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Tag No.: A0395
Based on a review of clinical records, staff interviews, and a review of the facility policies and procedures for one of ten sampled patients, (Patient #1), who were assessed for suicide risk, the facility failed to ensure every fifteen minute observations were conducted as ordered by the physician and/or in accordance with the facility policy. The finding include:
Patient #1 had a history of depression without any suicide attempts. Patient #1 was admitted to the facility voluntarily on 4/30/12 with a diagnoses that included Major Depressive Disorder, recurrent severe without psychotic features.
An initial suicidal assessment by the facility dated 4/30/12 at 5:09 PM that was completed by the admitting registered nurse identified minimal suicidal ideation with symptoms of hopelessness, helplessness, anhedonia (lack of pleasure in acts that are normally pleasurable) and guilt. An initial admission physician ' s evaluation was conducted on 4/30/12 at 7:23 PM by MD #2 indicating Patient #1 was passively suicidal without a plan or intent and that the resident was admitted for mood stablization.
Physician ' s orders dated 4/30/12 directed fifteen minute checks. The multidisciplinary treatment plan dated 4/30/12 identified passive suicidal ideations as a problem with interventions that included monitor sleep, administer medications as ordered, group treatment, therapeutic activity, family involvement, observation of patient for safety every fifteen minutes and discharge planning.
An initial physician ' s evaluation was conducted on 5/1/12 at 10:35 AM by MD #2, identifying active suicidal ideations without a plan or intent. Patient #1 ' s symptoms of depression were documented by MD #2 as sadness, excessive and inappropriate guilt, sleep disturbances, loss of appetite, anhedonia, decreased concentration, hopelessness and helplessness. Patient #1 ' s treatment included the administration of Fluoxetine to target symptoms of depression, to taper Depakote and Zyprexa, the attendance of group and mileau therapy, the initiation of family meetings, and disposition planning to be coordinated with the treatment care coordinator.
A suicidal re-assessment was conducted on 5/1/12 at 12:12 PM and identified no change in the patient's risk. Review of the clinical record on 5/1/12 indicated Patient #1 was future oriented in conversation and stated he/she would come to staff if he/she felt unsafe.
Interview and review of the clinical record with the Director of Nursing on 5/8/12 at 11:15 AM identified on 5/2/12 at 11:40 AM Patient #1 was observed hanging from the bathroom door of his/her room with a bathrobe sash around his/her neck. The patient was cut down and noted to be unresponsive and pulseless. A hospital code was initiated and cardiopulmonary resuscitation was administered. The emergency medical system arrived at 12:03 PM and continued with resuscitative efforts and transported Patient #1 to an acute care facility where he s/he expired.
An interview with the Director of Quality on 5/18/12 at 1:00 PM identified that a review of the monitor identified that a recording of the hallway activity did not corroborate what Psychiatric Technician # 1 had documented had occurred, in regards to the 15 minute observations. A review of the Observational Checklist dated 5/2/12 at 11:30 AM identified that according to Psychiatric Technician #1, Patient # 1 was awake in his/her room.
The Director of Quality further identified that a review Patient # 1's fifteen minute checks were completed on 5/2/12 at 11:12 AM for the 11:15 AM check. Observational checks were not completed again until 11:40 AM when Patient #1 was found unresponsive, a period of 28 minutes.
The Director of Quality identified checks should have been completed at 11:30 AM as ordered by the physician and in accordance with the hospital policy. The hospital policy for Patient Observation Levels and Observation Checklist, directed in part that the registered nurse assigns a staff member to every fifteen minute observation rounds. The assigned staff member utilizes the Observation Checklist to record the location of the patient, and initial the column corresponding to the time of the check.
Tag No.: A0432
Based on review of one of two patients who requested copies of clinical records, (Patient # 2), the Hospital failed to ensure that copies were provided in a timely fashion and in accordance with the Hospital policy. The findings include:
Patient #2 was admitted to the Hospital on 9/20/10 for alcohol detoxification. Patient # 2 was discharged on 10/14/10 after treatment for his/her long standing drinking problem. An interview on 5/9/12 with the Director of Medical Records identified that although the request for copies was recieved on 4/20/11 from an attorney, it wasn't cosigned by the patient until 4/28/11. The interview further identified that the facility requires payment to release records and didn't request payment until 8/3/11. The interview further identified that upon receipt of payment on 8/4/11, the records were sent out. The Medical Records Director further identified that she doen't know why it took so long to request payment for the records and/or to mail them out, but it is the facility's goal to turn around requests for medical records in a 7 day timeframe.