HospitalInspections.org

Based on observation, policy review and interview, the facility does not ensure the privacy of inpatients hospitalized on the medical/surgical unit.

Findings include:

Observation on 07/30/18 at 10:30 AM in the lobby between the Emergency Department and the Community Health Center revealed approximately 30 people. Staff (B), Chief Nursing Officer, stated that they were a group of Chinese tourists being led by staff from the Hospital Foundation. Upon entering the medical surgical floor at 10:55 AM, the group of Chinese tourists and guide from the Hospital Foundation were observed walking down the hallway, taking pictures with cell phones/cameras and looking into patient rooms. At the same time, there was a female patient in a hospital gown, ambulating the opposite way down the hall with Physical Therapy staff.

Review of facility policies revealed policies related to visitation by vendors, volunteers and visitors. However, none of the policies address large groups of people.

Interview on 07/30/18 at 10:55 AM with Staff (B), Chief Nursing Officer, verified this observation.

Based on policy review, medical record review, document review and interview, Pharmacy and medical staff did not address the need to re-order the seizure medication Phenytoin (Dilantin) and/or monitor therapeutic medications levels in a timely manner. Nursing staff did not ensure the Plan of Care addressed interventions related to seizure precautions and did not adequately monitor Patient #1, which caused a delay in providing emergency medical care and subsequent death.

See Tag # 0395, 0396 and 0500.

Based on policy review, medical record review, document review and interview, nursing staff did not perform required patient monitoring for Patient #1. Lack of monitoring caused a delay in providing emergency medical care and/or subsequent death of Patient #1.

Findings include:

Review of policy "Patient Monitoring/Rounds- Levels of Observation" last revised 10/17 indicates all routine admitted behavioral health patients are placed on Level III, which requires checks at least every 15 minutes utilizing the 24-Hour Observation Flowsheet-Level III. If a patient is in his/her room during rounding, the staff member is required to enter the room to observe the patient. Observations will be conducted at least hourly by the RN/LPN.

Review of Nursing note dated 03/03/18 at 05:34 AM revealed Patient #1 was asleep with easy respirations and no acute distress. Level 3 observation maintained. At approximately 08:30 AM a nursing assistant alerted staff that Patient #1 was face down, unresponsive with sputum coming from the side of his face. His teeth were clenched, and some blood was noted around his mouth. CPR was initiated, and a Code Blue was immediately called. At 08:54 AM the code was called and Patient #1 was pronounced dead.

Review of the Quality Assurance Root Cause Analysis revealed a comparison of the 03/03/18 Behavioral Health Unit video and the Behavioral Health 24 Hour Observation Flowsheet showed 15 minute checks were not conducted by the Patient Care Aides (PCA) and/or nursing staff at 12:15 AM, from 12:45-01:15 AM, from 01:45-05:00 AM, at 06:45 AM and from 07:30-08:15 AM. At 08:28 Patient #1 was found unresponsive.

Interview on 07/31/18 at 02:30 PM with Staff (A), Director of Quality Assurance, verified these findings.

Review of the Autopsy report performed on 03/05/18 and finalized on 06/13/18 indicates that the cause of death is seizure disorder, etiology and manner of death are undetermined. The final diagnosis includes: Patient #1 was found face down in psychiatric ward bed with foam in his larynx. Antiseizure medications were not in theraputic range.

Based on policy review, medical record review and interview, nursing staff did not ensure the Plan of Care addressed nursing interventions related to seizure precautions for Patient #1.

Findings include:

Review on 07/31/18 of policy "Nursing Care Plan/Nursing Documentation" last revised 07/2015 indicates it is the Registered Nurse's responsibility for developing the Plan of Care, individualizing it to the patient and should be updated and revised as necessary, at least every 24 hours.

Review on 07/31/18 of the medical record for Patient #1 from 02/25/18 to 03/03/17 revealed active seizure disorder and/or taking Dilantin at home was found documented throughout the medical record. Examples include: the emergency department (ED) record on 02/25/18, the Intensive Care Unit (ICU) History & Physical (H&P) dated 02/25/18, ICU Pharmacy notes from 02/25/18 to 02/27/18, the Behavioral Health (BH) Nursing Admission note dated 03/01/08 and the BH Psychiatric consultation note dated 03/01/08. The Medication Administration Record (MAR) indicates on 03/01/08 at 09:00 AM, Dilantin 100 mg by mouth three times daily was ordered. The Plan of Care for both the ICU (02/25/18-02/28/18) and BH unit (02/28/18-03/03/18) admissions do not include seizure precaution interventions.

Interview on 07/31/18 at 02:30 PM with Staff (A), Director of Quality Assurance verified these findings.

Based on policy review, medical record review and document review, Pharmacy and medical staff did not address the need to re-order Phenytoin (Dilantin) and/or monitor therapeutic medications levels in a timely manner for Patient #1.

Findings include:

Review of policy "Clinical Medication Monitoring" last revised 08/15 indicates the Pharmacist will review the daily report of all patients receiving anticonvulsant's and address any sub or supra therapeutic levels. The Pharmacist will order/monitor laboratory parameters and order drug levels as appropriate. If the dose is inappropriate, the Pharmacist will consult with the practitioner. This policy does not address a mechanism to monitor medications that are on hold.

Review of patient #1, ED record dated 02/25/18 revealed seizure disorder is listed in the physician and nursing assessments. The medication list includes Phenytoin 300 mcg daily, Phenytoin (no dosage) and Phenobarbital (no dosage), which are prescibed for the treatment of seizures. Therapeutic levels were ordered and obtained: Phenytoin levels at 02:45 AM were 16.2 mcg/ml and at 01:56 PM were15.4 mcg/ml (normal range 10-20 mcg/ml). Phenobarbital levels at 02:46 AM were <1.1 mcg/ml (normal range 15-40 mcg/ml). No other therapeutic medication levels for Phenytoin were found in the medical record.

Review of physician order dated 02/25/18 at 03:34 AM revealed Dilantin 300 mg by mouth daily was discontinued.

Review of the ICU History & Physical dated 02/25/18 at 06:00 AM revealed that prescription bottles at the scene/ home seizure medications include Dilantin (Phenytoin) 300 mg by mouth daily and Phenobarbital (no dosage noted). Phenytoin and Phenobarbital levels were obtained. Seizure disorder medications were held due to the overdose, continue to monitor.

Review of ICU Physician Progress notes from 02/25/18 to 02/27/18 revealed "seizures" are listed on the problem list and Dilantin 300 mg/Phenytoin 50 mg are "documented" as home seizure medications. No further assessment for the seizure disorder is found.

Review of ICU Pharmacy notes from 02/25/18 to 02/27/18 indicate Phenytoin/Dilantin 350 mg is taken at home daily for seizure disorder, but is on hold. Levels are within normal limits (16.2 ->15.4 mcg/ml, normal 10-20 mcg/ml). Restart when appropriate as Patient #1 stabilizes.

Review of the Medication Administration Record (MAR) revealed on 03/01/08 at 09:00 AM, Dilantin 100 mg by mouth three times daily was re-ordered and Patient #1 received two doses on 03/01/08 and three doses on 03/02/18.

Review of the Behavioral Health Pharmacy Admission note dated 03/02/18 at 02:56 PM revealed the "Home Medications Held/Changed on Admission" section is blank. Patient #1 is on Dilantin for seizures per psychiatrist note. Consider checking levels for safety in a few days if he remains an inpatient.

No evidence was found to indicate the need to re-check Dilantin levels was addressed, despite the medication being on hold for approximately 4 days and therapeutic levels obtained on 02/25/18 indicated decreasing levels.

Review of the Autopsy report performed on 03/05/18 and finalized on 06/13/18 indicates that the cause of death is seizure disorder, etiology and manner of death are undetermined. Final diagnosis includes: Patient #1 was found face down in psychiatric ward bed with foam in his larynx. Antiseizure medications were not in theraputic range.

Based on policy review, observation and interview, the facility does not ensure nursing staff adherence to accepted standards of practice required to prevent healthcare-associated infections related to the use of personal protective equipment (PPE) during IV medication administration.

Findings include:

Review of policy "Standard Precautions and Respiratory Hygiene" last revised 04/18 indicates gloves must be worn whenever there is exposure to blood, masks & eyewear/face shields should be worn during procedures that are likely to generate droplets/splashing of blood and fluid resistant gowns/aprons should be worn when there is potential for soiling clothing with blood.

Observation on 07/30/18 at 10:40 AM in the Intensive Care Unit revealed Patient # 2 receiving hemodialysis treatment in room #8. Staff (H), RN, connected IV medication/tubing to the hemodialysis machine port, without wearing a mask, gown or gloves, despite the potential for exposure to blood. Staff (H) proceeded to manipulate the lines of the IV medication and touch the machine without gloves.

Interview on 07/30/18 at 10:40 AM with Staff (B), Chief Nursing Officer, verified this observation.