was provided a safe environment that did not afford the patient the opportunity for obtaining hazardous items that could be used for self harm which resulted in the patient obtaining two needles for 1 of 10 Emergency Department psychiatric patients reviewed out of a total sample of 31 (#6). Patient #6 swallowed one of the needles.
Findings:

1) The Medical Record for Patient #12, age 19, was reviewed. Patient #12 was triaged to the Emergency Department on 12/16/2011 at 1704 (5:04 p.m.) with a presenting problem documented as, "pt. (patient) brought in by (Local Sheriff's Department) stating family saw pt. take multiple Adderall pills and drink drain cleaner. . ." Review of the medical record revealed Patient #12 was placed on a PEC (physician emergency certificate) by the ED (Emergency Department) physician on 12/16/11. Documentation revealed that Patient #12 was positive for suicidal ideation and in need of immediate psychiatric treatment in a treatment facility. Documentation revealed that Patient #12 was to be transferred to a local psychiatric hospital. Review of Patient #12's Nursing Notes dated 12/16/2011 at 2106 (9:06 p.m.) revealed in part, " discussed pec (Physician's Emergency Certificate) status with pt. (patient). Pt. agitated and talking in loud voice, but cooperative" , and at 22:50 (10:50 p.m.) " notified pt (patient) that going to (local Psychiatric Hospital) . . . Pt. agitated and does not want to be admitted. Level 2 observation still in place. " , and at 2310 (11:10 p.m.), "Pt. agitated and does not want to be admitted." Review of Nursing documentation on 12/16/2011 at 2335 (11:35 p.m.) revealed in part, " (Transport staff) to bring pt to (local Psychiatric Hospital). Notified (Transport Staff) and security that pt (patient) was flight risk and must be escorted out to car with security guard. (Transport staff) verbalized understanding." Nursing documentation dated 12/16/2011 at 2340 (11:40 p.m.) revealed in part, " (Transport staff S57) came back into ER stating pt. (patient) had fled when he (Patient #12) had gotten to the car. (Transport staff S57) stated she (S57) was the only person escorting the pt. out to the car after she was (S57) told that security needed to go with her due to pt. (#12) being a flight risk. (Transport staff) states deputy and security are out looking for the pt. . . "

During a face to face interview on 12/22/2011 at 9:37 a.m., Registered Nurse S25 indicated she (S25) had been the nurse assigned to the care of Patient #12 when he eloped on 12/16/2011. S25 indicated she had just begun her shift when the incident occurred with Patient #12's elopement. S25 indicated she had received report from the off going nursing staff that Patient #12 had been a "high flight risk". S25 further indicated that she had left report and immediately went into the room of another patient, that was medically ill, due to the patient's need for immediate attention. S25 indicated Registered Nurse S31 had approached her (S25) to inform her of the arrival of the Contracted Transport Agency to transport Patient #12 to the accepting Psychiatric Hospital. S25 indicated she (S25) informed Registered Nurse S31 that Patient #12 was a high flight risk and needed to have a Security Officer accompany the Transport Staff from the hospital to the Transport vehicle.

During a face to face interview on 12/22/2011 at 1:10 p.m., Registered Nurse S31 indicated she (S31) had been assisting Registered Nurse S25 at the time of Patient #12's elopement on 12/16/2011. S31 indicated S25 had been busy with a medically ill patient at the time of arrival of the hospital's Contracted Transport Service. S31 indicated she (S31) instructed the Transport Staff (S57) and Security (S34) that Patient #12 was a high flight risk and needed to have both Security and the Transport Staff accompany him (#12) to the transport vehicle. S31 indicated both staff acknowledged understanding of her instructions. S31 indicated she (S31) left patient #12 in the care of Transport Staff S57 and Security Officer S34 to attend to another "sick" patient. S31 indicated she (#31) had not been present when Patient #12 had eloped.

During a face to face interview on 12/27/2011 at 9:50 a.m., Security Officer S34 indicated he (S34) had been sitting with Patient #12 on 12/16/2011 from 1815 (6:15 p.m.) to 2330 (11:30 p.m.). S34 indicated he (S34) had informed nursing staff that Patient #12 had been a flight risk, due to statements made by Patient #12 about not wanting to be admitted to a psychiatric hospital and demanding to be let go. S34 indicated he (S34) was observing two patients in the psychiatric holding area on 12/16/2011, one of which was Patient #12 (confirmed with record reviews). S34 indicated he (S34) would not have been able to abandon the care of the other psychiatric patient to escort Patient #12 to the transport vehicle. S34 indicated he (S34) had turned the care of Patient #12 over to a nurse (unsure of name) at the time transport services arrived. S34 indicated the nurse should have called Dispatch to request another Security Guard to assist the Transport Staff in escorting Patient #12 to the transport vehicle. S34 further indicated that he (S34) had never heard anyone provide instructions to himself or to the Transport Staff that Patient #12 should be accompanied by two staff; Security and Transport Staff, from the hospital to the Transport Vehicle.

During a face to face interview on 12/28/2011 at 9:10 a.m., Divisional Director of Emergency Department S3 indicated Security should call for back up and/or relief as needed. S3 further indicated if the Security Officer was not able to call for back-up, the Security Officer should have alerted the nurse to ensure she (nurse) made contact with the Dispatch Unit. S3 indicated the nurse is ultimately responsible for the care of the patient. S3 indicated there should always be clear communication between nursing staff and security officers to ensure assignment of duties was understood by both. S3 confirmed a failure of clear communication had occurred between the hospital's Security Guard S34 and Registered Nurse S31 since each thought the other was responsible for calling Dispatch to request assistance with Patient #12's transport.

During a face to face interview on 12/28/2011 at 10:00 a.m., Security Director S50 indicated he (S50) oversaw the hospital's security department and contracted security officers. S50 indicated all officers did not have radios for communication. S50 indicated the assignment of radios would not include security officers sitting with psychiatric patients. S50 further indicated any officer sitting with more than one psychiatric patient would not be able to leave his post for another assignment. S50 indicated it would be the responsibility of the nurse providing care to the patient to contact Dispatch for additional officers as needed.

Contracted Transport Officer S57 was not available for interview due to termination of employment.

Review of written statements obtained by the hospital's Quality Assessment Performance Improvement Department; as part of their ongoing investigation of the incident regarding Patient #12's elopement, revealed a statement had been obtained by the contracted Transporter S57 who could provide no explanation as to why she alone escorted Patient #12 from the hospital to the transport vehicle. Further documentation revealed there had been no call made to Dispatch to request the services of additional Security for transport. Patient #12 had never been located or returned to the hospital.

Review of the hospital policy titled, "Physician's Emergency Certificate Observation and Monitoring of Behavioral Patients" last revised 10/21/2011 " revealed in part, "Observation monitoring of psychiatric patients is delegated from RN (Registered Nurse) to appropriate unlicensed staff and RN retains accountability and supervision. . . Level 1- 1:1 Observation: The patient is observed on a 1:1 staff/patient ratio when clinical assessment indicates a high level for immediate or impulsive behavior that may be harmful to self or others exists. . . 1:1 Observation includes the following elements:
1:1 staff accompaniment (at arm ' s length) is required at all times, including times for personal hygiene, toileting and other self care needs
The staff member assigned to perform 1:1 observation should be of the same sex as the patient, as the staffing pattern allows. If this is not possible, arrangements should be made for same sex staff to accompany the patient during times of personal hygiene, toileting and other self care needs.
Access to sharps, razors, belts, cords, laces or other items which may increase risk should be denied.
Meals are provided on the unit and in the company of staff. Utensils and serving trays are disposable, with all utensils accounted for prior to disposal.
Visitation may be restricted at the physician's or nurse's discretion.
Patient may leave unit for medical consult/testing by physician order. Staff member must be arms length when accompanying patient.
A 1:1 observation patient means there can never be more than one patient watched by one observer. In other words, one staff member may never monitor more than one patient.
Level 2 - Constant Observation is less restrictive than 1:1 Observation and requires the patient to be in full visual contact by a trained staff member at all times. Up to 4 patients may be clustered in a defined area supervised by 1 staff member, as per patient and unit needs. Constant Observation includes the following elements.
The patient should be within visual range of the assigned staff at all times.
During times for personal hygiene, toileting and other self care needs, the staff maintains visual contact (direct line of sight) of the patient while keeping bathroom door ajar. When necessary, arrangements should be made for same sex staff to accompany the patient during times of personal hygiene, toileting and other self care needs.
Access to sharps, razors, belts, cords, laces or other personal items which may increase risk should be denied."

Review of the hospital policy titled, "Elopement" last revised June 6, 2011" revealed in part, "Staff may detain any patient attempting to leave a Mental and Behavioral Health unit or the hospital facility or grounds who is on one of the following legal statuses: Formal Voluntary Admission to a MBH unit (Medical Behavioral Health), Order of Protective Custody, Valid Physicians Emergency Commitment, Valid coroners Emergency commitment, Judicial commitment for mental health or substance abuse treatment. Patient admitted on an above noted Legal Status: Patient attempting to leave or missing. If patient is attempting to leave or the patient is seen leaving, a staff member is to call a "Code White" for additional assistance and to attempt to deescalate the situation. If patient is missing a "Code White" is not called. If efforts by the staff are unsuccessful in keeping the patient on the unit or on the hospital grounds, or if the elopement was not witnessed by staff, the charge nurse or designee will immediately contact the following: a. Security, b. East Baton Rouge Parish Sheriff's office, Baton Rouge cite Police - A copy of the legal hold documents will be faxed to law enforcement. c. House Manager and Page Operator who will notify the Hospital Administrator on Call and Risk Management. d. In addition, for MBH (patient: Nurse Manager or Nurse Manager on Call, e. Attending Physician or physician on call for the attending physician. f. all contact numbers available in the patient record. A complete description of the patient, including clothing being worn at the time the patient was last seen, is to be provided to people notified who will be searching for patient. If the patient who has eloped is not discharged until an order is received from the attending physician. A description of the events including the patient's behavior, interventions employed, notification of physician and others, and other pertinent information, including specific times is documented in the patient care notes and on a safety even report. . .

2) The Medical Record for Patient #6 was reviewed. Patient #6 was admitted to the hospital's Emergency Department on 12/15/2011 and transferred to the Psychiatric Department of the hospital from the Emergency Department on 12/16/2011 under a Physician's Emergency Certificate dated and signed 12/15/2011 at 2345 (11:45 p.m.) which indicated "Auditory Hallucinations, Etoh (alcohol) intoxication, Poly-substance Abuse. Homicidal Ideations." Further review revealed a Coroner's Emergency Certificate was completed on Patient #6 on 12/17/2011 at 1200 (12:00 p.m.). Patient #6 was triaged by Registered Nurse S25 on 12/15/2011 at 2005 (8:05 p.m.) with presenting problem documented as, "Pt (patient) states he is hearing voices to harm himself. + ETOH (positive alcohol). Drank 1 quart of liquor today." and Acuity level Assessed as "2 (Emergency/High Risk situation- Patient requires definitive care. A multi-member team responds to the patient with a high risk condition.)."

Review of Patient #6's "Behavioral Patient Observation Record revealed Patient #6 was checked as Observation Level 1:1 Observation (Arm's Length) with 15 minute documented observations from 12/15/2011 at 2015 (8:15 p.m.) through 12/16/2011 at 2330 (11:30 p.m.). Review revealed Patient #6 was observed by Nurse Tech S33 with 15 minute documented observations from 12/15/2011 at 2030 (8:30 p.m.) through 2245 (10:45 p.m., Security Officer S34 from 12/15/2011 at 2300 (11:00 p.m.) through 12/16/2011 at 0630 (6:30 a.m.), Security Officer S37 from 12/16/2011 at 0645 (6:45 a.m.) through 1130 (11:30 a.m.), Security Officer S47 on 12/16/2011 at 11:45 a.m., Security Officer S47 from 12/16/2011 at 1200 (12:00 p.m.) through 1230 (12:30 p.m.), Security Officer S26 from 12/16/2011 at 1245 (12:45 p.m.) through 1745 (5:45 p.m.), and Security Officer S29 from 12/16/2011 at 1800 6:00 p.m.) through 2330 (11:30 p.m.).

Review of Patient #6's electronic medical record revealed the patient was assessed by nursing staff as "Moderate Risk to Self " at the time of triage on 12/15/2011 at 2005 (8:05 p.m.), 12/16/2011 at 0227 (2:27 a.m.), and 12/16/2011 at 0648 (6:48 a.m.).

Further review revealed Patient #6 swallowed a needle while in the Emergency Department under constant 1:1 visual observations. Record review as follows:

Review of ED (Emergency Department) Physician Notes for Patient #6 revealed in part, "12/15/2011 at 2050 (8:50 p.m.), History of Present Illness: The patient presents with emotional disturbance. Pt. (Patient) stated that he is hearing voices to harm himself. . . General: Uncooperative, solnolent (somnolent) male, unresponsive to needle sticks and catheterization. . . Patient Care: Elopement Precautions, Suicide Precautions " , "12/16/2011 at 1756 (5:56 p.m.), Patient is going to his inpatient bed. . ." , "12/16/2011 at 1757 (5:57 p.m.), Patient apparently said that he swallowed a needle that he broke in half. I am not sure how or where he got the needle. He has had one on one security observation.", and "12/21/2011 at 0014 (12:14 a.m.): Addendum: Pt. was eventually admitted to psych under a pec - has had numerous pseudo-seizure and patterns of atypical weakness not consistent with stroke- he ate a needle which was unable to be scoped and he will be followed by GI on a as needed basis- the endoscopy in the ED did not show the needle- likely down to colon ; apparent there on X-ray- pt. was then admitted to psych."

Review of Patient #6's ED (Emergency Department) Nurses Notes revealed in part, "12/16/2011 at 1901 (7:01 p.m.), upon discharge from room, pt. in wheelchair- still under level 1 observation. Pt. threw a butterfly (without needle) and a cathelon retractable jelco on floor. . . pt. states he swallowed needles. (Physician) notified and pt escorted to x-ray."

Review of Patient #6's medical record revealed needles would have been brought into the room as follows:

Review of Patient #6's medical record revealed the patient had lab drawn on 12/15/2011 at 9:15 p.m., an Intravenous Heparin Lock begun on 12/15/2011 at 2110 (9:10 p.m.) and an Intravenous Heparin Lock restarted on 12/16/2011 at 1848 (6:48 p.m.).

During a face to face interview on 12/20/2011 at 12:00 p.m., Emergency Department Nursing Supervisor S30 indicated the practice in the Emergency department for patients that were assessed as a Moderate Risk for Self Harm was to allow the patient to remain in a fully stocked room with staff present at all times for visual monitoring of the patient. S30 indicated most psychiatric patients would be placed in the Psychiatric Holding room which had no equipment, only reclining chairs. S30 further indicated patients that were in need of medical attention and/or acting out aggressively would be placed in a treatment room. S30 indicated treatment rooms were not to be stocked with sharps/needles or hazardous solutions at any time regardless of whether there was a psychiatric patient placed in the room. S30 indicated Patient #6 had been placed in a Treatment/Exam Room due to having an altered level of consciousness upon arrival and later acting out aggressively.

During a face to face interview on 12/22/2011 at 10:50 a.m., Registered Nurse S27 indicated the practice in the Emergency Department for patients assessed as Moderate Risk for Self Harm was to ensure a trained staff member (nurse, security, or tech) was assigned to monitor the patient. S27 indicated the equipment and stock could remain in the room if the patient was assessed as Moderate Risk. S27 indicated a patient that had been assessed as High Risk would be placed in a room that had been stripped of all equipment and supplies in addition to having staff member assigned to Constant Visual monitoring of the patient. S27 indicated there was never to be needles, syringes, or hazardous material stocked in any treatment room at any time. S27 further indicated that although the practice in the hospital was to clear the room for High Risk patients and leave it equipped for Moderate Risk patients, he (S27) thought it would be safer to strip the room for all psychiatric patients being held in the Emergency Department.

During a face to face interview on 12/22/2011 at 9:05 a.m., Registered Nurse S23 indicated she (S23) admitted Patient #6 to Room C11 on 12/15/2011. S23 indicated she (S23) made the patient a Level I which indicated the patient would be assigned 1:1 staff for constant visual observation at arms length at all times. S23 further indicated she (S23) also assessed the patient as Moderate Risk for Self Harm. S23 confirmed that Patient #6's presenting complaint was of auditory hallucinations instructing him to harm himself. S23 indicated she (S23) made a visual inspection of the room but did not pull out drawers to check for supplies. S23 indicated there should never be needles/syringes stocked in any room. S23 indicated she did not remove anything from the room. S23 further indicated Patient #6 was non-responsive to painful stimulation when he first arrived and therefore needed a cardiac monitor and automated blood pressure monitoring device. S23 indicated she had seen no needles or sharps lying on the counter tops or in direct visual observation of the room (she had not searched the cabinets or drawers).

During a face to face interview on 12/22/2011 at 1:20 p.m., Registered Nurse S32 indicated she (S32) had been assigned to the care of Patient #6 on 12/16/2011 from 7:00 a.m. through 7:00 p.m. when the patient (#6) reported that he (#6) had swallowed a needle. S32 indicated she (S32) had already called report to the Psychiatric Unit; where Patient #6 had been admitted, when the patient (#6) threw something on the floor and said that it belonged in the sharps container. S32 indicated Patient #6 had thrown half of a butterfly, with the needle missing, and one intravenous catheter, with the needle intact, onto the floor. S32 further indicated Patient #6 told her (S32) he (#6) had swallowed a needle. S32 indicated she (S32) had no idea where Patient #6 had obtained the two needles and never asked him (#6) where or how he (#6) got the needles. S32 indicated the physician was notified and the patient was immediately sent to X-ray where the films confirmed that Patient #6 had ingested a needle. S32 indicated Patient #6 had been under 1:1 observation at all times and she (S32) could not imagine how he (#6) had obtained two needles. S32 indicated she (S32) had never performed a sweep of the room to ensure the room was free of sharps. S32 indicated the room was not supposed to be stocked with any sharps.

During a face to face interview on 12/27/2011 at 5:00 p.m., Physician S27 indicated he had been the Emergency Department physician providing care to Patient #6 when the patient reported that he had swallowed a needle. S27 indicated he had no knowledge as to how the patient had obtained two needles. S27 indicated the patient (#6) had been crying about swallowing the needle; however, never disclosed where or how he (#6) had obtained the needles. S27 indicated Patient #6 had been under 1:1 Constant Visual Observation and should not have had access to a needle. S27 indicated it was certain that Patient #6 did have access to needles and had ingested a needle while under the care of Emergency Department Staff on 12/16/2011.

Interviews were conducted with Nurse Tech S33 on 12/27/2011 at 9:25 a.m., Security Officer S34 on 12/27/2011 at 9:50 a.m., Security Officer S37 on 12/27/2011 at 10:40 a.m., Security Officer S47 on 12/28/2011 at 8:40 a.m., Security Officer S36 on 12/27/2011 at 10:20 a.m., Security Officer S26 on 12/27/2011 at 10:20 a.m., and Security Officer S29 on 12/22/2011 at 11:10 a.m. S26, S29, S34, S36, S37, and S47 indicated Patient #6 had been under Constant Visual Observation when they had been assigned to his care. All interviewed indicated the patient had been in paper scrubs while assigned to their care. All interviewed indicated they had no knowledge of how the patient would have obtained two needles for ingestion. All interviewed indicated they had never observed any opportunities for the patient to have obtained a needle. All interviewed indicated psychiatric patients were not to have needles in their possession.

During a face to face interview on 12/28/2011 at 10:30 a.m., Patient Safety Coordinator S51 indicated no psychiatric patient should have access to a needle in the Emergency Department. S51 indicated all psychiatric patients should have their personal belongings removed and be placed in paper scrubs. S51 confirmed that Patient #6 had two needles in his possession while in the Emergency Department. S51 indicated the needles should have been taken from the patient if he had brought them in from outside sources and at no time should a patient in the hospital be afforded the opportunity to obtain hospital supplies such as needles or any other hazardous material.

Review of the hospital policy titled, "Physician's Emergency Certificate Observation and Monitoring of Behavioral Patients, last revised October 21,2011, revealed in part, "Level I Observation (and) Level 2 Observation: Access to sharps, razors, belts, cords, laces or other items which may increase risk should be denied."

20638




25065

Based on record review and interview, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the care of each patient as evidenced by:
1) failing to perform an assessment of the patient's respiratory status prior to administering prn (as needed) respiratory medications for 2 of 2 patients' records reviewed who had orders for prn respiratory medications from a total of 31 sampled patients (#19, #25) and 2) failing to ensure a patient with command hallucinations instructing him to harm himself was assessed as "High Risk" for Self Harm as per the hospital's electronic assessment tool for Risk of Self Harm for 1 of 10 psychiatric patients reviewed out of a total sample of 31. (Patient #6)
Findings:

1)
Patient #19
Review of Patient #19's medical record revealed he was admitted on 12/19/11 to have a Right Hemicolectomy performed. Review of Patient #19's physician orders revealed an order dated 12/20/11 at 11:07am for Advair 250/50 inhalant, 1 inhalation BID (twice a day) prn (as needed) wheezing. Review of Patient #19's medical record revealed he received Advair on 12/20/11 at 12:45pm with no documented evidence of an assessment by the RN of his respiratory status that required the administration of Advair.

In a face-to-face interview on 12/21/11 at 3:45pm, RN S9 indicated she auscultated Patient #19's lungs, assessed no wheezing heard, and Patient #19 said he was "fine". S9 further indicated she administered the Advair at the request of Patient #19's daughter, but she failed to document her assessment.

Patient #25
Review of Patient #25's medical record revealed she was admitted on 12/19/11 for the administration of chemotherapy. Review of Patient #25's MAR (medication administration record) revealed she received Albuterol-Ipratropium (Combivent) inhalant, 2 inhalations as ordered every 4 hours prn as needed for wheezing (ordered 12/19/11 at 11:56am) on 12/19/11 at 1634 (4:34pm). Review of the medical record revealed no documented evidence of an assessment performed by the RN of Patient #25's respiratory status that warranted the use of the prn Albuterol inhalant.

In a face-to-face interview on 12/22/11 at 9:30am, Assistant Vice-President of Nursing S8 indicated that some prn medications, such as for nausea and sleep, were entered in the computer system to trigger a nursing assessment when they were administered. S8 further indicated respiratory treatments or medications were not "tasked" to require an assessment. S8 indicated there should be a nursing assessment when an inhalant was required to be administered prn.

Review of the hospital policy titled "Patient Assessment/Reassessment", revised 08/30/10 and submitted by AVP of Nursing S8 as the current policy for assessments, revealed, in part, "...6. Each patient may be reassessed for many reasons, including the following: a. To evaluate his or her response to care, treatment, and services. b. To respond to a significant change in status and/or diagnosis or condition...".

2)
Review of the hospital's electronic medical record screen for Risk of Self Harm revealed in part, "Risk to Self: Moderate- thoughts of self harm in past 7 days, reports from others of self harm threats, presence of hallucinations or delusions or psychotic behavior. High- currently threatens self harm, current self harm plan and access to means, presence of self inflicted wounds/burns within past 7 days, reports hallucinations that instruct patient to harm self."

The medical record of Patient #6 was reviewed. Review of Patient #6's nursing triage documentation dated 12/15/2011 at 2005 (8:05 p.m.) revealed in part, "Pt. (Patient) states he is hearing voices to harm himself. + ETOH (positive alcohol). Drank 1 quart of liquor today. . ." Further review revealed Physician's progress notes dated 12/15/2011 at 2050 (8:50 p.m.) indicating, "The patient presents with emotional disturbance. Pt. stated that he is hearing voices to harm himself."

Review of Patient #6's initial assessment for Risk to Self dated 12/15/2011 at 2005 (8:05 p.m.) revealed in part, "Moderate Risk to Self" and again on 12/16/2011 at 2:27 p.m. revealed in part, "Moderate Risk to Self: Presence of hallucinations or delusions or psychotic behavior." Review revealed no documented evidence of identifying the presenting complaint of hallucinations telling him to harm himself as "High Risk".

During a face to face interview on 12/20/2011 at 12:00 p.m., Emergency Department Supervisor S30 indicated a patient that was assessed with a Moderate Risk for Self Harm would have their assigned room fully stocked; however, there would be a staff member assigned to observe the patient. S30 further indicated a patient that was assessed with a High Risk for Self Harm would have their room stripped of all equipment and supplies, with the exception of medically needed supplies, to ensure no items would be available for the patient to be able to use to harm themselves. S30 further indicated High Risk patients would also have a staff member assigned to observe them. S30 indicated there was no hospital policy that defined these Intervention Differences between patients assessed as Moderate Risk versus High Risk but that had been the practice in the Emergency Department. S30 confirmed the presence of High Risk auditory command hallucinations with self harm content were documented on Patient #6 at the time of his presentation to the Emergency Department. S30 confirmed that there had been no identification in the drop down menu for assessment of Self Harm for Patient #6 regarding the command hallucinations for self harm. S30 confirmed that Patient #6 would have been identified as "High Risk" for self harm if the symptom had been checked on the Drop Down menu.

During a face to face interview on 12/22/2011 at 10:50 a.m., Registered Nurse S27 indicated the practice in the Emergency Department for patients assessed as Moderate Risk for Self Harm was to ensure a trained staff member (nurse, security, or tech) was assigned to monitor the patient. S27 indicated the equipment and stock could remain in the room if the patient was assessed as Moderate Risk. S27 indicated a patient that had been assessed as High Risk would be placed in a room that had been stripped of all equipment and supplies in addition to having staff member assigned to Constant Visual monitoring of the patient. S27 indicated there was never to be needles, syringes, or hazardous material stocked in any treatment room at any time. S27 further indicated that although the practice in the hospital was to clear the room for High Risk patients and leave it equipped for Moderate Risk patients, he (S27) thought it would be safer to strip the room for all psychiatric patients being held in the Emergency Department.

During a face to face interview on 12/22/2011 at 9:05 a.m., Registered Nurse S23 indicated she (S23) admitted Patient #6 to Room C11 on 12/15/2011. S23 indicated she (S23) made the patient a Level I which indicated the patient would be assigned 1:1 staff for constant visual observation at arms length at all times. S23 further indicated she (S23) also assessed the patient as Moderate Risk for Self Harm. S23 confirmed that Patient #6's presenting complaint was of auditory hallucinations instructing him to harm himself (hospital's electronic menu indicated command hallucinations instructing patient to harm himself would be a high risk symptom for potential of self harm). S23 indicated she (S23) made a visual inspection of the room but did not pull out drawers to check for hidden sharps. S23 indicated there should never be needles/syringes stocked in any room. S23 indicated she did not remove anything from the room. S23 indicated she had seen no needles or sharps lying on the counter tops or in direct visual observation of the room (she had not searched the cabinets or drawers).

During a face to face interview on 12/22/2011 at 1:20 p.m., Registered Nurse S32 indicated she (S32) had been assigned to the care of Patient #6 on 12/16/2011 from 7:00 a.m. through 7:00 p.m. when the patient (#6) reported that he (#6) had swallowed a needle. S32 indicated she (S32) had already called report to the Psychiatric Unit; where Patient #6 had been admitted, when the patient (#6) threw something on the floor and said that it belonged in the sharps container. S32 indicated Patient #6 had thrown half of a butterfly, with the needle missing, and one intravenous catheter, with the needle intact, onto the floor. S32 further indicated Patient #6 told her (S32) he (#6) had swallowed a needle. S32 indicated she (S32) had no idea where Patient #6 had obtained the two needles and never asked him (#6) where or how he (#6) got the needles. S32 indicated the physician was notified and the patient was immediately sent to X-ray where the films confirmed that Patient #6 had ingested a needle. S32 indicated Patient #6 had been under 1:1 observation at all times and she (S32) could not imagine how he (#6) had obtained two needles. S32 indicated she (S32) had never performed a sweep of the room to ensure the room was free of sharps. S32 indicated the room was not supposed to be stocked with any sharps. S32 further indicated she stripped Patient #6's room of all equipment and supplies after he had ingested a needle.

Review of Patient #6's medical record revealed the nursing assessment for Self Harm was changed to "High Risk to Self (post ingestion of a needle)" on 12/16/2011 at 1906 (7:06 p.m.) with "High Risk To Self Actions/Precautions: Continuous close observation by Staff, continuous close observation by Security, Close observation by frequent checks, Remove patient's clothing and belongings from room, Check and remove sharps and container, cables, tubing, IV pole, sheet, supplies and other potentially harmful articles, Disposable food tray and utensils only, Limit visitors."

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered as ordered by the licensed practitioner for 3 of 20 patients (#3, #17, #18) reviewed for medication administration and failed to ensure that all medications orders included all required order components (time intervals) as indicated in the hospital's policy/procedure for 2 of 20 patients (#17, #19) whose medical records were reviewed for medication administration out of a total of 31 sampled patients. Findings:

Patient #3
Review of Patient #3's medical record revealed that the patient was admitted to the facility on 12/16/11 and was transferred to the MICU (Medical Intensive Care Unit) on 12/19/11 due to a change in mental status and a possible seizure. Review of the physician's orders revealed an order dated 12/19/11 for Dantrium 70 mg. IV (Intravenous) BID (Twice a day).

On 12/21/11 at 10:45 a.m., the MAR (Medication Administration Record) for 12/21/11 was reviewed with the MICU Manager, S58RN. The MAR revealed that the Dantrium was scheduled for 9 a.m. and 9 p.m. The MAR revealed that the 9 a.m. dose had not been given as ordered. S58RN MICU Manager verified that the record indicated the Dantrium was scheduled for 9 a.m. and had not been given as of 10:45 a.m. S54RN was also interviewed at this time and verified that she was assigned to Patient #3. She verified that she had not administered the Dantrium yet, and stated she was waiting on Pharmacy to send the medication.

On 12/22/11 at 10:30 a.m., the MICU Manager, S58RN was interviewed and provided the MAR for 12/21/11 for review. Review of the MAR dated 12/21/11 revealed that the 9 a.m., dose of Dantrium was administered at 11:13 a.m. on 12/21/11. S58RN MICU Manager stated that the policy for medication administration was to administer medications within one hour, 30 minutes before the scheduled time, to 30 minutes after the scheduled time. He verified that the Dantrium was not administered until 11:13 a.m., over 2 hours after the scheduled time. He stated that the pharmacy required one hour preparation time for this medication. When asked if a medication error report was documented for the late administration of the Dantrium, he stated no.

On 12/22/11 at 10:35 a.m., S54RN assigned to Patient #3 on 12/21/11 and 12/22/11, was interviewed. She verified that she did not know the pharmacy needed one hour notification until yesterday when the medication was not available when she needed it. S54RN stated that she notified pharmacy around 9:15 on 12/21/11 that she needed the medication. She verified she did not administer the medication until 11:13 a.m. on 12/21/11. S54RN verified that she had not documented this late administration of Dantrium as a medication error.

On 12/22/11 at 10:40 a.m., the MICU Manager, S58RN was interviewed. When asked how the nursing staff was informed that pharmacy needed one hour notification to prepare the medication, he stated that was communicated verbally during report between oncoming and off-going nurses. S58RN stated that they use an electronic form entitled Safety Event Report to document medication errors. He stated that he expected the RN involved in the incident to complete the form. He stated that once the Safety Event Report was completed, he reviewed the documentation, investigated the incident and forwarded the report to Risk Management and Pharmacy. He verified the Safety Event Report had not been completed for the late administration of the Dantrium.

Patient #17:
Review of Patient #17's medical record revealed she was admitted on 12/20/11 with the diagnoses of Hypertension, Hypercholesterolemia, Depression, Urinary Incontinence, and Morbid Obesity. Review of Patient #17's admission physician's orders dated 12/20/11 at 11:08am revealed an order for Protonix 40 mg (milligrams) to be administered IV (intravenous) Push daily, to be started on 12/20/11. Review of Patient #17's MAR (medication administration record) revealed Protonix was first administered on 12/21/11 at 0557 (5:57am). Further review revealed a notation on 12/20/11 of "Not Done: Patient unavailable @ (at) 1108 (11:08am)".

In a face-to-face interview on 12/21/11 at 1:50pm, RN (registered nurse) Educator S7 indicated the nurse who didn't give the Protonix on 12/20/11 at the scheduled time should have rescheduled it in the computer.

Patient #18
Review of Patient #18's medical record revealed she was admitted on 12/18/11 with the diagnosis of possible Small Bowel Obstruction. Review of Patient #18's physician orders dated 12/18/11 at 12:47pm revealed an order for Magnesium Citrate 8.85% (per cent) oral liquid 300 ml by mouth stat. Further review revealed a telephone order received on 12/18/11 at 1600 (4:00pm) to discontinue the Magnesium Citrate. Further review revealed no documented evidence why the Magnesium Citrate had not been administered stat as ordered, which was more than 3 hours before the order was received to cancel the Magnesium Citrate.

In a face-to-face interview on 12/21/11 at 2:55pm, RN Nursing Supervisor of the Surgical Unit S20 could offer no explanation for the delay in administering the stat order of Magnesium Citrate prior to the order be canceled.

Patient #17:
Review of Patient #17's physician orders for PACU (post anesthesia care unit) dated 12/20/11 at 11:12am revealed the following orders: Fentanyl 25 mcg (micrograms), 0.5 ml (milliliters) IV Slow Push prn (as needed) for pain, Titrate administered in PACU only, maximum dose equals 100 mcg (pain scale 6-10); and Morphine 2 mg IV Push prn pain, Titrate to be administered in PACU only, pain scale 1-5 or after maximum dose of Fentanyl, use morphine for pain scale 1-10, maximum dose 20 mg over one hour. Further review revealed no documented evidence of an order for the time interval between the titrated doses for Fentanyl and Morphine.

In a face-to-face interview on 12/27/11 at 11:00am, Anesthesiologist S18 confirmed a time interval was not included in the above order as required by hospital policy.

Patient #19
Review of Patient #19's physician orders for PACU dated 12/19/11 at 1413 (2:13pm) revealed the following orders: Fentanyl 25 mcg (micrograms), 0.5 ml (milliliters) IV Slow Push prn (as needed) for pain, Titrate administered in PACU only, maximum dose equals 100 mcg (pain scale 6-10); and Morphine 2 mg IV Push prn pain, Titrate to be administered in PACU only, pain scale 1-5 or after maximum dose of Fentanyl, use morphine for pain scale 1-10, maximum dose 20 mg over one hour. Further review revealed no documented evidence of an order for the time interval between the titrated doses for Fentanyl and Morphine.

In a face-to-face interview on 12/27/11 at 11:00am, Anesthesiologist S18 confirmed a time interval was not included in the above order as required by hospital policy.

Review of the hospital policy titled "Orders: Medications (Required Elements)", revised 09/07/11 and submitted by Assistant Vice-President of Nursing S8 as the current policy for elements of a medication order, revealed, in part, "...Each medication order shall include: ... Medication name, strength (and dosage form, if necessary), Directions for use (including route of administration and frequency or time interval), Each practitioner who prescribes medications must clearly state the administration times or the time interval between doses...".




25065

Based on record review and interview, the hospital failed to ensure medication variances had been completed for errors in the time of medication administration for 2 of 20 patients' records reviewed for medication administration out of a total of sample of 31 patients (#17, #18). Findings:

Patient #17
Review of Patient #17's admission physician's orders dated 12/20/11 at 11:08am revealed an order for Protonix 40 mg (milligrams) to be administered IV (intravenous) Push daily, to be started on 12/20/11. Review of Patient #17's MAR (medication administration record) revealed Protonix was first administered on 12/21/11 at 0557 (5:57am). Further review revealed a notation on 12/20/11 of "Not Done: Patient unavailable @ (at) 1108 (11:08am)". There was no documented evidence that the nurse had completed a medication variance report for the medication not being administered timely.

In a face-to-face interview on 12/21/11 at 1:50pm, RN (registered nurse) Educator S7 indicated the nurse who didn't give the Protonix on 12/20/11 at the scheduled time should have rescheduled it in the computer.

Patient #18
Review of Patient #18's physician orders dated 12/18/11 at 12:47pm revealed an order for Magnesium Citrate 8.85% (per cent) oral liquid 300 ml by mouth stat. Further review revealed a telephone order received on 12/18/11 at 1600 (4:00pm) to discontinue the Magnesium Citrate. Further review revealed no documented evidence why the Magnesium Citrate had not been administered stat as ordered, which was more than 3 hours before the order was received to cancel the Magnesium Citrate. There was no documented evidence that a medication variance report had been completed by the nurse.

In a face-to-face interview on 12/21/11 at 2:55pm, RN Nursing Supervisor of the Surgical Unit S20 could offer no explanation for the delay in administering the stat order of Magnesium Citrate prior to the order be canceled.

In a face-to-face interview on 12/22/11 at 1:15pm, Clinical Nurse Specialist S14 confirmed medication variances had not been completed for Patients #17 and #18.

Review of the hospital policy titled "Safety Event (Incident or Variance) Reporting", revised 08/04/09 and submitted by Clinical Nurse Specialist S14 as the current medication variance policy, revealed, in part, "...E. Medication Error - 1. ... A medication error is any preventable event that may cause or lead to inappropriate use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such event may be related to professional practice, health care products, procedures and systems, including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use. ... Medication Safety Event Reporting 1. Medication safety events should be reported as soon as possible to the practitioner who ordered the medication. ... 4. A Medication Safety Event Report should be filled out in Quantros by the health care worker discovering the Safety Event after the initial investigation is completed. The report should be completed in Quantros as soon as possible, but no greater than 24 hours from time of discovery. ... 8. The facility shall review all medication error reports, and use individual and aggregate information to implement improvements to the system...".

Based on observation and interview, the hospital failed to ensure medical records were stored in a manner to ensure protection from water damage in the event of fire sprinkler activation. This was evidenced by having approximately 800 medical records stored in uncovered cardboard boxes that were stacked on the floor in the medical records department. Findings:

An observation on 12/27/11 at 10:05 a.m. revealed that there were greater than 80 cardboard boxes, each containing approximately 10 medical records, stored on the floor of the medical records department in a manner that would not prevent the records from being damaged by water in the event of fire sprinkler activation. The Director of Medical Records confirmed (at the time of this observation) that there were greater than 80 cardboard boxes of medical records that were not stored in a location that would protect them from water damage in the event of fire sprinkler activation. The Director of Medical Records indicated that staff are in the process of scanning the medical records to electronic format. The Director of Medical Records indicated the medical records department had recently hired new staff members in an effort to complete the backlog of medical records that need to be scanned.

25065

Based on observation, record review and interview, the hospital failed to ensure the proper storage of biohazardous waste including containers of used sharps. Findings:

The Public Health-Sanitary Code for the State of Louisiana was reviewed. The section titled "Management of Infectious Waste, Medical Waste and Potentially Infectious Biomedical Waste", revealed "Storage of potentially infectious biomedical waste shall be in a secure manner and location which affords protection from theft, vandalism, inadvertent human and animal exposure, rain and wind".

Observation on 12/21/11 between 9:40 a.m. and 2:05 p.m. revealed the following:
-greater than 30 red biohazardous sharps containers, each containing biohazardous waste including used sharps, were noted to be unattended on a rolling cart near the elevators on the third floor of the hospital. The biohazardous wastes was not protected from theft at the time of this observation. This observation was confirmed by S15 (Divisional Director of Post Op Surgical Services).
-greater than 40 red biohazardous sharps containers, each containing biohazardous waste including used sharps, were noted to be unattended on a rolling cart in the hall on the surgical unit. This observation was confirmed by S8 (AVP of Nursing).
-the soiled utility room on the orthopedic floor that contained biohazardous waste was noted to be unsecured.
-greater than 20 red biohazardous containers, each containing red bags of biohazardous waste, were noted to be unsecured outside the hospital in an area designated for biohazardous waste. This designated area was fenced off, however the gaits at two different entrances of the area were open and allowed for individuals to freely walk in and out of the area. The biohazardous wastes was not protected from theft, vandalism or inadvertent human exposure at the time of this observation. This observation was confirmed by S15 (Divisional Director of Post Op Surgical Services).

Based on observations, interviews and record review, the hospital failed to ensure that all facilities, supplies, and equipment was maintained in a manner to ensure an acceptable level of safety and quality. This was evidenced by:

Observation of the orthopedic unit on 12/21/11 at 9:40am revealed the hand rail located in the hallway outside the soiled utility room was loose and not securely fastened to the wall. This observation was confirmed by Assistant Vice-President (AVP) of Nursing S8.

Observation of the inpatient rehabilitative gym on 12/21/11 at 10:40 a.m. revealed three (3) therapy mats with rips/tears in the vinyl covering, a blue wedge with a rip/tear in the covering, and a balance pad with a rip/tear in the covering. These findings were confirmed by S15 (Divisional Director of Post Op Surgical Services) at the time of the observation.

Observation of the surgical trauma unit on 12/21/11 at 11:20am revealed the medication refrigerator door partially open with pharmaceuticals stored in the refrigerator. Review of the "Work Order Details" revealed a work order was submitted on 12/15/11 for the "refrigerator not working". In an interview on 12/21/11 at 11:20am, Manager of the Surgical Trauma Unit RN (registered nurse) S5 indicated the refrigerator had been broken for about a week. S5 indicated she had sent a work order for repair one week ago. S5 could offer no explanation for the refrigerator not being repaired as of the time of this observation.

Observation of the psychiatric unit 1-North on 12/21/11 at 2:30 p.m. revealed rips/tears in the chairs in Patient Rooms B & C.

Observation of the pediatric unit on 12/22/11 revealed sections of rust and flaking metal and/or paint on the surface of a wheelchair and on the surface of a crib in Patient Room E. In addition, rips/tears were noted on the vinyl covering of the sofa in Patient Room D. These findings were confirmed by S15 (Divisional Director of Post Op Surgical Services) at the time of the observation.

Observation of the SICU (Surgical Intensive Care Unit) on 12/22/11 at 9:30 a.m. conducted with the Unit Manager, S52 and S53RN revealed the following:
Room J - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed. Splinters of wood were observed protruding from the exposed wood edge. S52 Unit Manager stated that he submitted a work order yesterday for the repair. S52 verified that he had submitted work orders in the past, but stated he did not know when he had submitted the work order. When asked how long the Formica had been missing, he stated he did not know, and stated that the cabinet was probably hit by the bed. S53RN verified that the length of the cabinet was approximately 2 feet.
Room I - the cabinet adjacent to the patient's bed was observed to have approximately 1 foot of missing Formica from the edge of the cabinet next to the patient's bed. The other side of the cabinet was observed to have 2 feet of missing Formica. Rough, exposed wood was observed on both edges of the cabinet.
Room H - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed.
Room G - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed.
Room F - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed.
Room K - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed.
Room L - the cabinet adjacent to the patient's bed was observed to have approximately 1 foot of missing Formica from the top edge of the cabinet.
Room M - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed.
Room N - the cabinet adjacent to the patient's bed was noted to have approximately 2 feet of Formica missing from the edge of the cabinet that was next to the patient's bed.
S52 Unit Manager and S53RN both verified the above rooms with Formica missing from the cabinet edges.