HospitalInspections.org

Based on document review and interview the facility failed to provide the state address information for filing a grievance by mail to patients; resulting in the potential of denying all patients the the right to file a complaint/grievance in writing with an outside agency. Findings include:

On 03/04/2014 at 1530 during tour of 4 east with staff B and staff Q, request was made for the information that was given to patients to inform them of their patient rights. Staff B produced a folder that read "Port Huron Hospital Patient Handbook." A review of the handbook revealed a section on page 10 titled "Your Rights and Responsibilities." Review of the information revealed a lack of the State's address to file a grievance in writing.

On 03/05/2014 at 1000, during an interview with staff D she confirmed the findings and stated "we will need to add the information to the handbook."

Based on document review, interview and policy review the facility failed to send 1 of 5 patients (#26) a written resolution letter and failed to include the steps taken to investigate a grievance for 2 of 5 patients (#25 & #27). Findings include:

On 03/06/2014 at 0915 during a meeting with staff EE (Patient Representative) a review was completed on 5 grievances that had been filed on behalf of patients. The grievance documentation provided by the facility showed that grievances for patient #25, #26 and #27 were "Closed." A review of the grievance for patient #26 revealed that it had been filed with the facility on 12/11/2013. During the review for patient #26 staff EE was unable to produce a resolution letter for closure of the grievance. When Staff EE was queried about the lack of a letter, she stated "this was sent over to risk management and I will need to let them speak to whether or not a letter (of resolution) was sent or not." At 1000, staff CC from Risk Management spoke to the grievance documentation for #26 stating "No,there has not been a letter sent to the patient (#26) in regards to closure of the grievance." Staff CC went on to say that, "I was unaware that I needed to send a letter."

A review of the resolution letters sent to patients #25 and #27 revealed a lacked of information in regards to the steps taken to investigate their grievance.

On 03/06/2014 at 0955 staff EE, confirmed that an investigation did take place for patients #25 and #27 however the letters lacked information in regards to the steps taken to investigate their grievances.

On 03/06/2014 at 1030 a review of the facility's undated policy titled, "Patient/Family Complaints and Grievances" in the section titled "Procedure, K. [Facility A] will address the substance of each Patient Grievance through the Patient Grievance/Complaint Process as soon as possible. In any case, the Patient's Representative's Office will facilitate a written response to the patients representative within seven (7) business days from the date of receipt of a Patient Grievance. If the Patient Grievance is not resolved during the outlined timeframe for response, that information will be relayed to the patient. L. The Hospital's written response to the Patient Grievance will contain the following: a. The name of the contact person, b. The steps taken to investigate the grievance, c. The results of the Grievance/Complaint Process, d. The date of decision, e. If the Patient Grievance is not resolved, if the investigation is not complete, or if the corrective action is still being evaluated, the Hospital's response will appropriately reflect that point and will inform the patient that another follow-up response will be sent within an outlined timeframe."

Based on record review, interview and policy review, the facility failed to monitor 1 of 1 patients (#32) per policy resulting in a loss of the patient's right to be free from restraint. Findings include:

On 03/04/2014 at 1030, during tour of the behavioral health unit an inquiry was made in regards to current patients in restraints. Staff T (Unit Manager) stated, "we use restraints as a last resort, very infrequently" and then stated, "there is currently not anyone in restraints." When queried if the unit had a restraint log staff T replied, "yes." Information was obtained at that time of the last discharged patient (#32) who had been in restraints during their stay.
On 03/05/2014 at 1600, during review of the closed medical record for patient #32 it was revealed that the patient was placed into 4-point restraints for, "harming self, impulsive, threatening, verbally abusive other" on 02/24/2014 at 1900.
The documentation supports that:
At 1914 the events leading up to the patient being placed into restraints at 1900 were documented as:
"Patient agitated, hitting walls, swung at security guard, threatening self harm with an ink pen."
At 1920 vital signs were recorded on the patient,
At 1928, circulation checks were documented,
At 1938 the patient was offered "oral fluids,"
At 1944 and 1958 circulation checks were documented,
At 1959 the patient refused hygiene/toileting and skin was documented as "intact,"
At 2013 circulation checks were documented,
At 2018 'Patient pulled left wrist out of restraint, Patient refused to let staff put restraint back on. Patient grabbed nurses finger and attempted to bite staff."
At 2027 "Patient status-resting," circulation checks completed,
At 2041 per the Mental Health Technician's (MHT) documentation "Patient status-resting," circulation checks completed. The RN documents the patient's behavior as "patient is still verbally abusive and trying to get out of restraints."
At 2050 "Left upper arm restraint loosened to improve circulation."
At 2055 "agitated, anxious, boundaries, combative, threatening"
At 2056 "Patient status-resting," circulation checks completed, "Hygiene/Toileting-refused, ROM (Range of Motion) all limbs."
At 2110 documentation reads "Patient status-restless," circulation checks completed, "bedpan (offered), skin intact."

The record lacks any documentation of the patient's behavior (continued need for restraints) from 1900 when the restraints were applied until 2018, when the documentation states that the patient, "got her left wrist out of restraint and tried to bite a staff member." Then at 2055 the documentation states that the patient was, "agitated, anxious, boundaries, combative, threatening. At 2201 the nurse documents that the patient was given oral Ativan for screaming at staff and demanding to get out of restraints, appears to be effective, patient is not trying to get out of restraints but is still verbally assaultive toward staff." The documentation by the MHT (mental health technician) reads from 2210 the patient was "resting" until the patient's release from restraints at 2304.

At the time of the record review with staff B when queried as to the frequency of monitoring and documenting on the patient while in restraints for behavioral reasons she stated, "it is every 15 minutes." When queried about what staff are monitoring she stated, "toileting needs, circulation, offering fluids, the patient's behavior, range of motion when it's done, monitoring the patient to see if they are ready to come out of restraints."

A review of the facilities policy on 03/05/2014 at 1630 titled "Restraint and Seclusion, Use of, Policy No.: 1.2.17, Reviewed Date: 11/13 read, "The condition of the violent patient who is restrained or secluded must be monitored continuously. Staff that has completed the training specified in this policy should check the patient at a minimum of every 15 minutes. The patient should be checked for....Readiness for discontinuation from restraint/seclusion."

Based on record review, interview and policy review, the facility failed to ensure that staff provide complete information related to patient falls that occur during their hospitalization for 1 of 1 current patients (#17) resulting in the potential for unmet patient needs. Findings include:

On 03/04/2014 at 1530 during tour of 5 East with staff Q a query was made in regards to if there had been any recent patient falls. Staff Q (Unit Manager) replied, "yes, we just had one last night." She went onto say that, "I was told in report that the patient in room 556-1 had a fall on afternoons yesterday." An attempt was made by staff Q to locate documentation in patient #17's medical record; however she was unsuccessful in locating any documentation related to the patient's fall. Staff Q did state that she was, "told in report that the patient stated 'I just got up too fast,' she did not receive any injury from the fall."
When staff Q was queried about the missing documentation in the record she stated, "I don't know why there isn't any documentation in the record." A review of fall assessments for patient #17 at 1555 revealed a fall assessment for the patient competed on 03/03/2014 for both the day and afternoon shifts. At the time of the record review, there was no documentation of a fall assessment completed yet for 03/04/2014

On 03/06/2014 at 1015 a further review of the medical record documentation was conducted to review documentation for 03/04/14 and 03/05/2014. The review revealed that on 03/04/2014, no fall assessment was completed on the day shift for patient #17. The lack of documentation was confirmed by staff B at the time of the record review on 03/06/2014 at 1015.

On 03/05/2014 at 1430 during interview with staff C (Director of Nursing) when queried about the lack of documentation in patient #17's record related to the fall that occurred on 03/03/2014 she stated, "Staff told me that they were unable to locate documentation in the medical record regarding the fall." She then stated that the record should have contained documentation as to when the fall occurred and what happened."

On 03/06/2014 at 1100 a review of the facility's policy titled Fall Prevention Guidelines, Policy No.:1.2.7, Revised Date: 10/13 revealed on page 4 of 6 in the section titled "III. Documentation of Initial and On-going Assessment, C. If a patient fall occurs, document circumstances on the EMR (Electronic Medical Record). 1. Consider debriefing. Include information from all team members. 2. Patient appearance at time of discovery 3. Patient response to event 4. Evidence of injury 5. Location 6. Time of fall 7. Activity at time of fall 8. Mental status 9. Physician notification 10. Notify family, legal Patient Representative, patient support, and partner. 11. Medical/Nursing intervention."

Based on record review, interview and document review, the facility failed to ensure that telephone and/or verbal orders are used infrequently and authenticated promptly by the physician for 2 of 7 patients (#14, #18) resulting in the potential for inaccurate orders; placing patients at risk for medical errors. Findings include:

On 03/04/2014 at 1500 during review of the medical record for patient #14, who was admitted on 02/24/2014, revealed that the paper (hard copy) of the medical record contained the following unsigned telephone orders:
"02/24/2014 at 2020-Clonidine 0.1 mg q (every) 6 hours PRN (as needed) for systolic BP (blood pressure) > 140 or diastolic BP >90.
02/25/2014 at 2100-Tylenol 1000 mg IV every 6 hours as needed pain.
02/28/2014 at 0810- Potassium Chloride Replacement Order, For Serum Potassium less than 3-Peripheral Vascular Access Device (VAD) Potassium Chloride 10 mEq/100 ml water IVPB (intra-venous piggy back) every 1 hour times 3 doses (If GFR (Glomerular Filtration Rate) less than 50 ml/min give 2 doses).
02/28/2014 at 2100- Potassium Chloride Replacement Order, For Serum Potassium 3 to 3.5-Peripheral Vascular Access Device (VAD) Potassium Chloride 10 mEq/100 ml water IVPB (intra-venous piggy back) every 1 hour times 2 doses (If GFR (Glomerular Filtration Rate) less than 50 ml/min give 1 dose).
03/01/2014 at 0315-Potassium Chloride Replacement Order, For Serum Potassium 3 to 3.5-Peripheral Vascular Access Device (VAD) Potassium Chloride 10 mEq/100 ml water IVPB (intra-venous piggy back) every 1 hour times 2 doses (If GFR (Glomerular Filtration Rate) less than 50 ml/min give 1 dose).
03/02/2014 at 1053-Potassium Chloride Replacement Order, For Serum Potassium 3 to 3.5-Potassium Chloride Tablet (K-Dur) 20 mEq PO (by mouth) every 1 hour times 2 doses (if GFR less than 50 ml/min give 1 dose)".

On 03/04/2014 at 1515 during review of the medical record for patient # 18, who was admitted on 03/02/2014, revealed the following unsigned telephone order:
"03/02/2014 at 1045-Clarification: hold Clonidine today, may resume 3/3/14 0.1 mg oral BID (twice a day)."

On 03/04/2014 between 1500-1530 during review of the medical records for patients #14 and #18, staff Q confirmed the lack of signatures on the orders. When staff Q was queried about the use of telephone orders she stated, "they are supposed to be used infrequently and signed when the physician comes in."

On 03/06/2014 at 1145 during review of the (facility) Medical Staff Bylaws, Policies and Rules & Regulations adopted by the Medical Staff: February 5, 2002, Revised: 1/28/14, Approved by the Board of Trustees: February 26, 2002, Approved 1/28/2014, reads on page 6, "Verbal orders will only be allowed in the following circumstances: 1. When the ordering practitioner is actively engaged in attending to a patient during an emergency (e. g. during a Code Blue event), 2. When the ordering practitioner is actively preparing for a procedure (e.g. scrubbing) or performing a procedure, 3. If there is a risk to a patient or provider using another method of ordering."

Based on record review and interview the facility failed to ensure that 3 of 4 patients (#16, #30, #31) receiving services on the Psychiatric Distinct Part Unit (DPU) had initial psychiatric evaluations completed that contained all the required information about the patients regarding intellectual functioning, memory functioning and orientation. The evaluation must also include an inventory of the patients assets (strengths & weaknesses) in descriptive not interpretative fashion. A lack of the patient information may result in the potential for unmet needs for all twenty-one patients receiving treatment on the unit. Findings include:

On 03/04/2014 at 1050, a review was conducted of the medical record for patient #16 who was currently receiving services on the Mental Health Unit (MHU). A review of the document titled "History and Physical" completed by the attending Psychiatrist staff DD revealed a lack of the patient's assets and lacked information regarding the patient's memory function.

On 03/06/2014 at 0800, a review was conducted on the medical record for patient # 30 who was currently receiving services on the Mental health Unit (MHU). A review of the document titled "History and Physical" completed by the attending Psychiatrist staff DD revealed a lack of the patient's assets and a lack of the patient's intellectual functioning and orientation.

On 03/06/2014 at 0815, a review was conducted on the medical record for patient #31 who was currently receiving services on the Mental health Unit (MHU). A review of the document titled "History and Physical" completed by the attending Psychiatrist staff DD revealed a lack of the patient's intellectual functioning, memory functioning and a lack of the patients's assets.

On 03/06/2014 at 0845, during an interview with staff DD the three (3) above mentioned History and Physicals were discussed. When staff DD was queried about the lack of the information he stated, "I guess I can put a section in there that speaks directly to the patient's Strengths & Weaknesses and addresses all the other areas. He stated that he,"felt that the information could be gotten out of the information provided." Staff DD, then had to excuse himself to go to a meeting. Further discussion then took place with staff T, (MHU Manager) in regards to the fact that the information should be provided in descriptive detail not interpretative fashion. She stated, "I understand."

Based on observation and interview the facility failed to ensure that all staff that administer medications are aware of safe/acceptable standards of practice for all drugs that they administer resulting in the potential for adverse medication reactions for all patients being treated at the facility. Findings include:

On 03/04/2014 between 1000 and 1645 tours were conducted on the Mental Health Unit (MHU), 5 East Medical/Surgical Unit and 4 East Medical/Surgical Unit. At 1025 on the MHU when the medication room was toured with staff T, an observation was made of the medication refrigerator and it was noted that it did not contain any injectable Ativan. An inquiry was made to staff T about where they kept their injectable Ativan. Staff T was unsure and went to ask another staff member. Staff T came back and stated that they keep it in the Pixis (medication dispensing machine). A review of the Ativan in the Pixis machine with staff T and U (MHU RN) revealed a box with a hand written date on it. Further review of the bottom of the box revealed a date that was different (later) than the date written on the box. When staff U was queried about the date on the box she replied "It is the expiration date." When showed that the bottom of the box showed an expiration date for 2015 staff U replied "I am not sure then what that date is." When staff T was queried about what the hand written date on the box meant she stated "I am not sure." The Ativan box contained the following manufacturer's storage information: "Keep in refrigerator 2 degrees to 8 degrees C (36 to 46 degrees F.)."

On 03/04/2014 at 1545 during tour of 5 East, an observation was conducted of the medication room and the Pixis machine. When staff Q (Unit Manager) and staff R were queried about Ativan they revealed that it was kept in the Pixis machine. An inquiry was made to made to staff R about the date on the box and she stated "I don't know what the date means, it comes from pharmacy that way." Staff Q was also unaware of what the date on the box meant.

On 03/04/2014 at 1615 when staff S (Unit Manager) was queried if he knew what the date on the Ativan box was for he stated, "I would assume that it is the expiration date."

On 03/05/2014 at 1430 during an interview with staff O (Director of Pharmacy) and staff P (Pharmacy Manager) they were queried about the Ativan not being refrigerated and about the date on the box. Staff P provided documentation from the manufacturer about the Ativan that speaks to it being stable for 60 days after it is taken out of the refrigerator. The date on the box is the date that when someone in Pharmacy takes it out of the refrigerator; they then put that date on the box for when it is no longer stable. When queried as to how this information is made available to nursing staff, staff O stated, "I cannot speak about the nursing staff, but pharmacy puts a date into the Pixis machine that is the 60 th day date of being out of the refrigerator, a report is printed out and staff then go and remove the medication from the Pixis machine. When asked again how the nursing staff are supposed to know if they see the medication is still in the Pixis past the date written on the box that they should not use it. Staff O stated, "I am not sure how they get that information to nursing." Staff O did go on to say that, "we have a sticker that reads 'Do not use after_(date)_____,' that we can put that on the box."

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated March 27, 2014.
K-0021
K-0025
K-0033
K-0029
K-0046
K-0062
K-0072

Based on observation and interview, it was determined that the facility failed to ensure the facility was maintained in a clean and safe manner resulting in the potential for transmission of infectious agents among patients and staff. Findings include:

On 3/4/2014 at approximately 1330, during tour of the south building and the main hospital floors with staff N, the following were observed:

1. Ripped chair (cushion) (which does not provide a smooth surface for sanitizing and decontamination) was found still in service in operating room #2 of the south building, and in the chemistry area of the lab in the main building on the second floor

2. Rusted and stained wheel casters for typical furnishing was observed throughout the surgery suite and endoscopy area serving the south building as well as the radiology department on the first floor of the main building

3. Damaged laminate is visible throughout the hospital, which does not provide a smooth surface for sanitizing and decontamination

4. Large bio-hazard and open-lid sharp containers were observed placed inside the medication rooms and other designated clean areas throughout the facility which will lead to contamination of the area and a potential for bloodborne pathogen exposure

On 3/4/2014 from 1000 to 1630, staff N, the facility manager rounded with the engineer surveyor and confirmed the above findings as they were found.

Based on observation and interview, it was determined that the facility failed to ensure that; the facility was clean, cleaning products are secured and that cleaning products taken out of one container and placed into another container are labeled with the containers' contents and concentration resulting in the potential for patient harm for all 21 patients being treated on the Mental Health Unit (MHU). Findings include:

On 03/04/2014 at 1015 during tour of the MHU with staff T (MHU Manager), a housekeeping cart was observed unattended sitting in the hallway outside of a patient room. Upon observation of the area, a housekeeper (Staff X) was seen coming out of the bathroom in the patient's room. When staff X was queried about the cart being left unattended with a fluid filled bucket sitting on top of it she stated, "we can take it into the room with us, but I didn't." When queried about what the bucket contained she stated it was, "EC 660 All Purpose Cleaner." When queried about the bucket not being labeled with the contents she stated, "the bottle is down in the utility room."

On 03/04/2014 at 1045 with staff T, the bottle of EC 660 was found in the utility room on the MHU and contained the warning of, "May cause eye irritation, Keep out of reach of children."

On 03/05/2014 at 0915 during an interview with staff N (Director of Facilities Management), he confirmed that the staff had discussed the findings with him and stated that, "staff can take their carts or just the buckets into the rooms with them as long as there isn't issues with isolation." He also stated, "I was not aware that the buckets needed to be labeled with the contents." When asked for a policy regarding securing the housekeeping carts, their contents and labeling of the buckets staff N replied, "We do not have one, there is no policy that speaks to the issues."


13069

On 3/4/2014 at approximately 1130 during a tour of the southern building's operating room suite, found high dust on flat-topped surfaces of task lights, booms, and the tops of monitors in operating room numbers 1 thru 4. In the male locker room on top of the lockers of the surgical suite, dust was found on flat-topped surfaces above 68 inches of height.

Additionally, dust was found on the top of the task light and booms in rooms 12 and 14 serving the emergency room (ER), on top of pyxis machines, ice machine and refrigerator serving the nourishment area of the ER.

On 3/4/2014 from 1000 to 1630, staff N, the facility manager rounded with the engineer surveyor and confirmed the finding as they were found.

Based on document review and interview, the facility failed to disclose it's financial interest in a skilled nursing facility resulting in the potential for the decision makers not to be fully informed. Findings include:

On 03/05/2014 at 1100 during an interview with staff GG and HH related to discharge planning, staff GG was queried if the facility provides a list of skilled nursing facilities (SNF) for patients and/or families to choose from when one is needed. Staff GG replied, "we do have a list, I'll get you a copy." When staff GG was further queried if the hospital has any financial interest in any of the facilities listed, she replied, "we do, the hospital owns [facility Z], it is a skilled nursing facility." When queried as to if the list provided to patient and/or their family disclosed to them that the hospital has a financial interest in any of the facility listed she replied, "I am not sure."

On 03/05/2014 at 1130, a review of the list provided by staff GG titled "Extended Care Facility Information, [Facility A], Care Management Department contains the name of the SNF that staff GG stated was owned by the hospital but failed to disclose on the document that the hospital has a financial interest in the facility.