HospitalInspections.org

Based on a review of a hospital policy, a review of SECURITY/SAFETY ROUNDS CHECK forms for a ten day period, a review of one of three medical records, and interview with administrative staff, it was determined that patients did not receive care in a safe setting.

Findings include:

Reference #1: The PURPOSE section of Behavioral Health Services policy and procedure titled 'Safety and Security Precautions' indicated: "To provide patients with a safe and protected environment." The PROTOCOLS section of the policy indicated: "Routine Checks (q [every] 15 minutes) All patients shall minimally be placed on every 15 minute checks upon admission and through out [sic] their in-patient hospital stay to ensure their safety. This level of precaution shall be documented on the security check sheet. The GENERAL INFORMATION section of the policy indicated: ".....
C. The staff member assigned to the patient security check will document the location of the patient on the check sheet every 15 minutes. The staff member will assess each patient for changes in behavior or physical status; a change in behavior or physical status will be documented in the medical record.
....."

1. Review of 'One South Annex Unit SECURITY/SAFETY ROUNDS CHECK' forms dated 3/10/12 did not indicate that any of the 20 patients identified as being on routine 15 minute checks were checked between 1:45am and 3:00am.

2. Review of 'One South Annex Unit SECURITY/SAFETY ROUNDS CHECK' forms dated 3/15/12 - 3/16/12 did not indicate that any of the 18 patients identified as being on routine 15 minute checks were checked between 6:45am and 7:15am.

3. Review of a 'One South Annex Unit SECURITY/SAFETY ROUNDS CHECK' form dated 3/17/12 - 3/18/12 did not indicate that any of the 8 patients identified as being on routine 15 minute checks were checked between 2:15am and 2:45am.

4. Administrators #4 and #5 agreed with the findings on the afternoon of March 20, 2012.


Reference #2: The POLICY section of Behavioral Health Services policy and procedure titled 'Safety and Security Precautions' indicated: "All patients shall be assessed for their potential for suicide, elopement, assault, and injurious behavior and be placed on appropriate precaution." The PROCEDURE section of the policy indicated: "....
5. Any staff member who has information suggesting that the patient is a safety risk must inform the Charge RN immediately. The patient's physician and treatment team members shall be informed by the Charge RN of these changes as soon as possible. This shall be documented in the medical record.

1. Review of the 'Assessment Summary' section of a PSYCHIATRIC EVALUATION H (HISTORY) AND P (PHYSICAL) form dated 3/16/12 in the medical record of Patient #12 indicated the entry: "+ s/ideations" (positive suicidal ideations). There was no evidence in the medical record that the psychiatrist who performed the evaluation informed the Charge RN.

2. Administrators #4 and #5 agreed with the findings on the afternoon of March 20, 2012.

This is a repeat deficiency.

A. Based on a review of the medical records of two of two patients placed in physical restraints for behavior management and a review of facility policy and procedure, it was determined that the patients' responses to the intervention of physical restraint were not assessed.

Findings include:

Reference: The 'Behavior Management Debriefing After Restraint/Seclusion is Discontinued' section of facility policy titled RESTRAINT/SECLUSION stated:
"1. Debrief with the patient following a restraint or seclusion episode.
Note: The patient and staff participate in a debriefing about the restraint or seclusion episode. Debriefing is an important aspect in reducing the recurrent use of restraint or seclusion by identifying what led to the incident and what could have been handled differently. Debriefings also allow the opportunity to ascertain that the patient ' s physical well being, psychological comfort, and right to privacy were addressed.
2. Include the patient, and if appropriate, the family with staff members who were involved in the episode and who are available to participate in the debriefing.
3. Perform debriefing a soon as possible after the episode but not to exceed 24 hours.
4. Provide counseling to the patient for any emotional trauma that may have occurred during the restraint or seclusion. Modify the treatment plan as indicated.
5. Document the debriefing on a separate Behavioral Health Debriefing Form and placed [sic] in the medical record."

1. Review of the medical record of Patient #10 indicated that he/she was in physical restraints for two seperate episodes on 3/2/12. There was no evidence in the medical record of any of the components of the above referenced policy section having been implemented. There were no Behavioral Health Debriefing Forms in the medical record.

2. Review of the medical record of Patient #14 indicated that he/she was in physical restraints for three episodes on 3/8/12 and 3/9/12. There was no evidence in the medical record of any of the components of the above referenced policy section having been implemented. There were no Behavioral Health Debriefing Forms in the medical record.




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B. Based on review of 3 medical records of patients with wounds, it was determined that the facility failed to ensure that the Skin Management Profile policy was implemented for 2 patients.
Findings include:

The facility's Skin Management Profile Documentation Form policy stated, "Procedure: ...3. Stage and document the skin breakdown using the strategic key on admission and at each dressing change or every 7 days (which ever comes first)."

1. In Medical Record #9 the Skin Management Profile dated 1/31/12, date of admission, indicated stage 2 skin breakdown at the sacrum and stage IV at the posterior right leg. These areas were measured and described on the day of admission, as per policy.

a. There was no evidence that the above mentioned areas of skin breakdown were measured at each dressing change or every 7 days from 1/31/12 until 2/13/12, day of discharge, as per policy.

2. In Medical Record #8 the Skin Management Profile dated 2/6/12, date of admission, indicated multiple areas of skin breakdown at the sacrum, left and right foot/heel, ankle. These areas were measured and described on the day of admission, as per policy.

a. There was no evidence that these areas of skin breakdown were measured at each dressing change or every 7 days, from 2/6/12 until 2/15/12, day of discharge, as per policy.

3. The above was confirmed with Staff #1.

This is a repeat deficiency


Based on document review and staff interview, it was determined that the facility failed to ensure that physician orders were implemented.

Findings include:

1. In Medical Record #3 the physician order dated 3/15/12 at 740 PM stated, "Morphine 2 mg [milligram] IV [intravenous] Q [every] 4 hr [hour] prn [as needed] pain; Dilaudid 1 mg IV Q4hr prn severe pain; Tylenol 650 mg. po [by mouth] Q4hr prn temp [temperature] >101 (degrees Fahrenheit)." The Pain Assessment Form indicated that the patient, from 3/16/12 at 10 AM to 3/20/12 at 12 AM, received 8 doses of Tylenol 650 mg. for pain ranging from 4 to 8 from 0-10 pain scale.

a. The above physician orders were not implemented. There was no evidence that the physician was notified for a change in orders.

2. In Medical Record #4: The physician order dated 3/14/12 at 2200 stated, "B [blood] Glu [glucose] by finger sticks AC [before meals] and He [?] [with] Moderate Coverage (Humolog) ..."

a. The Medication Record lacked evidence that on 3/18/12 at 4 PM the glucose finger stick was done and that insulin was administered. There was no evidence that the physician was notified for a change in order.

3. In Medical Record #7: The physician order dated 2/6/12 at 845 PM stated, "Start on low dose sliding as per protocol [with] Reg. [regular] Humulin Insulin sq [subcutaneous] q6 [every 6 hours]."

a. The Sliding Scale section of the order indicated that for a blood sugar from 251 to 300, 8 units of insulin would be needed. On 2/10/12 at 12 noon the patient's blood sugar was 254. The patient received 6 unit of insulin instead of 8. There was no evidence that the physician was notified for a change in order.

c. The above was confirmed with Staff #2.

Based on document review and staff interview, it was determined that the facility failed to ensure that respiratory treatments orders were implemented.

Findings include:

Reference: The facility's Respiratory Policy, titled, "Treatment Times and Documentation"stated, 'Policy: 1. All routine treatments on Telemetry and Medical Floors will be administered between 7:00 am and 11:00 pm.
2. All treatments on Telemetry and Medical floors ordered with a frequency of (Q4 hours, Q6 and Q8) will be administered on a PRN basis during 11pm to 7am...
4. Treatments will be administered "while awake" between the hours of 10 pm - 8 am unless specifically written as around the clock (ATC).
5. The respiratory care department will consult with the physician and obtain a change in order or reschedule treatment if clinical indication is present...
7. All STAT treatments will be administered within 15 minutes of notification to (sic) the order.
8. Initial orders will be initiated with (sic) 4 hours of receipt of the order from the SMS system. "

1. In Medical Record #2 the following was evident:

a. The physician telephone order dated 3/12/12 at "12:10" stated, "Albuterol 2.5 mg (milligram)/3cc (centicubic) via nebulizer 4 x [times] daily." The respiratory care department progress notes indicated that the patient received one respiratory treatment on 3/12/12 at 21:15.

i.The initial Respiratory treatment was not initiated within 4 hours of receipt of order, as per policy. The patient should have received 2 treatments on 3/12/12 instead of one.

b. The physician order dated 3/13/12 at 1:30 pm stated, "Albuterol 2.5 mg. + 3cc NS (normal saline), Atrovent .5mg + 3cc NS } 4 times daily." The respiratory care department progress notes indicated that the patient continued to receive Albuterol treatments at 415 PM and 845 PM and on 3/14/12 at 730 AM despite the change in medication. Although there was an entry at 1130 AM on 3/14/12, there was no medication documented as given;

i. The treatments were administered three times per day and not four times, as ordered.

c. The physician telephone order dated 3/14/12 at 12:15 stated, "D/C [discontinue] current neb [nebulizer] tx [treatment], Xopenex 1.25 one unit dose Q8 circle [hour] ..." The respiratory care department progress notes indicated that the patient received Xopenex treatments on 3/14/12 at 1945, on 3/15/12 at 7:20 AM and 1940. Thereafter, the patient received Xopenex treatments twice a day on 3/16, 3/17, 3/18, and 3/19/12.

i. The treatments were administered two times and not three times. Although the respiratory policy indicated that treatments ordered every 8 hours should be given twice during the day and as needed at night, there was no evidence that the respiratory therapist clarified the order for this patient who was admitted for COPD exacerbation.

2. The above was confirmed with Staff #2.

3. Review of Medical Record #3 on 3/20/11 at approximately 1:00 PM revealed:

a. The physician order dated 3/19/12 untimed stated, "Proventil 2.5 mg. in 3cc (cubic centimeter) NS Q6 hours x7 days first dose now ... " The order was signed off by the nurse on 3/19 /12 at 3 PM. The respiratory care department progress notes indicated that the STAT order was given at 2000 on 3/19/12. This was not in accordance with the policy. There were no further respiratory treatments administered since.

4. The above referenced policy indicated that treatments Q4 hours, Q6 and Q8 would be administered on a PRN basis during 11 pm and 7 am. The policy did not include the indication, or indications, for PRN (as needed) use.

5. The above was confirmed with Staff #3.