HospitalInspections.org

Based on observations, interviews, and records review, it was determined that the Governing Body was not effective in its oversight of the hospital.

A) The governing body failed to ensure items that patients could use to hurt themselves were not readily accessible and included plastic liners in trash and linen barrels, multiple electrical and telephone cords, plastic audio and CD cassettes, and liquid cleaner, and

B) Physician ordered every fifteen minute observation rounds were not documented on 10/24/13 as completed from 08:30 AM to 09:30 AM for 17 of 25 current inpatients. (Patient #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23) housed on the adult II unit. The above practice placed patients at risk for injury.

Findings Included:

A) Plastic liners in trash and linen barrels, multiple electrical/telephone cords, plastic audio and CD cassettes, and liquid cleaner was available for use.

Cross refer to TAG A0144.

B) Physician ordered fifteen minute observation rounds were not completed for 17 of 25 current patients on 10/25/13 from 08:30 AM to 09:30 AM. Patient location and activity was not documented.

cross refer to Tag A0144.

Based on observations, interviews and records review, the hospital failed to ensure a safe environment was provided for inpatients in that

A) Items that patients could use to hurt themselves were readily accessible and included plastic liners in trash and linen barrels, multiple electrical and telephone cords, plastic audio and CD cassettes, and liquid cleaner, and

B) Physician ordered observation rounds were not documented on 10/24/13 as completed from 08:30 AM to 09:30 AM for 17 of 25 current inpatients (Patient #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23) housed on the adult II unit. The above practice placed patients at risk for injury.

Findings Included:

A) Plastic liners in trash and linen barrels, electrical and telephone cords, plastic audio and CD cassettes and chemicals were available for patient use.

Cross refer to Tag A0144.

B) Observation rounds on current inpatient psychiatric patients were not being conducted every fifteen minutes for 17 of 25 inpatients. Patient location and activity was not documented.

Cross refer to Tag A0144.

Based on observations, interviews and records review, the hospital failed to ensure a safe environment was provided for inpatients in that,

1) Items that patients could use to hurt themselves were readily accessible and included plastic liners in trash and linen barrels, multiple electrical and telephone cords, plastic audio and CD cassettes, and liquid cleaner, and

2) Physician ordered every fifteen minute observation rounds were not documented on 10/24/13 as completed from 08:30 AM to 09:30 AM for 17 of 25 current inpatients (Patient #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23) housed on the adult II unit. Patient location and activity was not documented. The above practice placed patients at risk for injury.

Findings Included:

1) On 10/23/13, at 04:20 PM, a plastic liner was observed in a trash can on the hospital's first floor Psychiatric Progressive Care Unit (PCU) dining and activity room. Two barrels with plastic liners were observed on the unit's hallway. One linen barrel and one trash barrel with plastic liners were observed on the hospital's second floor Adult II unit's open laundry room on 10/23/13, at around 05:05 PM. Personnel #2 agreed with the above findings.

On 10/23/13, at 04:55 PM, multiple electrical cords of several feet length were observed on the hospital's Adult II group room leading from the TV and radio recorder to the wall plugs. Personnel #2 agreed with the above findings.

On 10/24/13, around 09:45 AM, a plastic liner was observed inside a barrel overflowing with laundry on the hospital's CPC (Critical Psychiatric Care) unit. Personnel #2 and Personnel #10 verified the finding.

On 10/24/13, at 11:30 AM, observations on the hospital military unit's activity room reflected three electrical cords connecting the TV and the DVD player. On 10/24/13, at 11:37 AM, two portable phones in the unit's lobby and sitting area were observed with approximately four feet of telephone cords connecting them to the charging stations. The patient accessible desk top computer was connected with cords to its central processing unit. Personnel #25 and Personnel #2 verified the above findings.

Observations on the hospital's Critical Psychiatric Care Unit day room on 10/24/1,3 at 4:31 PM, revealed 25 plastic audio cassettes, three CD cases with CDs, and a screw. The unattended nursing station was patient accessible and contained a bottle of antibacterial cleaner labeled "Do Not Drink."

Review of the hospital's incident report tracking document reflected a 06/22/13, incident of a patient (Patient #29) grabbing a phone cord and wrapping it around her neck.

Review of (Patient #29's) medical record reflected a history of a traumatic self-inflicted wound on her right forearm after slamming her arm through a glass window. The patient's admitting and discharge diagnoses included Psychosis.

On 10/25/13, at 09:15 AM, Personnel #1 was interviewed regarding the 06/22/13, incident and stated "They [the cords] shouldn't have been there."

On 10/25/13, at 10:22 AM, Personnel #4 was interviewed regarding the ligature incident and stated "Somebody didn't follow policy."



2) On 10/24/13, at 09:30 AM, observation rounds were conducted on the Adult II Unit with Personnel #2. The surveyor entered the day room where patients were gathering for morning group. The surveyor asked Personnel #24 for the Q-15 (every) minute patient observation records. Personnel #24 stated she needed to catch up the rounds records. Personnel #24 verified the rounds records were incomplete for (Patient #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, 20, #21, #22, and #23) from 08:30 AM to 9:30 AM.

On 10/24/13, at 09:40 AM, the surveyor went to the Adult II nursing station where Personnel #16 was standing. Personnel #16 was asked what patients were not in the morning group. Personnel #16 stated (Patient #13, #19, #21, #22 and #23) were being monitored by her. The surveyor asked Personnel #16 for the above patients' rounds records. Personnel #16 stated that Personnel #24 had the rounds records in morning group. Personnel #16 did not provide any documentation which indicated she was monitoring the above patients every fifteen minutes. The above patients round records were in Personnel #24's possession and did not indicate rounds were completed from 08:30 AM to 09:30 AM on 10/24/13.

The inpatient psychiatric medical record information for (Patient #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23's) reflected the following:

- (Patient #7's) Psychiatric Evaluation dated 10/21/13, reflected "Patient is a 50 year old female...struggled with mood stability and problems organizing her thoughts...bipolarity...admitted 10/20/13...ideas of reference, hopeless and tired of fighting...schizoaffective disorder circular type with psychosis..."

The 10/20/13, physician order timed at 14:00 PM reflected, "Close observation for 48 hours and then routine observation..."

- (Patient #8's) Psychiatric Evaluation dictated 10/19/13, reflected "23 year old male admitted 10/15/13...patient's mother contacted him (Patient #8) a few minutes before she died, but he ignored the phone call only later to find out she was deceased...consumed by his grief...attempted to take his own life several times..."

The 10/15/13, physician orders timed at 20:50 PM reflected "Close observation for 48 hours and then routine observation..."

- (Patient #9's) Psychiatric Evaluation dated 10/24/13, reflected"The patient presents in an agitated psychotic state...thought process is disorganized and clear evidence of paranoid delusions...prior to admission 10/22/13...he was sleeping in the park...schizoaffective disorder..."

The physician orders dated 10/22/13, timed at 21:30 PM reflected "Close observation for 48 hours and then routine observation...."

- (Patient #10's) Psychiatric Evaluation dated 10/23/13, reflected "The patient came to us after he tried to hang himself...does have some ligature marks around his neck...admitted 10/22/13 for crisis stabilization...major depressive disorder, recurrent and severe without psychotic features..."

The physician orders dated 10/22/13, timed at 11:20 AM, reflected "Close observation for 48 hours and then continuous close observation..."

- (Patient #11's) Psychiatric Evaluation dated 10/23/13, reflected "Patient is a 38 year old male...the patient is physically disabled secondary to sequelae of drug addition...admitted 10/23/13...opiate dependence, rule out major depression, polysubstance dependence by history..."

The admission physician orders dated 10/23/13, timed at 16:15 PM, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #12's) Psychiatric Evaluation dated 10/22/13, reflected "25 year old male...admitted 10/21/13...diagnosis of bipolar disorder...increase in depression and suicidal ideation..."

The physician orders dated 10/21/13, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #13's) Psychiatric Evaluation dated 10/23/13, reflected "41 year old...reporting suicidal ideation as well as thoughts of crashing a vehicle into a bridge...admitted 10/22/13 with severe major depressive disorder with psychotic features..."

The physician orders dated 10/22/13, reflected "Routine observation..."

- (Patient #14's) Psychiatric Evaluation dated 10/10/13, reflected "Chief complaint...I would just like to go to sleep and never wake up...increased depression...major depressive disorder, recurrent, opiate dependence...admitted 10/09/13..."

The physician order dated 10/09/13, timed 21:30 PM, reflected "Close observation for 48 hours and then routine observation..."

-(Patient #15's) Psychiatric Evaluation dated 10/10/13, reflected "Patient has been drinking excessive alcohol...having withdrawal symptoms...social isolation...wants to be dead...feels hopeless and helpless...admitted 10/09/13."

The physician order dated 10/09/13, timed at 21:45 PM, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #16's) Psychiatric Evaluation dated 10/10/13, reflected "Patient went into opiate withdrawal...social isolation, withdrawn behavior...admitted 10/09/13...opiate withdrawal, dependence and bipolar disorder..."

The physician order dated 10/09/13, timed at 15:45 PM, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #17's) Integrated Assessment dated 10/23/13, reflected "Manic pressured speech, psychotic, delusional...admitted 10/23/13..."

The physician order dated 10/23/13, timed at 17:30 PM, reflected "Continuous observation..."

- (Patient #18's) Psychiatric Evaluation with a dictation date of 10/16/13, reflected "Schizophrenia chronic...rule out acute psychotic episode...refuses to give any information or to cooperate in any meaningful way...admitted 10/08/13...rambling paranoid."

The physician order dated 10/08/13, timed at 22: 41 PM, reflected "Routine observation..."

- (Patient #19's) Psychiatric Evaluation dated 10/24/13, reflected "58 year old female with a long history of depression...restless sleep, and hopelessness with thoughts of suicide by overdosing on medicine and jumping from a balcony...admitted 10/22/13..."

The physician order dated 10/22/13, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #20's) Psychiatric Evaluation dated 10/21/13, reflected "The patient is reporting suicidal ideation along with drinking alcohol, free floating anxiety...withdrawn behavior...admitted 10/19/13..."

The physician order dated 10/19/13, timed at 21:45 PM, reflected "Routine observation...."

- (Patient #21's) Psychiatric Evaluation dated 10/22/13, reflected "Patient has great difficulty harnessing his rage...trouble with the police..entertained thoughts of taking his own life...admitted 10/21/13...major depression recurrent..."

The physician order dated 10/21/13, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #22's) Psychiatric Evaluation dated 10/13/13, reflected "Thought process illogical, tangential..paranoid thinking and ideas of reference, insight and judgement impaired...admitted 10/18/13...bipolar manic with psychotic features.."

The physician order dated 10/18/13, timed at 14:50 PM, reflected "Close observation for 48 hours and then routine observation..."

- (Patient #23's) Psychiatric Evaluation dated 10/22/13, reflected "The continuing thought of daughters sexual assault coupled with the stress of chronic pain proved to be too much...began having transient thought of suicide...overcome by energy...admitted 10/20/13..."

The physician order dated 10/23/13, reflected "Continuous close observation for 48 hours and then routine observation..."

The policy and procedure titled "Provision of Care, Treatment and Services Observation Rounds with a revision date of 03/2013, reflected "It is the policy of...to provide a safe therapeutic environment for all patients, visitors, and staff...subsequent rounds are conducted according to the physician's observation level..standard observation every 15 minute direct observation of assigned patients..."

Based on interviews and records review, the RNs (Registered Nurses) failed to perform assessments and/or perform follow-up assessments for 1 of 29 patients (Patient #1) who was treated for altered skin integrity and constipation.

Findings Included:

1) (Patient #1's) Psychiatric Evaluation dated 10/19/13, reflected "In the last several days the patient has been picked up by the police on two occasions in a confused and disorganized state outside of his home...speech rambling, alert not oriented..."

The physician's orders dated 10/17/13, reflected "Milk of Magnesium 30 ml (milliliters) daily as needed for constipation..."

The daily progress note dated 06/26/13, timed at 04:00 AM, reflected "Patient complaining of constipation...given Milk of Magnesia..." No follow-up and/or documentation was found which indicated (Patient #1) had a bowel movement after the administration of the medication.

The daily progress note dated 06/28/13, timed at 04:30 AM, reflected "Patient up complaining of constipation administered Milk of Magnesia will pass on in report...at 13:00 PM...discharged home..." No documentation was found which indicated (Patient #1) had a bowel movement prior to discharge.

The daily nursing assessment and BHT (Behavioral Health Technician) flow sheets from 06/17/13 through 06/28/13, revealed no documentation which indicated (Patient #1) had a bowel movement while inpatient.

On 10/25/13, at 08:35 AM, Personnel #14 was interviewed. Personnel #14 was asked to review (Patient #1's) medical record. Personnel #14 stated that (Patient #1) did have some constipation but he was unaware whether (Patient #1's) constipation was relieved prior to discharge.

On 10/25/13, at 09:10 AM, Personnel #4 was interviewed. Personnel #4 reviewed Patient #1's medical record and informed the surveyor that (Patient #1's) constipation and monitoring of his bowel movements was not documented in the medical record.



2) The 06/24/13, physician order reflected "Laniseptic cream to crotch twice daily and as needed..."

The MAR (medication administration record) dated 10/24/13 through 10/28/13, reflected Laniseptic cream was applied to (Patient #1's) scrotum.

On 10/25/13, at 08:45 AM, Personnel #14 was interviewed. Personnel #14 was asked to review (Patient #1's) medical record. Personnel #14 was asked about the condition of (Patient #1's) altered skin condition. Personnel #14 stated that he saw (Patient #1's) perineal area. Personal #14 stated the skin was bright red and very excoriated so he ordered Laniseptic.

On 10/25/13, at 09:10 AM, Personnel #4 was interviewed. Personnel #4 reviewed (Patient #1's) medical record and informed the surveyor (Patient #1's) altered skin integrity was not documented in the nursing notes when first found nor was documentation found which indicated the results of the treatment provided.

The policy and procedure entitled, "Patient assessment and Treatment Process" with a revision date of 09/2011, reflected "...hospital provides assessments to determine what type of care is required to meet a patient's initial needs as well as his/her needs as they change in response to care...the assessment process is individualized..."

Based on interview and record review, the hospital failed to ensure 1 of 29 patients (Patient #1's) written treatment plan addressed altered skin integrity and constipation.

Findings Included:

1) (Patient #1's) Psychiatric Evaluation dated 10/19/13 reflected, "In the last several days the patient has been picked up by the police on two occasions in a confused and disorganized state outside of his home...speech rambling, alert not oriented..."

The Initial Treatment plan dated 06/17/13 reflected, "Axis III (medical) Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension, Weakness, Arthritis (pain)..."

The physician's orders dated 10/17/13 reflected, "Milk of Magnesium 30 ml (milliliters) daily as needed for constipation..."

The daily progress note dated 06/26/13 timed at 04:00 AM reflected, "Patient complaining of constipation...given Milk of Magnesia..."

The daily progress note dated 06/28/13 timed at 04:30 AM reflected, "Patient up complaining of constipation administered Milk of Magnesia will pass on in report...at 13:00 PM...discharged home..."

(Patient #1's) treatment plan revealed no documentation which indicated (Patient #1's) constipation was identified and/or addressed.

On 10/25/13 at 08:35 AM Personnel #14 was interviewed. Personnel #14 was asked to review (Patient #1's) medical record. Personnel #14 stated (Patient #1) did have some constipation but he was unaware whether (Patient #1's) constipation was relieved prior to discharge.

On 10/25/13 at 09:10 AM Personnel #4 was interviewed. Personnel #4 reviewed (Patient #1's medical record and informed the surveyor (Patient #1's) constipation should have been addressed on (Patient #1's) treatment plan.

2) The 06/24/13 order...Laniseptic cream to crotch twice daily and as needed..."

The MAR (medication administration record) dated 10/24/13 through 10/28/13 reflected, Laniseptic cream was applied to (Patient #1's) scrotum.

On 10/25/13 at 08:45 AM Personnel #14 was interviewed. Personnel #14 was asked to review (Patient #1's) medical record. Personnel #14 was asked about the condition of (Patient #1's) altered skin condition. Personnel #14 stated he saw (Patient #1's) perineal area. Personal #14 stated the skin was bright red and very excoriated soLaniseptic was ordered.

On 10/25/13 at 09:10 AM Personnel #4 was interviewed. Personnel #4 reviewed (Patient #1's) medical record and informed the surveyor (Patient #1's) altered skin integrity should have been addressed on the treatment plan.