HospitalInspections.org

48537

Based on interviews and record review, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice was evidenced by the failure of the admitting practitioner's failure to order medical care based on the medical diagnoses at the time of admission to the facility in 1 (#2) of 3 (#1-#3) patient records reviewed for the sample.

Findings:
Review of the hospital policy number QAPI-00 titled, "Quality Assessment and Performance Improvement (QAPI) Plan" last revised on 06/01/2024 revealed the following:
Policy:
Aligned with the organization's core convictions rooted in the belief that everyone deserves dignity and respect, the hospital is dedicated to delivering safe, compassionate, high-quality care.The plan focuses on the evaluation of the current performance of the hospital and the identification of opportunities for improvement. This involves systemic monitoring, measurement, analysis, and robust action planning using a defined performance improvement methodology to ensure that the hospital delivers high-quality care and meets regulatory requirement. The committee's primary objective is to identify and address any breakdowns that may compromise patient care and safety, striving to continuously improve and promote positive patient outcomes.
2. Medical Staff The medical staff provides effective mechanisms to monitor, assess, and improve the quality and appropriateness of patient care and the clinical performance and competency of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed, with improvement strategies and actions implemented, to ensure improved performance is achieved and sustained.

Review of Patient #2's medical record revealed she was admitting to the facility on 08/29/2024 at 5:45 p.m. from an outside referring facility emergency room after receiving one dose of oral Macrobid antibiotic treatment for a urinary tract infection with a diagnosis of major depressive disorder.

Review of Patient #2's medical record revealed the following:
On 08/29/2024 at 6:36 p.m. - Patient arrived via ambulance from nearby emergency room at 5:45 p.m. AAO x3. Patient is forgetful, but is able to verbalize partial reason for admission (UTI). Denies AVH, SI and HI. Patient easily reoriented to current situation. Signed by S9RN

Review of Patient #2's history and physical completed on 08/30/2024 at 5:13 p.m. by S10NP revealed Patient #2 was admitted to the psychiatric hospital facility after becoming overheated in the outside referring facility emergency room and developed visual hallucination reporting she believed someone wanted to kill her and palpitations. S10NP documented Patient #2's chief complaint in her own words to be "Can I have some Tylenol?" Continued review of the medical record revealed S10NP documented "negative" for each body system in the Review of Systems which indicated in his evaluation of her symptoms she was not reporting any symptoms including psychiatric symptoms like hallucinations. S10NP documented Patient #2's physical assessment to be normal and within the normal expected limits of a patient her age. S10NP documented "UTA" for Patient #2's neurological exam and cranial nerve exam. Review of S10NP's documented Assessment & Plan stated to follow up on admission labs. Further review of the history and physical revealed no documentation as to why S10NP did not address the urinary tract infection Patient #2 was tested for and diagnosed with at the outside referring facility emergency room or reference to acknowledging Patient #2 had a UTI..

Review of Patient #2's admission orders revealed the following orders placed on admission:
08/29/2024 Admit to Care of S8MD, PEC, Admitting Diagnosis: MDD
08/29/2024 Legal Status - LA Continuous Request Type: Now, Legal Status: Physician Emergency Certificate
08/30/2024 Methenamine Hippurate (Hiprex) 1G Take 1 tablet by mouth daily for prevention of bacterial urinary tract infection
08/30/2024 Urinalysis with Reflex to C/S Discontinued 08/31/2024

Review of S11NP's note dated 08/31/2024 at 7:39 p.m. it was documented Patient #2 continued to have episodes of confusion, paranoia and agitation particularly during the evening hours. She had also told S11NP she believed she was in there in the hospital because she had a urinary tract infection.

Review of S10NP's note dated 08/31/2024 at 10:24 p.m. it was documented Patient #2 was seen in gerichair with no new issues or complaints with poor insight. Plan to follow up on admission labs and no new recommendations for the day.

Review of Patient #2's lab orders revealed an order for a urinalysis with culture & sensitivity if indicated was originally ordered on 08/30/2024 by S10NP and discontinued on 08/31/2024. The urinalysis with culture and sensitivity if indicated was then reordered again on 09/01/2024 by S13NP and resulted on 09/03/2024.

On 10/22/2024 at 3:45 p.m., an interview was conducted with S12NS. She stated the reason for the delay in collecting the admission labs for Patient #2 was likely because she was admitted to the hospital on a weekend and the lab does not come to collect labs on the weekend and then that following Monday was the Labor Day. She stated since the provider did not order the labs as STAT orders and were just ordered as routine admit labs, they would just be collected by the lab on the next routine draw.

On 10/23/2024 at 1:36 p.m., a telephone interview was conducted with S10NP. He stated he was one of the medical NPs providing care for the patients at the facility. He stated he vaguely remembered Patient #2, but if the H&P was signed by him then he was the one who completed it. He stated his process for admitting a new patient who has been referred to the facility by an outside facility directly would be to review the referral paperwork that is sent from the referring facility for the patient including labs, tests and procedures completed prior to arrival. He stated based on what had already been done for the patient at the prior facility including recommendations, he would conduct his evaluation and assessment of the patient as to not duplicate or delay any treatment or medications if possible. He stated if a patient was transferred to the facility after having had a urinalysis completed in the emergency department to test for urinary tract infection and it came back with a positive result for a UTI, he would not reorder the urinalysis upon admission to the facility, he would just start the patient on antibiotics to begin/continue treatment for the UTI. He stated it could be possible for an older adult female in her early 80s, similar to the age of Patient #2, suffering from an untreated UTI for multiple days could exhibit symptoms easily mistaken for symptoms psychiatric in nature like altered mental status, increased agitation, and hallucinations. He stated he was unaware if this was true for Patient #2 because he could not remember her situation as he did not have her chart in front of him. He stated he was familiar with the hospital's lab collection procedure for which providers put in routine lab orders whether at admission or during the stay and the labs are collected the next morning by the outside lab provider Monday-Friday. He stated the lab provider does not come to the facility on weekends and/or holidays. The surveyor informed him Patient #2 had been diagnosed with a UTI at the ER of the outside referring facility on the day of admission to the facility and received a one-time dose of oral antibiotics prior to arriving at the facility, but her treatment for the UTI had not been continued upon her arrival to the facility and another urinalysis was ordered upon admission but was not collected until 09/03/2024 which had delayed Patient #2's treatment of the UTI. He stated "okay."

Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. The deficient practice is evidenced by failure of the hospital to initiate changes and monitor for compliance after allegation of abuse/neglect was made against members of the Behavioral Health staff.
Findings:

Review of the hospital's policy titled "Patient Grievance Process" last revised date 09/01/2024 revealed in part: GRIEVANCE: A formal or informed written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights. Role of the Patient Advocate: 2. Complete a thorough investigation of all grievances representing the expressed desires of the individuals served and advocating for the resolution of their grievances.

Review of the hospital's policy titled "Assessment and Reporting of Abuse, Neglect" last revised date 10/01/2024 revealed in part: PROCEDURE: C. A description of actions taken by the facility subsequent to the event to include: iv. Educational/training programs provided to staff members prior and subsequent to the event, to include, content and attendees.

Review of the hospital policy titled, "Quality Assessment and Performance Improvement (QAPI) Plan" last revised on 06/01/2024 revealed the following: Policy: Aligned with the organization's core convictions rooted in the belief that everyone deserves dignity and respect, the hospital is dedicated to delivering safe, compassionate, high-quality care.The plan focuses on the evaluation of the current performance of the hospital and the identification of opportunities for improvement. This involves systemic monitoring, measurement, analysis, and robust action planning using a defined performance improvement methodology to ensure that the hospital delivers high-quality care and meets regulatory requirement. The committee's primary objective is to identify and address any breakdowns that may compromise patient care and safety, striving to continuously improve and promote positive patient outcomes.
2. Medical Staff The medical staff provides effective mechanisms to monitor, assess, and improve the quality and appropriateness of patient care and the clinical performance and competency of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed, with improvement strategies and actions implemented, to ensure improved performance is achieved and sustained.

In an interview on 10/23/2024 at 10:00 a.m. S1QD verified that the only interventions done related to the self-report involving Patient #2 was education for the registered nurses only regarding skin assessments.

In an interview on 10/23/2024 at 2:34 p.m. S3DON reveals she can't remember if she did an educational in-service with the nurses regarding skin assessments. Furthermore she was unable to produce educational material or an in-service sign in sheet for attendees of the education.

In an interview on 10/23/2024 at 3:30 p.m. S2HA verified that there was no follow up with S3DON regarding required education for the nurses as a result of the investigation related to allegations of abuse.

Based on interviews and record review, the hospital failed to ensure the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by the failure to update the care plan of 1 (#2) of 3 (#1-#3) patients reviewed for completed and updated care plans.

Findings:
Review of the hospital policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary" last revised on 07/01/2024 revealed the following:
Procedure:
2. The admitting nurse is responsible for the following:
-Formulating the initial treatment plan based on physician's orders/initial orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 hours (1 treatment day IOP) of admit or sooner if patient's needs warrants immediate action.
-Initiating individualized treatment problem/nursing diagnosis list as identified in the assessment
-Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations and physician's orders.

Review of the hospital policy number NSG-42 titled, Activities of Daily Living (ADL) last revised on 03/01/2023 revealed the following:
Purpose:
To establish procedures for assisting patients with activities of daily living to promote positive self-concept and overall well-being and functional independence.
Policy:
Patients are encouraged ...The functional ability of each patient is determined on admission during the nursing admission assessment. Depending upon the functioning abilities of each patient, the nursing staff will supervise, assist, teach, and/or provide activities of daily living including personal hygiene.
Procedure:
6. The RN will incorporate the patient's level of performing activities of daily living in patient's treatment planning with the goal to have the patient perform these self-care task independently, as deemed appropriate.

Review of the medical record for Patient #2 revealed she was admitted to the hospital on 08/29/2024 at 5:45 p.m. S9RN documented Patient #2 was incontinent upon arrival, was cleaned, a new depends was applied and she was transferred to unit bed and redness was noted to her sacrum with otherwise skin intact.

Review of the Hospital's Observation Check Sheet/Graphic Flowsheet dated 08/29/2024 - 09/05/2025, Patient #2 received incontinent checks by the assigned mental health techs and nurses assigned to her care every two hours while she was in the facility.

Review of Patient #2's Nursing Plan of Care started on 08/29/2024 revealed no documentation of a care plan problem related to incontinence care or risk for impaired skin integrity.

On 10/23/2024 at 3:55 p.m., an interview was conducted with S1QD. She stated the expectation for all nurses is to make sure the nursing care plans are individualized and current to the needs of each patient. She stated if a patient were to be incontinent and have a documented redden sacrum on admission that would mean they were at higher risk for potential skin breakdown and should be care planned accordingly. S1QD reviewed Patient #2's nursing care plan and confirmed no documentation related to incontinence care or impaired skin integrity was on the nursing care plan and should have been.

S2HA reviewed Patient #2's nursing care plan and confirmed no documentation related to incontinence care or impaired skin integrity was on the nursing care plan and should have been.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:
On 10/23/2024 at 2:10 p.m. during a tour of the facility, the counter top in Room a was missing a piece of laminate exposing wood.
In an interview on 10/23/2024 at 2:10 p.m. S1QD verified laminate was missing from the counter top in Room a exposing wood.

Based on record review and an interview, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients' individual treatment program as evidenced by failure to have a signed master treatment plan by MD for 1 (#2) of 3 (#1-#3) patients' treatment plans reviewed for the sample.

Findings:
Review of the hospital policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary" last revised on 07/01/2024 revealed the following:
Purpose:
To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.
Policy:
The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure:
1. The admitting physician is responsible for providing the following:
-Prescribing treatment modalities for the initial plan of care in the psychiatric evaluation.
-Providing direction to the multi-disciplinary team in the formulation of treatment planning goals, objectives and clinical interventions.
-Certifying admission/stays and levels of care.
-Documenting progress towards meeting the treatment objectives and direction for patient plan.
4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT).

Review of Patient #3's medical record revealed he was admitted to the facility on 10/18/2024 at 3:30 a.m. from an outside referring facility emergency room for dementia with behavioral disturbance.

Review of Patient #3's Interdisciplinary Treatment Plan Master Sheet dated 10/18/2024 was not signed by the physician. Review of Patient #3's Interdisciplinary Treatment Plan Update - Inpatient dated 10/22/2024 was also not signed by the physician.

On 10/23/2024 at 9:45 a.m., an interview was conducted with S7QA during patient record review. While reviewing the treatment plan, she confirmed the S8MD had not signed the Interdisciplinary Treatment Plan Master Sheet date 10/18/2024 or the Interdisciplinary Treatment Plan Update - Inpatient dated 10/22/2024.

On 10/23/2024 at 10:15 a.m., an interview was conducted with S1QD. She stated interdisciplinary treatment plan master sheet is signed by the patient, admitting registered nurse, therapist/social worker, recreational therapist, and admitting psychiatric MD. She stated the weekly updated treatment plans are signed by the same individuals with the exception of the registered nurse may change depending on which nurse is caring for the patient on the day of the IDT meeting. She stated the master treatment plan is completed upon admission and is signed by the patient and admission nurse within 24 hours of the patient's admission. The therapist/social worker, recreational therapist and psych MD have 72 hours from the time of the patient's admission to the hospital to sign the master treatment plan. S1QD confirmed S8MD had not signed the Interdisciplinary Treatment Plan Master Sheet dated 10/18/2024 or the Interdisciplinary Treatment Plan Update - Inpatient dated 10/22/2024.