HospitalInspections.org

Based on observation, medical record review, review of video surveillance, policy and document review and staff interview, it was determined that the hospital failed to inform the patient, or patient's representative, of the patient's rights in advance of furnishing patient care (refer to A 117); and failed to ensure patients received care in a safe setting (refer to A 144). The cumulative effect of these deficient practices resulted in the hospital's inability to protect patient rights and provide services in a safe setting.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 35 patients (Patient #'s 1 and 12) in the sample, the facility failed to inform the patient, or patient's representative, of the patient's rights in advance of furnishing patient care. Findings included:

The hospital document entitled "Patient Rights & (and) Responsibilities" stated, "Your rights as a patient...Consent - You have the right to know how certain treatments could affect you and...other choices you have. You have the right to refuse a medication unless you are immediately endangering others..."

The hospital policy entitled "Consent for Treatment With Psychiatric Medication" stated, "...MeadowWood Behavioral Health System obtains the informed consent...prior to initiating or change in treatment with psychotherapeutic medications...This specifically includes any medication whose primary purpose in this use is the treatment of a psychiatric/mental health disorder...consent is obtained by the physician if physically present during the admission process. If the physician is not physically present, consent is signed by the RN (registered nurse)...at the time of admission...When a patient...declines to consent...The attending physician is notified. A progress note is written explaining patient...reasons for refusing...medication is held until consent is given..."

The hospital policy entitled "Patient Rights and Responsibilities Procedure" stated, "...The Admissions Department representative asks the patient, parent or legal guardian of a minor, or legally authorized individual for dependent adult or legally authorized individual for dependent adult, surrogate or lay care giver to sign an acknowledgment of receipt of the patient rights and privacy practices statements. The acknowledgement of receipt is placed in the medical record...employees...Medical Staff shall...Honor the patient's right to give or withhold informed consent..."

Medical record review revealed:

A. Patient #1 (admitted 3/16/19)

1. "Practitioner Order Sheet" dated and timed 3/16/19 at 9:10 PM, included verbal/telephone orders for Thorazine (anti-psychotic medication) to be given every 6 hours PRN (as needed) for agitation

2. The "Medication Consent - Psychotropics":
- stated, "...I, the undersigned, hereby authorize the professional staff of this facility to administer treatment, limited to the psychotropic medications indicated...Thorazine...patient shall always be asked to sign this authorization form...if the patient...is incompetent to consent to treatment, the consent of his or her legal representative shall be obtained"
- failed to contain the patient or legal representatives signatures to consent for the administration of Thorazine
- failed to contain the RN or physician signature

3. Medication administration record entitled "PRN Medications & Response" documented that Patient #1 was given 100 milligrams (mg) of Thorazine on 3/17/19 at 4:00 AM and 10:00 AM.

4. No evidence that the:
- patient was offered or declined to sign the consent for Thorazine
- physician was notified that the patient had not consented for Thorazine

During an interview on 4/2/19 at 12:52 PM, Director of Nursing A:
- confirmed that staff failed to adhere to the policy regarding consent for treatment with psychiatric medication
- reported that the consent should have been offered during admission intake and, if declined, when the patient was initially assessed by the nurse on the unit, and before administration of Thorazine

B. Patient #12 (admitted 2/28/19)
- no documented evidence to support that the patient, or patient's representative, was informed of his/her patient rights

Interview with Nursing Supervisor B on 3/29/19 at 2:45 PM confirmed this finding.

Based on observation, medical record review, policy and document review and staff interview, it was determined that for 8 of 35 patients (Patient #'s 1, 18 - 20 and 22 - 25) in the sample, the hospital failed to ensure patients received care in a safe setting. Findings included:

The hospital policy entitled "Patient Rights and Responsibilities Procedure" stated, "...employees...shall...ensure the patient's right to be free from neglect..."

The hospital policy entitled "Routine Observation of Inpatients" stated, "...The location and safety of all inpatients is checked and documented every 15 minutes by nursing staff. A single observation record is completed for each patient on unit regardless of supervision level...Staff completing rounds enters her/his initials in the box corresponding to the appropriate time. Each staff making a 15 minute rounds enters her/his signature and initials..."

I. Patient #1

A. The "MWBHS (MeadowWood Behavioral Health System) Safety Huddle Nursing Shift Report" dated 3/17/19, documented that Unit D West Behavioral Health Associate (BHA) assignments were as follows:
1. BHA #1 was responsible for every 15 minute checks:
- from 11:00 AM - 1:00 PM
- for the 1:15 PM Smoke Break

2. BHA #2 was responsible for every 15 minute checks:
- from 1:00 PM - 3:30 PM

B. On 3/29/19 between 1:24 PM and 2:25 PM, video surveillance for Unit D West hallway on 3/17/19 between 1:15 PM and 1:47 PM was reviewed with Director of Risk Management A and revealed the following:

1:16 PM: Patient #1 entered the hallway from the outside courtyard, and was in view of BHA #2 only, as the patient crossed the hall, and entered Bedroom A
1:45:21 PM: Patient #35 (Patient #1's roommate) opened the door and entered Bedroom A
1:46:16 PM: Patient #35 re-enters hallway and approached BHA #1
1:46:27 PM: BHA #1 and Patient #35 enter Bedroom A
1:46:48 PM: BHA #1 exits Bedroom A, appears to be calling out and re-enters Bedroom A
1:46:49 PM - 1:47 PM: other staff enter Bedroom A
1:47:15 PM: BHA #1 exited Bedroom A

Based on video surveillance review, no staff observed Patient #1 between 1:16 PM and 1:46 PM on 3/17/19.

C. Review of Patient #1's medical record revealed:

1. "Initial Treatment Plan (Nursing)" completed 3/16/19 at 10:10 PM documented:
- Problem: "Disturbed Thought Paranoid Delusional"
- Intervention: "Monitor for symptoms...engage patient...Q (every) 15 minute safety check..."

2. "Patient Observations" form dated 3/17/19 included documentation by BHA #1 that he/she visualized the patient and recorded the patient's location, behavior and activity as follows:
1:15 PM: outside; behavior calm; activity "Talking with Peers"
1:30 PM and 1:45 PM: in room; behavior calm; activity "Sitting/Lying"
2:00 PM and 2:15 PM: in room; calm behavior; activity "Talking with Peers"

3. "Progress Notes" dated 3/17/19 contained the following documentation:
1:50 PM: "...pt (patient) was found by staff in...room lying...in bed with a sheet wrapped around...neck. Pt was unresponsive."
1:51 PM: "Code Blue called...CPR (cardiopulmonary resuscitation) started."
1:53 PM: "911 called, cont (continue) CPR..."
1:56 PM: "cont CPR..."
1:58 PM: "Pt unresponsive, cont CPR..."
2:01 PM: "EMS (emergency medical services) arrived"

4. Review of "Code Blue" report documented:
2:10 PM: EMS transported Patient #1 to Hospital A's Emergency Department

During an interview on 3/29/19 at 2:32 PM, Director of Risk Management A confirmed that:
- staff failed to observe Patient #1 on 3/17/19 between 1:16 PM and 1:46 PM
- BHA #1 falsely documented that he/she performed checks of Patient #1 on 3/17/19 between 1:15 PM and 1:46 PM

D. Review of Hospital A's medical record revealed a "Death Notice" dated 3/21/19, which documented Patient #1's death on 3/21/19 at 12:42 PM.

II. Patient #'s 18 - 20 and 22 - 25

A. During an interview on 3/29/19 at 5:00 PM, BHA #3 reported that:
- he/she had the "Patient Observations" logs for all Unit D East patients, including Patient #'s 18 - 20 and 22 - 25
- Patient #'s 18 - 20 and 22 - 25 had left Unit D East to go to the cafeteria accompanied/supervised by BHA #5

B. On 3/29/19 at 5:30 PM:
- BHA #5 was observed returning from the cafeteria to Unit D East with Patient #'s 18 - 20 and 22 - 25
- Interview revealed that BHA #5 did not have the "Patient Observations" logs for the patients he/she was accompanying

C. During an interview on 3/29/19 between 5:40 PM and 5:50 PM, BHA #4 confirmed that he/she:
- documented the 5:15 PM and 5:30 PM checks for Patient #'s 18 - 20 and 22 - 25 that had gone to the cafeteria with BHA #5
- was not with Patient #'s 18 - 20 and 22 - 25 in the cafeteria at 5:15 PM and 5:30 PM to perform the check

During an interview on 3/29/19 at 6:00 PM, Director of Nursing A and Chief Executive Officer A:
- confirmed these findings
- reported that staff should only document the checks that he/she personally performs
- confirmed BHA #4 falsely documented that he/she performed checks of Patient #'s 18 - 20 and 22 - 25 on 3/29/19 at 5:15 PM and 5:30 PM

Based on observation, policy review and staff interview, it was determined that for 100 of 100 current patients, the hospital failed to ensure that facilities were maintained to ensure an acceptable level of safety, quality and cleanliness. Findings included:

The hospital document entitled "Safety/Hazard Surveillance" stated, "...To promote an environment for patients, staff, and visitors that is free from safety hazards and that all facility areas are in compliance with local and state regulations..."

The hospital policy entitled "Safety Survey Rounds (Correction of Hazardous Conditions)" stated,"...Regular surveillance is conducted throughout the facility to identify any physical condition that may pose hazards to patients, employees or visitors..."

During an environmental tour of inpatient areas of the hospital on 4/1/19 between 9:28 AM and 11:25 AM, the following observations were made and confirmed by Plant Operations Director A at the time of the finding:

1. Unit A
a. Patient Room #57:
- peeling paint on the ceiling around the variable air volume box

b. Patient Room #54:
- golf ball size hole in the wall
- chipped wall paint in the bathroom

2. Unit C
a. Group Room:
- chipped wall paint

3. Unit D East
a. Day Room:
- blistered/bubbled paint on the cabinet door

b. Patient Room #24:
- chipped wall paint

4. Medication Room between Unit D East and D West
- stained ceiling tile

5. Unit D West
a. Patient Room #16:
- chipped wall paint

6. Unit E
a. Patient Room #2:
- chipped wall paint