HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that legal custody confirmation was documented in the medical record for 1 of 30 sampled patients (11).

Findings:

Patient 11 was admitted to the hospital on 10/20/15, according to the Facesheet. The medical record for the patient was reviewed on 10/26/15.

On 10/20/15, the MD 2 for Patient 11 ordered the hospital to obtain confirmation of legal custody papers. The medical record for the patient was reviewed with Licensed Nurse (LN 1) on 10/26/15 at 11:30. LN 1 was unable to find the patient's legal custody papers.

On 10/26/15 at 11:45 A.M., SW 2 was interviewed via telephone. SW 2 stated he requested the legal custody papers from the patient's mother on 10/20/15. SW 2 stated the mother had not provided the paperwork.

On 10/26/15 at 12:01 P.M., MD 2 was interviewed. MD 2 stated his expectation was for the legal custody papers to be in the patient's medical record.

On 10/29/15 at 10 A.M., the DSS was interviewed. The DSS stated her expectation of SW 2 was to have legal custody papers in the patient's medical record "within 24 hours" of a written physician's order.

According to the hospital policy approved 6/03 and titled, Caregiver Authorization Affidavits: "Upon admission of a minor patient, staff (Intake, Social Services, Clinical Services) will clarify the custody status of the minor."

Based on observation, interview, and record review, the hospital failed to ensure patient confidential information was not displayed on white boards in public areas on 3 of 5 nursing units (PICU, ASU 2, and ASU 3). The hospital also failed to ensure staff did not use telephones located in public areas outside 2 of 3 nursing stations.

Findings:

1. During the initial tour of the hospital on 10/26/15 at 9:15 A.M., a large white board was observed outside of the entrance doors to PICU and ASU1. In the nursing station between ASU 2 and ASU 3 were two white boards that faced out towards the public area. Some and/or all of the following confidential patient information was documented on the white boards: Patient Name and Room Number, Legal status (Voluntary, legal hold expiration, reised (legal process to enforce medication administration upon a patient), temporary conservatorship, conservatorship), Doctor, Counselor, Program (Chemical Dependency), detoxification, and/or special observations (seizure, fall risk.)

On 10/27/15 at 10:15 A.M., the DCS was interviewed. The DCS stated legal holds, temporary conservatorships, reise hearings, and other personal or legal information should not be on the white boards.

According to the hospital's policy, entitled, Patient Rights, "H. You DO have the Right to confidentiality. All communications and records pertaining to your care, including the source of payment for treatment, shall be treated as confidential."


2. During the initial tour of the hospital on 10/26/15 at 9:15 A.M., tables with a telephone were located outside the nursing units in public areas.

On 10/27/15 at 11:20 A.M., a physician was observed seated at the PICU/ASU 1 table and was over heard discussing/dictating a patient's confidential information. The physician's voice could be heard at both of the nursing stations. Two patients stood by the nurses station and a patient and several staff also walked by while the physician was on the phone.

The DCS was asked about the physician dictating. The DCS heard the physician and stated, "This will not work, she is not supposed to do this here." The DCS then walked over to the physician and informed her she was not to dictate on the phones outside of the nursing stations. The physician replied to the DCS, "I didn't know I couldn't."

On 10/28/15 at 8:55 A.M., RN 2 stated the phones were for staff/physician overflow away from being in the nurses station. RN 2 stated, "Yes I have heard doctors dictate (on the phone at the table.)" RN 2 further stated, "My understanding was the table and phones could be used for dictation or utilization review calls." RN 2 further stated that patient confidential information should not be discussed where others could hear.

On 10/28/15 at 9:15 A.M. SW 4 said, phone outside of the nursing stations were for doctors or social workers to make calls. SW 4 further said it was, "...Ok for doctors to dictate psychiatric or medical evaluations."

On 10/28/15 at 9:35 A.M. SW 5 was interviewed. SW 5 said the tables with phones were placed outside the nurses stations because the nurses stations were too crowded. SW 5 stated, social services and doctors used the tables to review charts and to dictate. SW 5 also stated, social services used the phones to call in legal holds, reises, utilization reviews, and placement updates. SW 5 further stated, "Yes, we were told that's what it is for. The social workers offices are at the end of the hall, this is easier."

According to the hospital's policy, Patient Rights, "H. You DO have the Right to confidentiality. All communications and records pertaining to your care, including the source of payment for treatment, shall be treated as confidential."

Based on observation and interview, the hospital failed to ensure patient areas were ligature (a cord used for binding) free. The hospital also failed to ensure the seclusion and restraint area was easily accessible in case of an emergency for 1 of 3 seclusion and restraint room areas.

Findings:

1. The intitial tour was jointly conducted on 10/26/15 at 9:15 A.M. with the DCS. The following were observed:

a. A metal pipe approximately 2 1/2 inches long was observed in room 108. The pipe stuck out of a shower wall. The end of the pipe had a half circle cut out. This could be used by a suicidal patient as a ligature point.

The DCS did not know the purpose of the pipe and acknowledged the pipe posed a ligature risk for a suicidal patient.

b. In addition, room 108, had an over head cabinet with two open handles that measured approximately 2 inches by 4 inches. The handles could be used as a ligature fixture for a suicidal patient.

The DCS acknowledged this was also a ligature risk.

c. The bathroom in room 315 had a 2 inch hook shaped plastic piece sticking out of the shower wall.

Again, the DCS was unable to identify the purpose for the plastic piece and acknowledged the ligature risk.

2. During the same tour, the seclusion/restraint area between ASU 2 and ASU 3 was observed. The seclusion room and the restraint room doors were located within one other room. Outside of the restraint room and the seculsion room were 5 chairs and 1 bedside table. Chairs had to be moved in order to open the seclusion/restraint rooms.

The DCS stated, sometimes the therapists and doctors brought chairs in to conduct counseling sessions in the area.

On 10/28/15 at 10:55 A.M., the seclusion and restraint room area was jointly observed with the DPO. There was 1 chair and 1 large soiled linen barrel in the area. The DPO stated, "So someone could get hurt here! (referring to an emergency situation where staff needed to have easy access to the rooms.) The DPO further said he continued to remove the chairs and desks, but staff continued to bring them back into the seclusion and restraint room area.

On 10/29/15 at 1:25 P.M. MHW jointly observed the seclusion and restraint room area. The MHW stated, "They are supposed to take out chairs, desks and check the area every shift. Yes, it would be bad if a patient went off back here and the chairs weren't removed. Yes, someone would get hurt, either the patient or one of us."

The hospitals policy and procedure, reviewed 4/14, entitled, Safety, "To eliminate hazardous conditions and prevent unsafe situations." "It is the policy of ABHC that the Clinical Services Department is maintained so as to assure patient safety."

Based on interview and record review, the facility failed to ensure a qualified Registered Nurse with advanced or thorough knowledge of the psychiatric population, supervised nursing services, as the Director of Nurses.

Findings:

During an interview with DON, on 10/27/15 at 11 A.M., he stated, "...No psych experience at all...This is my first, but no psych experience in the past."

On 10/29/15 the DON job description along with his resume was reviewed. According to the undated, job description, "Qualifications: Advanced or thorough knowledge (equivalent to Master's level) of psychiatric and general nursing care concepts and methodologies and skills in their implementation...working knowledge of, and skills in maintaining therapeutic milieu."

The resume' of the DON was reviewed. Under the heading of any additional Licenses and Certifications, the DON listed, "HFEN (Health Facility Evaluator Nurse) successful exam completion."

The Director of Nurses stated on 10/29/15 at 10 A.M., "I never worked for the state as a HFEN or took any other tests. I only took the application test online."

Based on interview and record review, the hospital failed to ensure bowel monitoring was accurately documented, as ordered by the physician, for 1 of 30 sampled patients (12). The hospital also failed to ensure fluid intake was accurately documented, as ordered by the physician, for 1 of 30 sampled patients (12).

Findings:

1. Patient 12 was admitted to the hospital on 7/16/15, according to the Facesheet. On 10/27/15 at 10:45 A.M., the medical record was reviewed with LN 1.

On 8/16/15, the physician ordered the patient's BM be recorded every shift on the BMS.

The BMS dated 8/22/15 through 10/2/15 was reviewed with LN 1. According to LN 1, the BM were recorded twice on the 7 A.M. to 3 P.M. shift and once on the 3 P.M. to 11 P.M. shift. LN 1 stated the BMs were not documented on the 11 P.M. to 7 A.M. shift.

The BMS dated 8/22/15 through 10/2/15 was reviewed with the DON and RN 1. The DON and RN 1 stated the BMS were incorrect.

2. On 10/27/15 at 10:55 A.M., the medical record for Patient 12 was reviewed with LN 1.

On 8/16/15, MD 3 ordered the patient to drink 12 oz of water six times a day. On 10/10/15, MD 3 also ordered the hospital to monitor the patient's intake.

LN 1 stated the physician's order to drink 12 oz of water six times a day was documented on the facility's Routine Medications sheet. The Routine Medications was reviewed with LN 1. There was no documentation of how much water the patient consumed on a daily basis. LN 1 stated, "...there was no documentation of how much water the patient drank."

MD 3 was interviewed on 10/27/15 at 2 P.M. MD 3 stated her expectation was for staff to document the patient's fluid consumption.

According to the hospital policy revised 1/12 and titled, Guidelines For Charting: "All documentation must be accurate..."

Based on interview and record review, the hospital failed to develop a Treatment Plan for 1 of 30 sampled patients (12) with a history of constipation. The hospital also failed to review and update a Treatment Plan at least weekly per their policy for 1 of 30 sampled patients (12).

Findings:

1. Patient 12 was admitted to the hospital on 7/16/15, according to the Facesheet. On 10/28/15 at 11:30 A.M., the medical record was reviewed with RN 1.

According to a Physician's Order dated 8/24/15, Patient 12 was prescribed Lactulose every day for constipation.
RN 1 stated Patient 12 was known to the hospital and had a history of constipation. The Treatment Plans in the patient's medical record were reviewed. There was no Treatment Plan initiated for the patient's constipation. RN 1 stated a Treatment Plan for constipation should have been developed because, "It's a medical issue that we're treating."

According to the hospital policy revised 11/11 and titled Interdisciplinary Treatment Plan: "Purpose: To formulate a plan of care that meets the patient's objectives and needs."

2. On 10/28/15 at 11:30 A.M., the Treatment Plan updates for Patient 12 were reviewed. Patient 12 had a Treatment Plan update dated 8/12/15, for aggression and skin integrity. The next Treatment Plan update for aggression and skin integrity was not addressed until 10/12/15.

MD 1 was interviewed on 10/28/15 at 11:20 A.M. MD 1 stated she did not believe it had been 2 months between the Treatment Plan update. MD 1 stated she sometimes conducted Treatment Team downstairs. She further stated, "Maybe the nurse didn't bring the chart down" for signature.

On 10/28/15 at 11:30 A.M., the Treatment Plan updates were reviewed with RN 1. RN 1 stated, "A lot of times MD 1 forgets to have Treatment Team." RN 1 stated the Treatment Team for MD 1 was scheduled for Monday and Wednesday at 9 A.M., but MD 1 was not at the hospital during that time. The Treatment Team schedule was reviewed with RN 1. There were multiple other days and times available for Treatment Team however, RN 1 stated, "I can't say if a more convenient time has been offered to MD 1."

According to the hospital policy revised 11/11 and titled Interdisciplinary Treatment Plan: "The Treatment Plan shall be reviewed and updated as frequently as clinically indicated...but at a minimum, the treatment goal is to be reviewed weekly."

Based on interview, and record review, the hospital failed to ensure the LNs documented a re-assessment of 3 of 30 sampled patients after a PRN pain medication was administered.

Findings:

a. Patient 19 was admitted to the hospital on 10/22/15, per the Call Sheet.

On 10/23/15, a hospital nurse documented a PRN dose of robaxin (muscle relaxant) and a dose of Motrin (anti-inflammatory) were administered to Patient 19 for a "back ache," per the All PRN and PAIN Medication Charting Profile - 24 hour form. There was no documented numerical pain rating of the back ache before or after the PRN medications were administered.

In addition, on 10/24/15 a hospital nurse documented the administration of PRN Motrin for "pain/back," and the numerical pain number was 6 out of 10. There was no documented re-assessment of the patient's pain after the PRN medication was administered.

b. Patient 21 was admitted to the hospital on 9/9/15, per the Facesheet.

On 9/12/15, a hospital nurse documented a dose of Tylenol was administered to Patient 21 for a pain level of "10."

There was no documented re-assessment of Patient 21's pain level after the PRN pain medication was administered.

On 9/14/15, a hospital nurse documented the administration of a PRN dose of Tylenol to Patient 21 for a pain level of "7." A nurse documented an arrow pointing down, instead of a number, in the section to document the level of pain after medication.

c. Patient 23 was admitted to the hospital on 10/16/15, per the Facesheet.

On 10/17/15, 10/21/15, and 10/23/15 a hospital nurse documented the PRN administration of Tramadol (a narcotic-like pain medication used to treat moderate to severe pain) to Patient 23 for a pain level of "10." There was no documented re-assessment of Patient 23's pain after the administration of the PRN pain medication.

On 10/24/15, a hospital nurse documented a PRN dose of Tramadol was administered to Patient 23 for "pain/gen" (generalized). The nurse did not document a pain level before or after the administration of the PRN pain medication.

On 10/25/15, a hospital nurse documented a PRN dose of Motrin was administered to Patient 23 for low back pain. The nurse documented Patient 23's pain was a "20" out of 10. There was no documented re-assessment the the patient's pain level after the administration of the PRN pain medication.

The DON stated on 10/28/15 at 3:50 P.M., the nurses were supposed to document a follow-up re-assessment after a PRN medication was administered. The DON also said when a PRN pain medication was re-assessed the documented assessment should be in numerical form.

According to the hospital policy, entitled, Pain Assessment and Management, last revised 12/08, "Each patient will be taught to use the 0 - 10 Faces pain scale to report their pain intensity."

According to the hospital policy entitled, Administration of Medication, last revised 11/13, "One hour after administration of medication, reassess the patient and document effectiveness of medication on the PRN Medication Administration Record."

Based on interview and record review, the hospital failed to ensure all entries in the medical record were legible, dated, timed, and authenticated by the person that made the entry for 3 of 30 sampled patients (11,12,13).

Findings:

On 10/29/15 at 1:05 P.M., the medical records for Patient 11, Patient 12, and Patient 13 were reviewed with the DMR. The following omissions were identified:

1. Patient 11- The entries in the medical record dated 10/22/15 at 12 noon and 10/22/15 at 1 P.M. were not authenticated by the person that made the entry.

2. Patient 12-The Physician's Order dated 9/8/15, did not have the date or time the order was noted by the licensed nurse. The physician's signatures on the Physician's Order dated 10/15/15, 10/16/15, 10/24/15, and 10/25/15 were illegible. The Physician's Orders dated 10/10/15 and 10/25/15 were not signed, dated, and timed by the licensed nurse.

3. Patient 13- The Physician's Orders dated 10/15/15 did not have the time the order was noted by the licensed nurse. Two Physician's Orders dated 10/16/15, did not have the date the order was noted by the licensed nurse.

The DMR acknowledged the above omissions in the medical records.

According to the hospital policy revised 1/12 and titled Guidelines For Charting: "The documentation shall be clear, concise, legible, and accurate" and "All staff signatures must be legible..."

Based on interview, document and medical record review, the hospital failed to ensure that preprinted physician orders were clear and specific in accordance with hospital policy and acceptable standards of practice regarding multiple medications ordered for the same indication. There was no documentation of clarification by nursing staff for the unclear physician orders for 8 out of 30 records reviewed.

Findings:

A record review was conducted of 10 patient records on 10/27/15 at 10:15 A.M. Patient records 1,2,5,6,7,8,9 all contained a form entitled "Physician Admitting Orders" dated 11/2014. The form indicated under medications checked as ordered by the physician that Motrin (pain medicine) 400 mg by mouth every 4 hours as needed for 30 days and Tylenol (pain medicine) 325 mg by mouth 2 tablets every 4 hours as needed for 30 days for pain. There was no documentation of the order of preference for the two pain medications ordered for the same indication. The form indicated that the RN noted the medication orders; however there was no documentation of clarification by the RN of the order. The Physician Admitting Orders form for patients 1,2,3,5,6,7,8,9 indicated that Mylanta (stomach medicine) 15 cc by mouth every 4 hours as needed for gastric (stomach) distress for 30 days and Tums (stomach medicine) 2 tablets every 4 hours as needed for gastric distress were both marked as ordered by the physician. The form indicated that the RN noted the medication orders; however there was no documentation of clarification by the RN of the order.

A review of the hospital's policy and procedure entitled "Administration of Medication" dated 4/2014 was conducted on 10/27/15 at 2:00 P.M. The policy specified that, "Any questions or inconsistencies should be clarified by consulting the physician, another R.N. (Registered Nurse), a pharmacist and/or reference materials as appropriate".

A review of Institute for Safe Medication Practices (IMSP) Guidelines for Standard Order Sets dated 2010 was conducted on 10/29/15 at 8:30 A.M. The Guidelines indicated that order sets are to "use a standard method (e.g., check boxes, circling) for prescribers to activate/select desired orders that minimize confusion regarding how inactivate/unselected orders are to be interpreted". The guideline further specified that "Orders exclude...overlapping parameters to guide medication administration that make it difficult to interpret the correct directions".

An interview with the DQRM was conducted on 10/27/15 at 10:25 A.M. The DQRM acknowledged that the multiple pain and gastric distress medications ordered for the same indication on Physician Admitting Orders form dated 11/2014 was not clear and specific as to the order or preference of medicine to be administered by the RN. The DQRM also acknowledged that these unclear medication orders should have been clarified by the RN. The DQRM stated that the hospital had developed an updated "Physician's Admitting Orders" form dated 6/2015 to help clarify these orders and the form dated 11/2014 should not have been used.

A concurrent interview with the DQRM, the DP and review of the hospital's form entitled "Physician Admitting Orders" dated 6/2015 was conducted on 10/27/15 at 10:50 A.M. The form indicated that Motrin is to be administered "If Tylenol not effective". The form did not specify the preference for use of Mylanta and Tums (if both gastric distress medications are ordered). Both the DP and the DQRM acknowledge that the updated Physician Admitting Orders dated 6/2015 did not specify which order of preference for the two gastric distress medications when both are ordered at the same time for the same indication.

27013


3. On 10/27/15 at 10:25 A.M., a medication cart was noted outside of ASU 1's nurses station in the patient hallway, unattended. Two patients walked by the medication cart then went into the group room.

LN 3 was observed in the nursing station on the phone, his back was towards the cart. He finished his call and walked around the nurses station and conducted other tasks.

At 10:30 A.M., the DP walked onto the unit. The surveyor showed the DP the cart was unlocked and unattended. The DP stated, "This isn't good. I'm here to check orders."

The DCS walked up and asked where the medication nurse was. She then walked into the nurses station and talked to LN 3.

LN 3 came out of the nurses station and stated, "I thought I locked it." He further stated it was not the practice to leave the medication cart outside of the nurses station.

According to the hospital policy, reviewed 4/14, entitled, Role of Nursing in the Medication Distribution and Administration System, "The medication cart is a locked cabinet on wheels, which contains portable modules. Each module contains individual patient drawers." "Syringes and needles are to be stored in the interior section of the medication cart and must be locked at all times."




29707

Based on observation, interview, and record review, the hospital staff failed to:
1. Dispose of an unused portion of a controlled substance medication (medications with high propensity for abuse) in 1 of 3 medication rooms;
2. Follow their policy and procedure for medication brought from home for 3 of 30 sampled patients (13, 21, 22); and
3. Ensure 1 of 5 medication carts was locked when unattended.

Findings:

1. On 10/27/15 at 10:38 A.M., a medication room inspection, located between ASU 2 and ASU 3, was conducted with RN 3 and LN 2, and a random check of the controlled substances count was performed.

There was a manufacturer's blister pack (unit dose of a pill individually sealed) labeled 0.5 mg of Klonopin (controlled substance medication used to treat seizure or anxiety disorders) which was opened and one half of a tablet of a medication was observed placed back into the open blister pack.

RN 3 and LN 2 were unable to explain how a nurse, who might subsequently want to administer one half of a Klonopin tablet, would be able to identify the half of a pill in the open blister pack was actually Klonopin.

The DP stated on 10/27/15 at 10:42 A.M., it was expected that when only half of a controlled substance medication was administered the other half should be wasted (proper disposal by 2 nurses).

According to the hospital policy, entitled, Administration of Medication, last revised 11/13, "Keep unit dose packages intact until just prior to administering the medication."

2 a. During a medication room inspection on 10/27/15 at 10:38 A.M., there was a plastic bag which contained 7 plastic weekly medication organizers (7 day pill storage container). Each of the 7 weekly organizers had mutiple pills/tablets in each week day section of the storage containers. There was a duplicate copy of a Record of Patient's Own Medications (a form used to document medications brought to the hospital at the time of admission) which had Patient 21's name.

Patient 21 was admitted to the hospital on 9//9/15 and was discharged on 9/29/15, per the Facesheet.

Located in Patient 21's medical record was the original Record of Patient's Own Medications form. A staff member documented 7 weekly medication organizers which contained "various pills," were brought in at the time of admission. There was no specific quantity of pills documented. The form was dated 9/9/15 and was signed by the patient and staff member.

On 9/10/15, Patient 21's physician signed Patient 21's Record of Patient's Own Medications form in the section entitled, "The hospital may release the medications as checked per my order on discharge." At the top of the form where the pill boxes were listed was the word "No" underlined twice. It was unclear if the physician wrote the word "No" to indicate the medications should not be returned to the patient upon discharge.

2 b. During a medication room inspection on 10/27/15 at 10:38 A.M., there was a plastic bag which contained 3 bottles of medications labeled with Patient 22's name.

Patient 22 was admitted to the hospital on 9/20/15 and discharged on 9/25/15, per the Facesheet.

Located in Patient 22's medical record was a Record of Patient's Own Medications form. There were 3 different medications listed on the form. For 2 of the medications, the staff documented the bottles were 1/4 full and no specific count was listed. For the 3rd medication, the staff documented "3 pills left."

There was no documentation in Patient 22's medical record to indicate whether or not the medications brought from home should be returned to the patient upon discharge.

On 10/27/15 at 11 A.M., RN 3 and LN 2 stated the nurse who prepared a patient for discharge was supposed to clarify with the patient's physician if medication should be returned to the patient upon discharge. If medications were not sent home with a patient the medications should be turned over to pharmacy upon discharge. Neither was able to explain why the medications for Patient's 21 and 22 were still in a drawer in the medication room on the unit.

The DP stated on 10/27/15 at 2:50 P.M., when a patient or medication was discharged and the medication was not sent home with a patient, the medications should be removed from the unit and returned to the pharmacy right away.

2 c. On 10/26/15 at 10:45 A.M., the second floor medication room was observed with LN 1.

A half empty bottle of multi vitamins (MVI) was observed inside a medication cabinet. LN 1 stated the bottle of MVI belonged to Patient 13.

According to the Facesheet, Patient 13 was admitted to the facility on 10/14/15 and discharged on 10/19/15. LN 1 stated the MVI were brought from home to the facility by the family of Patient 13.

The discharge medical record of the patient was reviewed with LN 1. LN 1 stated that medications brought from home should be documented on a facility Record Of Patient's Own Medications form and returned to the patient on discharge. LN 1 was unable to locate a Record Of Patient's Own Medications form. The medication was not returned to the patient or to the pharmacy 7 days after his discharge.

According to the hospital policy, entitled, Medication Brought in with Patients, last revised 03/09, "Nursing staff will fill out the 'Record of Patient's Own Medications' form upon admission. This includes inventory of medication by strength and quantity, and the patient's signature acknowledging the meds were brought in and stored."

In addition, per the policy, upon discharge the nurse will contact the physician to obtain an order to release the medications, and, "In the event that the physician does not want some or all meds returned, they would be given to the pharmacist, who will then destroy them..."