HospitalInspections.org

Based on record review and interview, the facility failed to ensure:

1. a Registered Nurse (RN) was supervising and assessing the care and health status of 1 (Patient #1) of 1 patients reviewed.

2. a Registered Nursed reassessed the pain level after pain interventions of 1 (Patient #1) of 1 patients reviewed according to facility policy.


This deficient practice had the likelihood to cause harm to all patients if RN supervision, assessment, and reassessments were not completed in a timely manner.


Findings Include:



PATIENT #1

1. A review of Patient #1's medical record revealed:

Patient #1 was a 60-year-old man involuntarily admitted to the facility on 9/17/2019 at 4:45 PM with a diagnosis of Schizoaffective Disorder. Patient #1 was placed on the Stabilization Care Unit (SCU).

A review of the document titled, "PATIENT ACTIVITY RECORD" revealed Patient #1 was sleeping in the dayroom from 12:45 PM on 9/22/2019 through 6:30 AM on 9/23/2019 by Staff #6 and #7.

An interview was conducted with Staff #6 on 1/14/2020 after 2:30 PM. Staff #6 was asked if he was the MHT responsible for the Q 15-minute checks for Patient #1 on the 9/22/2019 PM shift and 9/23/2019 AM shift. Staff #6 answered, "Yes, our shift is 6:45 PM to 7:15 AM." Staff #6 was then asked if he visualized Patient #1 breathing during his 15-minute patient observation checks. Staff #6 replied, "Yes, patient #1 sat in a chair all night. He was upset because he had been assigned a roommate. I watched him all night, but I didn't make him move." Staff #6 was asked to clarify the required elements staff must perform during their Q 15-minute patient checks. Staff #6 said, "We are supposed to count 3 respirations and make them move positions during their checks." Staff #6 was asked to clarify the process of counting respirations. Staff #6 said, "We just watch until we can see 3 respirations, just the rise and fall of the chest. I don't know if we are supposed to count the respirations for a certain amount of time." (Normal respirations are 12-20 breaths per minute. Anything less than 20 or greater than 25 breaths per minute while resting are considered abnormal) Staff #6 was then asked if he offered Patient #1 any water or bathroom time and he stated, "No." Staff #6 confirmed he documented Patient #1 asleep in the dayroom from Midnight on 9/22/2019 until 6:30 AM on 9/23/2019 when the patient was found unresponsive, pulseless, and not breathing. Staff #6 was asked if he documented any abnormal findings on Patient #1's log or if he notified the nursing staff of abnormal findings. I asked Staff #4 to come and look at Patient #1 sometime around 5:30 AM because something didn't look right with his breathing. Staff #4 went and checked on him. Later that morning his breathing started to look funny again and it was hard to tell if it was the draft from the door opening and closing moving his paper scrubs or if it was his breathing. During our shift change report and rounds we noticed Patient #1 was cold to the touch and he wasn't breathing and then they called 911 but we never did CPR." Staff #6 was asked if the nursing staff made observation rounds with them to ensure there were no problems with any of the patient. Staff #6 said, "No not usually. The only time they look at or do the rounds with us is when we are leaving for a lunch break and we take 30 minutes for lunch."


This surveyor sat next to the door that leads to the outside smoking area and observed little to no draft upon the opening and closing of the door. Staff #3 confirmed the findings.


A review of the document titled Patient Observation Rounds revealed Staff #7 completed the Q 15-minute checks at 2:30 AM, 2:45 AM, 3:00 AM, and with Staff #6 at 3:15 AM on the morning of 9/23/2019. Staff #6 was asked if Staff #7 was allowing him to take lunch at that time. Staff #6 stated, "Yes, that is about the only time they look at our log sheet."


An interview was conducted with Staff #10 on 1/14/2020 at 12:35 PM. Staff #10 was the Mental Health Tech (MHT) assigned to the 7:00 AM shift on 9/23/2019. Staff #10 was asked the nursing staff made observation rounds with the MHT's. Staff #10 said, "No they don't make rounds with us we just notify them of any problems, but they usually only cover us for our lunch breaks." Staff #10 was asked if they checked the vital signs for the patients while they were on their shift." Staff #10 said, "Yes the techs usually do that and write them on a log sheet that is used for the whole unit." Staff #10 was asked how many respirations he counted when doing his observations. Staff #10 said, "We just have to count 3 respirations is all." Staff #10 was asked how long he could take to count 3 respirations. Staff #10 said, "There is no certain amount of time. You just have to be sure you observe at least 3 respirations." Staff #10 was then asked if 3 respirations over a minute was sufficient. Staff #10 stated, "Well I know it is not sufficient because I used to be an EMT and I hope the other MHT's know that too."




A review of the policy titled, "Patient Observation Rounds" was as follows:


" ...PROCEDURE:

MHT:

Review and update patient observation forms. Reflect changes in individual patient precautions levels, room or bed changes, new admissions and/or discharges as they occur

Clearly sign employee name and initials in the appropriate section of the patient observation form

Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form ...

Observe patients on bed rest or when sleeping by:
Looking for the rise and fall of the chest
Counting at least 3 respirations, and
Making sure that the patient has moved from his/her previous sleeping
Position ..."


Staff #6 confirmed he did not ensure Patient #1 moved from his previous sleeping position at any time during the night of 9/22/2019 and morning of 9/23/2019.



An interview was conducted with Staff #3 on 1/14/2020 after 10:00 AM. Staff #3 was asked to provide a policy regarding the nursing responsibility for oversight during patient observation rounds that were completed by the MHT's. Staff #3 said, "We don't have a specific policy that states how often or when the nursing staff is to observe patient rounds with the MHT's. The nursing staff does take over for the MHT's when they go to lunch." Staff #3 was asked if there was any other policy that clarified how the respiration count was to be performed. Staff #3 said, "No, there is no other policy."


A telephone interview was conducted with Staff #4 on 1/13/2020 after 6:30 PM. Staff #4 was asked if she documented her assessment of Patient #1 for the morning of 9/23/2019. Staff #4 said, "No nursing assessment was documented by her for Patient #1 on 9/23/2019." Staff #4 also said, "He refused all his medications on the 22nd at their scheduled time but did agree to take them later that night. He refused his medications a lot." Staff #4 was also asked if she documented the refusal of medications in the medical record for Patient #1. Staff #4 stated, "No I did not."

Staff #1, #3, #6, and #10 confirmed the above findings.


A review of a document provided to this surveyor was a typed time line of the video surveillance on the morning of 9/23/2019 revealed:

" ...0547 Observations rounds check by Staff #6 (Staff #6 felt patients respirations were shallow and requested RN assess)

0549 Staff #4 approached patient and put her hand on his chest

0558 Observation rounds check by Staff #6

0610 Male peer approached patient and touched patients shoulder (Staff #6 stated the patient had made some type of sound which resulted in the male peer walking over to the patient and touching him on the shoulder.

0626 Observation rounds check by Staff #6 (MHT approached patient and looked at his chest them moved to the patients side and leaned down to look at his chest. MHT then stood erect and backed against the wall while looking at the patients chest. Another patient came in from the smoke deck while the MHT was backed against the wall and looking at the patients chest)

0645 Observation rounds check by Staff #6 during walking shift change rounds with Staff #10 and #14. Patient discovered to be cold to touch and joints stiff.



A review of document titled, Daily Nursing Assessment/Progress Note revealed:

"At 0645 on 9/23/19 during the q 15-minute checks at shift change Pt presented cold and stiff with rigor mortis to his jaw. House supervisor and 911 notified. Pt was sitting in day room chair with no signs of life. Pt often noted to sleep while sitting in the dayroom chair and while sitting in bed. MHT reports pt did not show any signs of struggle. Pt appeared to have died quietly in his sleep."

Staff #1 and #3 confirmed no staff signed the progress note but confirmed Staff #7 made the entry. Staff #1 and #3 also confirmed the timeline of the video presented by the facility does not show Staff #7 to be present in the video at 6:45 AM on 9/23/2019.


The video was not available for viewing at the time of the survey. Staff #1 stated the video had already been sent to the corporate legal office.


Staff #1 and #3 confirmed again no abnormal findings, assessments, or additional attempts to obtain vital signs were documented by Staff #6, #4 or #7 within the medical record of Patient #1.



2. A review of the document titled, "Medication Administration Record" (MAR) revealed:


Tramadol (a medication classified as an opioid used for pain control) 50mg was given for pain on;

9/18/2019 at 5:26 PM for a pain level of 8 documented by Staff #8.
Reassessment of pain level after medication intervention documented at 7:42 PM by Staff #15.

9/19/2019 at 4:44 AM given for a pain level of 9. Reassessment of pain level documented by Staff #15 at 6:20 AM as "effective".

9/19/2019 at 2:43 PM given for pain level of 4. No documentation of reassessment of pain level after medication intervention found in the medical record.

9/20/2019 at 9:37 AM given for pain level of 6. No documentation of reassessment of pain level after medication intervention found in the medical record.

9/20/2019 at 8:14 PM given for pain level of 7. Next pain assessment after medication intervention was documented at 10:18 PM.


9/22/2019 at 11:40 AM for a pain level of 7. Next pain assessment after medication intervention was documented at 1:13 PM as "effective" with a pain rating of 2.

.
9/22/2019 at 10:49 PM given for a pain level of 8. Reassessment of pain level documented at 11:49 as "unable to assess-sleeping pain." No other documentation was within the medical record of pain reassessment after medication intervention given at 10:49 PM.



A review of the MAR did not show documentation of staff member administering the medication to Patient #1 only the time given.



A review of the policy titled, "Assessment and Reassessment of Patients" with a revision date of 08/2019 was as follows:

" ...SCOPE:
All RN's on all nursing units.

PURPOSE:
To utilize the Nursing Process and assess all patients at a minimum of every shift and document findings.

PROCEDURE:
All patients admitted to the units will have a Nursing Admission Assessment completed by an RN within eight hours of their admission, If the patient refuses the assessment or is unable to participate in the assessment process, the RN will document this in the Multidisciplinary Progress Note and on the assessment. Continued attempts to complete the assessment will be documented on the form at a minimum every day.

The Registered Nurse will assess each patient at a minimum every shift and more often as deemed necessary. Assessment will include the patient's psychiatric, behavioral, and physical status. A full review of systems will be documented each shift. Abnormal findings will be documented on the Nursing Progress Note.

Pain assessments are completed on all patients and are assessed by a nurse at a minimum per shift. Patients are asked if they are experiencing pain and if positive; a new pain reassessment form will be completed. Pain re-assessments including type, location, and duration of pain are completed within an hour after pain medication is administered as well as interventions implemented ..."


During an interview with Staff #1 and #3 the findings were confirmed.

Based on observation, document review, and interview the facility failed to maintain a clean and sanitary environment in 2 (Progressive Care Unit (PCU) Medication Room and Stabilization Care Unit (SCU) Medication Room) of 3 medication rooms observed.


Findings:


An observation tour of the PCU and SCU was conducted on 1/13/2020 with Staff #3 after 10:00 AM. The following was observed:


PCU MEDICATION ROOM

The sink in the medication room was soiled with a dried white liquid near the faucet handles. The top of the sink was covered with dirt, dust and debris. Inside the sink around and in the drain was covered with rust. On top of the medication refrigerator was very heavy dirt, dust, and debris. The wooden platform that the fridge was sitting on top of was covered with dirt, dust, trash, and a black colored stain. Inside the refrigerator the bottom shelf was noted to have dirt, dust, and debris. At the back of the middle shelf a black substance was seen. The black substance could be wiped with a sani-wipe and removed. The floor beside and behind the refrigerator was heavily covered with dirt and dust. This surveyor was able to draw a definite line in the dust with one finger. The bottom of the medication cart that held patient medications was covered with dirt, dust, debris, and human hair.

An interview was conducted with Staff #13 on 1/13/2020 at 10:35 AM. Staff #13 was asked who was responsible for cleaning the medication room. Staff #13 said, "The housekeeping department does the cleaning in here, but a nurse has to be in here while they clean."

Staff #3 and #13 confirmed the above findings.




SCU MEDICATION ROOM

A black chair in the medication room was observed missing the vinyl covering exposing the surface underneath. The surface underneath was of cloth like material and could not be properly sanitized to prevent cross contamination of infectious diseases between patient. The top of medication refrigerator was heavily soiled with dirt, dust, debris, and human hair. The medication cart, used to store patient medications, was heavily soiled with dirt, dust, and debris. The bottom shelf inside the cabinet that was storing supplies was heavily soiled with dirt, dust, and debris.


A review of the policy titled, "Medication Room Inspection" was as follows:

" ...SCOPE: RN's

POLICY: It is the policy of Glen Oaks Hospital that the pharmacists or an appropriately trained or experienced individual under the supervision of the pharmacist will assure the adequate storage of medications under proper sanitation, temperature, light, moisture, ventilation, segregation, and security conditions make monthly inspections of all drug storage units including emergency boxes ..."


Staff #3 confirmed the above findings.