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Based on observation and interview, the facility failed to notify each patient of the state agency's complaint hotline number in the emergency department. This had the potential to affect all patients who receive care at this emergency department. The facility's census at the time of the survey was 255 patients.

Findings:

On 01/03/13 at 11:10 A.M. a tour was conducted of the waiting area of the emergency department. Staff H examined the walls and was unable to find the state's complaint hotline phone number posted. Observation of paperwork given to patients and families failed to contain the complaint hotline phone number.
Staff G, a nurse who works in the emergency department, found a sign hanging high on a wall in registration area perpendicular to where the patient sits out of plain sight from the registration area or the waiting area. The sign read Ohio Department of Health "Health Services Hotline".

Based on clinical record review, interview, and policy review, the facility failed to ensure Patient #18 and Patient #19 was able to request or refuse treatment upon admission to the facility. The sample size was 19 patients and the census was 255 patients.

Findings:

The clinical record review for Patient #19 was completed on 01/04/13. The clinical record review revealed the 75 year old patient was admitted to the facility on 12/30/12 with a diagnosis of hypotension. The most recent consent that was located in the record was dated 06/12/12.

The clinical record review for Patient #18 was completed on 01/04/13. The clinical record review revealed the 41 year old patient was admitted to the facility on 12/31/12 with diagnoses of endocarditis. The record revealed a consent for treatment to the facility dated 01/02/13. Another consent dated 11/26/12 was found in the record.

Review of the policy, Consent Authorization Patient-Minor Signed-Unsigned, last revised 06/04/12 stated:

"A consent form is required for each initial registration. Effective 9/2/09, the consent will be valid for 365 days, except in the case of a patient 17 years and younger. "

On 01/03/13 at 3:56 P.M. in an interview, Staff H stated patients do not have to give consent again if they've already consented in the past year.

Based on clinical record review and interview, the facility failed to ensure Patient #17 and #18 were given advance directives, and failed to have Patient #19's advance directives easily accessible. The sample size was 19 patients and the census was 255 patients.

Findings:

The clinical record review for Patient #17 was completed on 01/04/13. The clinical record review revealed the 62 year old patient was admitted to the facility on 12/31/12 with a diagnosis of elevated chest pain. The clinical record review in its electronic form revealed the patient did not have any advance directives. The clinical record review in its electronic form did not reveal where any information on advance directives was offered.

On 01/03/12 at 3:30 P.M. in an interview Staff R confirmed there wasn't evidence information on advance directives had been offered to the patient.

The clinical record review for Patient #18 was completed on 01/04/13. The clinical record review revealed the 41 year old patient was admitted to the facility on 12/31/12 with diagnoses of endocarditis. The clinical record review in its electronic form revealed the patient did not have any advance directives. The clinical record review in its electronic form did not reveal where any information on advance directives was offered.
On 01/03/12 at 3:30 P.M. in an interview Staff R confirmed there was no evidence information on advance directives had been offered to patients.
The clinical record review for Patient #19 was completed on 01/04/13. The clinical record review revealed the 75 year old patient was admitted to the facility on 12/30/12 with a diagnosis of hypotension. The clinical record review in its electronic form revealed the patient had a living will and a health power of attorney and the forms were in the paper version of the chart.
Review of the clinical record in its paper version was completed on 01/03/13, and did not reveal the advance directives.
On 01/03/13 at 4:00 P.M. in an interview, Staff T, the patient's nurse, was asked to locate the patient's advance directives. Staff T looked in the electronic record and stated they would be in the paper chart. Unable to find them in the paper chart, Staff T attempted to locate them in the electronic record. Staff T said, "That's the only place I know to look," and was unable to locate the advance directives.

Based on observation, clinical record review, and interview, the facility failed to ensure staff did not restrain patient (#14) for control of behavior. The sample size was 19 patients and the census was 255 patients.

Findings:

The clinical record review of Patient #14 was completed on 01/04/13. The clinical record review revealed the 83 year old patient was admitted to the facility for a chief complaint of a fall with left sided weakness and a right subdural hematoma.

The clinical record review revealed a physician's order dated 01/03/13 at 12:44 A.M. for bilateral arm and leg restraints.

The clinical record review revealed a nursing assessment at 01/03/12 at 2:00 A.M. that stated the patient wasn't following instructions, and was attempting to pull at medical equipment, namely, a drain to her/his head, placed there after surgery.

On 01/03/13 at 10:30 A.M. in an interview, Staff P stated the patient had been trying to get out of bed and that a constant companion had not been attempted prior to the use of the four restraints.

Based on observation and interview, the facility failed to ensure less restrictive measures were employed while Patient #15 was restrained. The sample size was 19 patients and the census was 255 patients.

Findings:

The clinical record review for Patient #15 was completed on 01/04/13. The clinical record review revealed the 86 year old patient was admitted to the facility on 12/29/12 with diagnoses of congestive heart failure and difficulty breathing. The clinical record review revealed the physician ordered and the patient had both hands placed in restraints on 01/02/13 at 5:30 P.M. for attempting to pull out a nasogastric (NG) tube. A caregiver positioned at the patient's bedside was not attempted prior to the application of restraints on 01/02/13.

On 01/03/13 at 11:15 A.M. the patient was observed in bilateral wrist retraints, lying quietly with NG tube in place with a caregiver sitting next to the patient.

On 01/03/13 at 11:30 A.M. Staff Q was interviewed and revealed he/she had not observed the patient with the use of a caregiver minus the restraints.

Based on interview and clinical record review, the facility failed to ensure restraint orders written for Patient #13 were not written on an as needed basis. The sample size was 19 patients and the census was 255 patients.

Findings:

The clinical record review for Patient #13 was completed on 01/04/13. The clinical record review revealed the 46 year old patient came to the emergency department on 12/21/12 with a drowsy and confused level of consciousness, and a later psychiatric consultation (dated 12/22/12 at 1:15 P.M.) said he/she often overuses her/his barbiturate and believed he/she overdosed on Tylenol with codeine. The consult stated he/she was quite combative and verbally abusive. The consult concluded with diagnoses of polysubstance dependency and mood disorder.

The clinical record review in its electronic form revealed a physician's order dated 12/21/12 at 12:22 A.M. for four soft limb restraints and "Posey vest if needed. "

On 01/03/12 at 3:00 P.M. in an interview Staff S confirmed the finding.

Based on review of patient's clinical records, staff interview and policy review the facility failed to assess pain for four of 19 patient clinical records reviewed. (Patient numbers 1, 2, 11 and 3) and failed to assess body temperature for one of 19 patient's clinical records reviewed. (Patient number 2)

Findings included:

Review of the clinical record of Patient #1 on 1/02/13 revealed this patient presented to the emergency department on 12/04/12 at 9:47 AM for complaints of abdominal pain and vaginal bleeding and a pain level of 9 out of 10 being the worst pain. At 10:02 AM the patient's pain level continued to be 9 of 10. At 10:46 AM the patient's level of pain was assessed as "cramping" The patient's discharge time was listed as 12:28 P.M.. The patient left without receiving discharge instructions or prescriptions written. The patient received no medication or evidence the patient's physician addressed the patient's pain. The patient was given antibiotics. There was no evidence the patient's pain was assessed or addressed. Interview of Staff C on 1/2/13 at 4:55 P.M. revealed pain should be assessed and treated.

Review of the clinical record of Patient #2 on 1/02/13 revealed this patient arrived to the emergency department on 12/4/12 with a complaint of abdominal pain at 10:16 P.M.. The patient's body temperature at that time was 97.3 Fahrenheit. The patient received the last intravenous pain medication on 12/5/12 at 4:12 AM for pain described as 8 of 10 with 10 being the worst pain. At 4:27 AM the patient's pain was assessed as 7 of 10. On 12/5/12 at 6:11 AM the patient's intravenous line was discontinued. The patient was discharged at 6:15 AM. There were no further pain assessments completed past 4:27 AM or at the patient's time of discharge.

Interview of Staff C on 1/2/13 at 4:55 P.M. revealed pain should be assessed and treated. Review of the facility's policy called "Pain Management" with the last revision dated 6/12 Pain is reassessed for effectiveness 1 to 2 hours after interventions and medications are titrated as prescribed by the physician until pain is relieved or ceiling medication is reached.

In addition, The patient had blood work that indicated an infection. The record lacked evidence any additional body temperatures were taken after the first reading at 10:16 P.M. the previous evening.


21521

The electronic clinical record review for Patient #11 was completed on 01/04/13. The review revealed the patient was triaged in the emergency department at 2:43 P.M. with left lower abdominal pain of 10/10. At 4:00 P.M. the patient's pain was assessed at 10/10, at 6:00 P.M. the patient was brought back to the treatment area and the pain was assessed as 10/10.
The clinical record review revealed the patient was ordered pain medicine at 7:32 P.M. and again at 7:48 P.M. After administration of the medication, the patient's pain was assessed at 8/10 at 7:54 P.M. and 5/10 at 8:09 P.M.
Review of policy "Pain Management", last revised on 06/12/12, revealed, "pain assessment results are reported to the physician as appropriate and a plan is developed to relieve pain."
On 01/03/13 at 3:00 P.M. in an interview, Staff S was unable to locate in the electronic chart where the physician was notified of the patient's pain of 10/10 between 2:43 P.M. and 6:00 P.M.




32059

The clinical record for Patient #3 was completed on 1/3/13. The clinical record revealed the patient arrived to the emergency department on 1/2/13 at 1:41 P.M. with complaints of upper abdominal pain. The triage assessment indicated the patient reported abdominal pain of 10 on a scale of 0-10 with 10 being the most severe. The charting flow sheet revealed documentation at 2:17 P.M. that indicated elevated blood pressure and a pain score of 10. The patient continued to report abdominal pain of 10 and documentation revealed elevated blood pressure at 4:00 P.M. while in the waiting area.
Patient #3 was moved to the treatment area at 6:18 P.M. and Dilaudid 1mg was administered intramuscularly at 6:59 P.M. as ordered by the physician. The patient continued to have ongoing pain rated 10 throughout the stay in the emergency department. The patient was discharged at 8:45 P.M. with a diagnosis of abdominal pain (non-specified) with continued pain rated at 10. .
The chart lacked documentation that the physician was notified of the ongoing severe abdominal pain for an extended period of time as required per policy entitled "Pain Management".
This was confirmed with Staff L on 1/4/13 at 4:15 P.M..

Based on observation and interview, the facility failed to ensure an integration of psychiatric services with emergency services within the emergency department. This affected Patient #10 who, while psychologically deteriorating, was threatened with restraints and had security officers attend to him/her. The patient was never attended to by nursing staff from the facility's psychiatric department. The sample size was 19 patients and the census was 255 patients.

Findings:

The clinical record review for Patient #10 was completed on 01/04/13. The clinical record review revealed a triage note that stated the 41-year-old patient presented to the emergency department on 01/01/13 at 6:55 P.M. accompanied by the local police department due to being found screaming, violent and looking around in room mouthing words. The note stated the patient was bipolar and not taking his/her medications.

The clinical record review revealed a physician progress note dated 01/01/13 at 7:51 P.M. stating social work had evaluated the patient and had him/her "pink slipped"-i.e., for psychiatric reasons, the patient would be held at the hospital and against his will if necessary.

The clinical record review revealed a social worker note dated 01/01/13 at 10:36 P.M. that stated the patient had a diagnosis of schizophrenia.

The clinical record review revealed an observation monitoring record wherein the patient's location and behavior was recorded every 15 minutes. The record began on 01/02/13 at 12:00 A.M. The record showed the patient was calm and in his/her room from midnight to 1:00 A.M. The record showed from 1:00 A.M. to 3:30 A.M. the patient was sleeping, and from 4:30 A.M. to 7:30 A.M. he/she sleep again. The record showed from 8:00 A.M. to 12:45 the patient was calm and either watching television or having something to eat.

The observation monitoring record revealed at 01/02/12 at 1:15 P.M.-a little more than 13 hours from midnight when he/she was sleeping--the patient began walking and becoming agitated. The observation monitoring record revealed from 1:30 P.M. to 2:00 P.M. the patient was agitated in his/her bed. At 2:00 P.M. the patient was again walking and agitated.

On 01/02/12 at 2:15 P.M. tour of the emergency department occurred with Staff G, H, and I. During the tour, Patient #10 was observed standing with Staff F, a social worker, in an intersection where one hallway of the emergency department met another. Staff F was overheard sternly tell Patient #10 that if he/she didn't sit down in his/her bed in curtain area he/she would be tied down.

On 01/02/12 at 2:30 P.M. two security officers were observed to be monitoring the patient. In an interview at the time, Staff O, a charge nurse in the emergency department stated the patient was getting antsy and his/her behavior was escalating; therefore, security had been called.

On 01/03/12 at 4:15 P.M. in an interview, Staff G stated the facility's psychiatric nurses do not come to assist in the emergency department when psychiatric patients deteriorate because staffing on their own unit makes it difficult to provide assistance.