HospitalInspections.org

Based on record review, document review, and interview, the facility failed to ensure the family/Conservator was notified of a change of condition for 1 of 7 (Patient #1) sampled patients.

The findings included:

1. Medical record review revealed Patient #1, was admitted to the facility on 1/8/2022 with admitting diagnoses which included Schizoaffective Disorder and Mild Intellectual Disability.

Review of the Judicial Court Order for Patient #1 dated 11/5/2007 revealed a named Conservator and Standby Conservator. The Conservator was granted, "The authority and right to give or withhold consent and make other informed decisions relative to physical, habilitate medical, psychological, psychiatric...including but not limited to hospitalization..."

On 1/25/2022, Patient #1 began experiencing symptoms of Covid-19 and tested positive. The patient was transferred to the Covid unit and placed in transmission-based precautions.

The facility was unable to provide documentation the Conservator was informed of Patient #1's change of condition or unit change.

On 1/26/2022 at 2:00 PM, Patient #1 was transferred to Hospital #2's Emergency Department (ED), with complaints of overall discomfort. The patient was transferred back to the facility at 10:44 PM, with diagnoses included Sore throat and Pneumonia of left upper lobe due to infectious organism.

The facility was unable to provide documentation the Conservator was informed of Patient #1's transfer to the ED or diagnosis of pneumonia.

On 1/27/2022 at 12:00 PM, Patient #1 was seen by the Nurse Practitioner (NP) and was transferred to Hospital #3's ED.

Patient #1 arrived at Hospital #3's ED on 1/27/2022 at 7:00 PM, with complaints of difficulty breathing. After reexamination/reevaluation, ED physician recommended discharge on antibiotics ordered by Hospital #2. Patient #1 was discharged back to the facility with diagnosis which included Developmental Delay and Pneumonia due to Covid.

The facility was unable to provide documentation the Conservator was informed of Patient #1's transfer to the ED.

3. In an interview in the conference room on 3/2/2022 at 11:06 AM, Registered Nurse (RN) #1 was asked if Conservators are notified if patients are sent to the ED or have a change in condition. RN #1 verified if a patient had a Conservator, they must be notified.

In an interview in the conference room on 3/2/2022, the Director of Risk Management and Performance Improvement verified Patient #1's Conservator had not been notified of her change of condition and transfers to the ED.

Based on policy review, record review, and interview, the facility failed to ensure nursing staff assessed and evaluated pain management for 1 of 3 (Patient #2) sampled patients; failed to ensure medications were administered as ordered by the physician for 2 of 3 (Patient #3 and #4) sampled patients; and failed to ensure wound treatment was provided as ordered by the physician for 1 of 2 (Patient #5) sampled patients.

The findings included:

1. Review of the facility's policy "ASSESSMENT/REASSESSMENT" dated 12/2020 revealed, "...Reassessments are completed by the registered nurse on day and evening shifts and documented on the nursing reassessment form...In addition each patient is reassessed as necessary...including change in the patients level of pain...minimum two times per day...Pain assessments are also conducted following administration of pain medications..."

Review of the facility's policy "MEDICATION ADMINISTRATION AND DOCUMENTATION" dated 2/2022 revealed, "...P.R.N. [as needed] Medications...a. The dosage, route, time interval and reason for P.R.N. medications must be specific...b. Effect of the P.R.N. medication must be documented after 1 hour of giving medication....Pain Medication...Prior to administration of a medication designated for Pain Management, either a routine or PRN medication, the nurse shall assess the patient's level of pain (0-10) and document on the Medication form and progress note...b. Document the effectiveness of the medication including the level of pain after a reasonable length of time based on route of administration of the medication..."

Medical record review revealed Patient #2 was admitted to the facility on 2/14/2022 with diagnoses which included Bipolar Disorder.

Review of a physician order dated 2/15/2022 revealed, "...TYLENOL...(ACETAMINOPHEN) 325 mg [milligram] tab [tablet] 2 tabs Q [every] 6 hours PRN for pain..."

The Progress Notes dated 2/22/2022 at 12:15 AM revealed, "...Pt. reports falling at approximately 1800 [6:00 PM] on 2/21/22...pain to his L [left] shoulder...history of a collarbone fracture...feeling like he may have broken something again...ROM [range of motion] intact...Acetaminophen given at 2100 [9:00 PM]...Reported to [named practitioner]...ordered a L shoulder X ray..."

The facility was unable to provide documentation of the effectiveness of the PRN medication administered to Patient #2 on 2/21/2022 at 9:00 PM.

Review of the Medication Administration Record (MAR) revealed, Patient #2 received Tylenol 650 mg on 2/22/2022 at 9:23 AM and 4:40 PM and on 2/25/2022 at 10:10 PM.

The facility was unable to provide a pain level score prior to the administration of the medication to Patient #2 on 2/22/2022 at 9:23 AM and 4:40 PM and on 2/25/2022 at 10:10 PM.

The facility was unable to provide documentation of the effectiveness of the PRN medication administered to Patient #2 on 2/22/2022 at 9:23 AM and 4:40 PM and on 2/25/2022 at 10:10 PM.

Review of the Nursing Reassessment form dated 2/22/2022 for the day and evening shift revealed, "...Pain Assessment...none [circled]..."

Review of the Psychiatric Progress Notes dated 2/22/2022 at 5:00 PM revealed, "...Chief Complaint...I'm hurting..."

Review of the Nursing Reassessment form dated 2/23/2022 for the evening shift revealed Patient #2 complained of left shoulder pain and refused Tylenol.

Review of the Nursing Reassessment form dated 2/24/2022 at 4:13 PM revealed, "...Pain Assessment...8 [circled] [scale with 10 as worst]...shoulder pain radiating...PRN...Narrative Daily Progress Note...No complaints..." There were no PRN pain medications documented as given in the medical record on 2/24/2022.

Review of Consultation Report dated 2/25/2022 at 3:00 PM revealed, "...c/o [complains of] R[right] shoulder pain from fall...X-ray R shoulder - WNL [Within normal limits]...Start NSAIDS as needed..."

Review of the Radiology Report Left Shoulder dated 2/22/2022 at 5:04 PM, revealed no acute fracture or dislocation. The x-ray showed Patient #2 had Calcific tendinitis (a build-up of calcium in the rotator cuff that can cause intense pain). Nurse Practitioner #2 documented review of the Radiology Report on 2/25/2022.

Review of a practitioner order dated 2/25/2022 untimed revealed, "...Naproxen [a non-steroidal anti-inflammatory] 500 mg tab BID [twice a day] PRN..."

In interview in the conference room on 3/2/2022 at 10:05 AM, the Interim Chief Nursing Officer (CNO) verified the effectiveness of the PRN pain medication was not documented in the medical record.

2. Review of the facility's policy "MEDICATION ADMINISTRATION AND DOCUMENTATION" dated 2/2022 revealed, "...Medication Administration Documentation Process...a. Chart the time in the appropriate column to indicate that a medication was given...b. All medications must be charted on the Medication Administration Record immediately following administration...f. Record and circle the scheduled time on the Medication Administration Record if for any reason any scheduled drug is not administered based on nursing assessment or patient refusal. Indicate the date, medication, dosage, time, reason, and nurse signature. Document physician notification in the Progress Note..."

Medical record review revealed Patient #3 was admitted to the facility on 11/21/2021 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

Review of the physician orders dated 11/21/2021 revealed Patient #3 was to continue medications of Depakote (treats certain types of seizures) Delayed Release (DR) 500 mg 2 tabs (1000mg) BID and Topamax (used to treat and prevent seizures) 50 mg BID.

Review of the MAR from 11/21/2021-12/10/2021 revealed the MAR was blank for the administration of Patient #3's Depakote 1000 mg and Topamax 50 mg on 11/27/2021 at 9:00 AM and on 11/23/21, 11/24/21, 11/29/21, 11/30/21, 12/7/21, and 12/10/21 at 9:00 PM.

In an e-mail on 3/16/2022, the Interim CNO revealed, "...Those medications are in our medication cabinet and are pulled when the medication is due. From chart review, it appears the medication was not signed off by the nurse..."

Medical record review revealed Patient #4 was admitted to the facility on 1/28/2022 with diagnoses which included Diabetes Mellitius.

Review of the Medication Reconciliation Orders dated 1/28/2022 at 5:00 PM, revealed Patient #4 was to continue Advair Diskus (used to treat asthma and chronic obstructive pulmonary disease) 250/50 1 puff BID.

Review of the MAR from 1/28/2022-2/19/2022 revealed the MAR was blank for the administration of Patient #4's Advair Diskus inhaler on 1/28/22, 1/29/22, 1/31/22, and 2/13/22 at 9:00 PM, and 2/3/2022, and 2/6/22 at 9:00 AM. On 1/30/2022 the shift was circled with "not given" with no further documentation.

In an e-mail on 3/16/2022, the Interim CNO revealed, "...was admitted on 1/28/2022. Advair is a medication we do not stock in our pharmacy. We order it once the medication is ordered by the physician. As the inhaler is used by the patient each day and not removed from the medication cabinet every day, it is stored in a separate location in the med room but close to the medication cabinet/window. For the "not given" note, the nurse may not have seen the inhaler thinking it had not been brought to the unit yet and/or was not signed off..."

In a telephone interview on 3/17/2022 at 11:12 AM, the Interim CNO was asked if the nursing staff was expected to administer medication according to the physician orders. The Interim CNO stated, "Yes."

3. Medical record review revealed Patient #5 was admitted to the facility on 2/8/2022 with diagnoses including Schizoaffective Disorder. The Nursing Assessment dated 2/8/2022 at 5:55 PM, revealed the patient had an laceration with intact stitches to the left wrist.

Review of a physician order dated 2/9/2022 at 9:55 AM revealed, "...ABX [antibiotic] ointment to L wrist..."

The facility was unable to provide documentation the physician's order was implemented.

In an interview in the conference room on 2/23/22 at 3:44 PM, the Interim CNO verified there was no documentation the antibiotic ointment had been applied to Patient #5's laceration as ordered by the physician.