HospitalInspections.org

Based on record review and staff interview, the Hospital failed to ensure the medical staff was accountable to the governing body for the quality of care provided to patients as evidenced by the medical staff failing to write specific orders for treatments and medications upon admission for 1 of 1 (#3) sampled patients reviewed for physician orders out of a total sample of 5 (#1-#5). Findings:

Review of the governing body bylaws, provided by S2ExecDir as current, revealed in part the following: The governing body must ensure that the medical staff is accountable to the governing body for the quality of care provided to patients....The governing body must ensure patients are admitted to the hospital only on the recommendations of a licensed practitioner by the state to admit patients to the hospital....

Review of the medical staff bylaws, rules and regulations, provided by S2ExecDir as current, revealed in part the following: Patients may be admitted and discharged only on order of a credentialed and privileged licensed independent practitioner....The psychiatrist must clearly justify the patient being admitted on an emergency basis, and an admission order must be completed and recorded on the patient's medical record upon admission....Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders, as well as results of tests and treatments.

Patient #3
Review of the medical record for Patient #3 revealed the patient was an 80 year old admitted to the hospital on 10/04/16 with a diagnosis of Major Depressive Disorder, recurrent severe without psychosis. The record revealed the patient resided in a skilled nursing facility. Further review revealed the patient had been found lying face down with a plastic bag over her head at the skilled nursing facility.

Review of the physician orders dated 10/20/16 revealed the patient was discharged back to the skilled nursing facility with orders to follow up with the primary care physician and the intensive outpatient program. Review of the record revealed the following physician order:
"10/22/16 at 11/30 a.m. Cancel discharge-continue current treatment. RBTO S5APRN/S6RN."
There was no documented evidence of any specific orders for medications or treatments upon admission to the hospital.

Further review of the record revealed the following:
Physician Progress Notes dated 10/23/16 at 1:40 p.m., documented by S5APRN: Readmit note/continued stay: Patient #3 was discharged on Thursday back to the nursing home-on Saturday morning she was found once again with a trash bag over her face-she was immediately sent back here.
Multi-Disciplinary Note dated 10/22/16 at 11:30 a.m. documented by S6RN: Patient accepted as per cancel previous discharge orders per S5APRN. Nursing home staff reported that patient was found with a plastic bag completely over her head.

In an interview on 11/03/16 at 2:24 p.m. S2ExecDir stated if a patient is not gone for 3 mid-nights it is a continued stay. She confirmed the patient was discharged on 10/20/16 and the patient was brought back to the hospital from the nursing home 2 days later (10/22/16) after the patient was found with a plastic bag over her head.

In an interview on 11/03/16 at 3:13 p.m., S2ExecDir reviewed the medical record for Patient #3 and confirmed there should have been specific orders written for the patient's care and treatment when she returned to the Hospital. S2ExecDir confirmed there was no reconciliation of the patient's medications.

Based on record review and staff interview, the Hospital failed to ensure the patient received care in a safe setting as evidenced by transporting a suicidal patient by hospital van with only a van driver, resulting in the patient opening the van door during transport and attempting to exit the moving van for 1 of 1 (#3) sampled patients reviewed for transportation out of a total sample of 5 (#1-#5).

Findings:

Review of the Hospital policy titled, Transportation of Patient/Perspective Patients, Policy number EOC-16, revealed in part the following: All transportation provided by the facility for a perspective patient or a currently admitted patient will be provided according to the assessed security needs of the individual including: Transport of prospective patients....
Facility Van: The facility van may be utilized to provide transportation to incoming preadmissions in certain circumstances which may include nursing home admission, individuals who are known to the facility (i.e. outpatients) or referrals for assessment by sources known to the facility. In this case triage would determine the security level needed. A second technician may be authorized for transport as needed.
Ambulance: May be utilized by medical facilities wishing to refer an acceptable medically stable individual for psychiatric assessment/admission.

Patient #3
Review of the medical record for Patient #3 revealed the patient was an 80 year old female admitted to the hospital on 10/04/16 with a diagnosis of Major Depressive Disorder, recurrent severe without psychosis. The record revealed the patient resided in a skilled nursing facility and was found in the skilled nursing facility with a plastic bag over her head lying face down.

Review of the physician orders dated 10/20/16 revealed the patient was discharged back to the skilled nursing facility with orders to follow up with the primary care physician and the intensive outpatient program.
Further review of the record revealed the following:
Physician Progress Notes dated 10/23/16 at 1:40 p.m., documented by S5APRN: Readmit note/continued stay: Patient #3 was discharged on Thursday back to the nursing home-on Saturday morning she was found once again with a trash bag over her face-she was immediately sent back here-also on the way here she opened the van door and made comments such as, "I want to jump."
Multi-Disciplinary Note dated 10/22/16 at 11:30 a.m. documented by S6RN: Patient accepted as per cancel previous discharge orders per S5APRN. Nursing home staff reported that patient was found with a plastic bag completely over her head. S4MHT reported that patient attempted to exit the moving van during transport. S5APRN and S2ExecDir called and informed of above.

Review of the physician's orders from the skilled nursing facility dated 10/22/16 revealed one on one supervision was ordered for the patient.

In an interview on 11/03/16 at 3:13 p.m., S2ExecDir confirmed she was aware of the incident that occurred with Patient #3 during transport from the nursing home to the hospital. She stated she was very familiar with this patient and was, "taken aback" that the patient tried to get out of the van. She stated they knew the patient and did not consider her high risk. S2ExecDir stated the patient was always so timid and quiet when hospitalized. S2ExecDir confirmed this was the second incident where the patient had been found with a plastic bag over her head. She confirmed the patient should have been transported by ambulance or at least with another MHT beside the driver.

In an interview on 11/03/16 at 3:20 p.m. S4MHT confirmed she picked up Patient #3 from the nursing home in the hospital's van to transport her back to the hospital. She confirmed no other staff had accompanied her. S4MHT stated the van doors locked from the outside, but pulling the door handle from the inside opens the door. She stated the patient did open the door and stated she was going to jump. S4MHT stated the patient closed the door and she pulled over when she got to the grocery store because other vehicles were behind her. She stated the patient said she didn't want to come back to the hospital. S4MHT stated after getting back on road the patient kept saying she wanted to die and did not want to come back to the hospital. She stated she tried to talk to her and calm her down.