HospitalInspections.org

Based on observation and interview, the facility failed to implement their policy on the seclusion room. The window in the door had been damaged which severely impeded the viewing of patients.

The findings:

On 3/5/13 at approximately 10:28am, Staff E was observed sitting in a chair outside a seclusion room. Staff E stated that Client #14 was in the seclusion room. The window to the room was observed to be severely scratched and had some sort of paper pieces inside it. The window appeared opaque. Attempted to view the patient through the window, and was unable to see her. Staff E stated that she was by the door. Upon looking a second time, could just make out the outline of a blanket.

An interview was conducted with Staff E during the observation. Staff E was asked how she was able to observe the client as the window was virtually opaque. Staff E stated that she unlocks and opens the door in order to view what the client is doing. Staff E opened the door and the patient was clearly visible laying on a mattress in front of door covered by a blanket. The program director, who was present during the observation, stated that the window was going to be replaced.

A record review was conducted of The Seclusion/Restraint/Physical Hold Policy dated December 2011. The policy stated, "During seclusion episodes, staff is to continuously monitor the patient through the window of the locked quiet room door. If the patient moves our of direct staff view, the staff is to open the door to maintain continual visual contact with the patient."

Based on record review and staff interview, the facility failed to obtain a medical history and physical either 30 days before or 24 hours after admission for 9 of 15 sampled patients (#1, 3, 4, 5, 9, 10, 12, 13, and 14).

The findings:

A medical record review was conducted for 15 sampled patients.

Patient #1 was admitted on 7/6/12. Her medical history and physical were conducted on 7/10/12, 4 days later.

Patient #3 was admitted on 8/3/12. Her medical history and physical were conducted on 8/8/12, 5 days later.

Patient #4 was admitted on 1/22/13. Her medical history and physical were conducted on 1/25/13, 3 days later.

Patient #5 was admitted on 6/12/12. Her medical history and physical were conducted on 6/22/12, 10 days later.

Patient #9 was admitted on 3/9/12. Her medical history and physical were conducted on 3/16/12, 7 days later.

Patient #10 was admitted on 3/9/12. Her medical history and physical were conducted on 3/16/12, 7 days later.

Patient #12 was admitted on 2/13/13 . Her medical history and physical were conducted on 2/22/13, 9 days later.

Patient #13 was admitted on 4/13/12. Her medical history and physical were conducted on 4/20/12, 7 days later.

Patient #14 was admitted on 9/14/12 . Her medical history and physical were conducted on 9/21/12, 7 days later.

An interview was conducted with the program director on 3/7/13 at approximately 12:00pm. The program director stated that all of the patients were required to have a medical history and physical prior to admission at Gulf Coast Treatment Center. The history and physical documentation should be located with the other documentation from the transferring facility. This documentation was not observed.

Based on record review and staff interview, the facility failed to ensure that new medication orders were started timely and in accordance with stated policies. Antibiotics ordered on Friday were not started until Monday for 2 of 15 sampled patients, #1 and #15. Another medication had a 13 day delay between the order and the onset for 1 of 15 sampled patients, #14.

The findings:

A medical record review was conducted for Patient #1. On Friday, 3/1/13, the physician ordered 2 different antibiotics for patient #1. The physician ordered Septra DS 1 tablet twice daily for 10 days and Vibramycin 100mg 1 tablet twice daily for 10 days. Both of these antibiotics were started 3 days later on Monday, 3/4/13.

An interview was conducted with the nurse on duty, Staff I on 3/7/13 at approximately 10:30am. Staff I confirmed that Septra and Vibramycin did not come in from the pharmacy until 3/4/13.

A medical record review was conducted for Patient #15. On Friday, 3/1/13, the physician ordered the antibiotic Septra DS 1 tablet twice daily for 10 days. The antibiotic were started 3 days later on Monday, 3/4/13.

There was no evidence that the physician was notified of the delay in starting the ordered antibiotics for either patient.

An interview was conducted with the unit manager on 3/7/13 at approximately 12:00pm regarding the delay in starting antibiotics. She stated that the medical physician usually comes in on Friday afternoons. If a prescription is not faxed to pharmacy by 1:00pm, we won't get it until the following Monday. The unit manager also stated that they could not start the medication until they got a consent, we call RX Advantage - and say "hold for consent" before filling a medication.

An interview was conducted with the Director of Nursing (DON) 3/7/13 at about 3:00pm regarding the delay in antibiotic therapy. The DON stated that it was her understanding that the facility did not need to wait on a consent to start antibiotics. If the medicine was ordered on a Friday, the pharmacy should have sent enough to cover until Monday. The patient should not have to wait until Monday. Medications are supposed to be started within 12 hours. We do not keep antibiotics in the pharmacy or in the after hours or emergency kits.

A medical record review was conducted for Patient #14. On 1/8/13 a physician ordered the laboratory tests of a TSH (thyroid stimulating hormone) and QBHcg (Quantitative Beta HCG) for patient #14. After the labs were obtained, the physician ordered to start the medication LoLoestrin 1 tab daily. The labs were not drawn until 1/25/13, 17 days later, however, the medications were stared on 1/21/13.

An interview was conducted with the Unit Manager on 3/7/13 at about 12:00pm. The unit manager stated that the ordering physician did not realize that those labs were drawn on admission, and they did not need to be obtained. The medication was late in starting due to needing a consent signed.

The Emergency Drug Procurement policy was reviewed. The Policy stated, "It is the policy of Gulf Coast Youth Services to use all the resources available to procure a medication that is needed for a patient. A mechanism exists through the night cabinet and secondary supplier to accommodate this. Part C of the procedure stated, "Notify the physician and nursing station if any undue delay is incurred.

The medication policies of "Medication Ordering, Dispensing and Administration", "Emergency Drug Procurement", and "Procurement and Receiving of Medications" None of the policies addressed the timeframes from the ordering of medication to the patient receiving it. The written policies also did not discuss the stated policy that new prescription orders are faxed to the pharmacy with the notice to "hold for consent" before filling a medication.

Based on record review and staff interview, the facility failed to record results of X-rays results in the patient medical's record for 1 of 15 sampled patients, #1. The facility failed to ensure that all laboratory reports were filed in the patient's record for 1 of 15 sampled patients, #12.

The findings:

1. On 3/7/13 a record review was conducted for patient #1. On 12/14/12 the physician ordered an X-ray of the nose due to possible fracture for Patient #1. The X-ray was not completed for 2 weeks, on 12/28/12. There were no X-ray results in the medical record.
The unit manager called and obtained a copy of the X-ray results. The report was not signed by the ordering physician. The report stated, "Impression Non-displaced fracture of the nasal bones" A further record review revealed no evidence that the physician was notified of the nasal fracture. There were no orders regarding treatment for the fracture.
An interview was conducted with the Unit Manager on 3/7/13 at approximately 12:00pm. The unit manager stated that the physician had called over and told us there was no fracture. No treatment was ordered. The unit manager stated that the 2 week delay in getting the X-ray was due to the patient's behaviors. There were some behavioral issues documented in the nursing notes.

2. A record review was conducted for Patient #12. On 2/25/13 a physician ordered a CBC with diff (complete blood count with differential). On 2/26/13 the physician ordered a UA (urinalysis) for culture and sensitivity. The laboratory reports were not located in the medical record.

An interview was conducted with the unit manager on 3/7/13 at approximately 12:00pm. The unit manager stated that the UA and the CBC were done on February 26th. She confirmed that the laboratory results were not in the medical record and had not been seen by the physician.
The lab usually mails the reports out. We either get them, or they go down to the boys unit. We have a lab log, and when we get the lab results done we record it. Our 3rd shift goes through and makes sure that we get the results. At approximately 12:12pm, the unit manager called the lab and got the results faxed over.