HospitalInspections.org

Based on review of medical records, hospital documents and interviews, it was determined that the hospital permitted individuals, employed by outside agencies, to provide Crisis Assessments for 4 of 4 ED patients, who presented with behavioral health chief complaints, without a contract with the outside agencies for the provision of Crisis Assessment services (Pt #s 1, 31, 32, and 34), posing a risk to patient health and safety.

Findings include:

Review of Pt # 1's medical record revealed:

On 4/4/2016, at 1500, MD # 20 documented: "...presents to the emergency department reporting an...overdose...Patient is somnolent on arrival, but is able to answer questions...does report depression...."

On 4/4/2016, at 2004, a Case Manager documented: "...is now awake. Pt. a client at (Name of Behavioral Health Agency). Paged Crisis at 7:56 pm. Awaiting callback...."

Pt # 1's medical record contained a document titled (Name of Behavioral Health Agency) Crisis Assessment: "...Assessment Date: 4/4/16...Assessment Time: 2121...Presenting Issue: ...Suicidality...." The form contained spaces for: "...Danger to Self and Others...Applicable Risk Factors...Substance Abuse...Medical Information...Psychosocial Information...Psychiatric Treatment History...Mental Status Exam...Diagnostic Impression...Additional Information...Consulted With...Disposition: Recommendations: ...admitted...status post OD....staffed with (name of agency Nurse Practitioner) met medical necessity requirements for psychiatric hospitalization...to remain at...pending placement...Signatures...."

Review of Pt # 31's medical record revealed:

Pt # 31 presented to the ED with an Overdose and Possible Suicide Attempt. S/he was brought to the ED via Emergency Medical Service (EMS) "with altered mental status."

On 8/15/2016, at 1329, MD # 18 documented: "...Felt it was appropriate to observe the patient in the ER until clinically sober so they could be reassessed and have a crisis evaluation performed to make sure there is not a component of suicidality...."

On 8/16/2016, at 1519, MD #10 documented: "...At this time the patient has a benign pulmonary exam and her hypoxia is completely resolved...we can transfer her to psychiatric institution...."

Pt # 31's medical record contained a document titled Crisis Assessment with letter head (Name of Behavioral Health Agency): "...Presenting Issue: ...Suicidal...Anxiety...Depression...Substance Abuse...Medication Issues...." The form contained spaces for: "...Current Stressors...Danger to Self and Others...Risk Factors...Substance Abuse...Medical Information...Current Medications...Psychosocial Information...Mental Status Exam...Diagnosis...Additional Information...Consulted With...Disposition: (Pt # 31) is in need of psychiatric inpatient stabalization (sic) due to suicidal ideations and overdose, unmanged (sic) depression and anxiety...." and a space for signature.

Review of Pt #32's medical record revealed:

Pt # 32 presented to the ED with a chief complaint of depression.

On 8/16/2016, at 0659, MD #11 documented: "...We'll have him speak with crisis counselor, patient agrees with plan...Patient has been seen by (Name of Behavioral Health Agency), they have worked out a safety plan and he is planning to follow up with many outpatient resources over the next few days...Patient agrees the (sic) plan and feels safe going home...."

Pt # 32's medical record contained a document titled Crisis Assessment with letter head (Name of Behavioral Health Agency): "...Presenting Issue: ...Anxiety...Depression...Medication Issues...Mania...." The form contained spaces for: "...Current Stressors...Danger to Self and Others...Risk Factors...Substance Abuse...Medical Information...Current Medications...Psychosocial Information...Mental Status Exam...Diagnosis...Consulted With...." and a space for signature.

Pt # 32's medical record also contained a document titled Support/Safety Plan with letter head (Name of Behavioral Health Agency). The document contained sections including: "...Concerns...Plan...Action Steps...Contact Information...." and a space for signature.

Review of Pt # 34's medical record revealed:

On 7/12/2016, at 1357, RN # 55 documented: "...Pt of the (Name of Behavioral Health Agency) and sent here today for aggressive behavior and homicidal behavior...."

On 7/12/2016, at 1710, MD # 10 documented: "...(Name of Behavioral Health Agency) did come to evaluate the patient and agree that he needs inpatient psychiatric services. We are awaiting placement...."

Pt # 34's medical record contained a document titled (Name of Behavioral Health Agency) Crisis Assessment: "...Assessment Date: 7/12/16...Assessment Time: 1610...Presenting Issue: "...Anxiety...Other: Violent bx (behavior)...Danger to Self and Others...." The form contained spaces for: "...Applicable Risk Factors...Substance Abuse...Medical Information...Psychosocial Information...Psychiatric Treatment History...Mental Status Exam...Diagnostic Impression...Additional Information...Consulted With...Disposition: Recommendations: per (name of agency psychiatrist) Ct (Client) is to go inpatient due to his bx DTO/DTS (Danger to Others/Danger to Self) violent behaviors. Ct is unable to control himself. impulsive, reactionary...Signatures...."

The Director of Quality and Performance Improvement confirmed, during interview conducted on 8/17/2016, that the hospital was unable to provide evidence of contracts for services provided by the behavioral health agencies that employed the personnel conducting the "Crisis Assessments" for ED Pt #s 1, 31, 32 and 34.

Based on review of medical records, hospital documents and interviews, it was determined that the hospital permitted individuals, employed by outside agencies, to provide Crisis Assessments for 4 of 4 ED patients, who presented with behavioral health chief complaints, without documentation of competence to perform such assessments, prior to conducting the assessments (Pt #s 1, 31, 32 and 34), posing a risk to patient health and safety.

Findings include:

Review of Pt # 1's medical record revealed that an employee of an outside agency completed a "Crisis Assessment" for Pt # 1, on 4/4/2016, at 2121, during her stay in the ED.

Review of Pt # 31's medical record revealed that an employee of an outside agency completed a "Crisis Assessment" for Pt # 31, on 8/16/2016, at 0825, during her stay in the ED.

Review of Pt # 32's medical record revealed that an employee of an outside agency completed a "Crisis Assessment" for Pt # 32, on 8/16/2016, at 0920, during his stay in the ED.

Review of Pt # 34's medical record revealed that an employee of an outside agency completed a "Crisis Assessment" for Pt # 34, on 7/12/2016, at 1610, during his stay in the ED.

Cross reference Tag 0083 regarding information related to the hospital's inability to provide evidence of a contract with the agencies for the provision of Crisis Assessment services.

The Director of Quality Assessment and Performance Improvement and the Assistant Chief Nursing Officer confirmed, during an interview conducted on 8/18/2016, that the hospital did not have documentation of the individuals' competence to conduct the Crisis Assessments prior to the individuals' provision of the Crisis Assessment services to the ED patients listed above.

Based on review of hospital policy/procedure, Medical Staff General Rules and Regulations, Medical Staff Bylaws, medical records and interviews, it was determined that the hospital failed to specify in hospital policy, Physician and other LIP training requirements and/or required documentation of working knowledge of hospital policy regarding the use of restraint or seclusion, for 2 of 2 physicians who ordered restraints and/or seclusion for the management of violent and/or self destructive patient behavior (MD #s 9 and 10), which poses a risk to patient health and safety.

Findings include:

Review of hospital policy/procedure titled Restraints and Seclusion Policy revealed: "...The use of restraint or seclusion must be in accordance with the order of a physician or designated licensed independent practitioner (LIP) who is responsible for the care of the patient...Physicians and LIPs authorized to order restraint or seclusion must have a working knowledge of hospital policy regarding the use of restraint or seclusion...."

Review of the hospital Medical Staff General Rules and Regulations and Medical Staff Bylaws revealed that neither document contained specific training requirements of physicians and/or LIPs who have authority to order seclusion and/or restraints.

Review of the credential files of MD #s 9 and 10 revealed that they did not contain documentation of orientation of the two physicians to the hospital Restraint and Seclusion Policy.

Review of Pt # 35's medical record revealed:

MD # 9 entered an order in the electronic medical record, on 5/4/2016, at 1943: "Initiate Violent Restraint 18 yrs and older...Physical Abuse to Others Locking for 4 hours...."

A nursing progress note contained documentation that the restraints were removed on 6/4/2016, at 2248.

On 5/4/2016, at 2028, MD #9 documented: "...The patient had a be (sic) placed in hard restraints as he was very combative with the police and with our staff here. I had a face-to-face evaluation with him and ordered these restraints. Per the patient (sic) did become calm and I had a lengthy discussion with the family...."

Pt # 35's medical record did not contain documentation of the required components of the face-to-face evaluation conducted within one hour after initiation of restraints for the management of violent and/or self-destructive behavior. (Cross reference Tag 079 for specific required components of the one hour face-to-face evaluation).

Review of Pt # 34's medical record revealed:

Physician # 10 entered an order in the electronic medical record on 7/12/2016, at 1708: "Restraint Initiate/Continue Violent 9-17 yo (?sic) Physical Abuse to Others, Seclusion Order Valid for 2 hrs Evaluate patient and order Restraint Continue Behavioral if indicated...."

A "Stop" order was entered on 7/12/2016, at 1840.

MD #10 documented a Physical Examination on 7/12/2016, at 1357 and Reexamination/Reevaluation, on 7/12/2016, at 1707: "...Though initially cooperative once the patient found out that he would need to go inpatient psychiatric again he became agitated. He continues to run from the ER will not sit in the room...Multiple other attempts were made to admit him trying to run from the ER including using the side rails and multiple distracting techniques but as he continues to attempt to elope and is currently under inpatient psychiatric treatment we will have to place him in seclusion to maintain his safety. If he continues with significant agitation we will also had (sic) chemical restraints. Face-to-face evaluation was performed...07/12/16 1725: Assessment: Patient unfortunately is more and more agitated...we'll also institute chemical restraints and patient was given Haldol...07/12/16 1838...Course: Improving...Assessment: Patient is now calm and cooperative one hour after IM Haldol. Seclusion will be removed as long as the patient remains in his room...."

Pt # 34's medical record did not contain documentation of the required components of the face-to-face evaluation conducted within one hour after initiation of seclusion or chemical restraint. (Cross reference Tag 079 for specific required components of the one hour face-to-face evaluation).

The CMO, Director of Quality and Director of Medical Staff Services confirmed, during interview conducted on 8/18/16, that they were unable to provide documentation of MD #9's and/or MD #10's training or orientation regarding the hospital policy/procedure related to Seclusion and Restraint to provide them with a working knowledge of the policy/procedure, as required.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that the 1 hour face-to-face evaluation of a patient after the initiation of seclusion or restraint for the management of violent or self-destructive behavior include an evaluation of the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint or seclusion, for 2 of 2 patients restrained and/or secluded in the Emergency Department (Pt #s 34 and 35).

Findings include:

Review of hospital policy/procedure titled Restraints and Seclusion Policy revealed: "...When restraint or seclusion is used for violent or self-destructive behavior there must be documentation in the patient's medical record of the following:...The one hour face-to-face medical and behavioral evaluation...A description of the patient's behavior and the intervention used...Alternatives or other less restrictive interventions attempted (as applicable)...The patient's condition or symptom(s) that warranted the use of the restraint or seclusion; and...The patient's response to the intervention(s) used, including the rationale for continued use of the intervention...the patient must be evaluated face-to-face within 1 hour after the initiation of the intervention by a Physician or other LIP (Licensed Independent Practitioner). The evaluation must include: a. The patient's immediate situation; b. The patient's reaction to the intervention; c. The patient's medical and behavioral condition; and d. The need to continue or terminate the restraint or seclusion...."

Review of Pt # 34's medical record revealed:

Physician # 10 entered an order in the electronic medical record on 7/12/2016, at 1708: "Restraint Initiate/Continue Violent 9-17 yo (?sic) Physical Abuse to Others, Seclusion Order Valid for 2 hrs Evaluate patient and order Restraint Continue Behavioral if indicated...."

A "Stop" order was entered on 7/12/2016, at 1840.

MD #10 documented a Physical Examination on 7/12/2016, at 1357 and Reexamination/Reevaluation, on 7/12/2016, at 1707: "...Though initially cooperative once the patient found out that he would need to go inpatient psychiatric again he became agitated. He continues to run from the ER will not sit in the room...Multiple other attempts were made to admit him trying to run from the ER including using the side rails and multiple distracting techniques but as he continues to attempt to elope and is currently under inpatient psychiatric treatment we will have to place him in seclusion to maintain his safety. If he continues with significant agitation we will also had (sic) chemical restraints. Face-to-face evaluation was performed...07/12/16 1725: Assessment: Patient unfortunately is more and more agitated...we'll also institute chemical restraints and patient was given Haldol...07/12/16 1838...Course: Improving...Assessment: Patient is now calm and cooperative one hour after IM Haldol. Seclusion will be removed as long as the patient remains in his room...."

Pt # 34's medical record did not contain documentation of the required components of the face-to-face evaluation conducted within one hour after initiation of restraints for the management of violent and/or self-destructive behavior as required by hospital policy/procedure.

Review of Pt #35's medical record revealed:

MD # 9 entered an order in the electronic medical record, on 5/4/2016, at 1943: "Initiate Violent Restraint 18 yrs and older...Physical Abuse to Others Locking for 4 hours...."

A nursing progress note contained documentation that the restraints were removed on 6/4/2016, at 2248.

PA # 8 documented a Physical Examination on 5/4/2016, at 2126. Lab results were entered on 5/4/2016, at 1933.

On 5/4/2016, at 2126, PA #8 documented: "...Upon arrival he is very combative and therefore was placed in hard restraints. Patient then fell soundly asleep. Several hours later the patient is now awake and alert...."

On 5/4/2016, at 2028, MD #9 documented: "...The patient had a be (sic) placed in hard restraints as he was very combative with the police and with our staff here. I had a face-to-face evaluation with him and ordered these restraints. Per the patient (sic) did become calm and I had a lengthy discussion with the family...."

Pt # 35's medical record did not contain documentation of the required components of the face-to-face evaluation conducted within one hour after initiation of restraints for the management of violent and/or self-destructive behavior, as required by hospital policy/procedure.

RN # 5 confirmed, during interview conducted on 8/17/2016, that the documentation of the one hour face-to-face evaluations did not include the required components.

The Assistant Chief Nursing Officer and RN # 53 confirmed, during interview conducted on 8/18/2016, that the medical records of Pt #s 34 and 35 did not contain the required components of the face-to-face evaluations conducted within one hour after initiation of restraints for violent and/or self-destructive patient behavior.

Based on facility policies and procedures, document review, manufacturer's recommendations and staff interview, it was determined the Administrator failed to require the contracted dialysis staff to promptly notify the facility of colony counts and endotoxin culture results obtained monthly for 1 of 1 hemodialysis machines and 1 of 1 reverse osmosis machines as per their policy; which has the potential risk of water contamination due to the level of bacteria in the hemodialysis machines used to dialyze patients.

Findings include:

Contracted Facility's policy and procedure titled "Microbiological Sample Collection: Treated Water for Inpatient Services " revealed: " ...Ensure that Microbiological monitoring for Water Purification Systems...Ensure sample results are reviewed and correct individuals notified when results are above action level or exceeding allowable limit...Collect Microbiological samples...ship specimens...."

Contracted Facility's policy and procedure titled Microbiological Monitoring: Portable Water Purification Systems for Inpatient Serviced" revealed: "...Samples will be collected at a minimum of monthly...Samples shall be collected and sent...Additional testing should be undertaken if microbial samples continue to contain microbiological levels exceeding action level or allowable limits, as a troubleshooting strategy to ensure that system components are maintained...to assist with identifying the source of contamination...Monthly trending of results shall be completed...."

Contracted Facility's policy and procedure titled "Microbiological Sample Collection: Dialysate for Inpatient Services " revealed the following: "...Ensure that microbiological monitoring of Dialysate...Ensure sample results are reviewed and correct individuals notified...Ensure microbiological monitoring data is presented and reviewed...Collect Microbiological samples...ship specimens...."

The Risk Manager #11 confirmed in an interview conducted on 8/16/16, that the facility has adopted the contract service's policies and procedures.

The Director of Quality #54 and the CNO # 2 confirmed in individual interviews conducted on 8/17/16, that the facility has adopted the contract service's policies and procedures.

Review of the facility documentation titled "Facility Summary by Date 01/01/16 to 4/30/16'" revealed the dates of the collected specimen, the test name, status, source, and results.

The Biomedical Technician # 25 confirmed in an interview conducted on 8/17/16, that the hemodialysis machine and the reverse osmosis machine needs to have colony counts and the endotoxins checked monthly.

The Infection Preventionist # 16 confirmed in an interview conducted on 8/17/16, that the results of the colony counts and the endotoxins for the hemodialysis machine and the reverse osmosis machine needs to have colony counts and the endotoxins checked monthly, with the results sent to the facility monthly for review. She confirmed that there was no documentation of the results for colony counts and the endotoxins after 4/19/16.

The Risk Manager # 6, the Clinical Coordinator # 4, the Clinical Coordinator # 23, the CNO # 2, and Clinical Coordinator #11 confirmed in individual interviews conducted on 08/16/16, that the contracted services send a quarterly report to the facility with the results of the endotoxins and colony counts. They confirmed that the contracted agency only sends the reports quarterly to the facility. They also confirmed that there was no documentation of results of colony counts and endotoxins for the machine and water system after 4/19/16.