HospitalInspections.org

This Condition of Participation for Patient Rights is not met as evidenced by:

Based on review of clinical records review of facility policies and procedures, hospital documentation and interviews with facility personnel, the facility failed to provide a safe environment for nine patients residing on the psychiatric unit, as evidenced by the failure to ensure that for five patients (P#1, #2, #3, #4, #5) who had visitors between 2/1/15 through 2/10/15, were educated regarding items considered contraband, including smoking materials in accordance with hospital policy.

Please refer to A144

Based on review of facility documentation, review of facility policies and procedures and interviews with facility personnel for five of nine patients (#1, #2, #3, #4, #5) residing on the psychiatric unit, identified that visitor sign in sheets were not completed prior to visitors entering the psychiatric unit. The findings include:

a. Review of visitor sign in sheets for six patients (P#1, P#2, P#3, P#4, P#5) who had visitors between 2/1/15-2/10/15 identified that the sign in sheets were not dated, signed and/or the name of the patient to be visited was not listed. Review of hospital policy identified that all visitors are to read and sign the visitor sign in sheet regarding items that can and/or cannot be brought in to patients on the psychiatric unit. Further review identified that smoking is not allowed at any time at this facility and visitation privileges will be suspended if any smoking or tobacco materials are given to the patient. Interview with the Nursing Director of Psychiatry on 2/13/15 identified the visitor sign in sheets were not completed. Further interview identified that he/she was not aware how P#1 had gotten a smoking excelerant.

On 2/13/15, the facility submitted an immediate action plan indicating that all staff/visitors would be educated on the visitors policy and visitors sign in sheet requiring all visitors to review and sign the sheet prior to entering the psychiatric unit.

This Condition of Nursing Services is not met as evidenced by:

Based on review of clinical records review of facility policies and procedures, hospital documentation and interviews with facility personnel, for nine patients residing on psychiatric unit, the facility failed to ensure one patient (P#1) patient ' s safety status was reassessed when the patient had a change in condition resulting in P#1 setting a mattress on fire, in his/her room. In addition, the facility failed to ensure that P#1 had a comprehensive master treatment plan developed upon admission identifying the patient's smoking history.

Please refer to A395 and A396.

Based on review of the clinical record, review of facility policies and procedures and interviews with facility personnel for one of twelve sampled patients (Patient #1), the facility failed to ensure that the patient ' s safety status was changed to prevent an incident and/or failed to ensure that P#1 did not have access to a smoking excelerant and/or failed to reevaluate the patient after a change in condition was noted. The findings include:

a. Patient #1 was admitted to the hospital on 2/4/15 with a diagnosis of paranoid Schizophrenia. Patient #1 was found to be dehydrated, hypokalemic and had stopped taking her psychiatric medications since 8/2014. Patient #1 was placed on the medical floor and was on constant observation until medically cleared. While on the medical floor, P #1 was agitated, belligerent, hostile spitting on the floor and at staff and refused medications. On 2/5/15, Patient #1 was sent to the psychiatric unit and placed on constant observation through 2/6/15, at which time the patient was placed on every fifteen minute checks. Review of the clinical record dated 2/6/15-2/9/15 (four days) identified that the patient continued to be agitated, belligerent, hostile, spitting on the floor and at staff and refused medications. Patient #1 ' s behaviors continued however, the patient remained on to every fifteen minute checks. On 2/9/15 at 1:45 PM, Patient #1 had behaviors of refusing meals, medications, slamming doors and spitting. Patient #1's behavior continued to escalate and he/she refused to go to her room. P#1 was escorted to the quiet room, the door remained open due to the need to clean P#1's room and was unrelated to P#1's behavior. Further review identified that MD#1 was notified at 1:45 PM about the patient's escualating behavior and the patient was given Haldol 5mg IM and Cogentin 1mg IM. Patient #1 ' s behaviors continued to be noted, at 2:45 PM, the patient came out of the quiet room and went into his/her room slamming the door and became belligerent with staff. MD #1 was notified and the patient was given Thorazine 50mg IM. The patient remained on every fifteen minute checks. At 2:55 PM, Patient #1 opened the bedroom door and yelled " come on in " to RN #2. Interview with RN #2 on 2/13/15 identified she had entered the patient ' s room after being summoned to the room by P#1 and found the corner end of the mattress from an unoccupied bed in her room on fire. Patient #1 was laughing, psychotic, refused to cooperate with a request to leave the room and laid down on the floor. Patient #1 was removed from the room immediately, after being carried out by multiple staff members and a Code Red was called simultaneously. Patient #1 sustained no injuries.

Review of hospital policy identified that patients whose behavior presents a clinical picture of potentially significant problematic behavior without continuous staff presence should be placed on close observation status. Interview and review of the clinical record on 2/13/15 with MD # 1 identified that since the patient ' s behaviors had escalated and the patient needed medication administered twice within an hour ' s time, the patients observation status could have been changed to a constant observation (MD#1 had only been employed by the hospital for a two week period).

Further review of the facility policy identified that smoking is not allowed at any time at this facility and visitation privileges will be suspended if any smoking or tobacco materials are given to the patient. Subsequent to the incident, on 2/10/15, the facility assessed all patients in the psychiatric unit for safety status and contraband.

b. Review of the progress notes dated 2/9/15 failed to identify that P#1 was evaluated by the psychiatrist after the need to emergently medicate P#1 with Haldol 5mg IM and Cogentin 1mg IM and subsequently, with Thorazaine 50mg IM. Review of hospital policy identified any qualified practitioner with clinical privileges can be called for consultation within his/her area of expertise. Interview with MD #1 on 2/13/15 identified that she was on the unit and signed off orders for medications that were given to Patient #1, however never reevaluated the patient. Interview with the Medical Director of Psychiatry on 2/19/15 identified that the physician should of re-evaluated by MD #1 when the patient ' s behaviors were escalating.

Based on review of the clinical record, review of facility policies and procedures and interviews with facility personnel for one of twelve sampled patients (Patient #1), the facility failed to ensure that a comprehensive master treatment plan was developed for the patient. The findings include:

Patient #1 was admitted to the hospital on 2/4/15 with Paranoid Schizophrenia. Patient #1 was found to be dehydrated, hypokalemic and had stopped taking her psychiatric medications since 8/2014. Patient #1 had a history of smoking. Patient #1 was placed on the medical floor with constant observation until medically cleared. While on the medical floor, P #1 was agitated, belligerent, hostile spitting on the floor and at staff and refused medications. On 2/5/15, Patient #1 was sent to the psychiatric unit and placed on constant observation through 2/6/15, at which time the patient was placed on every fifteen minute checks. Review of the clinical record dated 2/6/15-2/9/15 (four days) identified that the patient continued to be agitated, belligerent, hostile, spitting on the floor and at staff and refused medications. Review of the master treatment plan dated 2/4/15-2/9/15 failed to identify that P#1 was a smoker and any education and/or interventions related to the patient having Nictotine withdrawl. Review of hospital policy identified the individualized multidisciplinary treatment plan is based on a comprehensive assessment by each team member of the patient's strengths/disabilities and clinical needs. The team conference summarizes the findings of the team and prioritizes these findings into problems, short and long term goals. Interview with Person #1 on 2/23/15 identified that P#1 was a heavy smoker and was only smoking and drinking coffee and had lost 40 pounds prior to her admission to the hospital.