HospitalInspections.org

Based on observation, record review and interview, the hospital failed to ensure psychiatric patients admitted to the inpatient psychiatric hospital were provided care in a safe setting. This deficient practice is evidenced by failing to ensure patients who were determined to have been a harm to themselves or others were observed by MHTs as ordered by the physician for 2 (#4,#9) of 2 patients ordered to be 1:1 (within arms reach) at all times.

Findings:

Review of the Hospital Policy titled Patient Observation revealed in part:
5. Patients ordered for 1:1 observation must have a staff member assigned to remain with the patient at all times to ensure the safety of the patient and others. The assigned staff member is responsible for ensuring the following:
a. Maintain arm's length and visual field of the patient at all times.
c. Keep bathroom door cracked to maintain patient's privacy and safety.

Patient #4 (main campus)

Review of Patient #4's medical record revealed an admission date of 5/28/18 with an admission diagnosis of Bipolar Disorder. Further review revealed Patient #4's legal status was CEC. Additional review revealed Patient #4 had been placed on 1:1 supervision due to having attempted to drink hand sanitizer on 6/4/18.

On 6/5/18 at 11:25 a.m. an observation was made of Patient #4 (who remained on 1:1 supervision at the time of the observation) going into the bathroom in her room. The door to the bathroom had a small crack in it, but S8MHT remained outside of the door, failing to maintain Patient #4 within arms' reach, in her direct line of sight, at all times.

In an interview on 6/6/18 at 1:00 p.m. with S1Adm, she confirmed patients on ordered 1:1 supervision should remain within direct line of sight, within arm's reach of the staff member assigned to observe them. S1Adm further confirmed S8MHT should have maintained Patient #4 within her direct line of sight, within arm's reach, when she was in the bathroom on 6/5/18. S1Adm indicated, after being informed of the above referenced observation, that there was a need for further education of staff regarding 1:1 supervision.

Patient #9 (offsite campus)
Review of Patient #9's medical record revealed he had been admitted on 6/2/18 with diagnosis including Depression and Suicidal ideations.

Review of a physician's order dated 6/4/18 at 10:35 a.m. revealed Patient #9 was to be on 1:1 observation with no utensils, finger foods only.

Observation on 6/5/18 at 8:55 a.m. revealed Patient #9 was in a hall bathroom with the door closed. S4MHT assigned to observe Patient #9 on a 1:1 basis was outside of the closed door.

In an interview with S4MHT, she said she was new. S4MHT said she was watching Patient #9 1:1 because he was suicidal.

In an interview on 6/5/18 at 10:15 a.m. with S3ADON, she said S4MHT should have been in the restroom with Patient #9 instead of outside of the door.

Based on record review and interview, the hospital failed to ensure the RN who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician as soon as possible after the evaluation for 1 (#10 ) of 2 (#8, #10) patients' records reviewed for restraints or seclusion.

Findings:

Review of the hospital policy titled Seclusion and Restraints revealed in part:
5. A physician, trained RN, or designee must examine the patient and evaluate the need for restraint or seclusion within one hour after the initiation of this intervention. A trained RN must report the face-to-face assessment to the physician.

Review of Patient #10's medical record revealed he had been admitted on 5/16/18 with diagnosis which included Paranoid Schizophrenia.

Review of Patient #10's medical record revealed he had been placed in restraints on 5/17/18 at 4:51 p.m. for aggressive and violent behavior.

Review of Patient #10's medical record revealed a 1 hour evaluation had been completed by S5RN at 5:50 p.m. Further review revealed no documentation of physician or other LIP notification of the findings of the 1 hour face to face evaluation.

In an interview on 6/5/18 at 10:05 p.m. with S3ADON, she verified there was no documentation of physician notification about the RN's 1 hour face to face evaluation. There was also no documentation of what S5RN evaluated.

Based on policy review, medication variance review, medical record review, and interview, the hospital failed to ensure drug administration errors were documented in the patient's medical records for 1 (#14) of 1 patients reviewed for medication variances from a total patient sample of 14 (#1 - #14).

Findings:

Review of the hospital policy titled, "Medication Variance Report", policy number: P 1.009, revealed in part: II. Purpose: To record any incident where the actual med-pass differs from what physician ordered. To track variances in actual med-pass from what physician ordered. To notify appropriateness parties (Physician, DON (Director of Nursing), Pharmacy, etc ...) of any medication variance. To create awareness and reduction in medication variances. III. Procedure; B. Notification When the Medication Variance Report has been completed, notification of DON, Physician and Pharmacy must be carried out. In the event of an emergency good nursing judgment should prevail and notification of necessary parties may take place prior to completion of Medication Variance Report. Any instructions or orders resulting from notification should be noted on the form as well as the chart if applicable.

Review of the hospital's policy titled "Medication Error Reporting/Incident Reports", provided as current by S2DON, revealed the following must be completed (when a medication error is discovered):
1) Any actual or potential medication errors will be reported in writing to the Pharmacy Manager for a complete review, investigation, adverse outcome, and plan of action response. Quarterly reviews are conducted;
2) It is required to note the specifics of the medication and the order;
3) Record the patient's response to medication error;
4) Patient's physician is to be contacted immediately when the error is discovered;
5) Document a narrative of the incident;
6) Complete an incident report including persons involved along with patients condition and any follow up actions done;
7) Plan of action after the investigation;
8) The reports will be reviewed quarterly for trends with pharmacy; and
9) Document what has been implemented to prevent future errors.
Further review of the above referenced policy revealed it was the "Medication Error Reporting/Incident Reports" policy of the hospital's former contracted pharmacy.

In an interview on 6/6/18 at 12:30 p.m. with S3ADON, she verified the policy provided by S2DON on 6/5/18 was the "Medication Error Reporting/Incident Reports" policy of the hospital's former contracted pharmacy. S3ADON also verified the referenced policy was still being used by this hospital despite having a contract with another pharmaceutical company.

Review of the hospital provided medication variance reports revealed a medication error involving Patient #14. Further review of the report revealed the following summary of events: On 4/9/18 at 9:00 a.m. (S9LPN) gave medication as scheduled (Invega SUS) but only crossed out medication on the MAR (Medication Administration Record), with no signatures. The medication was injected again on 4/9/18 at 9:00 p.m. by S10LPN. Medication variance type: Extra Dose. Breakdown Point: Medication not correctly documented on MAR after administration. Actions taken to rectify error: Physician was notified and the nursing supervisor. The incident report indicates 4/10/18 re-educated S9LPN on proper way to fill out MAR. Entire nursing staff will be re-educated. An attached form with an example of a correctly filled out MAR was included when staff was in-serviced on proper documentation of medication administration on MAR.

Review of Patient #14's medical record revealed no documented evidence of an account of the medication variance or notification of the physician.

In an interview on 6/5/18 at 1:15 p.m. with S12RN, she verified, after review of Patient's #14's complete medical record, that there was no documentation regarding the medication error, notification of the physician, nor was there an update of the patient's status/response to the medication as directed per policy and as staff had been instructed to do upon discovery of a medication error.

Based on record review and interview, the hospital failed to ensure policies and procedures were developed that provided for safety for affected patients and hospital personnel. This deficient practice was evidenced by failure to include provisions for safety in its policy that included shielding for patients, personnel, and facilities, the manner of notifying others when portable x-rays were being taken, and determining whether female patients were pregnant prior to taking an x-ray.

Findings:

Review of the policy #PC-028, titled "Radiology Services", presented as a current policy by S7HR, revealed no documented evidence that safety provisions for patients and personnel during portable x-ray procedures conducted by the contracted x-ray company were included in the policy.

In an interview 6/6/18 at 9:15 a.m. S7HR , after review of the hospital's only Radiology policy, verified the policy did not include provisions for shielding for patients, personnel,and facilities, the manner of notifying others when portable x-rays were taken or determining whether female patients were pregnant prior to taking an x-ray.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by having no documentation indicating the hospital had a Director of Radiology for the hospital.

Findings:

A review of the hospital's organizational chart, provided by S1Adm as a current organizational chart, revealed no documentation of a Radiologist as the Director of Radiology for the hospital.

A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S7HR as a current list, revealed no documented evidence that a Radiologist was identified as the Director of Radiology.

A review of the hospital contracts, revealed the hospital had contracts with x-ray service providers to perform Radiology services at both hospital campuses.

In an interview 6/6/18 at 9:15 a.m. S7HR verified she was the credentialing coordinator. S7HR reported that the hospital did not currently have an appointed Director of Radiology.

Based on record review and staff interview, the Hospital failed to ensure patient History and Physical examination documentation included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 3 (#2, #3, #4) of 4 (#2, #3, #4, #11) patients reviewed for neurological assessments out of a total sample of 14. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.

Findings:

Patient # 2
A review of the medical record for Patient #2 revealed the patient was admitted to the hospital on 5/29/18 with diagnoses of Schizoaffective Disorder with a history of Bipolar Disorder. Review of the History and Physical, dated 5/30/18, revealed boxes adjacent to cranial nerves I-XII with the option to check "yes" or "no". Further review revealed no documentation to support how the function of Neurological cranial nerves I-XII had been assessed for Patient #2.

Patient #3
A review of the medical record for Patient # 3 revealed the patient was admitted to the hospital on 5/30/18 with diagnoses of Depression with Suicidal Ideation and history of Bipolar Type I Disorder. Review of the History and Physical, dated 5/30/18, revealed boxes adjacent to cranial nerves I-XII with the option to check "yes" or "no". Further review revealed no documentation to support how the function of Neurological cranial nerves I-XII had been assessed for Patient #3.

Patient # 4
A review of the medical record for Patient # 4 revealed the patient was admitted to the hospital on 5/28/18 with diagnoses of Bipolar disorder, Borderline personality, Alcohol use disorder, Homicidal ideation, and Substance abuse. Review of the History and Physical, dated 5/29/18, revealed boxes adjacent to cranial nerves I-XII with the option to check "yes" or "no". Further review revealed no documentation to support how the function of Neurological cranial nerves I-XII had been assessed for Patient #4.

In an interview on 6/6/18 at 11:40 a.m. with S2DON, she confirmed, after review of the above referenced Neurological cranial nerves I-XII assessments, that there was no documentation to support how the function of the Neurological cranial nerves I-XII had been assessed.









39791






30420

30984

Based on record review and interview, the hospital failed to ensure the mental status examination on the psychiatric evaluation included supportive information used to determine level of function. This deficient practice was evidenced by failure to include supportive information on the psychiatric evaluation that was utilized for assessment of insight and judgement for 3 ( #3, #4, #11) of 3 ( #3, #4 ,#11) patient records reviewed for psychiatric evaluations from a total sample of 14.

Findings:

Patient #3
Review of Patient #3's medical record revealed an admission date of 5/30/18 with an admission diagnosis of Depression with Suicidal Ideation and Bipolar Type I Disorder. The patient's legal status was CEC.

Review of Patient #3's Psychiatric Evaluation, dated 5/31/18, revealed the patient's insight and judgement were both documented as poor. Further review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's insight and judgement.


Patient #4
Review of Patient #4's medical record revealed an admission date of 5/28/18 with an admission diagnosis of Bipolar disorder, Borderline personality disorder, Alcohol use disorder,, Homicidal ideation, and Substance Abuse. The patient's legal status was CEC.

Review of Patient # 4's Psychiatric Evaluation, dated 5/29/18, revealed the patient's insight and judgement were documented as poor. Further review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's insight and judgement.


Patient #11
Review of Patient #11's medical record revealed an admission date of 4/18/18 with an admission diagnosis of Major Depressive Disorder recurrent, severe with Suicidal Ideation.

Review of Patient #11's Psychiatric Evaluation, dated 4/19/18, revealed the patient's insight and judgement were both documented as poor. Further review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's insight and judgement.


In an interview on 6/6/18 at 11:40 a.m. with S2DON, she confirmed, after review of the above referenced psychiatric evaluations, that there was no documented evidence of supportive information/methodology utilized for determining the patients' insight and judgement.

30984

Based on record review and interview, the hospital failed to ensure the psychiatric evaluation included supportive information utilized to determine intellectual level of functioning and memory functioning for 3 (#3,#4, #11) of 3 (#3, #4, #11) patient records reviewed for psychiatric evaluations from a total sample of 14.

Findings:

Patient #3
Review of Patient #3's medical record revealed an admission date of 5/30/18 with an admission diagnosis of Depression with Suicidal Ideation and Bipolar Type I Disorder. The patient's legal status was CEC.

Review of Patient #3's Psychiatric Evaluation, dated 5/31/18, revealed the patient's intellectual functioning was documented as average. Further review revealed the patient's memory was documented as follows: remote is inconsistent; recent is inconsistent but fairly intact. Additional review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's intellectual functioning and memory.


Patient #4
Review of Patient # 4's medical record revealed an admission date of 5/28/18 with an admission diagnosis of Bipolar disorder, Borderline personality disorder, Alcohol use disorder,and Homicidal Ideation. The patient's legal status was CEC.

Review of Patient # 4's Psychiatric Evaluation, dated 5/29/18, revealed the patient's intellectual functioning and memory were not specifically addressed. Additional review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's intellectual functioning and memory.


Patient #11
Review of Patient #11's medical record revealed an admission date of 4/18/18 with an admission diagnosis of Major Depressive Disorder recurrent, severe with Suicidal Ideation.

Review of Patient #11's Psychiatric Evaluation, dated 4/19/18, revealed the patient's intellectual functioning was documented as average. Further review revealed the patient's memory was documented as follows: immediate, recent and remote were all documented as intact. Additional review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's intellectual functioning and memory.


In an interview on 6/6/18 at 11:40 a.m. with S2DON, she confirmed, after review of the above referenced psychiatric evaluations, that there was no documented evidence of supportive information/methodology utilized for determining the patients' intellectual functioning and memory.