HospitalInspections.org

Based on observation and interview facility staff failed to provide personal privacy by not adequately shielding the names of patients undergoing telemetry monitoring {telemetry is continuous monitoring of a patient's heart rate and rhythm} on units Four Gold, Four Blue, Four Red, Four Green, and Three Red and failed to adequately shield the names of patients listed on white dry erase boards on the units. The census were: Four Gold-16 patients; Four Blue-16 patients; Four Red-12 patients; Four Green-18 patients; Three Red - 12 patients. The facility census was 202 patients.

Findings included:

1. Observation on 12/01/10 at 10:25 AM, on Four Gold unit showed staff maintained three approximate 19-inch ceiling mounted telemetry monitors with the room numbers, first three initials of the patients' last names and the first initial of the patients' first name out in the main corridors in full view of the public.

During an interview on 12/01/10 at 10:25 AM, Chief Nursing Officer (CNO), Staff V stated three telemetry monitors were located at the ends of the halls on Four Gold and on Four Blue, and each telemetry monitor showed the patients identified by the first three initials of the patient's last name and the first initial of the patient's first name.

During an interview on 12/01/10 at 10:30 AM, the Assistant Patient Care Manager (APCM), Staff D for unit Four Gold stated there were three telemetry monitors located at the ends of the hallways in full view of the public.


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2. Observation on 11/30/10 at 1:36 PM, on unit Four Green showed staff maintained telemetry monitors with patients' vital signs, room numbers, first three initials of the patients last names and the first initial of the patients first name displayed out in the main corridors in full view of the public.

3. Observation on 11/30/10 at 1:56 PM, on unit Four Red showed staff maintained a large white board behind the nurses' station approximately three feet high and three feet wide with the patients' room numbers, first three initials of the patients last names and the first initial of the patients first names on this unit in full view of the public.

During an interview on 11/30/10 at 2:15 PM, on unit Four Red the Charge Nurse, RN, Staff Y, stated they do things differently on unit Four Green - they keep their white board in a different place.


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4. Observation on 12/02/10 at 9:30 AM, showed a white dry-erase type board, approximately three feet by five feet in size, on the wall at the nurses' station on unit Three Red. This sign was visible by all who pass down the hallway. The sign included the first three initials of 12 patient names.

Based on observation, interview and record review facility staff failed to provide care in a safe setting in the Behavioral Health Unit (BHU), by using a predictable, patterned method of checking patient status and location during 15 minute checks. The facility failed to ensure safety by allowing one patient (#12) to have and use ear buds on the unit. The facility failed to ensure the patients on the BHU-2D felt safe and secure related to one patient's (Patient #1) verbal and physical outbursts and threats. The facility also failed to have a system in place to ensure safety equipment was secured, monitored and checked for current working order. The census on BHU-2C was 25 patients; the census on BHU-2D was 25 patients, and the facility census was 202.
Findings included:
1. Review of the facility policy titled "Precautions" approved 02/09 showed, in part, the following:
-The policy defined precautions were staff interventions for patient safety.
-The purpose of specialized interventions was to provide a more intensive level of observation and safety for patients who present a heightened level of danger to themselves or others.
-Close observation: Patients placed on Close Observation were to be closely observed and their specific activities monitored and documented by the assigned nursing staff four times per hour, with no interval between monitoring to exceed twenty (20) minutes. These patients were to be located within the immediate visual area and were restricted to the unit.
-Indications for one to one and close observation precautions may have included, but were not limited to the following; serious suicidal attempts, continuing verbalization of suicidal intent, repeated self injury, combative behavior, destructive behavior, severely disoriented and/or severely impaired reality orientation, motivation and potential for elopement (when one or more of the above also applies) and ninety-six hour involuntary {hold} patients.
-Close Observation: Patients at Moderate Risk for Harm to Self and/or Others Including Elopement.
-Procedure and documentation requirements included the patient shall be observed by the nursing staff at least every 15 minutes with documentation on the Close Observation Flow Sheet.

Review of the "Behavior Observation Record" form #90068, dated 02/10 directed staff to record visual appearance, behaviors and location in 15 to 20 minute intervals.

2. During an interview on 11/29/10 at 2:10 PM, Mental Health Technician (MHT), Staff F stated if he/she were assigned to perform 15 minute patient checks he/she started on one end of the hall and sequentially moved to the end of the other hall. The order, path and times of checking were not varied.
During an interview on 11/29/10 at 2:20 PM, MHT, Staff G stated if he/she were assigned to perform 15 minute checks he/she started at one end of the assigned hall and went room to room to check on patients. He/she stated the 15 minute checks were easier if the patients were in a group meeting because he/she could see multiple patients at once. Otherwise, the order, path and times of the room to room checks were not varied.
During an interview on 11/29/10 at 2:45 PM, MHT, Staff H stated if he/she were assigned to perform 15 minute checks on patients he/she would knock on the door, find where the patient was and what the patient was doing. The order, path and times for the fifteen minute checks were not varied.
During an interview on 11/29/10 at 3:16 PM, Assistant Patient Care Manager (APCM), Staff D stated the following:
-MHTs on the unit were routinely assigned to perform 15 minute checks on the patients.
-The 15 minute checks usually took 15 to 20 minutes to complete.
-The MHTs take the same path daily.

During an interview on 11/30/10 at 11:03 AM, BHU RN, Staff P stated the following:
-The usual census on the unit was 25 patients.
-The unit seldom had less than 20 patients.
-Many of the recent past admissions were suicidal and/or homicidal and violent.
-Sometimes the 15 minute checks were done by two staff (each MHT looked for half the census or 12 to 13 patients in a 15 minute span of time).
-If we were short of help one MHT could be assigned to do 15 minute checks on all 25 patients which was physically impossible to do in 15 minutes.
-If the MHT had not worked here or was off for a few days then, they may not know what a newly admitted patient looked like or be familiar enough to know who they were looking for.


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3. Observation on 11/29/10 at 1:45 PM, on the BHU Patient #12 was seen walking around the common area with ear buds (small headphones that contain a pair of tiny speakers that rest inside the ears and attached to a mechanical device for private listening) in both ears. He/she used a walker to ambulate and the pink cords reached from his/her ears down below the waist and into a pants pocket (an approximate length of 4 feet). The use of cords is strictly prohibited in a psychiatric milieu due to the possibility of suicide risks for patients with mental diagnoses.

During an interview on 11/29/10 at 1:45 PM, with RN Staff D, when asked about the patient wearing ear buds stated, "It's ok, he/she has an order for them".

Record review on 11/30/10 showed Patient #12 had a physician's order dated 11/19/10 and timed at 14:31:00 stating, "Patient can use his/her Walkman to listen to music when there is no therapeutic activities going on" . There was no mention of ear buds on the order or what mechanism would be used to listen to music. Note: Walkman is a trademark name for a pocket-sized cassette player, compact disk player, radio, or combined unit with headphones or lightweight earphones.

During an interview on 11/30/10 at 3:55 PM, with Staff M, RN, Director of Behavior Health Unit (BHU), stated that he/she was unaware there was a patient on the BHU wearing ear buds and he/she would investigate, but agreed that it was an unsafe practice for that unit.

4. Observation on 11/29/10 at 2:45 PM, in the Medication Room of BHU showed a log for safety checks for November 2010. The log contained the following columns: Date; Accucheck QC Done; 02 tank readings; restraints complete; PPE complete; AED green check lit; nurses ' signature. There was not a column for the checking of the suction safety equipment and the dates of 11/12/10-Friday, 11/13/10-Saturday and 11/14/10-Sunday were blank where the safety equipment had not been checked. The log also had blank spaces for the dates of 11/20/10-Saturday and 11/21/10-Sunday where the safety equipment had not been checked.

During an interview on 11/30/10 at 4:00 PM, with Staff L, RN, Director of Nursing for the BHU stated it was the responsibility of the APCM ' s to be sure the safety equipment was checked and the safety log was completed. Staff L stated that he/she looks at the log once a month for quality checks. Staff L stated this was an issue at the time of the last survey and they thought it was corrected.

During an interview on 11/30/10 at 4:15 PM, with Staff M, said, "we are still trying to come to an agreement about the suction [safety device] since we have a Code Blue Team [a team of medical professions that respond to an emergency]" . "The Code Blue Team for this facility is in another building across the street and response times are logged from two and one-half minutes to seven minutes."


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5. Observation and interview on 11/29/10 at 1:43 PM, showed the BHU-2D housed male and female patients from the age of 18 and up. There was no written admission criteria that required ambulation or certain physical abilities, or alleviated some medical diagnoses.

The census of the BHU-2D included one 81 year old patient in a wheelchair with diagnoses of acute edema of the lungs, dementia and delusional disorder. The census also included a 65 year old patient with a diagnoses of asthma, Meniere's Disease (a disorder of the inner ear), and high blood pressure. (diagnoses that could potentially require a code cart or suction-or higher risk). The facility failed to consider these patients' medical needs while not securing a code cart or suction machine.

During an interview on 11/30/10 at 2:50 PM, Staff L stated there was no suction machine on BHU-2D. Staff L stated this unit never had a suction machine.

Review of an Event Timeline prepared by facility staff dated 11/11/10 showed a patient (Patient #2) on BHU-2D was discovered unresponsive with pink, frothy fluid coming from his/her mouth. No suction was available. MAST was called and responded. Patient #2 later expired in the hospital's intensive care unit.

Observation and interview on 12/01/10 showed no crash cart on BHU-2D. Staff M stated that the code carts had been ordered and would be received in about two weeks. The suction machine had been implemented on 11/30/10 at about 5:30 PM, after surveyor inquiry.

Facility staff failed to identify the high risk factors of their patient population and obtain a code cart and suction machine to prevent and/or assist with untoward events.

6. Observation and interview on 11/29/10 from 1:43-2:25 PM, showed patient #1 wandering around on BHU-2D screaming, cursing and threatening other patients, staff and this surveyor. Staff A stated this was consistent behavior for patient #1, and that he/she had been in this unit before with the same behaviors.

During an interview on 11/30/10 at 11:30 AM, patient #8 stated patient #1 had almost hit him/her a few days prior. Patient #1 got upset that patient #8 changed a television channel and he/she got in the face of patient #8 and then swung at him/her, cursing and threatening him/her. Patient #8 stated that at least three other patients were afraid of patient #1.

During an interview on 11/30/10 at 3:55 PM, Staff M stated patient #1 would be more appropriate for long-term psychiatric placement, but there were no positions open at the local facility. Staff M stated patient #1's rapport with staff varied day-to-day.

Based on record review the facility failed to develop a care plan for the use of behavioral restraints for one patient (Patient #1) reviewed with behavioral restraints. The facility census was 202.

Findings Included:

1. Review of Patient #1's History and Physical (H & P), dated 10/26/10 showed patient #1 was admitted on 10/26/10 with a diagnosis of schizophrenia (a mental disorder characterized by paranoia, delusions, and hallucinations).

Review of a Physician's Progress Note dated 10/29/10, showed patient #1 pushed and kicked the staff. The patient was screaming and threatening staff. Staff placed the patient in four-point restraints at 7:40 PM, and he/she remained in these restraints until 11:05 PM.

Review of the patient's care plan initiated on 10/26/10 showed a problem in the "Risk for Injury" area, with a goal that the patient would be free from injury throughout the hospital stay. Interventions included the following:
-assess for restraint discharge criteria, and
-monitor patient per restraint protocol.
Facility staff failed to modify the care plan to include the actual restraint for behaviors, develop a goal specific to the restraint and individualize the interventions to the specific situation/patient.

Review of a facility policy entitled, "Management of Restraints, Behavioral," revised 01/10, showed restraint use is implemented in accordance with a written modification to the patient's care plan.

Observation, interview and record review showed staff failed to ensure restraint orders were signed within 24-hours as dictated in the facility's policy for two of four patients reviewed with restraints (Patients #14 and #13 ). The facility census was 202.

Findings Included:

1. Review of Patient #14's History and Physical (H & P) dated 11/23/10, showed Patient #14 was admitted on 10/27/10, with a diagnosis of sepsis (systemic infection), and acute respiratory failure requiring ventilator support (a breathing machine).

Observation on 12/01/10 at 10:18 AM, showed Patient #14 laying in bed with bilateral wrist restraints on.

Review of the patient's physician's orders for restraints showed an order dated 11/30/10, timed 7:00 AM. However, the new order for restraints for 12/01/10 had not been signed at 10:21 AM, or approximately three hours late.

During an interview, RN, Staff E stated that the physicians normally sign the restraint orders when they do their daily rounds, and this physician just finished making his/her rounds.

Review of the facility policy entitled, "Management of Restraints, Behavioral," revised 01/10, showed every 24 hours, a physician, clinical psychologist, or other authorized licensed independent practitioner responsible for the patient evaluates the patient before writing a new order.

2. Review of Patient #13's face sheet showed the patient was admitted on 11/25/10 with a diagnosis of acute renal failure.

Observation on 12/01/10 at 10:30 AM, showed Patient #13 laying in bed with bilateral wrist restraints on.

As of 10:30 AM on 12/01/10, the most current signed restraint order (a form completed by staff, requiring a physician's order), was dated 11/30/10 at 7:20 AM, or approximately three hours late.

Based on interview and record review the facility failed to perform the one-hour face-to-face assessment for one patient (Patient #1) reviewed with behavioral restraints. The facility census was 202.

Findings Included:

1. Review of Patient #1's History and Physical (H & P), dated 10/26/10, showed patient #1 was admitted on 10/26/10 with a diagnosis of schizophrenia (a mental disorder characterized by paranoia, delusions, and hallucinations).

Review of a Physician's Progress Note dated 10/29/10, showed patient #1 pushed and kicked the staff. The patient was screaming and threatening staff. Staff placed the patient in four-point restraints at 7:40 PM, and he/she remained in these restraints until 11:05 PM.

Facility staff failed to provide documented evidence of a one-hour face-to-face assessment, with the required elements, regarding the above restraint period for approximately three hours.

During an interview on 11/29/10 at 3:25 PM, RN, Staff A stated that the facility had a form that was completed prior to the incorporation of the electronic medical record. Now, that form is not on the electronic program. Staff A stated the doctor was to document the one-hour face-to-face in the progress notes.

Review of a facility policy entitled, "Management of Restraints, Behavioral,"revised 1/13/10 showed the following:

a) A physician, or trained RN must complete a face-to-face evaluation within one hour from initiation of behavioral restraints to determine the ongoing needs for restraints.

Based on interview and record review facility staff failed to ensure non-English language speaking patients were administered medications using dual patient identification as directed in facility policy for one patient (#24), of six current patients identified by staff as unable to understand the English language. The facility also failed to administer medications to two patients (#13 and #14) in a timely manner. The facility census was 202 patients.

Findings included:

1. Record review of the facility policy titled, "Dual Identifiers - Patient Identification," approved on 11/12/08, directed in part, the following:
-All healthcare providers will ensure accuracy of patient identification when providing services including administration of medication.
-Patient identification should include the active participation of the patient.
-In order to positively identify the patient and match the patient to the service or treatment, two identifiers must be used patient name and date of birth.
-Inpatient Care: Acceptable patient identifiers for the purposes of administering medication consists of patient name (patient stated) and date of birth (patient stated).

2. Record review of Patient #24's current admission history and physical (H & P), showed the physician admitted the patient on 11/24/10 with chief complaint of chronic cough and body aches. Further review of the patient's H & P showed the physician assessed the patient was taking insulin for diabetes and a medication which the patient pronounced similar to propranolol {medication used to help the heart to beat more regularly, to treat high blood pressure, heart muscle disease, prevent chest pain and prevent migraine headaches}. Patient #24's H & P also outlined the physician's assessment and plan to provide testing for tuberculosis, provide Insulin injections twice a day for diabetes, verify Insulin was a home medication, provide propranolol for high blood pressure, verify propranolol was a home medication, and provide Heparin {blood thinner} to prevent blood clots.

During an interview on 12/01/10 at approximately 2:30 PM, in the patient's room and with the aid of Interpreter Services, Staff T, patient #24 stated when he/she required medication for a headache he/she had to use hand gestures to make staff understand and when medications were provided staff looked at his/her arm band and did not say or do anything else.


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3. During an interview on 12/01/10 at 2:07 PM, the Chief Nursing Officer, Staff V stated she was not aware there was a 30-minute before, or after, scheduled medication administration times to administer medications without being considered late.

During an interview on 12/01/10 at 2:15 PM, Registered Nurse (RN), Staff W stated he/she was aware of the regulation regarding the 30-minute timeframe for administering medications. Staff W stated the policy and procedure for this regulation was currently being revised and undergoing the approval process. Staff W stated all staff will not be properly trained regarding this regulation until the policy is approved.

During an interview on 12/02/10 at 9:41 AM, Staff DD stated he/she had one hour before, and after the scheduled time to administer medications.

4. Review of Patient #13's face sheet showed the patient was admitted on 11/25/10 with a diagnosis of acute renal failure.

Review of Patient #13's Medication Administration Record (MAR) from 11/26-12/01/10 showed the following:

a) A seven gram protein supplement due at 1:00 PM, administered at 1:40 PM on 11/26/10.
b) A seven gram protein supplement due at 5:00 PM, administered at 5:59 PM on 11/27/10.
c) A seven gram protein supplement due at 9:00 AM, administered at 9:58 AM on 12/01/10.
d) Insulin due at 1:00 PM, administered at 1:40 PM on 11/26/10.
e) Insulin due at 5:00 AM, administered at 6:08 AM on 11/28/10.
f) Metoprolol (medication for high blood pressure) due at 11:00 PM, administered at 2:50 AM on 11/26/10.

5. Review of Patient #14's History and Physical (H & P) dated 11/23/10, showed patient #14 was admitted on 10/27/10 with a diagnosis of sepsis (systemic infection), and acute respiratory failure requiring ventilator support (a breathing machine).

Review of Patient #14's Medication Administration Record (MAR) from 10/30-11/27/10 showed the following:
a) A breathing treatment called Albuterol due at 12:00 (noon), administered at 8:25 AM on 10/30/10.
b) Abilify (an anti-psychotic) due at 9:00 AM, administered at 10:25 AM on 11/09/10.
c) Abilify due at 9:00 AM, administered at 11:39 AM on 11/20/10.
d) Aspirin due at 9:00 AM, administered at 10:04 AM on 11/22/10.
e) Aztreonam (an anti-infective) due at 9:00 PM, administered at 9:47 PM on 10/31/10.
f) Diltiazem (cardiac medication) due at 1:00 PM, administered at 2:21 PM on 11/21/10.
g) Insulin due at 1:00 PM, administered at 2:22 PM on 11/27/10.