HospitalInspections.org

Based on review of clinical records and interview it was determined the Facility failed to assure chemical restraints were not ordered PRN (as needed) for seven (#1-#7) of 7 patients on 8E (East)/8W (West), the Psychiatric Unit. Failure to assure chemical restraints were not ordered PRN did not assure patients' behavior was managed by physician order and not at the discretion or convenience of a nurse. This failed practice was likely to affect all patients admitted to the Facility. Findings follow:

A. Review of Order Information for chlorpromazine (Thorazine) for Patients #1 and #2 revealed chlorpromazine 50 mg (milligram) IM (intramuscular) PRN agitation, threatening self or others or acute psychotic symptoms was ordered.

B. Review of Order Information for haloperidol (Haldol) for Patients #3-#7 revealed haloperidol (Haldol) 5 mg IM PRN agitation, threatening self or others or acute psychotic symptoms was ordered.

C. Findings were confirmed during interview with the Registered Nurse #1 on 10/02/14 at 1015.

Based on review of clinical records and interview, it was determined the Facility failed to have a policy for bathing patients and nursing staff failed to document baths for four (#9, #10, #13 and #18) of 13 (#8-#20) patients admitted to 4NW (Northwest), a Medical Surgical Unit. The failed practices did not assure personal hygiene was offered or conducted and was likely to cause skin breakdown, infections, decreased dignity and self-esteem. Those failed practices were likely to affect all patients admitted to the Facility. Findings follow:

A. During interview with the Regulatory Officer on 10/02/14 at 1230 when asked for a policy for bathing schedules and documentation, she stated there was no policy.
B. Review of Activities for Daily Living, Hygiene for Patient #9, admitted 09/22/14 revealed no baths were documented from 09/22/14 through 09/25/14 or that Patient #9 refused a bath.
C. Review of Activities for Daily Living, Hygiene for Patient #10, admitted 09/28/14 revealed no baths were documented from 09/28/14 through 10/01/14 or that Patient #10 refused a bath.
D. Review of Activities for Daily Living, Hygiene for Patient #13 admitted 09/20/14 revealed no baths were documented from 09/20/14 through 09/24/14, 09/26/14 and 09/27/14, 09/29/14 and 09/30/14 or that Patient #13 refused a bath.
E. Review of Activities for Daily Living, Hygiene for Patient #18, admitted 08/07/14 revealed no baths were documented from 08/07/14 through 08/09/14 or that Patient #18 refused a bath.
F. During interview with Registered Nurse #2 on 10/02/14 at 1015, he confirmed baths/showers were poorly documented in the clinical records under review.
G. Findings were confirmed with Registered Nurse #2 on 10/02/14 at 1050.

Based on review of clinical records and interview, it was determined staff failed to document percentages of meals eaten in six (#9, #10, #12, #13, #15, and #17) of 13 (#8-#20) records for patients admitted to 4 NW (Northwest), a Medical Surgical Unit. Failure to document percentages of meals eaten prevented staff from assuring the nutritional needs of patients were being met and was likely to affect all patients admitted to the Facility. Findings follow:
A. Review of Activities for Daily Living, Nutrition for Patient #9, admitted 09/22/14 revealed no documentation of percent of meals eaten from 09/27/14 through 10/01/14.
B. Review of Activities for Daily Living, Nutrition for Patient #10, admitted 09/28/14 revealed no documentation of the percent of dinner eaten on 10/01/14 and no documentation of the percent of breakfast eaten on 10/02/14.
C. Review of Activities for Daily Living, Nutrition for Patient #12, admitted 09/26/14 revealed no documentation of the percent of meals eaten from 09/26/14 through 10/02/14 with the exception of breakfast on 10/02/14.
D. Review of Activities for Daily Living, Nutrition for Patient #13, admitted 09/20/14 revealed no documentation of the percent of meals eaten from 09/20/14 through 10/02/14 with the exception of supplement on 09/23/14, breakfast and lunch on 09/24/14, breakfast and lunch 09/25/14 and breakfast 10/02/14.
E. Review of Activities for Daily Living, Nutrition for Patient #15 admitted 09/28/14 revealed no documentation of the percent of meals eaten from 09/28/14 through 10/02/14 with the exception of breakfast on 10/02/14.
F. Review of Activities for Daily Living, Nutrition for Patient #17 admitted 08/06/14 revealed no documentation of the percent of meals eaten from 08/06/14 through 08/08/14 with the exception of breakfast on 08/07/14.
G. Findings were confirmed with Registered Nurse #2 on 10/02/14 at 1050.