HospitalInspections.org

A hospital must protect and promote each patient's rights

Based on record review and interview the hospital failed to ensure:

A. Written notification of resolution, steps taken in the investigation, results and completion date for four of 10 (Grievances #1, 2, 3, and 4) grievances reviewed. See Tag A-0123.

B. A safe environment for psychiatric patients entering the Emergency Department (ED) by providing one to one monitoring. This failed practice resulted in one patient (Patient #2) who presented with suicidal ideation leaving the hospital without the knowledge of hospital staff and nine of nine (Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9) suicidal patients of the 23 medical records reviewed not being monitored for safety while in the ED. This practice had the potential cause serious harm, injury or death to all patients, staff and/or visitors. See Tag A-0144.

C. Written policies and procedures for investigating abuse/neglect allegations that include screening, identifying, training, protecting, investigating and reporting. This failed practice had the potential to increase the risk of abuse to all patients who seek care at the hospital. See Tag A-0145.

D. Patient confidentiality by allowing visible patient information on unlocked computers and displaying a patient in the background of photograph of another patient. These failed practices had the potential for disclosure of patient information without a patient's authorization. See Tags A-0146 and A-0147.

E. Patient's plan of care reflected a process for assessment, intervention and evaluation when restraints, seclusion and/or physical hold were utilized. This failed practice had the potential to increase the risk to patient safety for all patients who were placed in restraints, seclusion and/or physical hold. See Tag A-0166

F. A physician order was obtained for each restraint, seclusion and/or physical hold use per hospital policy and CMS regulations. This failed practice had the potential to increase the risk to patient safety for all patients placed in restraints, seclusion and/or physical hold. See Tag A-0168

G. An RN monitored patients in restraints per hospital policy. This failed practice had the potential to cause harm to the patient through bodily injury, asphyxiation, and/or mental distress. See Tag A-0175

Based on record review and interview the hospital failed to provide documentation of written notice to each patient reporting the grievance resolution, steps taken in the investigation, results, and completion date for 4 of 10 (Grievances #1-4) grievances reviewed.

Findings:

Policy titled "Grievance Management" states a patient grievance is a formal or informal written or verbal complaint that is made to the hospital and that a written response will be provided to the grievant.

Grievance #1 submitted on 03/22/17, #2 submitted on 06/13/17, #3 submitted 04/23/17 and #4 submitted on 03/22/17 contained a document titled "Grievance/Compliance Issue Record and Action Report" which showed no resolution letter was sent to the complainant.

On 08/17/17 at 11:21 am, Staff B and Staff C stated the findings of no resolution letter being sent to the grievants #1-4 were correct.

Based on record review and interview the hospital failed to ensure a safe environment for psychiatric patients in the ED by providing one to one monitoring.

This failed practice resulted in one patient (Patient #2) who presented with suicidal ideation leaving the hospital without the knowledge of hospital staff and nine of nine (Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9) suicidal patients of the 23 medical records reviewed not being monitored for safety while in the ED. This practice had the potential cause serious harm, injury or death to all patients, staff and/or visitors.

Findings:

Review of policy titled "Discharge Against Medical Advice" showed if patient leaves hospital without knowledge of hospital staff patient should be considered Left Without Notice (LWN)...following search nurse manager, physician, family and local police should be notified and documented in the medical record. Patient #2 was not provided monitoring as per hospital policy and left the ED without the knowledge of hospital staff.

Review of policy titled "Psychiatric Patient Care in the Emergency Room" showed patients should be provided a safe environment ...it may be necessary for security to be in attendance ...patients determined to be a danger to self.

Review of policy titled "Suicide Precautions" showed all patients should be provided a safe and protected environment on admission including protection from self-infected injuries and potential suicidal situations ...nurses should assess patients for behavior (verbal/nonverbal) suggestive of serious and/or imminent suicide potential ... patients should have direct line of site maintained at all times. Policy failed to address how suicidal patients should be managed in the ED. No evidence patients who arrived in the ED with suicidal ideation and/or suicide attempts were placed on suicidal precautions with 1:1 observation.

Review of policy titled "Staffing Plan" showed RN permanently assigned to ED 24 hours a day ...tech assigned during hours of 1100-2300 as time frame identified when volumes and activity are greatest.

On 08/16/17, surveyor requested a policy regarding hospital elopement (when a patient who is cognitively, physically, mentally, emotionally and/or chemically impaired, walks/runs/wanders/escapes or otherwise leaves a facility unsupervised/unnoticed prior to their scheduled discharge), and none was provided.

Nine (Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9) of 23 medical records showed 9 patients in the ED with suicidal ideation and/or suicide attempt had no evidence of 1:1 monitoring. No documentation in the medical record to indicate the presence of a police officer, security staff, medical technician or mental health technician present providing 1:1 monitoring to ensure the safety of the patient.

One (Patient #2) of 23 medical records showed patient arrived in the ED at 10:18 pm via ambulance. Prior to arrival Patient #2 had attempted to commit suicide by ingesting sleeping pills and had stated he/she used methamphetamines earlier in the day. Patient #2 was immediately triaged and assessed by the RN. The ED Nursing Notes documented at 11:05 pm the RN discovered patient was gone. Review of ED Log for 10:00 pm to 11:00 pm, during the time the patient was in the ED there were 4 additional patients with 1 discharging. Staffing included the ED physician, RN and the medical technician. No evidence of documentation of 1:1 monitoring by hospital staff or notification of hospital administration patient LWN per hospital policy.

On 08/16/17 at 9:52 am, Staff D stated a staff member is expected to provide 1:1 observation for suicidal patients unless they are in police custody; and there should be documentation in the medical record. Staff D stated staffing in the evening would include the physician, RN and admission clerk, and also stated the medical technician is off-duty at 11:00 pm and security staff at 9:00 pm. Staff D stated if the ED needs staff to monitor suicidal patients they can call the Mental Health Unit to see if they have a medical technician available to come and monitor the patient. Staff D stated there was no monitoring of Patient #2 based on review of the medical record.

Based on record review and interview the hospital failed to provide written procedures for investigating abuse/neglect allegations that include screening, identifying, training, protecting, investigating, and reporting.

This failed practice had the potential to increase the risk of abuse to all patients who seek care at the hospital due to no procedures in place to guide in the investigative process of abuse/neglect.

Findings:

Policy titled "Alleged or Suspected Abuse Department: Mental Health" does not include the necessary components pertaining to the allegations of a staff member; screening, identification, training, protection from the alleged abuser, investigation and reporting/responding.

On 08/17/17 at 11:21 am, Staff C and Staff B stated their current policy did not address removal of employees during investigation for alleged incidents of abuse/violence against another employee or patient.

Based on observation and interview, the hospital failed to ensure the confidentiality of patient records by allowing an unlocked, open computer with visible patient information in an unrestricted corridor.

This failed practice had the potential of disclosure of patient information without a patient's authorization of current and previous patients at the hospital.

Findings:

On 08/16/17 at 11:39 am, an open, unlocked computer with patient information visible was observed unattended in the unrestricted access medical/surgical hallway. There was no nurse in the hallway and patients' doors were closed; there were people in the unrestricted hallway that were not wearing hospital identification badges.

On 08/17/17 at 11:21 am, Staff B and Staff C stated the computer should have been locked.

Based on observation and interview, the hospital failed to protect the confidentiality of patients' medical records by displaying identifiable photographs of patients in another patient's individual identification picture.

This failed practice increased the risk of potential disclosure of patient identification without a patient's authorization by displaying the photograph of one patient in the background of the identification photograph of another patient.

FINDINGS:

On 08/16/17, 3 (Patients #16, 18 and 23) of 23 patients' records reviewed contained pictures of other patients/staff or open computer screens displaying patient information visible in the patient's individual identification picture.

On 08/17/17 at 11:21 am, Staff B and Staff C stated that hospital staff should be taking the identification pictures with only the brick wall (a wall located in the facility) as a background and no other patients or computer screens visible in the identification pictures.

Based on record review and interview the hospital failed to ensure the patient's plan of care reflected a process of assessment, intervention and evaluation when restraints, seclusion and/or physical hold were utilized.

This failed practice had the potential to increase the risk to patient safety for all patients who were placed in restraints, seclusion and/or physical hold.

Findings:

Document titled "Nursing Plan of Care" showed the plan of care is based upon data collected from reassessments of the patient's nursing care needs ...formulate nursing diagnosis(es) and coordinate nursing care ...addresses patient responses to interventions and progress toward the care plan goals.

Document titled "Information for Staff" showed reassessment for restraints should be done by an RN and include patient's physical and mental status, readiness for release, if alternative methods can be used or attempted and if the restraint can be discontinued.

Six (Patient #10, 11, 17, 19, 22 and 23) of 23 medical records showed for the six patients who had restraints there was no evidence the patient's Initial/Intermediate Treatment Plan or Master Treatment Plan was revised/updated after each time a restraint, seclusion and/or physical hold was used.

On 08/16/17 at 9:40 am, Staff C stated nursing staff try to update the patient's treatment plan and nursing care plan when a restraint/seclusion or physical hold is used; and if restraints/seclusion or physical hold is used multiple times then the plan of care should be updated.

Based on record review and interview the hospital failed to ensure a physician order was obtained for each time a restraint, seclusion and/or physical hold were used per hospital policy and CMS regulations.

This failed practice had the potential to increase the risk to patient safety for all patients placed in restraints, seclusion and/or physical hold.

Findings:

Document titled "Restraint and Seclusion" showed a physician order must be obtained for restraints (physical and chemical), seclusion and/or physical holds.

Document titled "Information for Staff" showed for behavioral management a physician should be contacted and initial order obtained within 15 minutes of initiating a restraint.

Three (Patient #10, 11, and 19) of 23 medical records showed for those six patients who had restraints, seclusion and/or physical hold there was no evidence of a physician order for the use of restraints, seclusion and/or physical hold.

On 08/16/17 at 2:28 pm, Staff C stated restraints including physical holds are a one-time order from the physician and nursing staff should obtain a new order from the physician each time one of these methods are utilized.

Based on record review and interview, the hospital failed to ensure an RN monitored a patient in restraints per hospital policy for two (Patients #17 and 19) of 23 records reviewed.

This failed practice had the potential to cause harm to the patient through bodily injury, asphyxiation, and/or mental distress.

Findings:

A policy titled "Restraint and Seclusion" listed areas of concern to be monitored every 15 minutes, including:

1. The physical well-being of the patient;
2. The emotional well-being of the patient;
3. The patient's rights, dignity, and safety are maintained;
4. Whether a less restrictive method is now applicable to the assessed need of the patient;
5. Any changes in the patient's behavior or clinical condition that may initiate the removal of restraint/seclusion;
6. Whether the restraint/seclusion has been appropriately performed, applied, removed, or reapplied;
7. Justification for continued restraint;
8. Ensure with use of chemical restraints that side effects are observed and reported to attending physician.

Patient #17

A review of the clinical record showed no monitoring of the patient's condition was done during an episode of restraint on 07/27/17 from 9:25 am to 10:30 am.

Patient #19

A review of the clinical record showed no monitoring of the patient's condition was done during an episode of restraint on 07/16/17 from 5:02 pm to 5:30 pm.

On 08/17/17 at 11:30 am, Staff C stated the documentation did not reflect the patient's condition per hospital policy.

Based on record review and interview the hospital failed to:

A. Ensure adequate staffing in the ED to meet the needs of psychiatric patients. As a result of no one to one monitoring in the ED there was a potential for psychiatric patients' safety to be at risk. (See Tag A-0392)

B. Ensure nursing staff performed assessments/reassessments per policies and procedures (P&P), evaluated patient's pain using a pain intensity scale, and assessment and monitoring of patients in the ED. The failure of diligent nursing surveillance and nursing assessments had the potential to affect the safety and health outcomes of all patients coming through ED. (See Tag A-0395)

C. Ensure nursing staff implemented interventions for medical problems within the nursing care plan and/or Master Treatment Plan. This failed practice had the potential to affect patients admitted to the behavioral health unit of the hospital with medical problems that could result in delayed recognition and/or treatment of active problems that could influence patient recovery, functional status and quality of life.(See Tag A-0396)

Based on record review and interview the hospital failed to ensure adequate staffing in the ED to meet the needs and ensure the safety of suicidal patients by providing one to one monitoring. (See Tag A-0144)

This failed practice resulted in one patient (Patient #2) who presented with suicidal ideation leaving the hospital without the knowledge of hospital staff and nine of nine (Patient #1, 2, 3, 4, 5, 6, 7, 8 and 9) suicidal patients of the 23 medical records reviewed not being monitored one on one by hospital staff while in the ED. As a result this practice had the potential to affect all suicidal patients who arrived in the ED increasing the risk to patient safety.

Based on record review and interview the RN failed to:

A. Ensure nursing staff perfomed nursing assessment/reassessments for 15 of 23 patient's (Patient #4, 6, 8, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 22) records reviewed per hospital policy. This failed practice had the potential to affect all psychiatric patients admitted to the behavioral health unit with medical problems from having timely recognition of changes in medical status affecting health outcomes.

B. Evaluate the pain assessment/reassessment utilizing the pain intensity scale was documented for 10 patients reporting pain (Patient #1, 12, 13, 14, 15, 16, 18, 19, 20, and 23) of 23 medical records reviewed. This failed practice had the potential for 10 of 23 patients to have poorly controlled pain affecting their psychological and functional status.

C. Ensure the nine of nine documented suicidal patients presenting to the ED (Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9) for the 23 records reviewed were assessed and provided one on one monitoring. This failed practice resulted in one patient (Patient #2) who presented with suicidal ideation leaving the hospital without the knowledge of hospital staff and nine of nine (Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9) suicidal patients not being monitored one on one by hospital staff while in the ED. This practice had the potential cause serious harm, injury or death to all patients, staff and/or visitors.

Findings:

A. Nursing Assessment

Review of policy titled "Charting" showed documentation should include relief of patient symptoms, improvement or deterioration of condition and relief of pain based on a pain intensity scale.

Review of policy titled "Assessment of Patient Care Needs" showed assessment includes psychological, social and physical observation and/or examination necessary to establish nursing diagnosis and patient problems.

Review of policy titled "Assessment of Patient Care Needs/Responsibilities/Delegation/Involvement" showed data collection for assessment should include review of relevant major body systems and appropriate physiologic and psychosocial parameters.

Review of policy titled "Reassessment of Patient Care Needs" showed Mental Health Unit patients primarily have psychological and behavioral issues but when they have medical problems reassessments are determined by the RN in charge.

15 (Patient #4, 6, 8, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 22) of 23 medical records showed no evidence of a basic nursing assessment for psychiatric patients with medical conditions on an ongoing basis to ensure the patient's needs were being met.

On 08/16/17 at 9:40 am, Staff C stated at admission a physical assessment would be completed as part of the initial interview; and nursing staff do not document a basic nursing assessment on an on-going shift basis.

B. Pain Management

Review of policy titled "Pain Management (Pediatric, Adolescent, Adult, Geriatric)"showed patients should have assessment and management of pain and document effectiveness of medications.

Review of policy titled "Charting" showed documentation should include relief of pain based on a pain intensity scale ...treatment provided, patient response and follow up to individualized nursing plan of care.

Review of policy titled "Reassessment of Patient Care Needs" showed reassessments should be documented in response to medications, treatments, and therapies ...pain scale ratings should be used.

10 (Patient #1, 12, 13, 14, 15, 16, 18, 19, 20, and 23) of 23 medical records showed no evidence of documentation of assessment of patient's pain before and after an intervention using a pain intensity scale for the 10 patients who reported pain.

On 08/16/17 at 9:40 am, Staff C stated patients who report pain should be assessed using a pain intensity scale and a reassessment for effectiveness.

C. ED Assessment and Monitoring

Review of policy titled "Standards of Care" showed all patients in the ED are assured a safe environment and timely care based upon severity or level of illness/injury.

Review of policy titled "Assessment of Patient Care Needs" showed assessment includes physical and psychological examination and observation necessary to determine patient problems ...time frames for completion of initial nursing assessment for patients presenting to the ED is 1 to 2 hours depending on triage class (emergent to non-urgent).

Review of policy titled "Suicide Precautions" showed all patients should be provided a safe and protected environment on admission including protection from self-infected injuries and potential suicidal situations ...nurses should assess patients for behavior (verbal/nonverbal) suggestive of serious and/or imminent suicide potential ... patients should have direct line of site maintained at all times. Policy failed to address how suicidal patients should be managed in the ED. No evidence patients who arrived in the ED with suicidal ideation and/or suicide attempts were placed on suicidal precautions with 1:1 observation.

Nine (Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9) of 23 medical records showed no evidence of initiation of suicide precautions for the nine patients who presented to the ED with thoughts of suicide and/or suicide attempts.

On 08/16/17 at 9:52 am, Staff D stated all psychiatric patients with suicidal ideation and/or suicide attempt are triaged immediately and a staff member should be with them at all times; and stated the ED had no suicide risk assessment tool.

Based on record review and interview the hospital failed to ensure nursing staff individualized and implemented interventions within the nursing care plan and/or Master Treatment Plan for 12 (Patient #10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 22) of 23 patients with medical problems.

This failed practice had the potential for 12 of 23 patients with medical problems to have a delay in treatment of problems secondary to no identified nursing interventions.

Findings:

Review of policy titled "Nursing Plan of Care" showed the Mental Health Unit incorporates care plan into a comprehensive multi-disciplinary treatment plan. Evaluation of patient's nursing care should be accomplished weekly addressing patient response to interventions and progression towards goals listed on the care plan.

Review of policy titled "Reassessment of Patient Care Needs" showed assessments may determine alterations in the plan of care.

12 (Patient #10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 22) of 23 medical records showed no evidence of development of nursing interventions or goals within the patient's care plans for identified medical conditions.

On 08/16/17 at 2:28 pm, Staff C stated nursing problems are identified at the time the patient is admitted and there should be nursing staff interventions for each problem; and stated during review of the Master Treatment Plan there were no nursing staff interventions for the patient's medical problems.

Based on record review and interview, the hospital failed to ensure contracted staff received hospital oreintation and verification of skills competencies for 5 of 5 contracted employee records reviewed.

This failed practice had the potential to affect all patients due to untrained and/or unqualified staff failing to follow hospital policy in a disaster and failing to competently perform skilled tasks.

Findings:

A policy titled "Agency Nurses" listed orientation requirements including internal and external disaster plans, fire plan, and hazardous communications for the hospital. The responsibilities of the agency included evidence of a skills checklist to verify competencies, and documented clinical competency in the patient care area assigned.

Personnel records for Staff I, J, K, L, and M showed no documentation of orientation to the hospital or competency checklists.

On 08/17/17 at 11:50 am, Staff B stated the hospital did not provide orientation and expected the agencies to provide the training; and the hospital did not keep records of training for agency staff.

Based on observation, record review and interview the hospital failed to ensure medication samples were prepared by authorized personnel under the supervision of a pharmacist for dispensing to patients.

This failed practice increased the risk of inappropriate medications being dispensed in an unsafe manner that does not meet the needs of the patient; the medications were not reviewed by the pharmacist prior to being available for patient use.

Findings:

On 08/15/17 at 11:18 am, medication samples of Viibryd (used to treat depression), Latuda (used to treat schizophrenia or bipolar disease) and Fanapt (an antipsychotic medication) were observed in an unlocked cabinet in the medication room located on the patient care wing. There was no indication the sample medications had been reviewed and prepared by the pharmacist for dispensing to patients.

Policy titled "Sample Medication" states that sample medications "will not be allowed ...Stocks of sample medications may not be maintained in the pharmacy or in any other department."

On 08/16/17 at 11:15 am, Staff G (Pharmacist) stated she was unaware the drugs were in the medication room and the medications had not been prepared by pharmacy staff.

Based on observation and interview, the hospital failed to provide a sanitary environment in the behavioral health wing, and increased the potential risk of infections to patients in the behavioral health wing by failing to ensure contaminated/clean equipment were not mixed with food service items; heavy-duty aerosol cleaners were not mixed with food service utensils; refrigerated foods were not stored in room temperature locations; and soiled floors, soiled and broken cabinets were clean and working properly.

Findings:

On 8/15/17 at 11:15 am, the following was observed in the galley (a small, narrow kitchen located in the unit for patient use):

a. Unable to identify patient-care equipment as either clean or dirty; bed padding was laying on the floor next to a cabinet without doors (containing plastic kitchen containers used for food/drink dispensing to patients), and a portable piece of equipment was uncovered standing next to a cabinet without doors (containing plastic kitchen containers used for food/drink dispensing to patients).
b. Two cans of 3M TroubleShooter Baseboard Stripper aerosol stored in an open cabinet with plastic kitchen containers used for food/drink dispensing to patients.
c. Mayonnaise-based salad dressing for patient use was open, half empty and not labeled as to when the dressing was opened and was stored in a cabinet. The dressing was labeled by manufacturer to refrigerate after opening.
d Barbeque sauce was open, partially used and not labeled as to when the sauce was opened and the sauce was stored in a cabinet. Sauce was labeled by manufacturer to refrigerate after opening.
e. Cabinet doors were removed from cabinets and laying in the floor exposing dishes and glassware provided to the patients to the potentially contaminated patient care equipment stored in the galley.
f. Handles missing from cabinet doors with cabinet doors left partially open exposing dishes and glassware provided to the patients to the potentially contaminated patient care equipment stored in the galley.
g. Floors soiled with dirt and dust
h. Wood cabinet interiors with rust stains and old food/liquid stains and accumulated dust

On 8/15/17 at 11:15 am, Staff C stated he/she agreed the potentially contaminated equipment should not be in the galley, the salad dressing and barbeque sauce would be disposed of, the cabinet doors and handles should be in working order to allow proper closure to avoid the potential of contamination, the floors and cabinets should be cleaned.

Based on observation and interview, the hospital failed to develop a system for monitoring infectious processes which increased the risk of infections by failing to assess the galley during routine rounding to ensure contaminated/clean equipment were not mixed with food service items; heavy-duty aerosol cleaners were not mixed with food service items; refrigerated foods were not stored in room temperature locations; and soiled floors, soiled and broken cabinets were clean and working properly. (Refer to Tag A-0747)