HospitalInspections.org

Based on medical record review and staff interview it was determined the facility failed to ensure patients/legal representatives were provided notice of the patient's rights for two (#3, #4) of eleven patients sampled of a census of 46.

Findings include:

According to the regulation at 42 CFR 405.1205 (c) hospitals are required to present patient's with follow up notification by providing a copy of the signed "an Important Message from Medicare" (IM) in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

1. Patient #3 was admitted to the facility as a voluntary inpatient on 1/21/2014. Review of the record revealed on 1/21/2014 the patient signed the IM acknowledging receipt on 1/21/2014. Documentation revealed the patient was discharged from the facility on 2/07/2014. There was no evidence a follow up notification of the IM was presented to the patient prior to discharge.

Interview with the Chief Nursing Officer (CNO) on 3/26/2014 at approximately 4:30 p.m. confirmed the findings.

2. Patient #4 was admitted to the facility as a voluntary inpatient on 1/21/2014. Review of the record revealed on 1/21/2014 the patient signed the IM acknowledging receipt on 1/21/2014. Documentation revealed the patient was discharged from the facility on 1/29/2014. There was no evidence a follow up notification of the IM was presented to the patient prior to discharge.

Interview with the CNO on 3/26/2014 at approximately 4:30 p.m. confirmed the findings.

Based on facility policy review, record review and staff interview, the facility failed to ensure the patients participated in the development and implementation of his or her plan of care for six (#3, #4, #5, #7, #9, #11) of eleven patients sampled of a census of 46.

Findings include:

Review of the facility policy Initial Patient Assessment & Reassessment, stated under the section titled Guidelines: (8) upon completion of the initial admission assessment, an individualized prioritized plan of care will be developed in consultation with the patient/significant other; (9) any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition; (10) the plan of care will be reviewed regularly in consultation with the patient/significant other and revised as patient's condition or diagnosis changes; and (11) discharge planning will be initiated at the time of admission and will be reassessed continuously throughout the patient's hospital stay. The patient/significant other will be involved in this process as appropriate.

A review of the facility policy titled: Hospital Plan for Nursing Care, #NS1001, Issued 09/2013, page 5 of 6, section Standards of Nursing Care, item A read: "Each patient has an Initial Nursing Assessment completed by a Registered Nurse within 8 hours after admission which is used as the basis for assessment".

1. Patient #3 was admitted to the facility on 1/21/2014 at 2:01 p.m. Review of the nursing documentation revealed no evidence of an initial care plan until 1/31/2014, ten days after admission. Review of the care plan revealed the patient had one problem identified which was for sleep.

Review of the patient's initial RN assessment dated 1/21/2014 at 3:05 p.m. revealed the patient had a history of anger problems and anxiety. The RN documented the patient was at risk for falls due to altered mental state including confusion and disorientation, impaired balance due to Parkinson's Disease, and use of a walker. Documentation revealed the patient was living at an ALF (Assisted Living Facility) and required assistance with ADLs (Activities of Daily Living). The patient reported pain in his legs and knees. Based on the RN assessment nursing failed to develop and prioritize a care plan that addressed the patient's identified problems. There was no evidence the patient participated in the development or implementation of his plan of care.

Review of the patient's record revealed on 1/29/2014 the patient inappropriately touched a female patient on the same unit. Review of the patient's record revealed at the time of the incident nursing had not initiated a plan of care. Review of the plan of care, initiated on 1/31/2014, revealed no evidence this problem was identified and no goal or interventions were added.

Review of the record revealed on 2/06/2014 at 10:15 a.m. the plan of care was reviewed by the RN. The plan of care remained unchanged from the initial plan of care dated 1/31/2014. No additional problems were added and the only problem identified was sleep. There was no evidence of discharge planning on the plan of care and no evidence of any other problems identified or changes in condition being addressed. Review of the record revealed no evidence the patient or significant other was involved in the plan of care.

2. Patient #4 was admitted on 1/21/2014. Review of the initial RN assessment on 1/21/2014 at 10:18 p.m. revealed the patient was admitted voluntarily to the facility for complaints of hallucinations and anxiety. Nursing documentation revealed the patient lived in an ALF (Assisted Living Facility) and was confused. Review of the record with the Chief Nursing Officer revealed no evidence the patient or significant other was involved in the plan of care.

Interview with the Chief Nursing Officer on 3/26/2014 at approximately 4:30 p.m. confirmed the findings.

3. Patient #5 was admitted on 1/24/2014. Review of the initial RN assessment on 1/24/2014 at 8:52 a.m. revealed the patient was admitted to the facility voluntarily. The patient treatment plan was initiated on 1/24/2014. Review of the treatment plan and nursing documentation revealed no evidence the patient was involved in his treatment plan.

Interview with the Chief Nursing Officer on 3/26/2014 at approximately 4:50 p.m. confirmed the findings.

4. Patient #7 was admitted on 3/22/2014. Review of the initial RN assessment on 3/24/2014 at 11:10 p.m. revealed the patient was admitted to the facility under the Marchman Act for self administering more opiates than medically prescribed and unable to care for self. Review of the record with the Chief Nursing Officer revealed no evidence a plan of care had been initiated.

Interview with the Chief Nursing Officer on 3/25/2014 at 11:40 a.m. confirmed the findings.

5. Patient #9 was admitted on 3/22/2014. Review of the initial RN assessment on 3/23/2014 at 9:00 a.m. revealed the patient was admitted to the facility for depression. Review of the record with the Chief Nursing Officer revealed no evidence a plan of care had been initiated.

Interview with the Chief Nursing Officer on 3/25/2014 at 11:55 a.m. confirmed the findings.

6. Patient #11 was admitted on 03/23/2014 at approximately 8:00 p.m. Review of the record revealed the initial treatment plan was initiated on 03/25/2014 at 7:18 p.m. and completed on 03/26/2014 at 8:55 a.m.

An interview with the chief nursing officer and risk manager on 03/26/2014 at approximately 4:30 p.m. confirmed the above findings.

Based on staff interviews, review of medical records and review of policy and procedures it was determined the nursing staff did not ensure the nursing care and services met the needs of the patients for eleven of eleven sampled records of forty six patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) by failing:

To ensure the registered nurse supervised and evaluated the nursing care for each patient for five (#3, #4, #5, #6, #8) of eleven patients sampled (refer to A395).

To develop and implement a nursing care plan upon admission and to keep the care plan current as the patient's needs changed for six (#3, #4, #5, #7, #9, #11) of eleven (refer to A396).

To ensure medications were administered according to the physician's orders four (#2, #4, #6, #10) and to ensure verbal orders were authenticated by the prescribing physician for six (#1, #3, #4, #6, #10, #11) of eleven records reviewed. (refer to A405).

The cumulative effect of these systemic problems resulted in the Condition of Participation for Nursing Services not being met.

Based on facility policy review, record review and staff interview, the facility failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care related to assessments for each patient for five (#3, #4, #5, #6, #8) of eleven patients sampled and failed to ensure nursing followed physician's orders for one (#6) of eleven patients sampled of a census of 46.

Findings include:

Review of the facility policy, Initial Patient Assessment & Reassessment, stated the RN will collect and analyze data about the patient, determine the need for additional data, the patient's healthcare or treatment needs and the care or treatment of the patient. The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population.

1. Patient #6 was admitted to the facility on 03/05/2014. Review of the physician orders revealed an order for a PA (posterior-anterior) and Lat (lateral) Chest x-ray dated 03/06/2014. A detailed review of the medical record found no documentation the chest x-ray was completed.

2. Patient #3 was admitted to the facility on 1/21/2014 at 2:01 p.m. Review of the nursing documentation revealed no evidence of a RN assessment on 1/27, 1/28, 1/29 and 1/30/14. Documentation revealed a MHT (Mental Health Technician) interacted with the patient and a nurse administered medication on the above dates but there was no evidence of an RN assessment.

Documentation by a MHT for patient #3 on 1/29/2014 at 11:35 a.m. revealed the patient inappropriately touched another patient as she was sitting in a chair asleep. Documentation revealed the patient reported this to the MHT at the time it occurred. Review of the record revealed no evidence the RN was informed, no evidence the physician was notified, and no evidence any interventions were completed.

Review of the record revealed at the time of the occurrence the patient was being observed at a level 2 every 15 minutes. Review of the record revealed a verbal order, dated 1/30/2014 at 1:00 p.m., to place the patient on level 3 for sexually familiarity precautions. Level 3 required random observations to occur two times in 15 minutes but does not require line of sight. Review of the nursing observation form dated 1/30/2014 revealed the patient was monitored at a level 2. Review of the nursing observation form dated 1/31/2014 revealed the patient was monitored at a level 2 until 9:13 a.m. when documentation revealed the patient was changed from level 3 to level 4 and remained on level 4 until discharge on 2/07/2014.

3. Patient #4 was admitted to the facility on 1/21/2014. Review of the initial assessment on 1/21/2014 at 10:18 p.m. revealed the patient was admitted with a laceration with stitches in place to the left hand and finger. Review of the daily nursing assessments of the patient revealed no evidence the patient's skin integrity, specifically to the patient's left hand, was assessed. Nursing documentation dated 1/26/2014 at 2:38 p.m. stated assistance was provided to help the patient clean the wound on left hand. There was no documentation of condition of the patient's left hand. No other documentation for assessment of the patient's skin was noted. Review of the patient's treatment plan dated 1/24/2014 stated nursing would assess daily to ensure appropriate healing was occurring.

4. Patient #5 was admitted to the facility on 1/24/2014 at 5:16 a.m. Review of the nursing documentation revealed no evidence of a RN assessment on 1/27, 1/28 and 1/29/14. Documentation revealed a MHT interacted with the patient and a nurse administered medication on the above dates but there was no evidence of a RN assessment.

5. Patient #8 was admitted to the facility on 3/22/2014. Documentation revealed an intake assessment was completed on 3/22/2014 at 11:49 p.m. by a licensed social worker. Review of the record revealed no evidence of a RN assessment within 8 hours as required by facility policy. Documentation revealed a RN assessed of the patient on 3/23/2014 at 4:17 p.m.

An interview with the chief nursing officer and risk manager on 03/26/2014 at approximately 4:30 p.m. confirmed the above findings.

6. Patient #6 was admitted to the facility on 03/05/2014. A detailed review of the medical record with the Director of Health Information Management revealed an incomplete transform form documenting the patient was transferred to an acute care hospital on 03/08/2014 at 7:15 a.m. by ambulance for a patient fall. A detailed review of the nursing assessment notes and progress notes did not reveal any documentation of the patient fall or patient assessment post fall.

An interview with the chief nursing officer and risk manager on 03/26/2014 at approximately 4:30 p.m. confirmed the above findings.

Based on policy review, record review and staff interview, the facility failed to ensure the nursing staff developed, implemented and kept current a prioritized nursing care plan for each patient for six (#3, #4, #5, #7, #9, #11) of eleven patients sampled of a census of 46.

Findings include:

Review of the facility policy, Initial Patient Assessment & Reassessment, stated under the section titled Guidelines: (8) upon completion of the initial admission assessment, an individualized prioritized plan of care will be developed in consultation with the patient/significant other; (9) any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition; (10) the plan of care will be reviewed regularly in consultation with the patient/significant other and revised as patient's condition or diagnosis changes; and (11) discharge planning will be initiated at the time of admission and will be reassessed continuously throughout the patient's hospital stay. The patient/significant other will be involved in this process as appropriate.

A review of the policy titled: Hospital Plan for Nursing Care, #NS1001, Issued 09/2013, page 5 of 6, section Standards of Nursing Care, item A read: "Each patient has an Initial Nursing Assessment completed by a Registered Nurse within 8 hours after admission which is used as the basis for assessment".

A review of the policy titled: Plan for the Provision of Care, #SS1302, Issued 09/2013, page 5, section 5.3.1 Inpatient Psychiatric Treatment: paragraph 3 read: "Nursing Assessment: Performed by a registered nurse within 8 hours of admission and includes the patient's physical/mental health, functional screen, pain assessment, and nutritional screening. The nurse initiates the preliminary treatment plan based upon findings of the assessment".

1. Patient #3 was admitted to the facility on 1/21/2014 at 2:01 p.m. Review of the nursing documentation revealed no evidence of an initial care plan until 1/31/2014, ten days after admission. Review of the care plan revealed the patient had one problem identified which was for sleep.

Review of the patient's initial RN assessment dated 1/21/2014 at 3:05 p.m. revealed the patient had a history of anger problems and anxiety. The RN documented the patient was at risk for falls due to altered mental state including confusion and disorientation, impaired balance due to Parkinson's Disease, and use of a walker. Documentation revealed the patient was living at an ALF (Assisted Living Facility) and required assistance with ADLs (Activities of Daily Living). The patient reported pain in his legs and knees. Based on the RN assessment nursing failed to develop and prioritize a care plan that addressed the patient's identified problems.

Review of the patient's record revealed on 1/29/2014 the patient inappropriately touched another patient on the same unit. Review of the patient's record revealed at the time of the incident nursing had not initiated a plan of care. Review of the plan of care initiated on 1/31/2014 revealed no evidence this problem was identified and no goal or interventions were added.

Review of the record revealed on 2/06/2014 at 10:15 a.m. the plan of care was reviewed by the RN. The plan of care remained unchanged from the initial plan of care dated 1/31/2014. No additional problems were added and the only problem identified was sleep. There was no evidence of discharge planning on the plan of care and no evidence of any other problems identified or changes in condition being addressed. Review of the record revealed no evidence the patient or significant other was involved in the plan of care.

2. Patient #4 was admitted to the facility on 1/21/2014. Review of the initial RN assessment on 1/21/2014 at 10:18 p.m. revealed the patient was admitted voluntarily to the facility for complaints of hallucinations and anxiety. Nursing documentation revealed the patient lived in an ALF and was confused. Review of the record with the Chief Nursing Officer revealed no evidence the patient or significant other was involved in the plan of care.

Interview with the Chief Nursing Officer on 3/26/2014 at approximately 4:30 p.m. confirmed the findings.

3. Patient #5 was admitted to the facility on 1/24/2014. Review of the initial RN assessment on 1/24/2014 at 8:52 a.m. revealed the patient was admitted to the facility voluntarily. The patient treatment plan was initiated on 1/24/2014. Review of the treatment plan and nursing documentation revealed no evidence the patient was involved in his treatment plan.

Interview with the Chief Nursing Officer on 3/26/2014 at approximately 4:50 p.m. confirmed the findings.

4. Patient #7 was admitted to the facility on 3/22/2014. Review of the initial RN assessment on 3/24/2014 at 11:10 p.m. revealed the patient was admitted to the facility under the Marchman Act for self administering more opiates than medically prescribed and was unable to care for self. Review of the record with the Chief Nursing Officer revealed no evidence a plan of care had been initiated.

Interview with the Chief Nursing Officer on 3/25/2014 at 11:40 a.m. confirmed the findings.

5. Patient #9 was admitted to the facility on 3/22/2014. Review of the initial RN assessment on 3/23/2014 at 9:00 a.m. revealed the patient was admitted to the facility for depression. Review of the record with the Chief Nursing Officer revealed no evidence a plan of care had been initiated.

Interview with the Chief Nursing Officer on 3/25/2014 at 11:55 a.m. confirmed the findings.

6. Patient #11 was admitted to the facility on 03/23/2014 at approximately 8:00 p.m. Review of the record revealed the initial treatment plan was initiated on 03/25/2014 at 7:18 p.m. and completed on 03/26/2014 at 8:55 a.m.

An interview with the chief nursing officer and risk manager on 03/26/2014 at approximately 4:30 p.m. confirmed the above findings.

Based on record review, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were administered according to physician's orders for four (#2, #4, #6, #10) and failed to ensure verbal orders were authenticated by the prescribing physician for six (#1, #3, #4, #6, #10, #11) of eleven records reviewed of a census of 46.

Findings include:

1. Patient #2 was admitted to the facility on 1/5/2014. Review of the physician orders revealed the following medications:
(a) On 1/05/2014 at 7:40 p.m. Clonidine 0.1 milligrams (mg) by mouth three times a day was ordered. Review of the Medication Administration Record (MAR) revealed on 1/06/2014 the Clonidine was administered twice with no documentation for not administering as ordered by the physician.
(b) On 1/05/2014 at 7:40 p.m. Ativan 2 mg by mouth three times a day was ordered. Review of the MAR revealed on 1/06/2014 the Ativan was administered twice with no documentation for not administering as ordered by the physician.

2. Patient #4 was admitted to the facility on 1/21/2014. Review of the physician orders revealed on 1/26/2014 an order for Doxycycline 100 mg by mouth twice a day was ordered. Review of the MAR revealed on 1/27/2014 only one dose of Doxycycline was administered. Review of the MAR and nursing documentation revealed no evidence why the medication was not administered.

3. Patient #6 was admitted to the facility on 03/05/2014. Review of the physician orders revealed the following medications:
(a) Ambien 5 milligram by mouth hours of sleep one doses only on 03/05/2014. After a detailed review of the medication administration record with the chief nursing officer no documentation was found it was given or refused.
(b) Nicoderm Transderm 21 milligram patch apply to skin every morning start on 03/06/2014. After a detailed review of the medication administration record with the chief nursing officer no documentation was found it was given or refused on 03/08/2014.
(c) Risperdal 1 milligram tablet by mouth twice a day start 03/06/2014. After a detailed review of the medication administration record with the chief nursing officer no documentation was found why it was given only once a day on 03/08/2014 and 03/09/2014.
(d) Tegretol 200 milligrams capsule by mouth twice a day start 03/07/2014. After a detailed review of the medication administration record with the chief nursing officer no documentation was found it was given or refused on 03/08/2014 morning dose.

4. Patient #10 was admitted to the facility on 03/22/2014. Review of the physician orders revealed the following medication orders:
(a) Bactroban Ointment 2% topical apply to affected area twice a day for 5 days start 03/24/2014. After a detailed review of the medication administration record with the chief nursing officer no documentation was found it was given or refused on 03/25/2014 evening application.
(b) Sulfadiazine Cream 1% topical apply to affected area twice a day for 5 days start 03/24/2014. After a detailed review of the medication administration record with the chief nursing officer no documentation was found it was given or refused on 03/25/2014 evening application.

A review of the facility policy titled: Role of Nursing in Medication Administration, #PHR-140, Issued 10/2013, page 4 section 4.5 titled: "Missed or late doses: When a medication is not administered at the scheduled time, the nurse will properly document the reason(s) on the MAR or patient record. The nurse may also need to communicate the reason to the physician or covering physician for further instructions (e.g. Patient continues to refuse medications which may lead to harm). Drug administration errors that result in no or insignificant harm to the patient must be documented in the medical record but do not necessarily require immediate reporting to the physician. For example, if an analgesic dose is missed during the night shift, it can be reported first thing in the morning. Nursing is expected to use their clinical judgment, based on patient presentation and assessment in accordance with other hospital policy and procedures, to determine whether immediate reporting to the physician is require".
A review of the facility policy titled: Medication Errors\Adverse Drug Events, #PHR-127, Issued 10/2013, page 1 section 2.2 read: "A medication error is defined as: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer [derived from NCCMRP]. Section 2.3 read "Medication errors include prescribing errors, dispensing errors, medication administration errors and patient compliance errors ...Several types of medication errors exist which include: 2.3.2 Omission Error: The Failure to administer an ordered dose to a patient before the next scheduled dose, if any. "Page 2 section 4.1 read: "When a medication error occurs, several things should occur by the nurse in this order: 4.1.1 Evaluate the patient; 4.1.2 Notify the physician immediately. 4.1.3 Notify patient and/or representative of error unless otherwise instructed by the physician. Document [the] evidence of [the] same. 4.1.4 Record the medication error in the progress note and the MAR. 4.1.5 Report the error in detail on the Incident Report Form ...".

An interview on 03/26/2014 at approximately 4:30 p.m. with the chief nursing officer and the risk manager confirmed the above findings and verified no incident reports were documented.

5. Patient #1 was admitted to the facility on 01/14/2014. Review of the record revealed multiple verbal orders dated 01/15/2014 at 12:24 a.m. including the following:
Regular diet
Regular routine admission lab screen: (if not completed from referring facility): CBC with differential/platelet count
Comprehensive Metabolic Panel
TSH
Routine Urinalysis
Urine Drug Screen
Urine HCG (if female patient under the age of 60)
Ambien 5 milligrams by mouth at hour of sleep for insomnia

A detailed review of the clinical order sheets revealed multiple verbal orders recorded by registered nurses however no documentation of a physician authenticating any of the orders.


6. Patient #6 was admitted on 03/05/2014 with verbal admission orders on 03/05/2014 at 9:52 p.m. for the following:
Admit to Unit A to attend and participate in unit programming activities
Classification 1-Off Unit Privileges
Level of Observation - Level 2 Every 15 minutes or greater Suicide precautions
Regular Diet

A detailed review of the clinical order sheets revealed multiple verbal orders recorded by registered nurses however no documentation of a physician authenticating any of the orders


7. Patient #10 was admitted to the facility on 03/22/2014 under baker act 52 with multiple verbal admission orders.
A detailed review of the clinical order sheets revealed multiple verbal orders recorded by registered nurses however no documentation of a physician authenticating any of the orders


8. Patient #11 was admitted to the facility on 03/23/2014 under baker act with multiple verbal admission orders.
A detailed review of the clinical order sheets revealed multiple verbal orders recorded by registered nurses however no documentation of a physician authenticating any of the orders.


9. Patient #3 was admitted to the facility on 1/21/2014. Review of the record revealed multiple verbal orders. Review of the clinical order sheets revealed multiple verbal orders recorded by registered nurses however no evidence of the ordering physician's authentication of the order.

10. Patient #4 was admitted to the facility on 1/21/2014. Review of the clinical order sheets revealed multiple verbal orders recorded by registered nurses however no evidence of the ordering physician's authentication of the order.

Review of the facility policy titled: Verbal and Written Orders, #MR8022, Issued 9/2013, page 1 policy stated: verbal orders are allowed; however, in an effort to reduce medication errors, the use of these types of orders is discouraged. On page 3 of 3 (6) stated: the prescribing practitioner must date, time and authenticate the verbal order within the time designated by state law, or if no state law exists, the verbal order must be authenticated within twenty-four (24) hours.

An interview on 03/25/2014 at approximately 2:00 p.m. with the Director of Health Information Management (HIM) revealed the physicians have all been trained on the electronic medical record order entry process but have been reluctant to use it.

An interview on 03/26/2015 at approximately 4:30 p.m. with the chief nursing officer and risk manager confirmed the above findings.