HospitalInspections.org

Based on observation interview and record review, the facility's nursing staff failed to administer medication prescribed by patient's physician in 1of 10 sampled patients. Patient # 2.
The facility failed to obtain orders for Foley catheter and Foley catheter care in 1 of 2 patients observed with a Foley catheter in place; Patient #2

Findings:


On 11/12/2019 at 9:20 a.m. Patient #2 was observed in the day room sitting in a Geri chair with a Foley Catheter in place anchored to the chairside.


Review on 11/12/2019 of the Patient's clinical record revealed a Physician's order dated 11/02/2019 for Pneumococcal 23, valps 25 mgs/ 0.5 mls intramuscular and influenza vaccine quad 0.5 mls intramuscular start date 11/01/2019 stop date 1/12/2019 at 01.54.

Review of the Patient's clinical record revealed no evidence that the Pneumococcal and influenza vaccinations were administered to the Patient.

On 11/12/2019 the Surveyor reviewed the Patient's record with the Director of the Unit. She confirmed that the vaccinations were not administered to the Patient.


Foley Catheter
Patient # 2
On 11/12/2019 at 9:20 a.m. Patient #2 was observed in the day room sitting in a Geri chair with a Foley Catheter in place anchored to the chairside
Interview at that time with Registered Nurse (D) revealed the Patient was admitted to the facility with a diagnosis of psychosis and has a Foley catheter in place due to urinary retention. She said the patient was admitted with the Foley Catheter in place.
Review of the Patient's clinical record revealed no order for a Foley catheter in place or a care of the Foley catheter.

Review of the Facility's current Policy and Procedure on Foley Catheter revised 5/16 directs staff as follows:
If a patient presents to the ER with a Foley catheter in place it will be removed if there is no contraindication per patient's history. If a catheter is medically necessary, a new catheter will be inserted. A urine specimen will be sent immediately."

Based on record review and interview the facility failed to document an investigation of alleged physical abuse of a patient by 1 of 1 facility's direct care staff.

Findings:

Review of documentation provided by the facility from Staff (G) regarding the incident on Patient #1:

Staff E - "MHT contacted me stating that she heard staff state that staff F MHT bent patient #1's thumb backwards in an aggressive manner while completing ADL care. Staff E said she was not in the bathroom with the patient but Staff H MHT, RN (D) Registered Nurse (I) and Registered Nurse (J) were aware of the situation."

4/26/19. "Notified Staff (K) of the complaint to investigate."

4/29/2019 "Spoke with Staff (K) to follow up on complaint. Staff K reported she spoke to staff H, Registered Nurse (D), Registered Nurse I and J, and the statement was unfounded and none of the staff she spoke with witnessed patient abuse."

During an interview on 11/12/2019 at 9:45 a.m. with the Geri Psych Unit Director revealed she she spoke with her boss and was told the Patient was agitated during care. She said Mental Health Technician E and F were fighting, Mental Health Technician (E) was not present in the bathroom during the care of Patient #1. She stated, "I do not have a formal incident."

Subsequent Interview on 11/12/2019 at 11:00 a.m. with Director revealed she was not present during the incident but was made aware of the incident by her boss. She said she spoke to the staff about the allegation but did not document or complete an incident report.

During an interview on 11/12/2019 at 2:04 p.m. with Director of Clinical Operations; Management Company revealed she said Mental Health Technician (E) called and told her while she was taking a patient to the bathroom, she was walking pass the bathroom and saw Mental Health Technician (F) pulled back a patient's finger. She said she was not told the Patient's name. She said she told the Program Director and to do an investigation.
She said the Program Director said she had a conversation and was told there was no incidence or potential for injury. She said the facility uses the Quantos System for incident reporting. She said she did not see an incident and did not do a root cause analysis.

On 11/12/2019 at 2:30 p.m. Mental Health Technician (H) was interviewed via the telephone. During the interview he stated "I was in the bathroom when the incident happened. We were trying to change him. Me and she who is not here anymore. Her name starts with an A, ----. We were getting him changed, he became agitated and grabbed the door. There were two nurses standing outside the door. MHT (F) was trying to get his hands off the door. She pulled his finger off the door when he was gripping it. When this happened, he yelled out a quick Ha.
I told her to leave the room, after she left we had a conversation and he told me" I don't like women." She peeled his hands off the door and he yelled out a hollow. He said he cannot recall the nurses who were standing outside the door coming into the room.

Review of the Patient's clinical record revealed no documentation of the incidence. There was no documentation of assessment by the nursing staff after they became aware of the incident. The Patient who was assessed as alert was not interviewed. There was no documentation that the incident was investigated.

Review of the Facility's Policy and Procedure on Staff, Visitor, or Other Patient Neglect / abuse of a Patient revised 5/2019 directed staff as follows:
"Cases of suspected / alleged abuse or neglect shall be immediately reported by staff member (s) to their direct Supervisor. The Supervisor is responsible for immediately informing the Administrator on Call (AOC). All such occurrences shall be reported to the appropriate agency in collaboration with member of the Executive team.
All occurrences of suspected patient abuse and/ or neglect shall be promptly reported to the attending physician.
An objective investigation of all allegations of abuse, neglect or mistreatment , including an appropriate assessment of patient by the attending physician or other physician designated by the attending will in a timely and through manner. The assessment will be documented in the Record.
Any incidents of abuse , neglect, or harassment will be reported will be reported and analyzed, and the appropriate, corrective, remedial or disciplinary action, will be taken in accordance with applicable local, state and federal laws."

Based on observation, interview and record, Patient's Attending Physicians failed to confirm information given by Registered Nurses regarding informed consents for psychoactive medications prescribed and administered to patients in 2 of 2 patient's record reviewed who had psychoactive medication prescribed from 10 sampled patients. Patient #s 4 and 3.

Patient #4

The Patient was alert and oriented. The lower aspect of her right leg was reddened.
Interview with registered Nurse (D) during the observation revealed the Patient was admitted to the unit with a diagnosis Schizoaffective Disorder.
Review of the Patient's clinical record revealed the following informed consents obtained on 11/04/2019 for psychoactive medication administration which were obtained by the Registered Nurse: Ativan, Haldol, Klonipin, Seroquel, Trazadone, and Trileptal.

Review of the consents for the psychoactive medications, revealed the signatures of the treating physician to confirm explanation given by the RN were missing on all the consents.

The consents dictate the following regarding the treating physician's signature:
"required within 2 working days of PA, R, PH, RN, or LVN giving explanation."

Patient #3
Review of the Patient's clinical record revealed the following telephone informed consents obtained on 11/01/2019 for psychoactive medication administration which were obtained by the Registered Nurse: Ativan, Haldol, Trazadone, and Risperdal.

Review of the consents for the psychoactive medications, revealed the signatures of the treating physician to confirm explanation given by the RN were missing on all the consents.

The consents dictate the following regarding the treating physician's signature:
"required within 2 working days of PA, R, PH, RN, or LVN giving explanation."

On 11/12/2019 at 12:30 p.m the Surveyor reviewed the Patient's clinical record with the Unit's Director. She confirmed that the consents were not signed by the physician.