HospitalInspections.org

A review of 54 open and closed medical records revealed that one record, for patient #23, a 98-year old Medicare Recipient, contained no Important Messages from Medicare. This patient was admitted on 10/29/10 and discharged on 11/2/10.

During a review of five complaint and grievance files, it was noted that five of five files failed to show evidence that a letter containing notice the decision, the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion had not been sent to the complainant. In an interview with the Risk Manager on 1/4/11, the risk manager confirmed that the hospital has not been sending close letters to complainants.

Based on a review of policies, procedures along with review of five closed seclusion/restraint records, it was determined that one record contained inadequately documented justification for seclusion.

Patient #19 is a 26-year-old male admitted 12/12/2010 after being found by police to be leaping over cars, cracking the windshield of one of those cars, and stating he was God. Patient #19 was found to have a long-standing psychiatric history with at least one prior in-patient admission for Bipolar Affective Disorder. Patient #19 also had a history of cannabis and cocaine abuse.

On 12/4/2010 at 6:30 PM, a nursing progress note states in part, "Pt. being escorted from dining room by this writer for disruptive behavior. Pt. was hit in the head by peer as we were walking out of dining room. Both patients were separated and medicated as per order. Patient #19 was given IMs [intramuscular injections] of Prolixin 5 mg, ativan 1 mg, and benadryl 50 mg." The nursing evaluation revealed that "Pt in his room quiet."

No further notes regarding the patient's behavior are found until a physician note of 12/4/2010 at 11:30 PM states, "Called to see pt. placed in seclusion. Combative in seclusion room up and about room - angry."

A nursing note dated 12/4/2010 at 12 midnight, quoted patient #19 as saying "I'm dancing. I need to do push-ups." The note also stated "pt. in ___ very hyperactive on the hallway, swung around start doing push-ups on hallway and attempt to do flip-overs on hallway. BHT [behavioral health technician] and RN attempted to redirect pt."

The restraint/seclusion flow sheet reveals that patient #19 was placed in seclusion from 11:20 PM until 12 midnight on 12/4/10. A discrepancy exists between the physician's documentation of combative behavior noted above and the behavioral monitoring sheets, which indicate that patient #19 was consistently awake, hyperactive, and restless until his release at midnight when he is noted as quiet. The documentation does not include any indication that the patient was a danger to himself or others, or that he was violent. Combative behaviors are justification for seclusion; disruptive, hyperactive behavior is not.

Based on review of policy, procedure and review of five closed seclusion/restraint records, no seclusion order is found for patient #18 on 11/5/2010 at 7:15 am.

Patient #18 is a 39-year-old female with a long history of psychiatric illness. She was admitted on 11/3/2010 following presentation to the emergency department with hallucinations and religious delusions. She had not been compliant with outpatient follow-up following discharge from a psychiatric hospital. Diagnoses included Paranoid Schizophrenia, rule out Schizoaffective Disorder, episodic marijuana use, diabetes, and hypertension.

On 11/5/2010 at 7:15 am, a nursing progress note states in part, "Pt. (patient) slammed door to room, hostile aggressive mood, refused verbal interaction. Attempted to calm pt. Pt. verbalized, ' I know you f___ him last night, I ' m going to kick your ass. ' Pt. threatening, fists in the air... Order obtained for seclusion, Dr. __ made aware. " However, on review of the medical record, no order could be found for this episode of seclusion.

Hospital policy No.-R-10 (revised 9/10) Restraint/Seclusion Policy and Procedure for documentation on orders states "All orders must be in writing. The order will be documented on the Restraint/Seclusion Order Form and at a minimum must include:

a. The reason for restraint/seclusion use (clinical justification/rationale)
b. The type of restraint used; and
c. The time limits to the order"

This policy directive was not followed, nor was the regulatory requirement for a written order followed. Patient #18 was secluded for one hour and 15 minutes without a written order.

Based on a review of policies, procedures along with review of five closed seclusion/restraint records, it was determined that one record contained inadequately documented justification for one patient remaining in seclusion beyond the time he was exhibiting unsafe behavior. See also Tag A-0167.

Patient #19 is a 26-year-old male admitted 12/12/2010 after being found by police to be leaping over cars, cracking the windshield of one of those cars, and stating he was God. Patient #19 was found to have a long-standing psychiatric history with at least one in-patient stay for Bipolar Affective Disorder. Patient #19 also had a history of cannabis and cocaine abuse.

On 12/5/2010 at 11:15 pm, patient #19 was placed in seclusion for destructive behavior when he began throwing chairs and garbage cans. The seclusion flow-sheet indicates that at 12:45 am of 12/6/2010, patient #19 was noted as noisy, hyperactive and restless. By 1:45 am, documentation indicates that patient #19 was quiet and drowsy. Seclusion continued until 2:53 AM even though the documentation for almost two hours indicates that patient #19 was quiet and the unsafe situation had ended.

Based on a review of policies, procedures along with review of five closed seclusion/restraint records, it was determined that one patient did not have a face-to-face physician examination on two seclusion occasions.

Patient #19 was secluded on 12/4/2010 at 11:20 PM, and again on 12/5 at 11:15 PM.
The hospital Restraint/Seclusion Order Form, revised 9/28/2010, has a Face-to-Face Evaluation Documentation Form on the reverse side, which clearly addresses all face-to-face requirements. Although the physicians did see the patient and wrote progress notes, neither utilized the face-to-face form, and the progress notes failed to satisfy the requirements of this regulation.

The 12/4 physician face-to-face progress note of 11:30 PM states "Asked to see pt. placed in seclusion. Combative in seclusion room up & about room - angry." This progress note does not address continuation of seclusion, or behavioral/medical concerns, which could affect the need for seclusion.

On 12/5/10, patient #19 was placed in seclusion from 11:45 PM to 2:53 AM on 12/6/10. The face-to-face physician progress note was not completed until 12/6 at 2:52 am. It states, "Seen patient - seclusion room moving the floor bed, was medicated earlier due to him been uncontrolled. Vital signs stable. Continue to watch." This progress note was written approximately 2 1/2 hours beyond the required time limit for face-to-face, and does not address behavioral/medical concerns, nor does the progress note address the fact that the patient no longer met criteria for seclusion. See also Tag A-0174

Based on a review of policies, procedures, hospital training requirements and five closed patient seclusion/restraint records, incomplete records for patients #18, 19 and #20 were found as follows:

Patient #18's seclusion/restraint records reviewed revealed that there was no seclusion monitoring sheet for a seclusion occurring on 11/5/2010 from 7:15 am to 8:30 am.

Patient #19's seclusion/restraint records reviewed revealed that there was no RN assessments noted on the 12/5/2010 flow sheet starting at 11:30 PM until 12/6 at 2:45 am, when the patient was released from seclusion. Also, the 12/5 - 12/6 seclusion episode documentation indicates that patient #19 was monitored by the patient care technician every half-hour from 12/6 12:45 am on the flow sheet until 2:45 am instead of every 15-minutes, as required by hospital policy. There is also no documentation to indicate that fluids, toileting or other care was offered during the nearly four-hour 12/5-12/6 seclusion episode even though patient #19 was documented as being awake.

Patient #20's record revealed that Patient #20 was in seclusion from 12/19/2010 at 8:30 PM to 12:30 AM on 12/20/10. The seclusion flow sheet does not include any monitoring information for the last 30 minutes of the seclusion episode. The flow sheet kept by a behavioral health technician from 12/19/2010 from 8:50 PM until 12/20 at 12:30 am documents in each 15-minute behavioral box that patient #20 was "Noisy, abusive/threatening, hyper-talkative, hyperactive/restless, pacing, and physically abusive." Each note is identical and the behavior noted does not correspond with a 10:30 PM RN assessment which indicates patient #20 was "Sleepy." The documentation of 12/19/2010 at 8:20 PM reveals that patient #20 initially threatened to hit a peer with the phone. Following initiation of seclusion, no specific details of threats or behaviors are noted.

In a review of 15 medical records for patients discharged more than 30 days before the survey start date, it was determined that eight of the records had discharge summaries that were dictated and authenticated more than 30 days post discharge.

Patient #23 was discharged on 11/2/10. The discharge summary was dictated and authenticated on 1/3/11.
Patient #26 was discharged on 11/8/10. The discharge summary was dictated and authenticated on 1/4/11.
Patient #27 had two discharge summaries. Both were dictated and authenticated more than 30 days post discharge.
Patient #28 was discharged on 11/8/10. The discharge summary was dictated and authenticated on 1/4/11.
Patient #29 was discharged on 11/8/10. The discharge summary was dictated and authenticated on 12/13/10.
Patient #33 was discharged on 11/14/10. The discharge summary was dictated and authenticated on 1/3/11.
Patient #35 was discharged on 11/16/10. The discharge summary was dictated and authenticated on 1/3/11. This medical record also contained a final handwritten discharge progress note signed by the physician as a late entry on 1/3/11.
Patient #36 was discharged on 11/15/10. The discharge summary was dictated and authenticated on 12/28/2010.

Based on record review, staff interview and observation, it was determined that the facility staff failed to have pre-planned menus for patients on pureed diets, 2 gram sodium diets, low sodium diets and combination therapeutic diets. The findings include:

On 01/04/11, the surveyor reviewed the hospital's current diet order listing and menu spreadsheets. Menu spreadsheets are pre-planned menus (approved by a Registered Dietitian, or RD) that instruct staff what food items to give and in what amounts for the various therapeutic diets being offered daily. These spreadsheets prevent patients from receiving items that may not be in accordance with their diets, and also help to ensure that a nutritionally adequate diet is being provided.

Review of the hospital's diet order listing dated 01/04/11 revealed that there were multiple combination therapeutic diets ordered by physicians. Subsequent review of the hospital's pre-planned menus failed to reveal spreadsheets for these diets, which included but were not limited to the following:
1) cardiac/renal/diabetic/low cholesterol/low sodium/1800 calorie diet
2) 2000 calorie diabetic low cholesterol diet
3) Renal 20 gram protein low carbohydrate 2 gram sodium diet
4) 1800 calorie diabetic low sodium low cholesterol renal diet
5) Cardiac renal low cholesterol low sodium 1800 calorie diet
6) 2000 calorie diabetic low sodium low cholesterol diet
7) Low sodium low cholesterol cardiac 1500 calorie diabetic renal diet
8) 1800 calorie pureed diet
9) Diabetic cardiac renal diet

Furthermore, several patients were noted to have orders for 2 gram sodium diets, although upon interview with the RD (and review of the menus), it was determined that the facility was providing 2-4 gram sodium diets. This means that if a patient was supposed to be limited to 2 grams of sodium daily, the patient could potentially receive up to 4 grams of sodium - twice the amount that was ordered by the physician. It was also noted that there were no spreadsheets for a low sodium diet.

Further review of the hospital's foodservice records revealed that there were no pre-planned menu spreadsheets for patients on pureed diets. The hospital provides pre-formed commercially prepared pureed foods (rather than food items being pureed in-house from the regular menu). These pre-packaged pureed products often have a limited selection, and as a result, the pureed meals do not entirely replicate what is being served. For example, if meat loaf was being served that day, patients on pureed diets would receive commercially-prepared pureed beef. If beef teriyaki was being served that day, patients on pureed diets would receive commercially-prepared pureed beef. It was also confirmed upon interview with the Foodservice Director that there was no system in place to track what had actually been served in the days prior to patients on the pureed diet.

Facility staff must have pre-planned menus in place to meet patient needs and ensure that nutritionally balanced meals are provided that are consistent with all dietary restrictions. These menus must be planned in advance and approved by a Registered Dietitian.

Based on a tour of the facility on 1/3/11 and 1/4/11, the hospital was not maintained in a manner that was safe and well maintained in the following instances The following deficiencies regarding maintaining a safe, overall hospital environment were identified during a facility tour conducted on 1/3/11 and 1/4/11.

1.Outpatient Specialty Clinic-2nd floor:

Due to a roof leak that was repaired several months ago, (August estimate) the
ladies room off the waiting room had ceiling tile damage and severe wall damage on the walls surrounding the stalls. Plaster was loose and peeling, although no plaster was noted to be in danger of immediately falling. The no-longer-used radiator covers were rusted. On 1/4/11, the plaster was in the process of being repaired.

The Men's restroom was observed on 1/3 to have strong urine odors. The ventilation fan was inoperable. On 1/4, the replacement fan for the room was ordered and expected to arrive in a day or two

2. Fourth floor behavioral health unit:

Lockers for the patients on the fourth floor were unclean, had dried liquids on the outside, generally dusty and dirty. Since this area is part of the locked behavioral health unit, housekeeping staff can not consistently gain access to this area to clean. The unit supply room was also locked and the floor was unclean, for the same reason.

3. 5th Floor:

In the SW504 restroom, walls near sink and toilet were unclean, notably old stains, thick enough that hair was stuck to the dried liquids on the walls.

The push plate for the water fountain had a sizeable buildup of gummy, sticky material on the area to be pushed to dispense water.

Based on review of the water logs and interview of the clinical manager of the in-patient dialysis center, the facility staff failed to assure that the new water treatment system was properly monitored for bacterial contamination before being placed in service for patient dialysis. This could result in dialysis patients being exposed to bacteria or endotoxins resulting in illness.
When a new water treatment is installed, it is required that the facility staff tests the system for bacteria weekly to assure there is no bacterial contamination (Association for the Advancement of Medical Instrumentation (AAMI) RD62: Water Treatment Systems for Hemodialysis Applications). Review of the water treatment logs on 1/3/10, revealed that four new portable Reverse Osmosis (RO) (water purification system) were purchased and put in service between June and August, 2010. Review of the culture results revealed that each machine had been cultured and endotoxin tested one time before the first patient use. The manufacturer's manual was reviewed. The manual's recommendation for culturing the system after installation stated: "Disinfect the RO unit every day for one week after installation. This will ensure bacteria levels in the fluid paths will be controlled. Sample the purified water for bacteria before each disinfection." There was no evidence that the facility followed the AAMI or manufacturer's recommendations for the preparation of the portable RO water systems.