HospitalInspections.org

Based on review of medical records(MR) agency policies and interviews with the staff it was determined the facility failed to ensure:

1. All patients on the SBCU were kept safe from harm.

2. The use of a manual restraint which can cause an emotional and physical safety of the patient(s) and a potentially unsafe environment.

3. To have documented orders for restraints.

4. To document a patient face-to-face assessment within the policy time frame.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to:
A 145, A 159, A 168 and A 178 for additional findings.

Based on review of medical records (MR), agency policy and procedure, the posted patient bill of rights form posted on the SBCU (Senior Behavioral Care Unit) and interviews with the staff it was determined the facility failed to ensure all patients on the SBCU were kept safe from harm. This affected 2 of 11 MR's reviewed and did affect Patient Identifier (PI) # 5 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Patient Rights
Revised Date: 9/14/2008

"Purpose:

To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights and involvement of patient.

Policy/Procedure:

It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit.

Procedure:

F. The following patient rights are adhered to at all times on the unit:

1. A patient is provided with care, treatment and services in the least restrictive environment in accordance with laws and regulations.

14. Privileges may be reasonably restricted by the attending physician in accordance with state law to protect the patient or others from harm, harassment and intimidation...

16. The patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and/or exploitation."

Patient Bill of Rights Form:

"The Rights and Responsibilities of Our Patients:

Mizell Memorial Hospital, in order to foster better channels of communication, closer patient/hospital relationships and more efficient care, presents the following Bill of Rights for you and your family.

As a patient, you have the right to:

1. Be treated with respect and dignity as an individual.

10. Receive considerate and respectful care in a clean and safe environment..."

1. PI # 5 was admitted to the facility on 11/21/17 with admitting diagnoses of Psychosis and Inappropriate sexual behavior.

Review of the Patient Progress Notes on dated 11/21/17 revealed the patient weighted 161 pounds (lbs) and 9.6 ounces (oz).

Review of the Patient Progress Notes dated 11/26/17 revealed the patient weighted 158 lbs 3 oz.

Review of the spread sheet started on 11/21/17 and continues through discharge on 12/5/17 revealed a weight on week one as 158.2 lbs and at discharge or week two a weight of 149 lbs 8 oz.

Review of the Patient Progress Notes of the nutritional intake from 11/22/18 to 11/25/17 revealed the following:

11/22/17 8:34 AM - 50% of breakfast consumed.
12:00 PM - 75% of lunch consumed.
5:15 PM - 0% of supper consumed.

11/23/17
8:10 AM - 25% of breakfast consumed.
12:26 PM - 0% of lunch consumed.
5:15 PM - 50% of supper consumed.

11/24/17
8:26 AM - 5% of breakfast consumed.
11:30 AM - 0% of lunch consumed.
6:15 PM - 25% of supper consumed.

11/25/17
7:30 AM - 10% of breakfast consumed.
12:30 PM - 25% of lunch consumed.
5:45 PM - 50% of supper consumed.

11/26/17
7:30 AM - 75% of breakfast consumed.
12:26 PM - 0% of lunch consumed.
5:39 PM - 50% of supper consumed.

11/27/17
8:00 AM - 25% of breakfast consumed
12:45 PM - 50% of lunch consumed
6:00 PM - 100% of supper consumed

11/28/17
7:30 AM - 75% of breakfast consumed
12:46 - 0% of lunch consumed
5:30 PM - 50% of supper consumed

11/29/17
8:07 AM - 0% of breakfast consumed
12:29 PM - 0% of lunch consumed
5:51 PM - 75% of supper consumed

11/30/17
7:55 AM - 0% of breakfast consumed
No documentation of lunch consumption
5:57 PM - 25% of supper consumed

12/1/17
7:30 AM - 75% of breakfast consumed
12:15 PM - 25% of lunch consumed
5:30 PM - 75% of supper consumed

12/2/17
7:30 AM - 75% of breakfast consumed
No documentation of lunch consumption
6:45 PM - 50% of supper consumed

12/3/17
9:01 AM - 100% of breakfast consumed
No documentation of lunch consumption
6:22 PM - 10% of supper consumed

12/4/17
7:30 AM - 75% of breakfast consumed
12:30 PM - 50% of lunch consumed
5:15 - 75% of supper consumed

12/5/17
8:35 AM - 0% of breakfast consumed

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15, RN (Registered Nurse) and was asked if a weight loss was noticed on a patient what is typically done by the staff? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)."

Review of the entire MR revealed no documentation the patient was given a nutritional supplement at any time throughout each day.

Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal.

An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1, Director of SBCU, who confirmed the above mentioned findings.

Review of all the nursing progress notes dated 11/21/17 to 12/5/17 revealed no documentation the physician was notified of the patient's weight loss.

Review of the the patient progress notes dated 11/21/17 - 11/26/17 and 11/29/17 to 12/5/17 revealed the nursing staff documented under the nursing assessment skin: warm, dry, Changes to skin: none and in the wound assessment section of each note was documented N/A (not Applicable).

Review of the patient progress note dated 11/27/17 at 5:54 AM by EI # 15 documented under the narrative nurses note "Drsng (dressing) on left forearm changed, skin tear healing well, no bleeding."

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15 who stated when asked about the patient's skin tear was not sure how he/she received the skin tear but stated "he was always in the recliner and flailing his/her arms and sometimes they scrape them on the recliners... I remember his/her skin being like so many of the frail older people we get, just typical paper skin and easy to bruise."

Review of the patient progress notes dated 11/28/17 at 7:51 AM by EI # 1,Director of SBCU, revealed under the nursing assessment for skin: warm, skin tear to L (left) forearm. Changes to skin: skin tear. Wound assessment N/A.

In an interview on 7/12/18 at 2:28 PM EI # 1 was asked if he/she knew when the skin tear occurred. EI # 1 replied by stating" I do not. When I saw it, it had a dressing on it. It had gauze and coban around the outside. The daughter saw it because she asked about it being changed the day before I saw it. No one ever documented when the skin tear occurred only one documentation that it was cleansed, didn't say with what, and telfa on it."

Review of the progress note dated 11/28/17 at 4:35 PM by EI # 13, LPN (Licensed Practical Nurse) revealed the following documentation under the narrative nurse note " ...Dressing to arm changed as asked by family member during visitation. Continues to have some bloody discharge. No redness to area surrounding. Cleaned and covered with Telfa and wrapped with Coban."

Review of the entire nurse note dated 11/28/18 revealed no documentation of how the wound care was performed.

Review of all the physician orders revealed no documentation of an order written for wound care.

Review of the all of the nursing notes within the MR from 11/29/17 to 12/5/17 revealed no documentation of the healing of the skin tear or any further documentation of dressing changes.

An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1 who confirmed the above mentioned findings.

Based on review of medical records, Facility policy and procedure, and interview(s) it was determined that patient(s) were being placed in a manual hold for administration of psychotropic medications. The facility failed to recognize the use of a manual hold as a restraint. This had the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 10.


Findings include:

Policy: Restraint and Seclusion
Revised Date: 9/21/2017

"Purpose:

To establish guidelines for the safe, effective use of seclusion and/or restraints... To ensure the protection of the patient's rights, dignity, physical and psychological well being of individuals requiring restraint and/or seclusion

Definitions:

A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

B. Behavioral Health Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

...F. Continuous Observations: Face to face in person monitoring.

Policy/Procedure:

It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit.

Procedure:

...B. ...Any application of restraint must involve assessment within one hour by a qualified registered nurse (RN), physician assistant (PA) or LIP (Licensed Independent Practitioner) as to the degree and likelihood of the harm that may be produced by the restraint

...D. Orders:

1. Restraint shall be ordered by a physician or LIP authorized by the medical staff.

...3. The order shall specify the method of restraint and/or seclusion to be used.

...S. Each instance of restraint or seclusion is documented in the seclusion/restraint log. The log will include date, time, patient name, age, gender, case number, type of restraint/seclusion, time in, time out, staff initiating, and signature of review by the Program Director or Medical Director, and name of RN (Registered Nurse) who initiated the restraint or seclusion time of face to face evaluation and by whom.

1. PI # 10 was admitted to the SBCU (Senior Behavior Care Unit) on 7/11/18 with diagnosis of acute psychosis.

Review of the Verbal/Phone/Protocol Order dated 7/11/18 at 11:05 PM revealed physician order for Thorazine (chlorpromazine) Injection 50 mg (milligrams)/ 2 ml (milliters) 50 mg x (times) 1 IM (intramuscular)

Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:10 PM with documentation of patient becoming combative towards staff and MD (Medical Doctor) "notified with 1 x (one time) order for Thorazine 50 mg to be given at this time."

Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:12 PM with the following documentation, "PRN (as needed) Thorazine given at this time. Cleansed area and IM injected to left buttock."

An interview was conducted on 7/12/18 at 8:00 AM with EI (Employee Identifier) # 11, RN, during the interview the surveyor asked EI # 11 about how an injection would be given on a combative patient. EI # 11 stated, "We call the doctor. If the doctor gives the order then we don't let them refuse. We usually have someone hold them... We lay them over the bed and hold them down and give it. We had to do one last night."

Surveyor then asked EI # 11 what happened "last night." EI # 11 stated, "We laid her/him on bed chest down. She/He was admitted last night. She/He just got one shot."

Surveyor then asked EI # 11 how many people held patient for injection. EI # 11 stated, "Three of us held her/him and one gave the shot."

An interview was conducted on 7/13/18 at 7:45 AM with EI # 7, Patient Care Technication (PCT). During the interview the surveyor asked EI # 7 what occurred on 7/11/18 night shift with PI # 10. EI # 7 stated, "PI # 10 started going to door, then came at me and tried to grab my boobs. She/He picked up chair and throw it at the LPN (Licensed Practical Nurse). She/He tried to hit my partner in the privates. She was trying to hit us and kick. She wanted to leave.

EI # 7 then verbalized that EI # 11 called MD.

EI # 7 then stated, "We got a hold of him/her on each side under his/her arms. We got her/him in his/her room sat him/her on the bed and laid him/her down. Then the LPN gave him/her the shot."

Surveyor then asked EI # 7 to clarify how PI # 10 was "laid down." EI # 7 stated, "Turned on side and held his/her arm to keep him/her from hitting and holding him/her on the back to keep from rolling back over when the nurse was trying to give the shot."

EI # 7 then clarified how patient was placed on the bed. EI # 7 stated, "The nurse picked up his/her legs and put them on the bed. I was at the top part trying to get him/her on the side."

Based on the previous, it was determined that PI # 10 was placed in a manual method restraint for the purpose of administration of an injection.

An interview was conducted on 7/13/18 at 12:48 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings.

Based on review of medical records, Facility policy and procedure, and interview(s) it was determined that patient(s) were being placed in a manual hold for administration of psychotropic medications. The facility failed to have a documented order for a restraint. This had the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 10.

Findings include:

Policy: Restraint and Seclusion
Revised Date: 9/21/2017

"Purpose:

To establish guidelines for the safe, effective use of seclusion and/or restraints... To ensure the protection of the patient's rights, dignity, physical and psychological well being of individuals requiring restraint and/or seclusion

Definitions:

A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

B. Behavioral Health Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

Policy/Procedure:

It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit.

Procedure:

...D. Orders:

1. Restraint shall be ordered by a physician or LIP authorized by the medical staff.

...3. The order shall specify the method of restraint and/or seclusion to be used.

1. PI # 10 was admitted to the SBCU (Senior Behavior Care Unit) on 7/11/18 with a diagnosis of acute psychosis.

Review of the Verbal/Phone/Protocol Order dated 7/11/18 at 11:05 PM revealed a physician order for Thorazine (chlorpromazine) Injection 50 mg (milligrams)/ 2 ml (milliters) 50 mg x (times) 1 IM (intramuscular)

Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:10 PM with documentation of patient becoming combative towards staff and MD (Medical Doctor) "notified with 1 x (one time) order for Thorazine 50 mg to be given at this time."

Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:12 PM with the following documentation, "PRN (as needed) Thorazine given at this time. Cleansed area and IM (Intramuscular) injected to left buttock."

An interview was conducted on 7/12/18 at 8:00 AM with EI (Employee Identifier) # 11, RN, during the interview the surveyor asked EI # 11 about how an injection would be given on a combative patient. EI # 11 stated, "We call the doctor. If the doctor gives the order then we don't let them refuse. We hold them down and give it. We lay them over the bed and give it. We usually have someone hold them... We had to do one last night."

Surveyor then asked EI # 11 what happened "last night." EI # 11 stated, "We laid her/him on bed chest down. She/He was admitted last night. She/He just got one shot."

Surveyor then asked EI # 11 how many people held patient for injection. EI # 11 stated, "Three of us held her/him and one gave the shot."

An interview was conducted on 7/13/18 at 7:45 AM with EI # 7, Patient Care Technication (PCT). During the interview the surveyor asked EI # 7 what occurred on 7/11/18 night shift with PI # 10. EI # 7 stated, "PI # 10 started going to door, then came at me and tried to grab my boobs. She/He picked up chair and throw it at the LPN (Licensed Practical Nurse). She/He tried to hit my partner in the privates. She was trying to hit us and kick. She wanted to leave.

EI # 7 then verbalized that EI # 11 called MD.

EI # 7 then stated, "We got a hold of him/her on each side under his/her arms. We got her/him in his/her room sat him/her on the bed and laid him/her down. Then the LPN gave him/her the shot."

Surveyor then asked EI # 7 to clarify how PI # 10 was "laid down." EI # 7 stated, "Turned on side and held his/her arm to keep him/her from hitting and holding him/her on the back to keep from rolling back over when the nurse was trying to give the shot."

EI # 7 then clarified how patient was placed on the bed. EI # 7 stated, "The nurse picked up his/her legs and put them on the bed. I was at the top part trying to get him/her on the side."

Based on the previous, it was determined that PI # 10 was placed in a manual method restraint for the purpose of administration of an injection.

Review of the Verbal/Phone/Protocol Order and Physician Orders dated 7/11/18 revealed no documentation of an order for a manual hold to administer injection.

An interview was conducted on 7/13/18 at 12:48 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings.

Based on review of medical records, Facility policy and procedure, and interview(s) it was determined that patient(s) were being placed in a manual hold for administration of psychotropic medications. The facility failed to document a patient face-to-face assessment. This had the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 10.

Findings include:

Definition of restraint:

Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...

Policy: Restraint and Seclusion
Revised Date: 9/21/2017

"Purpose:

To establish guidelines for the safe, effective use of seclusion and/or restraints... To ensure the protection of the patient's rights, dignity, physical and psychological well being of individuals requiring restraint and/or seclusion

Definitions:

A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

B. Behavioral Health Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

...F. Continuous Observations: Face to face in person monitoring.

Policy/Procedure:

It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit.

Procedure:

...B. ...Any application of restraint must involve assessment within one hour by a qualified registered nurse (RN), physician assistant (PA), or LIP (Licensed Independent Practitioner) as to the degree and likelihood of the harm that may be produced by the restraint

...S. Each instance of restraint or seclusion is documented in the seclusion/restraint log. The log will include date, time, patient name, age, gender, case number, type of restraint/seclusion, time in, time out, staff initiating, and signature of review by the Program Director or Medical Director, and name of RN (Registered Nurse) who initiated the restraint or seclusion time of face to face evaluation and by whom.

1. PI # 10 was admitted to the SBCU (Senior Behavior Care Unit) on 7/11/18 with diagnosis of acute psychosis.

Review of the Verbal/Phone/Protocol Order dated 7/11/18 at 11:05 PM revealed physician order for Thorazine (chlorpromazine) Injection 50 mg (milligrams)/ 2 ml (milliters) 50 mg x (times) 1 IM (intramuscular)

Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:10 PM with documentation of patient becoming combative towards staff and MD (Medical Doctor) "notified with 1 x (one time) order for Thorazine 50 mg to be given at this time."

Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:12 PM with the following documentation, "PRN (as needed) Thorazine given at this time. Cleansed area and IM (Intramuscular) injected to left buttock."

An interview was conducted on 7/12/18 at 8:00 AM with EI (Employee Identifier) # 11, RN, during the interview the surveyor asked EI # 11 about how an injection would be given on a combative patient. EI # 11 stated, "We call the doctor. If the doctor gives the order then we don't let them refuse. We hold them down and give it. We lay them over the bed and give it. We usually have someone hold them... We had to do one last night."

Surveyor then asked EI # 11 what happened "last night." EI # 11 stated, "We laid her/him on bed chest down. She/He was admitted last night. She/He just got one shot."

Surveyor then asked EI # 11 how many people held the patient for injection. EI # 11 stated, "Three of us held her/him and one gave the shot."

An interview was conducted on 7/13/18 at 7:45 AM with EI # 7, Patient Care Technication (PCT). During the interview the surveyor asked EI # 7 what occurred on 7/11/18 night shift with PI # 10. EI # 7 stated, "PI # 10 started going to door, then came at me and tried to grab my boobs. She/He picked up chair and throw it at the LPN (Licensed Practical Nurse). She/He tried to hit my partner in the privates. She was trying to hit us and kick. She wanted to leave.

EI # 7 then verbalized that EI # 11 called MD.

EI # 7 then stated, "We got a hold of him/her on each side under his/her arms. We got her/him in his/her room sat him/her on the bed and laid him/her down. Then the LPN gave him/her the shot."

Surveyor then asked EI # 7 to clarify how PI # 10 was "laid down." EI # 7 stated, "Turned on side and held his/her arm to keep him/her from hitting and holding him/her on the back to keep from rolling back over when the nurse was trying to give the shot."

EI # 7 then clarified how patient was placed on the bed. EI # 7 stated, "The nurse picked up his/her legs and put them on the bed. I was at the top part trying to get him/her on the side."

Based on the previous, it was determined that PI # 10 was placed in a manual method restraint for the purpose of administration of an injection.

Review of the Patient Progress Notes 7/11/18 through 7/12/18 at 1:23 AM revealed no documentation of an RN assessment.

Review of the Patient Progress Notes 7/11/18 through 7/12/18 at 1:23 AM, revealed no documentation of an assessment within one hour by a qualified RN, PA, or LIP as to the degree and likelihood of the harm that may be produced by the restraint or a restraint log with time of face to face evaluation and by whom.

An interview was conducted on 7/13/18 at 12:48 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings.

Based on review of medical records (MR), facility policies and procedure, the 3M (Brand name of product) wound protocol and interviews with the staff it was determined the facility failed to ensure:

1. The physician was notified of patient weight loss and new wounds

2. Orders were written for wound care

3. 3M (Brand name of product) protocol followed for Skin Tears

4. Wound care orders were documented per physician's orders.

This affected 5 of 11 MR's reviewed and did affect PI (Patient Identifier) # 5, # 3, # 4, # 6 and # 7 and had the potential to negatively affect all patient served by the facility.

Findings include:

Policy: Physician Notification of change in Patient Condition
Reference # 9171
Revised Date; 10/17/11

Policy:

"The physician will be notified immediately of any adverse changes in the patient' condition.

Responsibility:

It is the responsibility of the nurse assigned to the patient to determine that the patient's condition has changed significantly and to notify the patient's attending physician, surgeon or consultant."

Policy: Wound Staging and Documentation
Reference # 9196
Revised Date: 8/5/15

1. MMH (Mizell Memorial Hospital) will utilize adopted 3M Wound Care Protocol

c. Institute nursing interventions to include speciality selection, preventive measures, skin protection, appropriate product selection based on stage of wound, exudates, presence of infection. and MMH product availability.

d. Make appropriate referrals/consults (Dietary, PT (physical therapy).
e. Determine goals/desired outcome of patient care.
f. Implement required Wound Care treatment (see protocols).

4. Interim Patient Interventions in lieu of a Physician Order:

a. Orders not received within 4 hours of patient arrival to the nursing unit will default to 3M wound care protocols, taking into consideration patient allergies and sensitivities.

b. The nurse will initiate such protocol which have been approved by the Medical Staff. ( 3M Wound Care Protocol).

c. The attending physician will review the protocol initiated and recommended any changes or variations to established treatment."

3M Wound Care Protocol
Reference # 9196 a
Revised Date: 8/5/15

F. Skin Tear

Definition: Skin tear is a traumatic wound that results in separation of the epidermis from the dermis. It can be partial thickness, usually due to friction and/or shear force.

1. Cleanse wound with 3M Wound Cleanser
2. Apply 3M No Sting Barrier film
3. Cover with 3M Tegaderm Transparent Film Dressing
4. Change every 7 days and as needed.

Policy: Physician Order Review- RN (Registered Nurse) Verification
Reference # 9172
Revised Date; 5/17/18

Policy:

"Every licensed nurse will be responsible to ensure that the physician's orders of each patient has been carried out as intended."

1. PI # 5 was admitted to the facility on 11/21/17 with admitting diagnoses of Psychosis and Inappropriate sexual behavior.

Review of the Patient Progress Notes on admission dated 11/21/17 revealed the patient weighted 161 pounds (lbs) and 9.6 ounces (oz).

Review of the Patient Progress Notes dated 11/26/17 revealed a patient weight of 158 lbs 3 oz.

Review of the spread sheet within the patient's chart revealed it was started on 11/21/17 and continues through discharge on 12/5/17. A weight on week one was documented as 158.2 lbs and at discharge or week two a weight of 149 lbs 8 oz.

Review of the Patient Progress Notes of the nutritional intake from 11/22/18 to 12/5/17 revealed the following:

11/22/17 8:34 AM - 50% of breakfast consumed.
12:00 PM - 75% of lunch consumed.
5:15 PM - 0% of supper consumed.

11/23/17
8:10 AM - 25% of breakfast consumed.
12:26 PM - 0% of lunch consumed.
5:15 PM - 50% of supper consumed.

11/24/17
8:26 AM - 5% of breakfast consumed.
11:30 AM - 0% of lunch consumed.
6:15 PM - 25% of supper consumed.

11/25/17
7:30 AM - 10% of breakfast consumed.
12:30 PM - 25% of lunch consumed.
5:45 PM - 50% of supper consumed.

11/26/17
7:30 AM - 75% of breakfast consumed.
12:26 PM - 0% of lunch consumed.
5:39 PM - 50% of supper consumed.

11/27/17
8:00 AM - 25% of breakfast consumed
12:45 PM - 50% of lunch consumed
6:00 PM - 100% of supper consumed

11/28/17
7:30 AM - 75% of breakfast consumed
12:46 - 0% of lunch consumed
5:30 PM - 50% of supper consumed

11/29/17
8:07 AM - 0% of breakfast consumed
12:29 PM - 0% of lunch consumed
5:51 PM - 75% of supper consumed

11/30/17
7:55 AM - 0% of breakfast consumed
No documentation of lunch consumption
5:57 PM - 25% of supper consumed

12/1/17
7:30 AM - 75% of breakfast consumed
12:15 PM - 25% of lunch consumed
5:30 PM - 75% of supper consumed

12/2/17
7:30 AM - 75% of breakfast consumed
No documentation of lunch consumption
6:45 PM - 50% of supper consumed

12/3/17
9:01 AM - 100% of breakfast consumed
No documentation of lunch consumption
6:22 PM - 10% of supper consumed

12/4/17
7:30 AM - 75% of breakfast consumed
12:30 PM - 50% of lunch consumed
5:15 - 75% of supper consumed

12/5/17
8:35 AM - 0% of breakfast consumed

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15, RN (Registered Nurse) and was asked if a weight loss was noticed on a patient what is typically done by the staff? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)."

Review of the entire MR to include patient progress notes and physician order revealed no documentation the patient was given a nutritional supplement at any time throughout each day during his/her stay on the behavioral unit.

Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal.

Review of all the nursing progress notes dated 11/21/17 to 12/5/17 revealed no documentation the physician was notified of the patient's weight loss.

Review of the the patient progress notes dated 11/21/17 - 11/26/17 and 11/29/17 to 12/5/17 revealed the nursing staff documented under the nursing assessment skin: warm, dry, Changes to skin: none and in the wound assessment section of each note was documented N/A (not Applicable).

Review of the patient progress note dated 11/27/17 at 5:54 AM by EI # 15 documented under the narrative nurses note "Drsng (dressing) on left forearm changed, skin tear healing well, no bleeding."

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15 who stated when asked about the patient's skin tear was not sure how he/she received the skin tear but stated "he/she was always in the recliner and flailing his/her arms and sometimes they scrape them on the recliners... I remember his skin being like so many of the frail older people we get, just typical paper skin and easy to bruise."

Review of the patient progress notes dated 11/28/17 at 7:51 AM by EI # 1, RN, Director of SBCU, revealed under the nursing assessment for skin: warm, skin tear to L (left) forearm. Changes to skin: skin tear. Wound assessment N/A.

In an interview on 7/12/18 at 2:28 PM EI # 1 was asked if he/she knew when the skin tear occurred. EI # 1 replied by stating" I do not. When I saw it, it had a dressing on it. It had gauze,well coban around the outside. The daughter saw it because she asked about it being changed the day before I saw it. No one ever documented when the skin tear occurred only one documentation that it was cleansed, didn't say with what, and telfa on it."

Review of the progress note dated 11/28/17 at 4:35 PM by EI # 13, LPN (Licensed Practical Nurse) revealed the following documentation under the narrative nurse note " ...Dressing to arm changed as asked by family member during visitation. Continues to have some bloody discharge. No redness to area surrounding. Cleaned and covered with Telfa and wrapped with Coban."

Review of the entire nurse note dated 11/28/18 revealed no documentation of how the wound care was performed and what the wound was cleaned with.

Review of all the physician orders revealed no documentation of an order written for wound care.

Review of the all of the nursing notes within the MR from 11/29/17 to 12/5/17 revealed no documentation of the healing of the skin tear or any further documentation of dressing changes.

An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1 who confirmed the above mentioned findings.



40119

2. PI # 3 was admitted to the facility on 10/27/17 with admitting diagnoses of Psychosis and Organic Brain Disease

Review of the Patient Progress Notes dated 10/27/17 revealed the patient weighed 138 lbs and 6.4 oz.

Review of the Patient Progress Notes dated 10/29/17 revealed the patient weighed 138 lbs and 0 oz and a note dated 11/5/17 revealed the patient weighed 131 lbs and 1.6 oz.

Review of the spread sheet within the patient's chart revealed it was started on 10/27/17 and continues through discharge on 11/10/17. A weight was documented on admission of 138 lbs and 6.4 oz. A second weight two days later dated 10/29/17, was documented as 138 lbs and 0 oz. A discharge or week two weight dated 11/5/17, was documented as 131 lbs and 1.6 oz.

Based on the previous, PI # 3 had a documented weight loss of 6 lbs and 9 oz in one week and a 7 lbs and 4.8 oz weight loss since admission of 10/27/18.

Review of the Patient Progress Notes of the nutritional intake from 10/27/18 to 11/10/17 revealed the following:

10/27/17 6:13 PM - 5% of supper consumed.

10/28/17
10:24 AM - 25% of breakfast consumed.
12:48 PM - 50% of lunch consumed.
6:06 PM - 0% of supper consumed.

10/29/17
7:57 AM - 0% of breakfast consumed.
1:10 PM - 50% of lunch consumed.
6:29 PM - 25% of supper consumed.

10/30/17
7:51 AM - 75% of breakfast consumed.
12:00 PM - 25% of lunch consumed.
6:08 PM - 75% of supper consumed.

10/31/17
8:16 AM - 0% of breakfast consumed.
12:56 PM - 0% of lunch consumed.
5:57 PM - 75% of supper consumed.

11/1/17
8:12 AM - 25% of breakfast consumed.
1:04 PM - 15% of lunch consumed.
No documentation of supper consumption

11/2/17
8:11 AM - 25% of breakfast consumed
12:26 PM - 25% of lunch consumed
6:02 PM - 5% of supper consumed

11/3/17
8:10 AM - 25% of breakfast consumed
12:54 - 30% of lunch consumed
5:45 PM - 50% of supper consumed

11/4/17
7:45 AM - 25% of breakfast consumed
12:15 PM - 25% of lunch consumed
6:05 PM - 50% of supper consumed

11/5/17
8:06 AM - 75% of breakfast consumed
12:55 PM - 100% of lunch consumed
5:52 PM - 75% of supper consumed

11/6/17
8:30 AM - 25% of breakfast consumed
12:52 PM - 25% of lunch consumed
6:04 PM - 50% of supper consumed

11/7/17
8:25 AM - 40% of breakfast consumed
1:09 PM - 50% of lunch consumed
6:34 PM - 100% of supper consumed

11/8/17
8:41 AM - 40% of breakfast consumed
No documentation of lunch consumption
No documentation of supper consumption

11/9/17
9:54 AM - 0% of breakfast consumed
11:45 PM and 2:15 PM- 25% of lunch consumed
5:15 - 50% of supper consumed

11/10/17
No documentation of breakfast consumption
12:30 AM - 100% of lunch consumed

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15. EI # 15 was asked if a weight loss was noticed on a patient what is typically done by the staff ? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)."

Review of the CNA (Certified Nursing Assistant) flow chart revealed that ensure was given on 11/1/17 at 6:01 PM and 11/3/18 at 9:34 AM. No documentation was found of amount of ensure that was consumed by patient on 11/1/17 or 11/3/17.

Review of the entire MR revealed no documentation that ensure was offered at any other date(s) or time(s).

Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal.

Review of all the nursing progress notes dated 10/27/17 to 11/10/17 revealed no documentation the physician was notified of the patient's weight loss.

An interview was conducted on 7/13/18 at 12:55 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings.

3. PI # 4 was admitted to the facility on 11/20/17 with admitting diagnoses of Alzheimer's dementia with mood disorder secondary to organic brain disease, organic brain disease.

Review of the Order Detail/ wound care for nursing report dated 11/30/17 at 1:10 PM revealed the following order: clean Lt (left) buttocks with NS (normal saline), pat dry with 4 x (by) 4 (gauze), apply foam dressing to area and cover with OP site (transparent, adhesive film) every other day and as needed.

Review of the patient progress notes dated 11/30/17 at 1:10 PM revealed the following documentation: Pt (patient) has shearing to left buttock area...treatment in progress applied foam dressing to area and cover with op site...

There was no documentation of what was used to clean the wound or that it was patted dry with 4x4 gauze.

Review of the order detail/ wound care for nursing report dated 11/30/17 at 5:22 PM revealed the following documentation under administrations: Given 1 EA (each) Topical

No documentation was found on the order detail/ wound care for nursing report of the actual wound care that was performed or what the "topical" treatment was.

Based on the previous the nurse failed to provide wound care per the physician's order on 11/30/17.

Review of the patient progress notes dated 12/2/17 revealed no documentation that wound care was provided to left buttock area.

Review of the order detail/ wound care for nursing report dated 12/2/17 at 4:15 PM revealed the following documentation under administrations: Given 1 EA Topical

No documentation was found on the order detail/ wound care for nursing report of the actual wound care that was performed or what the "topical" treatment was.

Based on the previous the nurse failed to document what wound care was provided to left buttock area on 12/2/17.

An interview was conducted on 7/13/18 at 12:56 PM, with EI # 1 and EI # 2, who confirmed the previous findings.

4. PI # 6 was admitted to the facility on 12/1/17 with admitting diagnoses of Psychosis NOS (Not otherwise specified).

Review of the graphic and I & O (intake and output) spreadsheet revealed the patient weighed 114 lbs and 2 oz on 12/1/17.

Review of the graphic I &O spreadsheet revealed the patient weighed of 119 lbs and 2 oz on 12/3/17.

This was a weight gain of 5 lbs within two days.

Review of the Patient Progress Notes of the nutritional intake from 12/1/18 to 12/3/17 revealed the following:

12/1/17 6:27 PM - 0% of supper consumed.

12/2/17
7:30 AM - 100% of breakfast consumed.
No documentation of lunch consumed.
6:50 PM - 100% of supper consumed.

12/3/17
9:31 AM - 50% of breakfast consumed.
12:00 PM - 25% of lunch consumed.
6:27 PM - 10% of supper consumed.

Review of the nursing progress notes dated 12/1/17 to 12/4/17 revealed no documentation the physician was notified of the patient's weight gain.

An interview was conducted on 7/13/18 at 12:51 PM, with EI # 1 and EI # 2, who confirmed the previous findings.

5. PI # 7 was admitted to the facility on 12/13/17 with admitting diagnoses of Psychosis NOS.

Review of the graphic and I & O spreadsheet revealed the patient weighed 134 lbs and 4 oz on 12/13/17.

Review of the graphic I &O spreadsheet revealed the patient weighed 169 lbs and 4 oz on 12/17/17.

This was a weight gain of 35 lbs within four days.

Review of the Patient Progress Notes of the nutritional intake from 12/13/18 to 12/17/17 revealed the following:

12/13/17 6:11 PM - 25% of supper consumed.

12/14/17
7:30 AM - 0% of breakfast consumed.
12:00 PM - 50% of lunch consumed.
5:59 PM - 25% of supper consumed.

12/15/17
8:38 AM - 90% of breakfast consumed.
12:00 PM - 0% of lunch consumed.
5:30 PM - 50% of supper consumed.

12/16/17
7:45 AM - 75% of breakfast consumed.
12:15 PM - 0% of lunch consumed.
5:15 PM - 50% of supper consumed.

12/17/17
8:54 AM - 0% of breakfast consumed.
12:00 PM - 50% of lunch consumed.
6:45 PM - 50% of supper consumed.

Review of the nursing progress notes dated 12/13/17 to 12/17/17 revealed no documentation the physician was notified of the patient's weight gain.

Review of the physician's orders dated 12/15/17 revealed order for daily dressing change to right big toe stitches as follows: Cleanse with normal saline daily, pat dry, and apply Band-Aid.

Review of the physician's orders dated 12/18/17 revealed the following order: Remove sutures to right great toe. Cleanse with soap and water, Bactroban to suture line for 5 days.

Review of the nursing progress notes and the wound care for nursing report(s) dated 12/15/17 to 12/22/17 revealed no documentation of the wound care that was provided to the right great toe for dates of 12/15/17 thru 12/20/17.

Based on the previous, nursing failed to document wound care that was provided.

Review of the nursing progress note dated 12/21/17 at 11:40 AM documentation as follows: Wound to right foot cleansed with wound cleanser, patted dry with gauze, skin prep applied to edges, and two steri-strips applied to close.

Further of the nursing progress note dated 12/21/17 at 11:40 AM revealed no documentation that the physician was notified the wound to the right foot was open and required "two steri-strips applied to close."

Based on the previous, nurse failed to provide wound care as per the physician's order.

Review of the nursing progress notes and the wound care for nursing report(s) dated 12/15/17 to 12/22/17 revealed no documentation of a wound assessment on the right great toe for the dates of 12/16/17 thru 12/20/17.

An interview was conducted on 7/13/18 at 1:00 PM, with EI # 1 and EI # 2, who confirmed the previous findings.

Based on review of medical records (MR), facility policy and procedure and interviews with the staff, it was determined the facility failed to ensure each patient's Plan of Care (POC) was complete, individualized and up to date to meet the patients needs.

This affected 2 of 11 medical records reviewed, including Patient Identifier (PI) # 5 and PI # 11 and has the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Care Planning
Reference # 9017
Revised Date: 10/17/11

Policy:

Care, treatment and services are panned to ensure that they are individualized to the patient's needs. Therefore, it is the policy of Mizell Memorial Hospital to provide and individualized, interdisciplinary plan of care for all patients that is appropriate to the patient's needs, strengths, results of diagnostic testing, limitations and goals.

Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable.

Procedure:

The plan of care shall be individualized, based on diagnosis, patient assessment and personal goals of the patient and his/her family.

The planning for care, treatment and services will include the following:

Regularly reviewing and revising the plan of care, treatment and services.

Documenting the plan for care, treatment and services.

Monitoring the effectiveness of the care planning and the provisions of care, treatment and services.

The plan of care will be individualized to the needs of the patient.

The plan of care will be continually evaluated based on the patient's clinical condition, results of diagnostic tests, care goals and the plan for treatment, care and services, and revised as needed to meet the needs of the patient's changing condition.

The plan of care shall be updated daily, with revisions reflecting the reassessment of needs of the patient."

1. PI # 5 was admitted to the facility on 11/21/17 with admitting diagnoses of Psychosis and Inappropriate sexual behavior.

Review of the the patient progress notes dated 11/21/17 - 11/26/17 and 11/29/17 to 12/5/17 revealed the nursing staff documented under the nursing assessment skin: warm, dry, Changes to skin: none and in the wound assessment section of each note was documented N/A (not Applicable).

Review of the patient progress note dated 11/27/17 at 5:54 AM by EI # 15, Registered Nurse (RN) documented under the narrative nurses note "Drsng (dressing) on left forearm changed, skin tear healing well, no bleeding."

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15 who stated when asked about the patient's skin tear was not sure how he/she received the skin tear but stated "he was always in the recliner and flailing his/her arms and sometimes they scrape them on the recliners... I remember his/her skin being like so many of the frail older people we get, just typical paper skin and easy to bruise."

Review of the patient progress notes dated 11/28/17 at 7:51 AM by EI # 1, Director of SBCU, revealed under the nursing assessment for skin: warm, skin tear to L (left) forearm. Changes to skin: skin tear. Wound assessment N/A.

In an interview on 7/12/18 at 2:28 PM EI # 1 was asked if he/she knew when the skin tear occurred. EI # 1 replied by stating" I do not. When I saw it, it had a dressing on it. It had gauze or coban around the outside. The daughter saw it because she asked about it being changed the day before I saw it. No one ever documented when the skin tear occurred only one documentation that it was cleansed, didn't say with what, and telfa on it."

Review of the progress note dated 11/28/17 at 4:35 PM by EI # 13, LPN (Licensed Practical Nurse) revealed the following documentation under the narrative nurse note " ...Dressing to arm changed as asked by family member during visitation. Continues to have some bloody discharge. No redness to area surrounding. Cleaned and covered with Telfa and wrapped with Coban."

Review of the entire nurse note dated 11/28/18 revealed no documentation of how the wound care was performed.

Review of the all of the nursing notes within the MR from 11/29/17 to 12/5/17 revealed no documentation of the healing of the skin tear or any further documentation of dressing changes.

Review of the Patient Progress Notes on dated 11/21/17 revealed the patient weighted 161 pounds (lbs) and 9.6 ounces (oz).

Review of the Patient Progress Notes dated 11/26/17 revealed the patient weighted 158 lbs 3 oz.

Review of the spread sheet started on 11/21/17 and continues through discharge on 12/5/17 revealed a weight on week one as 158.2 lbs and at discharge or week two a weight of 149 lbs 8 oz.

Review of the Patient Progress Notes of the nutritional intake from 11/22/18 to 11/25/17 revealed the following:

11/22/17 8:34 AM - 50% of breakfast consumed.
12:00 PM - 75% of lunch consumed.
5:15 PM - 0% of supper consumed.

11/23/17
8:10 AM - 25% of breakfast consumed.
12:26 PM - 0% of lunch consumed.
5:15 PM - 50% of supper consumed.

11/24/17
8:26 AM - 5% of breakfast consumed.
11:30 AM - 0% of lunch consumed.
6:15 PM - 25% of supper consumed.

11/25/17
7:30 AM - 10% of breakfast consumed.
12:30 PM - 25% of lunch consumed.
5:45 PM - 50% of supper consumed.

11/26/17
7:30 AM - 75% of breakfast consumed.
12:26 PM - 0% of lunch consumed.
5:39 PM - 50% of supper consumed.

11/27/17
8:00 AM - 25% of breakfast consumed
12:45 PM - 50% of lunch consumed
6:00 PM - 100% of supper consumed

11/28/17
7:30 AM - 75% of breakfast consumed
12:46 - 0% of lunch consumed
5:30 PM - 50% of supper consumed

11/29/17
8:07 AM - 0% of breakfast consumed
12:29 PM - 0% of lunch consumed
5:51 PM - 75% of supper consumed

11/30/17
7:55 AM - 0% of breakfast consumed
No documentation of lunch consumption
5:57 PM - 25% of supper consumed

12/1/17
7:30 AM - 75% of breakfast consumed
12:15 PM - 25% of lunch consumed
5:30 PM - 75% of supper consumed

12/2/17
7:30 AM - 75% of breakfast consumed
No documentation of lunch consumption
6:45 PM - 50% of supper consumed

12/3/17
9:01 AM - 100% of breakfast consumed
No documentation of lunch consumption
6:22 PM - 10% of supper consumed

12/4/17
7:30 AM - 75% of breakfast consumed
12:30 PM - 50% of lunch consumed
5:15 - 75% of supper consumed

12/5/17
8:35 AM - 0% of breakfast consumed

An interview was conducted on 7/11/18 at 4:34 PM with EI # 15, RN and was asked if a weight loss was noticed on a patient what is typically done by the staff? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)."

Review of the entire MR revealed no documentation the patient was given a nutritional supplement at any time throughout each day.

Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal.

An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1, Director of SBCU, who confirmed the above mentioned findings.

Review of PI # 5's plan of care dated 11/21/17 revealed no documentation of the patient's agitation, hitting the arms of the recliner, hypersexual inappropriateness and bruising of the skin or prevention of the bruising of the skin. The care plan failed to include interventions to prevent the above mentioned findings.

Review of the care plan dated 11/21/17 revealed no documentation the care plan had been updated to include the patient's skin tear or wound care for the skin tear, and the patient's weight loss while admitted at the SBCU or interventions to prevent the loss of 10 pounds during his/her admission.

An interview was conducted on 7/18/18 at 10:00 AM with Employee Identifier (EI) # 17, Corporate Executive Officer (CEO) who confirmed the plan of care for each patient should be individualized and updated and confirmed the above mentioned findings.

2. PI # 11 was admitted to the facility on 7/5/18 with an admitting diagnosis of Bipolar Type I Manic Phase.

Review of the Psychiatric Evaluation dated 7/8/18 revealed the patient has a past history of schizoaffective disorder. During examination the physician documented under psychiatric examination "mood and affect manic, labile. Thought process grossly disorganized. Psychotic thoughts, delusions and hallucinations. Grandiosity, verbosity and marked hypersexuality..."

Review of the physician progress note dated 7/7/18 revealed the physician documented "the patient's thought process has been bizarre and disorganized. He has been physically aggressive with staff. Attempted to publicly masturbate today and had to be sent back to his room".

Review of the physician progress note dated 7/9/18 revealed the physician documented "the patients thought process is bizarre and disorganized. The patient has become aggressive with the staff. He becomes easily agitated and has been heard cussing at the staff tonight."

Review of the physician progress note dated 7/12/18 revealed the physician documented "the patient was apparently still experiencing auditory hallucinations yesterday.. His thought process is bizarre..." Under the psychiatric examination the physician documented motor activity as tense, Thought process disorganized and Psychotic thoughts, delusions.

Review of the Patient Progress note dated 7/6/18 at 7:15 AM EI (Employee Identifier) # 3, Registered Nurse (RN) documented "Pt (patient) pacing around unit pulling pants down with staff redirecting and explaining to him that we could not do that in public. Pt speech pressured and difficulty to understand at times."

Review of EI # 3's documentation on 7/6/18 at 7:50 AM revealed the nurse documented Pt pulling his pants down as he is talking to EI # 1, RN Unit Director/Manager. Redirected by EI # 1 and Pt continues to try to pull them down as he is talking at rapid pressured manner. Pt is pacing around pulling his pants down with staff redirecting. Pt restless has problem being still, has no insite into staying out of others personal space, gets very close to them when he talks and while he exposes himself.

Review of EI # 3 documentation date 7/6/18 at 10:22 AM revealed the patient continues to pace, beats on wall, very loud with pressured speech, very labile and unable to redirect...

Review of EI # 3 documentation dated 7/6/18 at 3:35 PM revealed the patient pacing attempting to ambulate with eyes closed, attempting to wonder in other Pt's rooms, staff redirecting.

Review of the Patient Progress note dated 7/7/18 at 7:00 AM revealed the following documentation by EI # 3. Pt attempting to wonder in other Pt's rooms, getting in staffs face and space when attempting to redirect, continue to try to distract and redirect.

Review of the interdisciplinary Treatment Plan dated 7/5/18 revealed no documentation of the patients hypersexuality problems or behaviors only "Manic Behavior" is documented. Further review revealed no documentation of interventions to control the aggressive or threatening behavior or inappropriate sexual behavior and wondering into other patients rooms.

Review of the short term goals were documented as:

A. Patient will demonstrate the ability to socialize with peers with no episodes of inappropriate behavior.
B. Patient will demonstrate no violent behavior.
C. Pt will verbalize concerns to staff without being abusive or threatening.

An interview was conducted on 7/18/18 at 9:53 AM with EI # 1 who confirmed the Treatment Plan was not individualized to the patient.