HospitalInspections.org

Based on medical record review, document review, and staff interview, it was determined that the facility failed to obtain informed consent from 1 out of 4 patients in the sample (Patient #1). Findings include:

"Medication Administration for Nursing" policy: " ...The MD ordering medications is responsible for obtaining the necessary consents prior to administration of the first dose of psychiatric medications, and for documenting such in the notes section of HCS or on the consent form. The nurse administering the first dose of new psychiatric medication must witness consents for patients and or guardians ..."

Psychiatric Evaluation dated 11/17/2023 stated, " ...Denies being on any current medications ..."

Physician Medication Orders shows orders placed for the following psychotropic medications on 11/16/23:
-divalproex sodium ERT oral 500 mg tablet twice a day (Depakote - a mood stabilizer)
-olanzapine oral 10 mg tablet twice a day (Zyprexa - an antipsychotic)

There was no evidence of a signed patient consent for psychotropic medications.

In an interview with Employee #6 there was no evidence of consent in HCS [Electronic health system]. These findings were confirmed with Employee #6 on 12/1/23 at 10:45 AM.

Based on medical record review, policy review and staff interview, it was determined that for one (1) of two (2) (50%) restrained patients (Patient #4) in the sample, the restraint order failed to specify the information required by hospital policy. Findings include:

The hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revised 8/2020 states, "The physician's order for use of restraint or seclusion will be recorded in the medical record and include ... time limits not to exceed 4 hours for adults ...behavioral criteria for discontinuation of/release from physical restraint/seclusion ...staff shall assist the patient to meet the behavioral criteria for release ...use of restraint/seclusion shall be terminated as soon as criteria for release have been met."

Medical record review revealed:
Patient #4
1. "Seclusion/Restraint Order" for date 2/1/23 is missing:
a. "Date/Time of Intervention"
b. "Criteria for Release"

These findings were confirmed by Employee #6 on 12/1/23 at 11:05 AM.

Based on medical record review, policy review, and staff interview, it was determined that for two (2) of two (2) (100%) restrained or secluded patients in the sample (Patients #1 and #4), a restraint and/or seclusion intervention was utilized without a physician's order. Findings include:

The hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revised 3/2023 states, "...to support each patient's right to be free from restraint ...and therefore limit the use of these interventions...requires an order from a physician...physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint has been initiated...The physician shall authenticate the telephone/verbal order within 24 hours... A physician's order is required for each separate restraint and seclusion episode that is not considered one continuous episode...'Trial releases' ...are not allowed...If the patient is released from restraint...behaviors again become dangerous to themselves or others, a new order must be obtained..."

Medical record review revealed:
Patient #1:
1. "Seclusion/Restraint Order" for date 11/19/23 at 4:30 AM was blank for the "Practitioner's Signature" and "Date/Time"[of signature]
2. "Seclusion/Restraint Order" for date 11/23/23 at 11:15 AM was blank for the "Practitioner's Signature" and "Date/Time"[of signature]
3. "Seclusion/Restraint Order" for date 11/30/23 at 3:27 AM was blank for the "Practitioner's Signature" and "Date/Time"[of signature]

This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.

Medical record review revealed:
Patient #4:
1. "Seclusion/Restraint Order" for seclusion dated 1/20/23 at 11:20 PM shows two (2) "Date/Time of Interventions" including:
a. 1/20/23 at 11:20 PM
b. 1/21/23 at 1:20 AM
2. "Seclusion/Restraint Order" for seclusion date 1/20/23 at 11:20 PM shows "Practitioner's Signature" and "Date/Time" with one (1) signature and one (1) date:
a. 1/23/23 at 11:20 PM

This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.

Based on medical record review, policy review, and staff interview, it was determined that the physician's orders for one (1) of two (2) (50%) restrained patients (Patient #4) in the sample, failed to include a time limit for restraint use. Findings include:

The hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revised 8/2020 states, "The physician's order for use of restraint/seclusion will be recorded in the medical record and include...Time limits...If the attending physician did not order the restraint/seclusion...must be consulted as soon as possible - in most cases within 4 hours, but no longer than 12 hours..."

Patient #4 medical record review revealed:
1. "Seclusion/Restraint Order" for date 2/1/23 at 1350 is missing a time limit for restraint use
a. "Duration of Order" was left blank by the physician.

This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.

Based on medical record review, staff interview, and review of hospital policy, the hospital failed to ensure patients placed in physical restraint were monitored for respiratory rate and/or circulation checks for one (1) of two (2) restrained patients (50%) in the sample (Patient #4). Findings include:

The hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion"...revised 8/2020...states, "The patient shall be assessed...while in restraint/seclusion by trained staff...monitoring needs to take into consideration the patient's condition... including...circulation...vital signs shall be taken upon initiation and as clinically indicated..."

Patient #4 medical record review revealed:
"Post Intervention Face to Face Evaluation" for restraint order 2/1/23 at 1350 missing vital signs.

This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.

Based on policy review, document review, and interview with staff, it was determined that for 14 out of 14 patients assigned to the Middle Unit, and 2 out of 4 patients sampled (Patients #1 and #4), the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient. Findings include:

I. Patient Observations

Policy titled "Patient Observation Policy" revised 3/2023 stated " ... Charge Nurse/Nursing Supervisor/Team Leader ...ensures the patient observation rounds are occurring as ordered, 24 hours per day, seven days a week with reviewing the rounding sheet every four hours and the sign, date, and time ..."

During a unit tour of the Middle Unit on 11/30/23 between 11:08 AM and 11:20 AM, a review of patients forms titled "Patient Observation Record" revealed that charge nurse checks for the time frame between 04:00 AM and 08:00 AM on 11/20/23 were missing a charge nurse signature for all 14 patients on the unit.

During an interview on 11/20/23 at 11:15 AM with Employee #3, this finding was confirmed.


Medical record review for Patient #1 revealed:
Patient Observation Records showed nursing supervision of observations was missing for the following dates and times:

11/19/23 from 8:00 PM - 12:00 AM (1 supervision)
11/20/23 from 8:00 AM - 12:00 AM (4 supervisions)
11/21/23 from 4:00 AM - 8:00 AM (1 supervision)
11/22/23 from 8:00 PM - 12:00 AM (1 supervision)
11/23/23 from 4:00 PM - 12:00 AM (2 supervisions)
11/25/23 from 8:00 AM - 4:00 PM (2 supervisions)
11/27/23 from 12:00 PM - 4:00 PM (1 supervision)
11/29/23 from 8:00 PM - 12:00 AM (1 supervision)

The Patient Observation Record dated 11/30/23 was provided to surveyors after the discharge of Patient #1 on 11/30/23 at 2:54 PM.
Observations were done from 12:00 AM - 11:00 AM. (no observations done from 11:00 AM - 2:54PM (15 observations).
There was no nursing supervision signature for 4:00 AM - 8:00 AM and 12:00 PM - 4:00 PM.

Upon chart review on 12/1/23 the Patient Observation Record for 11/30/23 was discovered to have observations recorded until 3:00 PM. There was a signature for nursing supervision of observations from 12:00 PM - 4:00 PM that is timed for 12:15PM.

In an interview with Employee #6 on 12/1/23 that the record appeared to be backfilled and that there was no procedure or documentation that would explain the discrepancy. The employees who documented the added observations were unavailable for interview. These findings were confirmed with Employee #6 on 12/1/23 at 11:27AM.

Patient #4 medical record review revealed:
Patient Observation Records showed nursing supervision of observations was missing for the following dates and times:

1/18/23 from 12:00 AM - 8:00 AM; 9:00 PM -12:00 PM (3 supervisions)
1/19/23 from 4:00 PM - 12:00 PM (2 supervisions)
1/20/23 from 12:00 PM - 4:00 PM (1 supervision)
1/23/23 from 12:00 PM - 4:00 PM (1 supervision)
1/27/23 from 4:00 PM - 12:00 AM (2 supervisions)
1/29/23 from 4:00 AM - 12:00 AM (2 supervisions)
1/30/23 from 9:00 PM - 12:00 PM (1 supervision)
2/21/23 from 12:00 AM - 8:00 AM (2 supervisions)

This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.

II. Vital Signs

The hospital policy titled "Medical Record Documentation Requirements" issued 12/1996 states, "Documentation of patient care must be performed to communicate the treatment provided and its results. This documentation is to be timely...complete..."

Patient #1 medical record review revealed:
Orders placed on 11/16/23 at 8:33 AM for vital signs to be done twice a day for 3 days.
Orders placed on 11/16/23 at 8:33 AM for vital signs to be done daily after 3 days.

In an interview with Employee #6 on 12/1/23 at 11:45 AM it was verified that after taking vital signs twice a day on 11/16/23, 11/17/23, and 11/18/23 that vital signs would be done daily, per orders.

Vital signs were done once on 11/16/23 (missing 1 set).
Vital signs were done once on 11/18/23 (missing 1 set).
Vital signs were not done on 11/21/23 (missing 1 set)

These findings were confirmed with Employee #6 on 12/1/23 at 11:45 AM.

Patient #4 medical record review revealed:
Orders placed on 1/18/23 at 5:00 PM for vital signs to be done twice a day for 3 days.

Vital signs were done once on 1/19/23 (missing 1 set).
Vital signs were done once on 1/21/23 (missing 1 set).

This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.

Based on policy review, patient chart review, and interview with staff, it was determined that for 1 out of 1 patient (Patient #3) on increased level of observation in the sample, the hospital failed to ensure that all licensed nurses who provide services in the hospital adhered to the policies and procedures of the hospital. Findings include:

Agency policy titled "Special Precautions and Patient Level of Observation" reviewed 2/2023 stated, " ...A progress note entry by nursing staff should be documented in the medical record at least every hour, reflecting the patient's behavior, condition, mood and conversation. There must be a progress note entry by an RN every four (4) hours ..."

Review of patient record revealed:

Patient #3
"Final Ancillary Orders" indicated an order for "Level of Observation One on One While Awake" with a start date and time of 2/6/23 at 2:57 PM was placed by provider.

"Nursing Progress Note" dated 2/06/23 at 01:00 AM stated, "Pt [Patient] is constantly agitated, trying to go into other patient's rooms, pulling down notices, constantly pulling on the glass panes of the nursing station..."

"Psychiatrist Treatment Planning Progress Note" dated and timed 2/6/23 at 10:15 AM indicated that patient attitude was uncooperative and agitated. Note stated, " pt ... withdrawn...agitated, needed PRN med and frequent redirection...will need 1:1 ..."

"Psychiatrist Treatment Planning Progress Note" dated and timed 2/7/23 at 11:00 AM indicated that patients attitude was cooperative. Note stated, " ...D/C 1:1 level of observation ..."

"Patient observation records" dated 12/6/23 and 12/7/23 indicated that Patient #3 was awake from 3:00 PM to 11:00 PM on 12/6/23 and from 7:00 AM to 11:00AM on 12/7/23 (patient was awake for 12 hours during the time the 1:1 level of observation order was active).

"Nursing progress note" form dated 2/6/23 contained 1 hourly RS (Recovery Specialist) note (out of the required 12), and 0 RN progress notes (out of the required 3).

"Daily Nurse Progress Note" dated 12/6/23 indicated that no nursing assessment was completed for the 7:00 PM to 07:00 AM shift.

During an interview on 12/01/23 between 10:45 AM and 11:05 AM with Employee #6, this finding was confirmed.