HospitalInspections.org

Based on document review and interview, it was determined for 3 of 3 (Pt #1, Pt #2, and Pt #3) patient records reviewed on the Adult Behavioral Health Unit (6W), the Hospital failed to ensure consent for psychotropic medications was obtained.

Findings include:

1. The Hospital policy entitled "Psychotropic Medications-Informed Consent" (reviewed 03/2016) was reviewed on 10/17/16 and required, "...it is the policy of the [Hospital] Department of Psychiatry Behavioral Health Unit that informed consent be obtained relative to the administration of psychotropic medications. The physicians are required to document decisional capacity and obtain written consent from the patient and/or guardian/substitute decision maker. Additionally the physician must provide the patient with written and verbal information of the risk, benefit and side effects of said medications..."

2. The clinical records for Pt #1, Pt #2, and Pt #3 were reviewed on 10/17/16 at approximately 10:15 AM and included the following:

-Pt #1 was a 54 year old female admitted on 10/11/16 with a diagnosis of schizoaffective disorder. Physician's orders dated 10/11/16 included Depakote (anti-seizure medication) 500 mg every 12 hours and Zyprexa (anti-psychotic medication) 10 mg every morning and 20 mg every night. The medication administration record (MAR) documented that Pt #1 received these medications as ordered. However, the clinical record lacked documentation of medication education for Pt #1 by the physician and consent for the psychotropic medications.

-Pt #2 was a 57 year old male admitted on 10/06/16 with diagnoses of schizoaffective disorder and bipolar disorder. Physician's orders included: 10/6/16 - Haldol (anti-psychotic) 5 mg three times a day; 10/10/16 - Zyprexa (anti-psychotic)10 mg nightly; and 10/12/16 - Geodon (anti-psychotic) 80 mg twice daily. The MAR documented that Pt #2 received these medications as ordered. However, the clinical record lacked documentation of medication education for Pt #2 by the physician and consent for the psychotropic medications.

-Pt #3 was a 55 year old female admitted on 10/10/16 with a diagnosis of depression. Physician's orders included: 10/11/16 - Haldol (anti-psychotic) 5 mg every 4 hours as needed; 10/12/6 - Librium (sedative) 50 mg 3 times daily; and 10/11/16 - Neurontin (mood stabilizer) 600 mg 3 times daily. The MAR documented that Pt #3 received these medications as ordered. However, the clinical record lacked documentation of medication education for Pt #3 by the physician and consent for the psychotropic medications.

3. On 10/17/16 at approximately 3:00 PM, an interview was conducted with the Medical Director of the Behavioral Health Unit (E #4). E #4 stated the physician should obtain consent for psychotropic medications "ideally" during the first visit with the patient, but that is not always possible. E #4 stated that the physician must educate the patient on the ordered medications and complete and sign the medication consent form with the patient.

4. On 10/17/16 at approximately 3:10 PM, an interview was conducted with the Director of Behavioral Health (E #5). E #5 stated it was the responsibility of the physician to complete the medication education and obtain consent for psychotropic medications. E #5 stated the lack of consent did not preclude the nurse from administering the ordered medications, but the consents should have been completed and signed by the patient and the physician.

Based on document review and interview, it was determined for 1 of 2 (Pt. #14) patients who received blood, the Hospital failed to ensure the blood was completed within 4 hours as per policy.

Findings include:

1. The Hospital policy titled, "Blood Component Administration (reviewed March 2016)" was reviewed on 10/17/16. The policy included, "Any volume of blood not infused within 4 hours is placed in a biohazard red waste bag".

2. The clinical record of Pt. #14 was reviewed on 10/17/16. Pt. #14 was a 55 year old female admitted on 10/8/16 with the diagnosis of sepsis. The clinical record included a physician's order dated 10/14/16 at 12:09 PM to transfuse one unit packed cells. The transfusion record dated 10/14/16 included that the blood was started at 5:00 PM and finished at 10:59 PM (2 hours over allowed time).

3. During an interview on 10/17/16 at approximately 2:00 PM, the Quality and Safety Specialist (E#2) stated, "The blood should not hang for more than 4 hours".

Based on document review and interview, it was determined the Hospital failed to ensure the medical records were completed as required by the Medical Staff Rules and Regulations.

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (effective 7/26/16) were reviewed on 10/19/16 and required, "...A medical record which is not completed within 30 days after discharge is delinquent..."

2. On 10/19/16 at approximately 9:30 AM, the Manager of Health Information Management (E #6) presented the surveyor with a letter of attestation which included, "The number of delinquent medical records as of October 19, 2016 for [Hospital] is 143."

3. On 10/19/16 at approximately 9:30 AM, E #6 stated the medical records should be complete within 30 days after discharge.

Based on observation, document review and interview, it was determined for 1 of 3 emergency carts (malignant hyperthermia cart) in the outpatient surgical department, the Hospital failed to ensure all biologicals were not expired, potentially affecting more than 50 surgical and endocopy cases per day.

Findings include:

1. On 10/19/16 at approximately 9:00 AM an observational tour was conducted in the Hospital's outpatient surgical department. During the tour three (3) 1000 cc Sterile Water bags were available on the malignant hyperthermia cart with an expiration date August 2016.

2. Hospital policy entitled, "Shelf Life of Sterile Supplies," (revised date: May 2013) required, "...VI. Procedure...C. Supplies with specific expiration date...are not used after the expiration date..."

3. The Manager of Outpatient Surgery stated, during an interview on 10/19/16 at approximately 9:15 AM, that the pharmacy checks the cart monthly and should have removed the outdated fluids.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on October 17 - 19, 2016, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on October 17 - 19, 2016, the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview it was determined for 1 of 4 (Pt #32) closed clinical records reviewed for discharge planning, the Hospital failed to ensure the patient received a comprehensive list of available home health agencies.

Findings include:

1. Hospital policy entitled, "Social Work Documentation," (Last review date: 6/30/16) required, "...Procedure...2.0 Ongoing documentation...2.2 Documentation should include...2.2.5 Discussion of post-acute services and providing a list of providers/facilities..."

2. The clinical record of Pt #32 was reviewed on 10/19/16 at approximately 1:30 PM. Pt #32 was a 27 year old male admitted on 6/30/16 with a diagnosis of abscess. Social work documentation dated 7/1/16 included, "...patient will require home care RN for wound care management...Referral made to (Hospital's home care company)." The clinical record did not include documentation that a list of potential home health agencies was provided to the patient.

3. The Social Worker (E #3) on the 11th floor stated during an interview on 10/19/16 at approximately 1:40 PM that the documentation does not indicate the patient was given a list of home health agencies.