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Based on observations, interviews and record review, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of safety hazards.

Findings:

An observation on 08/03/15 from 10:05 a.m. to 11:00 a.m. of the locked in-patient psychiatric unit with SF1Adm. (Administrator) and SF2DON (Director of Nursing) revealed the psychiatric unit had 10 (ten) bedroom units with 2 (two) beds in each unit.
The beds in all the patient rooms had metal slatted frames with removable springs and each bed had 3 non-removable bed cranks at the foot of each bed.

In an interview on 08/03/15 at 10:30 a.m., SF1Adm stated the hospital had ordered 4 platform (box-type) beds to go into 2 patient rooms identified as "safe rooms." SF1Adm stated patients identified as suicide risk would be placed in those rooms. SF1Adm was unable to explain what actions had been taken to mitigate the safety hazard of the removable metal springs in the bed frames. SF1Adm stated the hospital's patient population was 50 and older, but the hospital did accept a lot of different types of patients and different ages.

Review of the current inpatient census revealed 6 patients were identified as needing observation for assault precautions out of a census of 15.

Review of the hospital policies titled Security Rounds and Room Checks revealed no documented evidence that observation of the bed frames to ensure the metal springs were all in place was included. Review of the Room Check form and the Security Rounds form revealed no documented evidence the metal springs in the bed frames were included in the checklist.

Review of the hospital inservice titled Suicide Risk, dated 07/23/15 at 2:00 p.m. revealed no documented evidence that the safety hazard of the metal springs in the bed frame were included in the staff training.



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Based on record review and interview the hospital failed to ensure drugs and biological were administered by accepted standards of practice as evidenced by patients' blood pressure and/or apical pulse not being monitored prior to administration of Antihypertensive medications for 3 of 3 (#F1, #F2, #F5) patients reviewed for the administration of Antihypertensive medication out of a sample of 7 patients.

Findings:


Patient #F1
Review of the medical record for Patient #F1 revealed the patient was a 68 year old male admitted to the hospital on 7/31/15 with the diagnosis of Dementia with Behavioral Disturbance. The patient's medical diagnoses included Hypertension and a history of Alcohol Abuse. The record revealed the patient resided in an nursing home where he had threatened to kill others in the nursing home.

Review of the Physician Orders, dated 7/31/15 revealed an order for Norvasc 5 mg.(milligrams) po (by mouth) once daily.

Review of the MAR (Medication Administration Record) dated 08/01/15 to 8/3/15 revealed no documentation of the patient's blood pressure being monitored prior to the administration of the medication, Norvasc (Calcium Channel Blocker medication used to treat hypertension).


Patient #F2
Review of the medical record for Patient #F2 revealed the patient was a 65 year old female admitted to the hospital on 7/23/15 with the diagnosis of Psychosis, Schizoaffective Disorder, and Bipolar Disorder. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Gastroesophageal Reflux Disease and Hyperlipidemia. The record revealed the patient resided in an nursing home.

Review of the Physician Orders, dated 7/23/15 revealed an order for:
Metoprolol Tartrate (Lopressor) 25 mg. po twice daily,
Lisinopril 5 mg. PO once daily (Both are medications used to treat hypertension).

Review of the MAR dated 07/31/15 to 8/3/15 revealed no documentation of the patient's blood pressure being monitored prior to the administration of the medications Metoprolol and Lisinopril.

In an interview on 08/03/15 at 1:25 p.m., SF2DON (Director of Nursing) reviewed the medical record for Patient #F2 and confirmed there was no documentation of the patient's blood pressure and pulse prior to the administrative of the anti-hypertensive medications. SF2DON indicated she expected the nursing staff to document the patient's blood pressure and pulse prior to administering the medications.



Patient #F5
Patient #F5 was a 82 year old male admitted to the hospital on 7/17/15 with the diagnoses of Parkinson, Hypertension, and a Chief Complaint of threatening to kill his roommate in the nursing home.

Review of the Physician Orders, dated 7/17/15 revealed an order for Norvasc 5 mg. po once daily.

Review of the MAR dated 7/17/15 to 8/3/15 revealed no documentation of the patient's blood pressure being monitored prior to the administration of the medication, Norvasc (Calcium Channel Blocker medication used to treat hypertension).

In an interview on 08/03/15 at 2:15 p.m., SF2DON and SF3LPN (medication nurse) indicated the previous contracted pharmacy used by the hospital included directions on the MAR to check and document a pulse and/or blood pressure prior to administering anti-hypertensive medications. SF3LPN stated, "We should know to check the blood pressure and pulse." She stated when it was written on the MAR there was a place to document it and it reminded the staff to do so. SF2DON stated she wanted the pharmacy to include the prompt on the MAR and provide a space to document the blood pressure/pulse. SF2DON confirmed the nursing staff had not documented the blood pressure and pulse prior to administering the anti-hypertensive medications.