HospitalInspections.org

Based upon record review and interview, the Governing Body (GB) failed to;

A.) allow the patient or the legal representative to participate in the development of treatment plan of care during treatment team meetings in 1 of 6 (Patient #s 1, 2, 3, 4, 5, and 9) charts reviewed.

Refer to Tag A0130


B.) maintain protection of the patients emotional health and physical safety while administering chemical and physical restraints in 3 (#1,#4, and #6) of 3 patient charts reviewed.

Refer to Tag A0144


C.) ensure adequate numbers of nurses and/or mental health technicians were available on 25 of the 29 days reviewed.

Refer to Tag A0392


D.) have the Registered Nurse (RN) evaluate the care of the patients on an ongoing basis and failed to document ongoing patient assessments, needs, conditions, and patient responses to interventions in 3(#1,4,and 6) of 3 charts reviewed.

Refer to Tag A0395


E. develop effective policy and procedure to control medications for 3 of the 3 units (Special Care Unit, Progressive Care Unit, and Youth Care Unit)

Refer to TAG A0491 Pharmacy Administration



F. follow established hospital policy to identify and minimize the risk of medication variances for 3 of the 3 units (Special Care Unit, Progressive Care Unit, and Youth Care Unit).

Refer to TAG A0492 Pharmacist Responsibilities


G.) ensure all areas of the hospital were clean and sanitary. The infection control program failed to include appropriate monitoring of housekeeping, maintenance, and other areas to ensure a sanitary environment was maintained in 3 out of 3 zones.

Refer to Tag A0747

Based upon record review and interview, the facility failed to;

A.) allow the patient or the legal representative to participate in the development of treatment plan of care during treatment team meetings in 1 of 6 (Patient #s 1, 2, 3, 4, 5, and 9) charts reviewed.

Refer to Tag A0130


B.) maintain protection of the patients emotional health and physical safety while administering chemical and physical restraints in 3 (#1,#4, and #6) of 3 patient charts reviewed.

Refer to Tag A0144

Based on review of records and interview, the hospital failed to allow the patient or the legal representative to participate in the development of treatment plan of care during treatment team meetings in 1(#9) of 6 (Patient #s 1, 2, 3, 4, 5, and 9) charts reviewed.


During chart reviews conducted on 9-7-2016, it was identified that Patient #9, who was an adolescent, had missing patient/guardian signatures on treatment team forms. No documentation was found that identified that the patient's legal guardian had been notified of treatment team meetings in Patient #9's chart. The patient had been admitted on 8-18-16 and had been there 21 days.


Interview was conducted with Staff #18 on 9-7-2016 on the adolescent unit in the nursing station. Staff #18 stated that treatment team consisted of Social Work, Charge Nurse, Utilization Review, Psychiatrist, and Clinical Supervisor. When asked if Patient #9 had attended treatment team, Staff #18 stated the patient had but the staff don't always get the patient to sign. Staff #18 stated that patients do come to the treatment team if it is appropriate, but not all of the time. Staff #18 stated that the family/guardians are not advised of treatment team date and times, nor are they invited to participate in treatment team. Staff #18 did not have an explanation as to why family/guardians were not allowed to participate in the development of treatment goals or plan of care for patients. .


A review of Glenn Oaks Hospital Policies and Procedures, Subject: Multidisciplinary Treatment Plan and Review was as follows:


"POLICY

Each patient will have a written, comprehensive treatment plan directing and coordinating the delivery of care for that patient's needs. The treatment planning process incorporates multidisciplinary assessments and evaluations into an organized statement of the patient's diagnosis, reasons for admission, strengths, weaknesses and impairments that will be addressed from initial contact to discharge and continuing care. The treatment plan establishes a series of patient outcomes objectives and specific interventions to be carried out by members of the team. It is the policy of Glen Oaks Hospital that the course of treatment of every patient shall be reviewed frequently and periodical, and the results of the review shall be fully documented in the patient's clinical record.


PURPOSE

1. Treatment planning utilizes interdisciplinary teams to optimize a comprehensive view of the patient, and produces an enhanced perspective for treatment strategizing.

2. Treatment planning defines, coordinates and monitors the delivery of multidisciplinary services, and is integral to credible, quality patient care.

3. To provide a complete, individualized, holistic plan of care based on an assessment of the patient's specific needs and problems.

4. To provide communication between staff members.

5. To foster consistency and continuity of staff members in the care of the patient.

6. To formulate a plan of care treatment that meets both the patient's objectives for him/herself, and the objectives of the staff for the patient.

7. The purpose of the Multi-disciplinary treatment plan review is to bring together the patient's treatment team to review the treatment plan, problem list and corresponding goals, to evaluate the patient's progress in meeting the goals, and to document the course of treatment rendered to each patient."


A review of Glen Oaks Hospital Policies and Procedures, Subject: Multidisciplinary Team Meetings was as follows:


"POLICY

Regular meetings at least once per week will be held to develop and review patient Multi Disciplinary (sic) Treatment Plans. Patient's assessment and treatment plan will be reviewed within 72 hours of admission and every 7 days there after (sic). Regular attendance shall be representative of the various disciplines involved in the treatment of the patient and shall include as many members of the program clinical staff as possible. In addition, any non-program professionals who are involved in the treatment of the patient shall attend.


PURPOSE:

1. To provide a structured forum for Multidisciplinary staff to plan patient treatment.
2. To develop and integrate summaries of patient status and progress.


PROCEDURE:

1. In the first Multi Disciplinary (sic) Treatment Meeting subsequent to patient admission, assessment date from each discipline will be presented to the Multi- disciplinary team, in the following format:

The psychiatrist will present a brief medical history, including admitting diagnosis, prior psychiatric treatment, significant medical problems, and current medications. He/she will review his/her goals for treatment including medication plan, treatment interventions, and psychological testing if needed.

The clinical staff will present the psycho/social history, including relevant childhood and early adulthood history, marital and work history, current living situation and support network. He/she will review his/her goals for social work, including psychotherapy objectives, family work, and preliminary discharge plans.


2. The information presented from each discipline will be integrated into the interdisciplinary Master Treatment Plan, revising and elaborating on the problem list and treatment interventions established by the clinical staff.


3. A member of the treatment team will be designated to review the Interdisciplinary Master Treatment Plan with the patient. The patient will be given opportunities to attend the meeting to review his/her treatment plan with the team.


4. In subsequent Interdisciplinary master (sic) Treatment Plan meeting, the patient problem list will be reviewed, with new problems established as needed and completion of the "Treatment Plan Review". Each discipline will report on patient progress. The Treatment Signature Sheet will serve as an integrated summary of the discussion and shall be signed by all staff and the patient."


Staff #19 was interviewed on the morning of 9-8-2016 in the conference room. Staff #19 confirmed that policies did not address the patient's or patient's parent/guardian/legally appointed representative's role in the treatment team process for the development of treatment goals and plan of care. Staff #19 acknowledged that patients were not consistently allowed to participate in treatment team and were not always signing their treatment plans. Staff #19 acknowledged that policy verbiage indicated that the plan was developed by the team then presented to the patient for signature and/or comment after the fact.

Based on chart reviews and interviews, the facility failed to maintain protection of the patients emotional health and physical safety while administering chemical and physical restraints in 3 (#1,#4, and #6) of 3 patient charts reviewed.

Review of patient #4 revealed the patient was ordered a chemical restraint on 3/18/16 at 3:55PM. The order stated, "Haldol 10mg IM, Benadryl 50mg IM, Ativan 2 mg IM NOW for severe agitation."

Patient #4's MAR revealed the patient was administered Haldol 10mg IM, Benadryl 50mg IM, Ativan 2 mg IM on 3/18/16. There was no time documented or where the medication was injected.

Review of the Nursing Admissions History dated 3/18/16 at 1800 revealed on page #5, written down the side of the page, "unable to assess due to acute psychotic state and emergency meds given in admission." Review of page #7 (last page of the assessment) stated, "1800 Pt was walked to unit with assist of 2 males. Pt was searched by 2 male MHT while this nurse was behind partition out of view. (See skin assessment) Pt drowsy and unable to assess due to psychotic state and emergency meds given. Pt taken to bedroom and is lying in bed asleep. Clothes searched and hair checked which is clean with no lice present. Pt placed on q15 min checks for safety." (SIC) There was no documentation found on the patient's chart of the behavior that called for a chemical restraint. There were no found interventions, or any nursing assessment of the patient before, during, or after the time chemical restraint was administered until 3/19/16. The nurse documented on the 3/19/16 7AM-7PM RN assessment that there were no medical issues or risks that needed monitoring. Review of the chart revealed there was no face to face documentation found.

Review of patient #1's physician orders revealed on 8/6/16 at 5:00PM stated, "Keflex 500mg po TID x 7days-right submandibular adenitis (swollen lymph nodes in the jaw area)." Review of the nurse's notes revealed there was no date on the note and there was no documentation of an assessment of the infection or medication ordered. The nurses note stated, "2100 ( 9:00PM)- Pt approaches nurses station and yells "I will kill you Bitch" pt does not make eye contact or face any specific staff member while yelling. Physician contacted with emergency med orders received for psychosis. Pt is escorted to his room and offer 3 IM meds per physician order. Pt states he doesn't like shots but he wants the medicine so he will take shots. Shots provided by med nurse without physical hold. At 2120 (9:20PM) pt at nurse's station to request snack-pt declines the snacks on unit and goes to bed. Q15 min checks, Suicide & Assault Precautions & Sexual Victim Precautions continue."


Physician telephone order dated 8/6/2016 at 9:00PM stated, "Haldol 10mg IM x 1 NOW- psychosis, Ativan 2 mg IM x 1 NOW anxiety, Benadryl 50mg IM x 1 NOW EPS." Review of the MAR revealed patient #1 was administered the medication at 9:10PM. A 1 hour face to face was performed on 8/6/2016 at 9:49PM. There was no further nursing assessment or observation documentation found until 8/7/16 at 8:15AM, a 10.5 hour span.

Review of the nurse's notes dated 8/7/16 at 5:55PM states, "pt. c/o "weird feeling" after taking Depakote states "I can't breathe" Breath sounds clear. No swelling noted to tongue, throat or lips. Staff #13(MD) notified. Depakote D/C'd and Benadryl 50 mg po ordered and administered. Will continue to assess. 8/7/16 6:00PM Pt states "Feeling better will continue safety check." There was no further nursing assessment, vital signs, or observation documented until 8/8/16 at 8:00AM, a 14 hour span.

Review of patient #1's nurse's notes dated 8/8/16 at 8:00AM stated, "Patient found on smoke deck, fidgeting and rocking back and forth, visibly anxious. Patient rates anxiety 10/10 denies depression, SI/HI or hallucinations. He reports racing thoughts and requesting Xanax to "slow down my head." He is cooperative, pacing often. Other patients on his unit report feeling threatened and afraid of him. Will continue Q15/PRN safety checks, medications, and precautions." Review of the MHT observation rounds shows the patient is not in the court yard until 8:30AM and was documented as calm from 6:00AM- 12:45PM.

Review of patient #1's physician telephone orders revealed an order that read, "Thorazine 75mg IM x 1 now-psychosis. Benadryl 50mg IM x1 NOW- allergy." The MAR revealed the medication was administered at 8:56AM. There was no restraint intervention or face to face found. There was no patient assessment, observation, or response to medication effectiveness documented. The nurse documented on 8/8/16 at 9:00PM, a 12 hour span, that "patient #1 took his night time medications and stated he needs an increase in his Klonopin. Patient was instructed to talk with MD in am." No further evaluation was found until 8/9/16 at 10:15AM, a 13.25 hour span.

AReview of patient #1's admission physician orders stated, "Special Precautions to be re-evaluated every 24 Hrs by physician." Special Precautions listed were Observation rounds q 15 minutes, Suicide precautions, Sexual Victimization, and Assault Precautions dated 8/5/16 at 1605. Review of the Physician Daily Progress Notes from 8/06/16- 8/10/16 revealed there was no mention of patient #1's special precautions reevaluation. Review of the Nursing Notes revealed the nurses were not listing the precautions as ordered or had changed the precautions without a physician evaluation;
8/5/16 and 8/6/16 only precaution checked for observation was only "Q15 minutes."
8/7/16 sexual victimization was not checked.

Review of the policy and procedure "Medication Administration for Emergency" stated, "Purpose: The purpose of these rules is to regulate the prescription and administration of psychotropic medication prescribed for the purpose of the treatment of mental illness. These rules do not apply to the prescription or the administration of psychotropic medication for the medical purposes other than the treatment of mental illness.
Procedure:
A. Emergency Administration of Meds
1.) Medication may be administered without the patient's consent in an emergency if other measures have been determined to be unlikely to prevent the threatened harm. The individual order for medication is valid for no longer than 24 hours. If the initial order for medication was authorized without personal observation of the patient by the physician, a physician shall evaluate the patient's condition within 24 hours of the order.
2.) The physician may renew emergency only one time for an additional 24 hour period and may do so only if the emergency continues. "

Review of patient #6's chart revealed he was a 13 year old, admitted on 8/25/16, with a bipolar disorder. A telephone physician order dated 8/26/16 7:35AM stated, "Place patient on 1:1 related to aggression towards peers." Review of the nurse's notes at 7:30AM stated, "Pt. oob at nurse's station requesting water. SN (skilled nurse) provided pt. with cup of water. Pt requested to call his mother. Staff reports/pt. required multiple redirection concerning phone times and unit program. SN observed pt. with staff and he appears to calm down. SN looked up after hearing a pt. cry out. Patient #6 was striking a peer with his fist that was sitting in a chair. SN and staff intervened. Pt stopped hitting peer and then attempted to strike another female peer. Staff attempted verbal de-escalation, pt. continued to attempt to strike his peers and staff. Staff members placed pt. in a handle with care approved hold. An order for hold and seclusion was obtained from the physician. Pt could not contain his composure. 1:1 continues order obtained from attending."

Review of the physician order dated 8/26/16 at 7:31AM revealed the nurse checked the following boxes;
It is immediately necessary to seclude/hold the patient to prevent imminent physical harm to others because the patient is behaving in a violent manner.
Preventative techniques ineffective: was checked but left blank. There was no techniques documented.
De-escalation techniques ineffective: was checked but left blank. There was no documentation of de-escalation techniques performed.
Verbal techniques ineffective: was checked but left blank. There was no documentation of de-escalation techniques performed.
Specific measures for safety, health and well-being: Pt 1:1 monitoring/ handle with care approved hold/Pt positioning/monitored.
Review of the physician signature revealed the physician had written 8/27/16 on his signature date and marked over it with 8/26/16.

Review of patient #6's chart revealed a "Restrictive Intervention Nursing Note Addendum" the nurse had charted that the patient was placed in seclusion on 8/26/16 at 7:31AM and ended at 8:00AM. Review of the face to face revealed the nurse saw the patient at 7:45 and documented at that time that the patient was calm and follows directions. The nurse documented there was no further need for the seclusion at 7:45AM but the patient was not taken out of seclusion until 8:00AM. Patient #6's 1:1 was discontinued on 8/27/16. There was no documentation of the patients 1:1 and seclusion in the treatment plan.

Review of the MHT observation records on 8/26/16 revealed the patient was being monitored q 15 minutes and was not on a 1:1. The MHT note stated the patient was in seclusion from 7:45AM -11:15AM. The last nursing documentation was at 8:00AM. There was no further documentation in the nursing notes until 8/26/16 at 11:00PM (15 hours later.) Review of the MHT notes revealed the patient consumed only 5% of breakfast and lunch and was blank for dinner. There was no documentation that the patient was offered supplements or snacks.

Review of patient #6's chart revealed there was no progress note in the chart for 8/26/16 and there was no mention of the seclusion or discontinuation of the 1:1 in the physician progress notes on 8/27/16.

Interview with staff #2 and #3 on 9/8/2016 confirmed there was no appropriate documentation on the patient's chemical restraint and continuing documentation of patient care after the medication administration.

Based on record review and interview, nursing services failed to:


A.) ensure adequate numbers of nurses and/or mental health technicians were available on 25 of the 29 days reviewed.

Refer to Tag A0392


B.) have the Registered Nurse (RN) evaluate the care of the patients on an ongoing basis and failed to document ongoing patient assessments, needs, conditions, and patient responses to interventions in 3(#1,4,and 6) of 3 charts reviewed.

Refer to Tag A0395

Based on review of records and interview, nursing services failed to ensure adequate numbers of nurses and/or mental health technicians were available on 25 of the 29 days reviewed.


Staff #2 provided the Staffing Grid. Per Staff #2, all staffing was done to this grid. Staff #2 stated that the grid had been approved through the Staffing Advisory Committee in October 2015. Staff #2 stated that these staffing levels had been agreed upon because it was needed for safe staffing and provided better staff coverage than the previous grid.


Upon review of the grid, there was a note at the bottom of the grid that stated, "Revised and Approved by the Glen Oaks Staffing Advisory Committee: October 13, 2015." Unit names were obliterated with ink and then handwritten in. Staffing level for Mental Health Technicians (MHTs) for the title "Unit Staffing PCU" (Progressive Care Unit) had been decreased from 3 to 2 by handwritten changes. The bottom of the grid for the PCU/SCU (Special Care Unit) and a separate grid for the Youth Care Unit (YCU) Staffing had an approval section for signatures of:


"Approved By:
Governing Board Date
Director of Clinical Services Date
Staff Advisory Committee Date
CEO Glen Oaks Date
Director of Nursing Date
CFO Date"


This entire section of the grid was blank.


When asked about the hand written changes to the staffing grid for the adult units, Staff #2 stated that he had swapped units several months back. He had decided the Special Care Unit (SCU) was the higher acuity of patient and originally had 22 beds. He moved them to the Progressive Care Unit to limit the census of high acuity patient to 16 beds. He moved the PCU to the old SCU unit so the lower acuity patients had 22 beds available. He then stated, "I didn't really change the number of MHTs because you don't need as many to take care of the PCU patients since the SCU patients were higher acuity." When asked if this had been approved through committee, he said, "No". He stated the unmodified grid had been approved by the Staff Advisory Committee. When asked for the minutes of the Staff Advisory Committee meeting in October 2015, where this had been approved, Staff #1 and Staff #2 stated those were not available. Neither one knew what the previous Chief Nursing Officer had done with them. When asked if there were minutes to meetings where any of the changes had been approved by any other committee as well as governing body, Staff #1 and Staff #2 stated there were not.


Review of the nurse staffing plan showed that the old staffing grid allowed for combining the census on the two adult units (SCU/PCU) and staffing to the combined number of patients when the nurses were at a nursing station that was shared by the two units. The new staffing grid did not allow for this. The new staffing grid kept staffing specific to the separate SCU and PCU census.


Staff #17 stated he was the staffing coordinator. He verified that he used the new staffing grid to staff the units. Staff #17 stated he went to the unit every morning around 6:00 A.M., prior to shift change, to verify patient census and discuss acuity needs with the current staff. Staff #17 stated that if he was short on scheduled staff, he would start calling people in. Shift change is at 7:00 A.M. Staff #17 stated that evening staffing was reviewed throughout the day based on admissions, discharges, and changes in patient acuity. Adjustments were made to evening staffing based on these changes.


A review of staffing sheets for 29 days during the month of July 2016 (July 18th and July 19th staffing sheets were missing) was made using the new staffing grid that allowed the units to be staffed for the specific census on the unit. A review was also conducted using the old staffing grid that allowed for a combined census on the adult units.


Shortages of nursing and/or MHT staff were observed on 25 of the 29 days reviewed using the new grid. Nine of the 25 days were observed to have shortages of staff when applying the old grid. When applying the new grid, there were 30 nurse shortages (22 on PCU/SCU - 8 on YCU) and 20 MHT (14 on PCU/SCU - 6 on YCU) shortages over the 29 days. When applying the old grid, there were 10 nurse shortages and 2 MHT shortages over the 29 days.


Nurse staffing sheets did not consistently address patient acuity, such as special monitoring, special visitations, or the additional staff needed for hall monitoring on the adolescent unit. The potential for additional staffing shortages existed when these situations were factored in, but could not be determined based on the information provided on the nurse staffing sheets.

Based on chart review nursing failed to have the Registered Nurse (RN) evaluate the care of the patients on an ongoing basis and failed to document ongoing patient assessments, needs, conditions, and patient responses to interventions in 3(#1,4,and 6) of 3 charts reviewed.

Review of patient #4 revealed the patient was ordered a chemical restraint on 3/18/16 at 3:55PM. The telephone order stated, "Haldol 10mg IM, Benadryl 50mg IM, Ativan 2 mg IM NOW for severe agitation."

Patient #4's MAR revealed the patient was administered Haldol 10mg IM, Benadryl 50mg IM, Ativan 2 mg IM on 3/18/16. There was no time documented or where the medication was injected.

Review of the Nursing Admissions History dated 3/18/16 at 6:00PM revealed on page 5 written down the side of the page, "unable to assess due to acute psychotic state and emergency meds given in admission." Review of page #7 (last page of the assessment) stated, "1800(6:00PM) Pt was walked to unit with assist of 2 males. Pt was searched by 2 males MHT while this nurse was behind partition out of view. (See skin assessment) Pt drowsy and unable to assess due to psychotic state and emergency meds given. Pt taken to bedroom and is lying in bed asleep. Clothes searched and hair checked which is clean with no lice present. Pt placed on q15 min checks for safety." (SIC) There was no documentation found on the patient's chart of the behavior that called for a chemical restraint. There were no found interventions, patient response, or any nursing assessment of the patient before, during, or after the chemical restraint was administered. There was no documentation found on the patient treatment plan concerning the chemical restraint.

Review of patient #4's chart revealed there was no documentation of the patient meals or fluids consumed from 3/18/16- 3/29/16.

Review of patient #4's chart revealed the RN performs a complete assessment of the patients systems on the day shift only. There was no neurological assessments found in the nursing system assessments. Nursing assessment notes were found to be blank or missing on the following dates:
3/23/16 nursing assessment blank.
3/24/16 nursing assessment blank.
3/25/16 revealed there was no nursing assessments found.
Nursing assessments had blanks in the "Medical Issues Needing Monitoring" and "Intervention/Response" sections of the nursing assessments on the following dates:
3/20/16 day shift
3/21, and 22/16 day and night shift
3/26/16 day and night shift.
3/27/16 day shift.
3/28/16 day and night shift and pain assessment section was blank.
3/29/16 day and night shift.
Review of patient #4's admission physician orders stated, "Special Precautions to be re-evaluated every 24 Hrs by physician." Special Precautions listed were Elopement Precautions, Sexual Perpetrator, Sexual Victimization, and Assault Precautions dated 3/18/16 at 1550. Review of the Physician Daily Progress Notes from 3/19/16- 3/29/16 revealed there was no mention of patient #4's special precautions reevaluation. Review of the Nursing Notes revealed the nurses were not listing the precautions as ordered or had changed the precautions without a physician evaluation;
3/19/16 every 15 min checks only.
3/22/16- 3/27/16 no precaution assessment found.
3/29/16 every 15 min checks only.

Review of patient #1's chart revealed on 8/5/16 at 1:20PM the patient complained of a headache. The physician was called and patient #1 ordered Tylenol 500mg x 2 by mouth as needed. Patient #1 was administered the Tylenol. There was no documentation on effectiveness of medication.

Review of patient #1's physician orders revealed on 8/6/16 at 5:00PM stated, "Keflex 500mg po TID x 7days-right submandibular adenitis (swollen lymph nodes in the jaw area)." Review of the nurse's notes revealed there was no documentation of an assessment of the infection or medication ordered there was no date on the nurses note. The nurses note stated, "2100 ( 9:00PM)- Pt approaches nurses station and yells "I will kill you Bitch" pt does not make eye contact or face any specific staff member while yelling. Physician contacted with emergency med orders received for psychosis. Pt is escorted to his room and offer 3 IM meds per physician order. Pt states he doesn't like shots but he wants the medicine so he will take shots. Shots provided by med nurse without physical hold. At 2120 (9:20PM) pt at nurse's station to request snack-pt declines the snacks on unit and goes to bed. Q15 min checks, Suicide & Assault Precautions & Sexual Victim Precautions continue."

Physician telephone order dated 8/6/2016 at 9:00PM stated, "Haldol 10mg IM x 1 NOW- psychosis, Ativan 2 mg IM x 1 NOW anxiety, Benadryl 50mg IM x 1 NOW EPS." Review of the MAR revealed patient #1 was administered the medication at 9:10PM. A 1 hour face to face was performed on 8/6/2016 at 9:49PM. There was no further nursing assessment or observation documentation found until 8/7/16 at 8:15AM, a 10.5 hour span.

Review of the nurse's notes dated 8/7/16 at 5:55PM states, "pt. c/o " weird feeling " after taking Depakote states, "I can't breathe" Breath sounds clear. No swelling noted to tongue, throat or lips. Staff #13(MD) notified. Depakote D/C'd and Benadryl 50 mg po ordered and administered. Will continue to assess. 8/7/16 6:00PM Pt states "Feeling better will continue safety check." There was no further nursing assessment, vital signs, or observation documented until 8/8/16 at 8:00AM, a 14 hour span.

Review of patient #1's nurse's notes dated 8/8/16 at 8:00AM stated, "Patient found on smoke deck, fidgeting and rocking back and forth, visibly anxious. Patient rates anxiety 10/10 denies depression, SI/HI or hallucinations. He reports racing thoughts and requesting Xanax to "slow down my head." He is cooperative, pacing often. Patients on his unit report feeling threatened and afraid of him. Will continue Q15/PRN safety checks, medications, and precautions. Review of the MHT observation rounds shows the patient is not in the court yard until 8:30AM and was documented as calm from 6:00AM- 12:45PM.

Review of patient #1's physician telephone orders revealed an order that read, "Thorazine 75mg IM x 1 now-psychosis. Benadryl 50mg IM x1 NOW- allergy." The MAR revealed the medication was administered at 8:56AM. There was no restraint intervention or face to face found. There was no patient assessment, observation, or response to medication effectiveness documented. The nurse documented on 8/8/16 at 9:00PM, a 12 hour span. The nurse documented that patient #1 took his night time medications and stated he needs an increase in his Klonopin. Patient was instructed to talk with MD in am. No further evaluation was found until 8/9/16 at 10:15AM.

Review of patient #1's admission physician orders stated, "Special Precautions to be re-evaluated every 24 Hrs by physician." Special Precautions listed were Observation rounds q 15 minutes, Suicide precautions, Sexual Victimization, and Assault Precautions dated 8/5/16 at 1605. Review of the Physician Daily Progress Notes from 8/5/16- 8/10/16 revealed there was no mention of patient #1's special precautions re-evaluation. Review of the Nursing Notes revealed the nurses were not listing the precautions as ordered or had changed the precautions without a physician evaluation;
8/5/16 and 8/6/16 only precaution checked for observation was "Q15 minutes" only.
8/7/16 sexual victimization was not checked.

Review of patient #6's chart revealed the patient was admitted on 8/25/16. A physicians telephone order dated 8/27/16 at 12:30PM stated, "Keflex 250mg po q 8 hours x 5days Infected ant bites rt foot."

Review of patient #6's Nurses Notes revealed the RN assessment box titled "Medical issues needing monitoring/problem/ intervention and response" was blank on both shifts. There was a comment under skin assessment that stated, "Rt. foot infected ant bites." There was no description of the skin, skin integrity, or the patient's responses or discomforts. Review of the RN assessment for 8/28/16- 9/1/16 revealed the "Medical issues needing monitoring/problem/ intervention and response" was blank on both shifts. There was a comment under skin assessment only the "within normal limits" box checked. There was no further mention of the patient's antibiotic use, ongoing assessment, if the medication was effective, or if any side effects.

Review of patient #6's Nurses notes on 8/30/16 revealed on the 7:00AM-7:00PM assessment boxes for pain showed the patient was in 2 out of 10 pain (10 being the worst) in the left leg. Under the intervention was "Advil." In the medication effectiveness box it was marked the patient was compliant and no side effects. There was no documentation that the medication was effective. Review of the nurse's clinical notes dated 8/30/16 at 8:10AM stated, "Reports cramping 2/10 to his left leg and requests Advil for pain." There was no entry in the medication MAR that Advil was administered to the patient. There were no PRN medications documented as given for 8/30/16. There was no further documentation of pain or an ongoing nursing assessment until 11:30PM (15 hours and 40 min. later). Review of the clinical notes for 8/30/16 at 11:30PM stated, "Pt reports leg pain 10/10 on scale. Reports depression 10/10 and anxiety 10/10. Denies SI/HI. Reports auditory hallucinations which tell him "you will go home." Continue to provide therapeutic milieu. Provide safety for pt. Offer meds as directed. Goal set "to be good." Continue tx plan. Continue Q15 minute safety checks."

Review of the MAR revealed patient #6 was given Trazadone 25 mg at 10:00PM. There was no other medications offered, no assessment of the patient's pain or why the patient was having such severe cramping. There was no call to the physician concerning the patient's drastic change in condition. There was no interventions offered for pain, anxiety or depression. There was no further ongoing nursing assessment documented until 8/31/16 at 7:00AM.

Review of patient #6's nursing care plan revealed there was no mention of antibiotics or any further assessment in the treatment plan. There was no mention of the severe leg cramps or the PRN Trazadone given every night for sleep. Review of the Master Problem List revealed all of patient #6's issues were resolved on 9/2/16. The patient was discharged from the facility on 9/1/16.

An interview was conducted on 9/8/16 with staff #3. Staff #3 stated they were aware of all the problems with the nursing notes and assessments.

Bsaed upon record review and interview, pharmaceutical services failed to:

A. develop effective policy and procedure to control medications for 3 of the 3 units (Special Care Unit, Progressive Care Unit, and Youth Care Unit)

Refer to TAG A0491 Pharmacy Administration



B. follow established hospital policy to identify and minimize the risk of medication variances for 3 of the 3 units (Special Care Unit, Progressive Care Unit, and Youth Care Unit).

Refer to TAG A0492 Pharmacist Responsibilities

Based on observations, review of records, and interview, the pharmacy failed to develop adequate oversight, policies, and processes to maintain control of floor stock (Wall Stock) medications and ensure a record of floor stock medication dispensation/administration was completed in 3 out of 3 unit's medication room (Special Care Unit (SCU), Progressive Care Unit (PCU), and Youth Care Unit (YCU).


On the morning of 9-7-2016, a tour of the Special Care Unit (SCU), Progressive Care Unit (PCU), and Youth Care Unit (YCU) was conducted. In the medication room of all three units was a cabinet stocked with floor stock medications. Per Staff #15, this was called Wall Stock and consisted of medications they could give rapidly during an emergency and over-the-counter medications. When asked how the medication was controlled, Staff #15 provided an inventory form. The form did not have a form number or title. Staff #15 stated they were to fill out the form each time a medication was used. There were columns to fill in the date/time, patient name, dosage, allergies, food/drug interactions, contraband, the medication given and the signature of two authorized nursing staff members. The following medications were listed on the inventory form:


Benztropine (Cogentin) 1 MG (milligram) Tab (tablet) (typically used to reduce the side effects of antipsychotic treatment)


Clonidine (Catapres) 0.1MG Tab (typically used to treat high blood pressure and can be used in the treatment of anxiety disorders and withdrawal from alcohol or opioids)


Diphenhydramine (Benadryl) 50 MG Cap (capsule) (used to reduce the side effects of medications used to treat psychiatric disorders. Also has a sedating effect and has been approved as a sleep aid.)


Haloperidol (Haldol) 5 MG Tab (an antipsychotic medication typically used to treat schizophrenia)


Hydroxyzine (Vistaril) 50 MG Cap (can be used as a sedative to treat anxiety and tension)


Olanzapine (Zyprexa) ODT (orally disintegrating tablets) 10 MG (typically used to treat Schizophrenia and Bipolar Disorder)


Albuterol Inhaler (typically used to treat breathing difficulties associated with Asthma and Chronic Obstructive Pulmonary Disease)


Diphenhydramine (Benadryl) 50 MG/ML (milligram per milliliter) INJ (injection) (used to reduce the side effects of medications used to treat psychiatric disorders. Also has a sedating effect and has been approved as a sleep aid.)


Haloperidol (Haldol) 5 MG/ML INJ (an antipsychotic medication typically used to treat schizophrenia)


Promethazine (Phenergan) 25 MG/ML INJ (has a strong sedative effect and weak antipsychotic effect)


Carmex (for chapped lips)


Cepacol Lozenges (for cough)


Oral Pain Relief (for mouth sores)


Clotrimazole 1% Cream (for athlete's feet)


Hydrocortisone 1% Cream (for skin itching)


Triple Oint Ointment (antibiotic ointment for cuts)


Ibuprofen 200 MG Tab (pain reliever)


Guaifen 100 MG/5 ML (for cough/congestion)


Guaifen DM 100 MG/10 MG per 5 ML (for cough/congestion)


Acetaminophen 325 MG Tab (pain reliever / fever reduction)


Milk of Mag SUSP (M.O.M.) (relieve constipation, indigestion, and heart burn)


Mag-Al Liq (reduce stomach acid and relieve stomach upset)


Staff #15 stated they are supposed to fill out the form, but the staff forgets to do it. "To be honest, when I have to pass medications for 20 patients, I forget to." Staff #15 advised that pharmacy inventories the Wall Stock and replaces when low.


Staff #16 was interviewed. Staff # 16 confirmed that the prescription medications in Wall Stock (floor stock) were only supposed to be given with a physician order. However, pharmacy had not always received the inventory form back from the units with the patient name that received the medications to verify that an order had been written. A spot check was done of the bin containing Haloperidol (Haldol) 5 MG/ML INJ. There should have been 5 vials in the drawer. Only 4 were present. The inventory form had not been documented. Staff #16 agreed that medications could have been given without a physician order and it would not be detected with the current practices. Staff #16 agreed this would pose a risk to patients.


Staff #16 stated the Wall Stock medications had been agreed upon by the Medical Staff, but did not go through the Pharmacy and Therapeutics Committee as a separate list. Staff #16 was unable to provide a list of medications that had been approved by committee to be used as Wall Stock. Staff #16 stated the medications used in Wall Stock were selected from the list of Night Locker medications that had been previously approved by the Pharmacy and Therapeutics Committee for Night Locker use. The Night Locker was to be used when Pharmacy was not available and was located off the units. It required two authorized staff to access the night locker. Wall Stock medications could be accessed by nursing staff at any time of the day/night, regardless of whether pharmacy was available or not. Per Staff #16, the floor stock medications were selected by nursing and the physicians so that nursing would have rapid access in an emergency and for staff/patient convenience.


Review of Pharmacy Policy #79 titled Floor Stock Medications revealed no process or requirement for nursing to document removal of medications from inventory. The policy stated the following:


"B. The list of drugs that shall be approved as floor stock items will be provided."


"C. The pharmacist shall review the stock levels of the floor stock drugs at least on a weekly basis, and replenish stock as needed; however, nurses who note that supplies are low, especially of controlled substances, should notify the pharmacist by placing a note in the pharmacy box."

Based on review of documents and interview, the pharmacist failed to ensure current pharmacy policies were followed on 3 units [Special Care Unit (SCU), Progressive Care Unit (PCU), and Youth Care Unit (YCU)] out of 3 nursing units.


On 9-8-2016 a review of Pharmacy Policy #120, Black Box Warnings was completed. The policy stated:


"The term "Black Box" refers to a warning imposed by the US Food and Drug Administration (FDA) on a drug. It is the strongest warning that the FDA can impose, signifying that the use of the product may lead to death or serious injury." Under the heading "PROCEDURE: 7. Information shall be supplied from the pharmacy and/or physicians, to the nursing staff in the form of hard copy or electronic media for all formulary medications carrying a black box warning. A listing and description of the black box warning for each pertinent medication will be at each nursing station for reference and review."


Staff #16 was interviewed on 9-8-2016. Staff #16 was advised that a listing of black box warnings had not been observed during a tour of the nursing stations on all three units. Staff #16 confirmed that the nursing staff were not provided a listing of Black Box warning medications to be kept in the nursing stations. Staff #16 stated she was not aware that a listing was supposed to be on the unit.


On 9-8-2016 a review of Pharmacy Policy #89 Medication Variance was completed. The policy definition stated:


"A medication variance is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures and systems, including prescribing; order communications; product labeling, packaging, and nomenclatures; compounding; dispensing; distribution; administration; education; monitoring; and used." Under "Types of Errors" was listed "Unauthorized Drug: Medication that was not authorized by a legitimate prescriber was dispensed and/or administered to the wrong patient." The policy further stated, "A staff member who identifies a medication variance or potential error should complete the Incident Report and return it anonymously to his/her supervisor."


An interview with Staff #16 was conducted. Staff #16 confirmed that floor stock medications were being removed from inventory by nursing staff, given to patients, and not logged on the inventory sheet on all three units. Staff #16 confirmed that there was no way of knowing which patient received the medication or if there was a physician order when there was a discrepancy between the expected inventory and the actual inventory in the floor stock medications when nursing failed to document medications removed on the inventory sheet. Staff #16 confirmed that these discrepancies were not being investigated as potential medication variances.


Staff #16 confirmed that errors in floor stock inventory were not reported to the PI Committee. Review of second quarter PI Committee meeting minutes revealed medications removed from the Night Locker by nursing staff and not properly documented on the inventory form are reported to the PI Committee, but the same discrepancies with floor stock inventory were not monitored and reported.

Based on observation, record review, and interview, the facility failed to ensure all areas of the hospital were clean and sanitary. The infection control program failed to include appropriate monitoring of housekeeping, maintenance, and other areas to ensure a sanitary environment was maintained in 3 out of 3 zones.

A tour of the facility was conducted on 9/8/2016 with staff #1, 2, and 3. The following infection control issues were found in the following areas:

1.) The plexus glass in the seclusion room, behind the adult nurses station, was dirty with hand prints smears and a dried liquid substance.

2.) On the adult SCU unit were chairs for patient use. The chairs were dirty with dried liquids, food, dirt, dust and hair. The floors around the chairs were soiled with paper, food, dirt and hair. The table on the adult unit had flying insects, dried liquids, food debris, dust and dirt.

3.) The door to the physician exam room behind the adult nurse's station was labeled as Oxygen and AED room. In the room clean patient supplies were found sitting on a soiled and dirty floor. Urine collection cups were soiled with dust.

The patient exam table was soiled with dust and hair. At the foot base of the exam table, the laminate was missing and it was soiled with dust and hair.

The patient refrigerator for urine and blood samples was sitting on the floor. The refrigerator was soiled on the inside with dust and hair. The freezer section of the refrigerator was covered in a thick layer of ice. A filled sharps container was found sitting on the floor next to the refrigerator.

The patient bedside table was made of exposed wood with deep scratches. The table was soiled with dust, and hair.

The uncovered EKG machine was soiled with dust and hair. A cup with a clear liquid substance was found sitting on the EKG machine. The cup had an open 20cc syringe sitting in it. The cup was unmarked and exposed to the environment.

A full trash can was found in the adult exam room. The biohazard trash had not been removed from the room. The exam room was supposed to be clean and ready for a new patient.

A drawer in the adult exam room had clean patient supplies (tape, vaginal probe, wound dressings, 4x4 ' s) mixed with metal detector wands, telephone cords, cords that plug into equipment, and blood pressure cuffs.

4.) The laundry storage room behind the adult units was found to have a electrical cord bent in the socket coming from the wall. The staff was unable to determine what that cord went to. The bent cord and poor connection could be a fire hazard in a linen room. The floor of the linen room was soiled with paper, dust, hair, and patient stickers with patient names and information. The top of the linen carts had linen sitting on top exposed to the dust and hair in the room.

In the linen room behind the adult unit nurse's station revealed a rolling walker hanging on the wall next to a clean linen cart. The front of the walker had tennis balls placed on the bottom of the walker to help it glide along the floor. The tennis balls were soiled with dirt and hair. The tennis ball had a 2 inch long dust bunny matted with hair and trash hanging from the ball. Underneath the walker sitting on the floor was a patient wheelchair. The wheel chair was soiled with dust, hair and an unidentifiable dried liquid down the side and in seat. The wheel chair had tears down the back of the chair and on the seat. The wheel chair was missing a part on the removable leg and was soiled with dirt and hair on the wheel spokes and legs.

5.) The door between the seclusion area and patient hallway was broken and cracked, exposing wood and metal hardware.

6.) Patient room 117 on the adult unit had soiled curtains in the patient's room. The curtains were soiled with dust and an unidentifiable black smears. The adult unit had multiple dead crickets on the floor in the hallway. Two of the crickets were dried up and decaying.

On the adult unit in the hallway, a trash can, the floor, and walls around the trash can were heavily soiled. The area was soiled with dirt, hair, dried food particles and dried liquids.

7.) The nurse's station for the adult unit's floor was soiled with dust, hair and paper. The floor was worn in large areas and the floor was littered with stickers adhered to the floor and worn. The chart rack was covered in dust, hair, and tape residue. Closed and empty patient charts were sitting on a bottom shelf in the nurse's station. The shelf and floor was heavily soiled with dust, hair, and paper trash. The bottom of the chart cart was covered in dust and dirt.

In the adult nurses station, patient game pieces were found lying under the nurse's desk on a heavily dusty floor.

8.) The nurses work station for the SCU was soiled with dust and pieces of paper trash. The medication refrigerator was sitting on the floor. The refrigerator swept in the dirt, dust, and hair off the floor each time it was opened and closed.

The medication refrigerator freezer was coated in ice. The inside of the refrigerator was soiled with hair, dust, and dried liquids.

A dusty fan was sitting next to the sink and was plugged into the wall. The fan cord was wrapped around the back side of the faucet. The fan was blowing on the medication preparation area. The fan cover and blades were soiled with heavy dust.

A nebulizer was found in the medication room cabinet. The nebulizer was broken and sitting in a heavily dusty and soiled cabinet.

9.) In the medication room of the PCU a full sharps container was sitting on the floor. The floor in the PCU medication room was soiled with dust, hair, and paper.

The nurses work station in the PCU medication room was broken and covered with work tape. The tape was heavily soiled with dust and hair. The vinyl flooring was worn and the inside of the cabinets were soiled with dust.

A purple fan was found sitting next to the sink and medication preparation area. The fan was covered in a heavy dust.

The floors were covered in dust, hair, paper, and old pieces of patient stickers adhered to the floor. There was a full biohazard box (filled with used syringes) sitting on the floor.

The refrigerator in the nurse's station medication room was found sitting on the floor. The refrigerator was soiled on the inside with dust and hair. The freezer was frozen over with a large ice buildup.

10.) In the patient exam room of the adolescent unit revealed a refrigerator holding patient urine and blood samples. The refrigerator was on the floor and swept in dust and contaminates off the floor. The inside of the refrigerator was soiled with dust and hair.

The floor of the adolescent exam room was soiled with dirt, dust and hair. An open canister was sitting on the counter with an open package of steri strips. The open canister was sitting on the counter with an open package of steri strips. The plastic canister was broken and cracked down the side.

A drawer was opened and the drawer had open patient supplies spilled out into the drawer and a hand wand metal detector. The shelves were stocked with patient supplies and were heavily soiled with dust and hair.

The patient supplies were in a container on the floor sitting next to a biohazard trash can.

The AED in the adolescent exam room was not charged and was not ready for an emergency use.

11.) In the adolescent unit medication room revealed the medication refrigerator was sitting on the floor and was soiled with dust and spilled liquids. The freezer section had ice buildup. The water pitcher was dirty and had no date on the pitcher.

An interview was conducted on 9/8/16 with staff #3 and #2. Staff #3 reported that the Environmental of Care (EOC) rounds were done weekly but there was no found evidence that the teams were identifying the infection control issues. Staff #3 stated she had not incorporated any of the cleaning issues in the infection control or QAPI data. Staff #2 stated that he had just started but was working on the issue. Staff #2 stated there was only three housekeepers for three zones. The three housekeepers do all the terminal cleans for a 30, 000 square foot building that included 3 patient units.