HospitalInspections.org

Based on document review and interview it was determined that in 5 of 5 (Pt #5, 6, 7, 8 and 9) clinical records reviewed, the Hospital failed to ensure patients were educated and consented to the administration of psychotropic medications.

Findings include:

1. Hospital policy titled, " Patient Medication Education," (rev 12/1/15) required, Client shall be informed and understand purpose, dose, frequency, and route of medication ordered... If PRN...shall be informed and understand circumstances under which he/she should request medication ....understand the most common side effects ...be informed of potential drug-food interactions. Med teachings shall be reviewed and revised periodically... Consent for psychotropic medication is obtained prior to the first dose being given."

2. The clinical record for Pt. #5 was reviewed on 4/5/16, Pt. #5 was a 32 year old female admitted on 4/3/16 with diagnoses of depression and suicide ideation. The clinical record contained an order for Zoloft (antidepressants) 50 mg daily and was documented as being given on 4/4/16. However the clinical record lacked a signed "Psychotropic Medication Notice and Consent" form.

3. The clinical record for Pt. #6 was reviewed on 4/5/16, Pt. #6 was a 28 year old female admitted on 4/3/16 with diagnosis of suicide ideation with a plan. The clinical record contained orders for Seroquel (antipsychotic), Haldol (antipsychotic), Ativan (antipsychotic). Haldol and was documented as being given on 4/2/16 and the Seroquel on 4/316 and 4/4/16. However, the clinical record lacked a signed "Psychotropic Medication Notice and Consent" form for the ordered and administered psychotropic medications.

4. The clinical record for Pt. #7 was reviewed on 4/5/16, Pt. #7 was a 36 year old male admitted on 3/29/16 with diagnoses of depression and suicide ideation with a plan. The clinical record contained an order for Effexor (antidepressant) in varying doses, and were administered daily from 3/29/16 through 4/5/16. However the clinical record contained a "Psychotropic Medication Notice and Consent" form which indicated "no home meds" lacking all the psychotropic medications ordered.

5. The clinical record for Pt. #8 was reviewed on 4/5/16, Pt. #8 was a 60 year old male admitted on 4/2/16 with a diagnoses of bipolar and depression. The clinical record contained an order for Prozac (antidepressant) that was administered daily from 4/2/16 through 4/4/16. However, the "Psychotropic Medication Notice and Consent" form was not updated to include the Prozac.

6. The clinical record for Pt. #9 was reviewed on 4/5/16, Pt. #9 was a 57 year old female admitted on 3/26/16 with a diagnosis of bipolar disorder. The clinical record contained orders for Seroquel (antipsychotic) in varying doses, Latuda (antipsychotic) and Depakote (mood stabilizer) which were administered daily from 3/26/16 through 4/4/16. The clinical record contained a "Psychotropic Medication Notice and Consent" form that was not updated to include the Seroquel, Latuda and Depakote.

7. The above findings were discussed with the Senior Vice President of Clinical Services on 4/5/16 at approximately 1:15 PM who stated that the psychotropic medications form should be completed, updated and signed.

A. Based on document review and interview it was determined that for 2 (Pt #1 and Pt #3) of 3 sexual assault allegations, the Hospital ailed to ensure policy was followed in securing a potential crime scene.

Findings include:

1. Policy entitled "Protection of evidence from assault" (Effective 11/2014) indicated "I. It is the policy of the (Hospital) to ensure that the evidence from assault is protected from destruction and tampering. II. Procedure: 4. The area where the assault occurred should be secured. Bed linen...will be taken to the hospital with victim. Items are to be placed in a paper bag labeled with the time, date, and name of patient, unit and the name of the staff securing the items."

2. Pt #3 was a 77 year old female admitted on 1/8/16 with diagnoses of bipolar and dementia with behavioral disturbances. Pt #3's discharge summary dated 1/18/16 indicated "On 1/17/16 I (the physician) was notified that she (Pt #3) had been found with a male patient during the night. When awakened in the bed, she (Pt #3) said she had been raped by this gentleman..."

3. The incident report dated 1/17/16 at 2:45 PM indicated "Pt (Pt #3) entered the room of (another patient) and was found lying down on an empty bed in his room.

4. The "Investigation summary and report finding" dated 1/17/16 indicated "Police came to the hospital on the PM shift and were seen by the RN Supervisor (E #3) who provided them with sheets, however, did not allow the officer to photograph the room due to having a gun ..."

5. The clinical record included, Pt #1 was a 50 year old woman admitted on 2/23/16 with a diagnosis of suicidal ideation. Pt #'1 discharge summary dated 3/17/16 indicated "There was an incident early in her stay where she had a nightmare that a patient had raped her in the night."

6. The incident report dated 2/28/16 from 12:00 AM to 5:00 AM was reviewed on 4/5/16. This report indicated the type of incident was of sexual behavior. Pt #1's allegations that she had a dream during the night and that her roommate came into her room and raped her. Pt #1 noticed vaginal tearing and bleeding. Pt (Pt #1) is concerned she may have been sexually assaulted."

7. On 4/5/16 the "investigation summary and report of findings" indicated "Per interview with the RN Supervisor (E #3), a directive was given to the Registered Nurse (E #4) to close off and lock Pt #1's room until further notice. This directive was not followed at any time. Pt #1 and roommate were allowed to have free access to the room, and the sheets and personal items of Pt #1 were removed from the room when Pt #1 left to the (acute care hospital). The police arrived on 2/28/16 at 5:25 PM...Soon taken to the unit, where it was discovered that the room was not kept closed and potential evidence was removed from the room ...the police was upset because evidence had been tampered with. "

8. On 4/6/16 at approximately 10:35 AM the Senior Vice President of Clinical Services (E #1) was interviewed. E #1 stated there had been some issues with the local police department (PD) when they came to collect evidence for an investigation for 2 allegations of sexual assault (1/17/16 and 2/28/16). E#1 stated based on the surveillance video E #3 obstructed the PD investigation by not allowing the officers to enter the patient units to obtain photos because they had guns; and for not securing the room when the local PD had requested for the room to be locked. E #1 stated a Registered Nurse (E #4) had been informed to close the room and for no one to enter and she didn't follow instructions. E #1 stated the linens were tossed and terminal cleaning was done to the room and a new patient had been assigned to this room prior to the PD arriving to the Hospital. E #1 stated E #3 and E #4 did not follow the Hospital policy.


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B. Based on document review and interview, it was determined that for 2 of 5 records reviewed (Pt's. #5, & 9), the Hospital failed to ensure patients' round sheets included the type of precautions ordered for monitoring the patients.

Findings include:

1. The Hospital policy titled "Observation Levels" (rev 12/1/16), required, "Observation levels are defined as levels of staff awareness and attention to patient safety. There are specific protocols and required documentation for each observation level... Procedures: The Rounds Sheet must designate the special observations that a patient is on...."

2. The clinical record for Pt. #5 was reviewed on 4/5/16, Pt. #5 was a 32 year old female admitted on 4/3/16 with diagnoses of depression and suicide ideation. Admitting orders dated 4/4/16 included the precautions, suicide and self harm. However the "Patient Safety Precautions Record" (rounds sheet) dated 4/4/16 did not include the the type of precaution that Pt. #5 was on.

3. The clinical record for Pt. #9 was reviewed on 4/5/16, Pt. #9 was a 57 year old female admitted on 3/26/16 with a diagnosis of bipolar disorder. Admitting orders dated 3/26/16 included the precautions suicide and assault/homicidal. However the "Patient Safety Precautions Record" (rounds sheet) dated 4/2/16 and 4/3/16 did not include suicide as a precaution and the round sheet dated 4/4/16 did not indicate the type of precaution that Pt. #9 was on.

4. The above findings were discussed with the Senior VP of Clinical Services during an interview on 4/5/16 at approximately 1:15 PM who stated that the type of precautions that the patient are being monitored should be documented.