HospitalInspections.org

Based on observations, interviews and record reviews, the facility failed to provide care in an emotionally safe environment to promote respect, dignity and comfort on 2 (Emergency Stabilization and North) of 3 units.

The Findings Include:

1. During the initial observation of the facility on 3/17/2014 at 10:00 AM, an interview with the Director of Nursing (DON) revealed the facility consisted of 3 separate units. The North Wing has 38 beds and houses male and female patients for chemical dependency and psych. The Emergency Stabilization Unit (ESU) has 26 beds housing both male and female patients. The Older Adult Unit (OAU) has 28 beds that houses male and female adults over 55 years of age. The DON stated the facility used cots for overflow patients, but the staff tries to arrange discharges throughout the day, so they can empty beds and not have to use cots.

The unit observations on 3/17/2014 at 10:00 AM revealed the North Wing's census was 42. There are cloth mattresses with vinyl coverings observed on the floor in 3 patient bed rooms. The mattresses are observed without sheets and pillows.

An interview with the DON at 10:00 AM confirmed the North Wing Unit is over capacity, despite already having 3 discharges this morning. An observation of the ESU revealed the census was 31 with 7 pending discharges. There are 7 mattresses observed in a closet touching each other. An interview with the DON at 10:15 AM revealed the mattresses on the floor (previously called cots) are for the overflow patients.

An observation of the OAU on 3/17/14 at 10:35 AM revealed the census was 27. There are 28 beds on the unit. One patient room is observed with 3 beds and 1 mattress on the floor; there were no sheets or pillows observed on the mattress on the floor.

2. An observation of lunch in the ESU on 3/18/14 at 12:10 PM revealed the room was not large enough to accommodate the 23 patients who were attempting to eat lunch. The room is observed with 4 round tables. Two patients are observed placing their food trays on the floor to add salt and pepper. These 2 patients then placed the lunch trays in their laps to eat. There were 5 patients observed eating lunch while holding their food plates in their laps, with their drinks on the floor. Two patients were observed standing at a counter eating.

An observation of a second activity room located within the ESU on the opposite side of the nursing station on 3/18/14 at 12:15 PM that was used for patients during meal times revealed 4 patients walking back and forth waiting for service and lunch. The ESU staff did not have enough juices or plastic ware to accommodate the patients in the units. The patients observed in the second activity room voiced concern to the staff about the possibility of not having enough food to go around.

The 4 patients in the second activity room walked into the main activity room and stood around the doorway until they were served. The ESU staff were observed apologizing to patients for reaching over them while they were eating, "We have some tight quarters here, I am just trying to make sure everyone gets something to eat and drink. We have called dietary to get more juice, so please be patient with me; everyone will get something to drink."

An interview with the DON on 3/18/2014 at 12:35 PM revealed she acknowledged the facility is aware of the dining situation in the ESU unit. The facility is planning on moving the activity room to a different location that is larger and can accommodate the patients in the area. The DON was informed of the Surveyors' concerns regarding patients putting the Styrofoam meal containers and drinks on the floor, while other patients and staff are walking around and over them. The DON was also asked what the facility will do in case of an emergency in the dining area during lunch. The DON stated the staff does a great job controlling the patients in the area during meal time, and the facility has not had any incidents.

3. A review of the facility's policy and procedures for Patient Rights with an effective date of 12/1999 and a last review date of 2/2014 revealed patients have the right to quality treatment. Each patient shall have treatment suited to his or her own needs, which shall be administered skillfully, safely, and humanely.

4. An interview with the Infection Control/Performance Improvement Director and Compliance Officer on 3/17/2014 at 1010 AM revealed the use of mattresses on the floor is better than throwing a blanket on the floor. She stated the mattresses are wiped down daily, but the facility did not have a policy and procedure related to the cleaning and use of the mattresses.

Based on record reviews and staff interviews, the facility failed to permit 1 (#7) of 11 patients the right to review her medical record. Patient #7 requested to review her medical record on 2/21/14 and was informed by a caregiver that this was only permitted after she was discharged.

The Findings Include:

1. Medical record review revealed Patient #7 was admitted to the facility on 2/17/14 under a Baker Act/involuntary admission, with diagnoses to include multiple psychiatric disorders. Nursing documentation on 2/23/14 revealed Patient #7 requested to see her medical record. The caregiver informed Patient #7 of the facility's policy; that she can only see the medical record after she is discharged.

Interview with the Director of Risk Management in Medical Records on 3/18/13 at 11:30 AM revealed a patient may review their medical record unless there is a restriction placed by the physician. She stated patients have the right to access their medical records. The Director of Risk Management stated she was unaware of the request on 2/23/14 for Patient #7 to review her medical record, and that a staff person declined that request. The Risk Manager stated if they want a copy after discharge, then that is a different procedure.

Based on record reviews and interviews, the facility failed to ensure telephone orders for restraints were authenticated by a physician for 2 (J#13 and J#14) of 3 patients.

The Findings Include:

1). A medical record review for Patient #J13 revealed that she was involuntarily admitted into the facility on 1/23/2014. On 2/2/2014, Patient #J13 was observed banging and kicking the door to the nurses' station while threatening staff. An emergency intervention telephone order was received at 12:07 AM for physical restraint, seclusion, and medication restraint. The maximum time ordered for this intervention is 4 hours. The criterion for release is that Patient #J14 must calm down. The physical restraint time is documented at one minute from 12:07 AM to 12:08 AM. Seclusion was initiated at 12:08 AM. Patient #J13 was chemically restrained using Prolixin 5mg IM for psychosis and Benadryl 50mg IM for anxiety. Patient #J13's seclusion ended at 1:05 AM. An observation of the medical record revealed that the restraint/seclusion telephone orders have not been authenticated.

2). A medical record review for Patient #J14 reveals he was involuntarily admitted into the facility on 1/17/14. On 1/20/2014 at 5:04 AM, Patient #J14 was observed cursing, yelling, and threatening other patients and staff. Emergency intervention orders for restraint, chemical restraint and seclusion was initiated via a telephone order, for a maximum time of 4 hours. The ordered use of chemical restraint includes Haldol 5mg intramuscularly (IM) for psychosis and Ativan1mg IM for agitation. The clinical justification is that Patient #J14 was a danger to others. Patient #J14 was in seclusion from 5:04 AM to 5:21 AM. An observation of the medical record reveals that the restraint/seclusion telephone orders have not been authenticated.

3). An interview with the Director of Nursing (DON) on 3/18/14 at 3:46 PM confirmed after reviewing the medical record that the Physician never signed the telephone order for the Physical and Chemical restraint, or Seclusion. It is a facility's expectation that physicians sign telephone orders for all restraints and seclusion. When asked, the DON revealed that she would try to get the physicians on the telephone to talk to this Surveyor regarding signing telephone orders.

4). An interview with the Director of Clinical Services on 3/19/2014 at 12:20 PM while reviewing the medical records for Patients #J13 and #J14 reveals that physicians are supposed to sign telephone orders to include restraint/seclusion orders within 48 hours of order initiation. The Director of Clinical Services confirmed that the restraint/seclusion orders have not been signed for either patient. She stated this has been an ongoing facility issue. Physicians are aware that they are supposed to sign the telephone orders in 48 hours, but they just do not do it.

5). An interview with the DON on 3/19/2014 at 1:30 PM reveals that none of the physicians who are identified as not signing the restraint/seclusion orders are in the facility at the present time. The DON was asked by this Surveyor if it was possible to talk to one of the physicians by phone since they were not in the facility. The DON stated that both physicians have a daytime practice with patients, so she was unsure if they would be available at this time. The DON was given this Surveyor's cell phone number and asked to have the physician call back. At 2:15 PM, the DON attempted to follow-up to see if a physician had made contact with this Surveyor. The DON stated that she would call again and leave another message to the physician to call this Surveyor. There was no call received by this Surveyor from a physician regarding this matter.

6). A review of the policy and procedures for telephone orders with an effective date of 11/2004 and a last revised date of 6/2009 reveals that physician telephone orders must be authenticated within 48 hours. If the practitioner is off duty, then another practitioner who is responsible for the patient's care can authenticate the verbal order of the ordering practitioner.

Based on medical record reviews, patient and staff interviews, the facility failed to ensure that patients and/or family were involved in the discharge planning process for 6 of 11 sampled patients (#1,#2,#4,#5,#6,#11).

The Findings Include:

Review of the medical record for Patient #1 revealed she was admitted to the facility on 3/9/14. Her discharge plan was to return to her previous living arrangement, and the patient signature was dated 3/13/14. On 3/17/14, the patient was still observed to be in the facility.

Interview with Patient #1 on 3/17/14 at 10:15 AM revealed she was admitted last Sunday and she is leaving with her fiance and will be staying at the Emerson Inn Motel, because she is homeless. She stated she has already signed her discharge forms a couple of days ago and they will give her prescriptions for her medication when she is discharged.


Interview with Patient #2 on 3/17/14 at 10:25 AM revealed he was admitted last Tuesday. He stated he was being discharged today to his mother's care.

Review of the medical record for Patient #2 revealed he was admitted on 3/11/14 and his final discharge papers were signed on 3/14/14. His final discharge forms included statements that his current medication list was given and explained. A copy of the Discharge Safety Plan was given and reviewed. A copy of all discharge instruction was given and reviewed. Patient's personal belongings from bedroom, belongings room and safe have been returned. Educated and provided hand-out on "Facts about Suicide and Depression" to patient and significant other/guardian, including "Black Box Warning for SSRI."


Review of the medical record for Patient #4 revealed she was admitted to the facility on 3/4/14. Her final discharge papers were signed on 3/7/14 to return to previous living arrangement. Patient #4 was observed on 3/17/14 to still be in the facility.


An interview was conducted with the Director of Quality on 3/17/14 at 2:30 PM. She was asked to review the medical records of Patient #2 and Patient #4, to explain why the discharge papers were filled out in advance of the patients' discharge and she stated she did not know. They will have to be signed again on discharge, so I don't know why they were already signed.

Interview with the Charge Nurse on 3/18/14 at 9:30 AM revealed her part of discharge planning starts the day of discharge. The therapist does her portion a little before the discharge. The patient is supposed to sign the forms when they are discharged. Recently, we have been having the patient sign all their forms at their first team meeting, but I don't know the reason. I think it is good for patients to sign them when they are competent and that isn't always at admission.


Observation of the treatment team meeting for Patient #4 was conducted on 3/18/14 at 10:00 AM. The Medical Director left before the meeting began; the Charge Nurse and Therapist were present along with Patient #4. The discussion was about the Assisted Living Facility not wanting Patient #4 to return to the facility.


Interview with the Therapist on 3/18/14 at 10:55 AM revealed they are trying to prepare Patient #4 for discharge. She stated we meet with patients every 7 days to see if they are meeting goals. She revealed she is the discharge planner. We discuss all paperwork within 48 hours of admission and patients are instructed to sign their discharge papers at that time. If things change, then we put a line through them on the form. The patient doesn't re-sign the changes. Discharge planning starts at admission. If things change, then we put a line through them, but no, the patient is not asked to re-sign. When asked how the facility documents, if the patient is advised of the changes or involved in the decision, she stated I guess we don't.


Review of the medical record for Patient #5 revealed she was admitted to the facility on 3/24/13 and her discharge papers were signed on admission. The patient was discharged from the facility on 4/5/13.


Review of the medical record for Patient #6 revealed she was admitted to the facility on 4/9/13 and her discharge papers were signed on admission. The patient was discharged from the facility on 4/15/13.


Observation of the discharge process for Patient #11 was conducted on 3/18/14 at 11:20 AM with the Therapist. Patient #11's discharge planning papers were blank. The Therapist stated she wanted to discuss her discharge plan. She asked the patient for her address that she would be going to, and a current telephone number for contact. She asked who would be picking her up and the patient stated her boyfriend. The Therapist stated she needed the patient to write down some wellness goals on her form and suggested that she write down that she was going to start running for stress relief. The Therapist did not ask the patient if she was a runner or wanted to start running. The Therapist stated there is supposed to be a family session prior to discharge, and was the patient interested in doing that over the telephone. The patient said no. The patient was told to sign the discharge plan and initial the safety statements. The Therapist stated she would print off a list of available services in the patient's area and she would give her a copy of everything she signed, as she was going out the door. The patient got up and left the room.

Interview with the Therapist on 3/18/14 at 11:30 AM revealed she met with Patient #11 once during treatment team, but her discharge papers were not filled out and I haven't seen her since. This is only her third day of admission. She revealed she does not do any follow-up with patients after their discharge. I have some patients who call me to talk, but I don't contact any patients.

Interview with the Director of Social Services on 3/18/14 at 3:30 PM revealed discharge planning starts when the patient is admitted. We have to initiate things within 72 hours. We have to continually update the plan, because it changes frequently. The therapist and patient develop the discharge plan with oversight from the psychiatrist or nurse. Patients sign their discharge papers in the beginning. We expect things to change and then we add to the form. The patient isn't asked to re-sign papers. My expectation would be for the patient to sign the final review of papers on discharge.

Review of Patient #2's discharge papers revealed the patient signed and dated the final discharge forms on 3/14/14 and wasn't discharged until 3/17/14. She stated the patient should not have been asked to sign his final discharge papers on 3/14/14. She stated they recently updated their forms and tried to improve the process, and it isn't being done as it was intended.