HospitalInspections.org

Based on document review, and information obtained during surveillance activities at the facility from 4/19/2010-4/23/2010, the Governing Body has failed to take appropriate actions to monitor and restore compliance related to deficient practices previously cited as a result of federal surveillance activities conducted at the hospital November 9, 2009. Specifically, corrective measures implemented by the facility related to certain deficient practices have not been effective. Several repeat deficient practices were identified during the follow-up survey.
Findings:
Specific repeat deficiencies are cited under tags #'s A 116 and A 144.
Additionally, the Governing Body has failed to provide adequate oversight relating to the quality of care provided to its patients. Deficient practices were identified regarding assessments and diagnoses, treatment and care plans, coordination of care and services, and patient rights. The organization and format of the hybrid medical record and the facility's failure to assure that documentation in the patients' medical records is accurate and complete has the potential to negatively impact the care provided to patients based on these findings.
Examples of a lack of adequate oversight related to the overall care of patients at the facility are noted below.

Findings:

MR # 25
This patient arrived in the main Emergency Department via EMS at 20:58 on 1/16/10 with a chief complaint of "having withdrawal symptoms like chills and sweat ". The documentation in the Emergency Department record is not consistent with information documented by the EMS providers. Specifically, there is a discrepancy between the patient's history and medications. The patient's past medical history was noted by EMS as "heroin, depression". The medications noted on the pre-hospital care report were "Truvada, Bactrim, Topamax, and Zoloft". However, the patient's current medications listed by the triage nurse were "Ambien, Seroquel, and Percocet".The patient's past medical history was noted by the RN as "HIV, psychiatric".

Additionally, documentation in the medical record is incomplete. The patient stated he "last used heroin this morning". Vital signs were 123/73, pulse 115, temperature 98.5, respirations 20 however there were no other nursing assessments documented. The patient was seen by the physician at 23:50. The patient ' s chief complaint was listed as "heroin withdrawal, started today". The review of systems was negative except for chills, physical examination was positive for pupillary dilation. The patient's past medical history was noted as " psych " with no further notation regarding either the patient's medical or psychiatric history. The patient was discharged at 00:15 on 1/17/10 with a diagnosis of opioid dependence, unspecified. The discharge instructions were as follows: " You cannot die from heroin withdrawal. If so desired, you can be evaluated for inpatient detoxification in the R building behavior center". Based on the lack of documentation in the medical record and the confusing nature of the discharge instructions it was not clear that the patient understood the plan for follow-up care. The patient was discharged from the Main ED but presented to the CPEP, 29 minutes later seeking treatment for detoxification. It was also noted that the physician's signature was missing on the discharge instructions.

The patient presented to the CPEP, R building at 0044 on 1/17/10, the chief complaint is noted as " I want detox" . The history of present illness noted by nursing includes "patient requesting detox from alcohol and heroin" , "patient reports last used alcohol and heroin prior to coming in", the patient was noted to be intoxicated, withdrawal was noted as " no ". The patient was seen by the attending psychiatrist for a CPEP brief evaluation at 01:11. The patient was again noted to be intoxicated with no withdrawal. In the CPEP MD Psychiatric Triage electronic note, the review of symptoms include: psychotic " yes ", depressed " no". At 01:18, the same physician noted that patient does not have affective and psychotic symptoms at this time, the patient to be admitted to the counselor and will be admitted to detox. The patient 's previous medical records were noted to be reviewed by the physician, yet there was no documentation by the physician regarding a history of bipolar disease. Documentation by the nurse and the counselor noted that the patient had been admitted to KCHC in October 2009 for 6 weeks for treatment of bipolar disease and Woodhull Hospital in August 2009 for bipolar disease. Additionally, the psychiatrist listed diagnoses of opioid type dependence, narcissistic personality disorder, post-concussion syndrome, social/substance abuse and GAF of 61-70. However, bipolar disease was not a listed diagnosis.

There are no current medications noted by the psychiatrist. Although the patient was noted to be intoxicated this is not supported by the ethyl alcohol level of less than 10 at 00:45 and there are no breathalyzer results noted.

At 02:47, the patient was seen by the physician for medical clearance. The chief complaint is noted as obesity, HIV/AIDS. The history of present illness included "presented to detox for ETOH. Not in acute distress. " Last drink was noted by the physician to be Monday, December 2, 2009, which is not consistent with information in the patient's medical record. The assessment and plan are ETOH dependence, detox protocol, monitor DT's, Librium 25 mgs po Stat. There are no withdrawal symptoms noted by the physician. The current medications being taken by the patient are not noted except for Kaletra and Truvada.

At 09:30 on 1/17/10, the patient was seen by the Addiction Counselor who noted that the patient was accepted for detox. The Addiction Counselor had recommended a psychiatric consult when the patient was admitted to the Detox Unit. However, there was no evidence that a psychiatric consult was done on the Detox Unit, R 2 East, despite a complex psychiatric history of bipolar disorder (on two medications as an outpatient), depression, narcissistic personality disorder, and poly-substance abuse.

The patient was discharged at 11:55 from the CPEP on 1/17/10 for transfer to R2E-detox.

The Health Status and Functional Assessment completed by nursing staff on the detox unit lacked the following:
- Family Medical History;
- History of prior injuries, or hospitalizations;
- Current health status;
- Further assessment of the patient's toothache pain of 8/10 on 1-10 scale; and
- Evidence that the physician reviewed the assessment as the assessment was not signed by the physician.

The Health Status and Functional Assessment by the RN noted the following medications were taken at home: " Topamax 100 mg TID, Kaletra BID, Truvada QD, Zoloft 15 mg PO QD, Ambien 10 mg PO Q HS" . However, despite the patient being on Zoloft 15 mg PO every day and Topamax 100 mg PO TID at home, these medications were not ordered and there was no documented evidence that a medication reconciliation was performed at any time.

Methadone was started on January 17, 2010 at 09:59, with no documented clinical evidence that the patient met criteria for a detox. admission/treatment. There was no documentation regarding the patient experiencing withdrawal symptoms and despite the patient being admitted for heroin detoxification, urine and blood toxicologies were not obtained. Furthermore, there were no MD orders for a baseline EKG prior to Methadone administration to assess the patient's cardiac status and QT monitoring.

A urine toxicology was not ordered until January 18, 2010 at 7:31, the collection time was not noted. The results of the urine toxicology from January 18, 2010, were positive for Methadone but negative for cocaine and opiates. The patient was continued on Methadone despite the negative urine toxicology results and documentation of only mild withdrawal symptoms. Additionally, despite negative ethyl alcohol reports in the CPEP and no symptoms of withdrawal, the patient was continued on Chlordiazepoxide.

Despite the patient's complex medical history including HIV, the medical record lacked documentation that a full internal medicine consult was obtained upon admission. Additionally, the documentation in the medical record did not reflect that the patient was assessed on a daily basis by internal medicine and psychiatry and the care was not modified to meet the patient's ongoing needs.
Since a baseline EKG was not obtained, the physicians should have subsequently ordered an EKG. The medical consultant on-call saw the patient for episodic care only such as dry eyes and right eye swelling.

There is no documented evidence in the patient's medical record that the patient was involved in any individual or group therapies while on R2East or if a treatment plan for this patient included these and other unit activities.

The patient was on the following medications: Chlordiazepoxide, Methadone, Kaletra and Ambien 10 mg PO Q HS. Despite being on multiple medications that could cause CNS (central nervous system) depression, cardiac arrhythmias, and PR and QT interval prolongation, the treatment plan was not modified. The treatment plan did not identify the possibility of life threatening cardiac arrhythmias and changes to both the monitoring and medical management of this patient. Vital signs were ordered every 8 hours, but more frequent vital signs including oximetry readings should have been considered.

Despite vital signs ordered per protocol every 8 hours, the vital signs were not taken as ordered. The vital signs on January 19, 2010 at 17:00 were BP 137/77, pulse 90, RR 18, TEMP 97.8. No vital signs were documented after 17:00. The patient was found unresponsive at 04:17 on January 20, 2010; 11 hours and 17 minutes after the last set of vital signs.

There is a nursing note dated January 20, 2010 and timed 3:30 AM. However, following that entry there is a lack of nursing documentation. The medical records lacks documentation describing the circumstances surrounding the cardiac arrest when the patient was found unresponsive and any actions taken prior to arrival of the code team.

There is a discrepancy in the medical record regarding circumstances regarding the resuscitation, there is documentation that the patient was found unresponsive at 04:17 by nursing and there is also documentation that the patient was found unresponsive at 4:30 PM and CPR is started at 4:30 AM.

There is a hand written note on the patient's Progress/Communication Record regarding the resuscitation, but it lacks the following information/documentation:
- Cardiac rhythm strips including cardiac rhythms at start, during, and conclusion of resuscitation efforts;
- Dosages and routes for all emergency medications given: atropine, epinephrine, sodium bicarbonate, and calcium chloride;
- Rate and amount of IV fluids;
- Date of arrest;
- Labs drawn besides arterial blood gas at 04:39 AM;
- Staff involved in resuscitation by name and title;
- The percentage FIO2 and route of oxygen supplied to patient including times;
- Signature of person documenting the note.

Per interview with facility staff, a standardized Cardiac Resuscitation Form is used by the facility. The facility was not able to provide evidence that the form was used when the patient was found unresponsive on January 20, 2010.

Because the record lacks the information noted above, it is not clear if the patient was resuscitated according to current ACLS guidelines; cardiac rhythms were not documented, dosages and routes of medications were not noted.

There is a discrepancy and missing documentation in the patient's medical record regarding the intubation of the patient. The size of ET tube is documented in the patient 's Progress/Communication Record as size 7.5; and size 8.0 in an electronic note by the anesthesiologist that intubated the patient . The anesthesiologist does not document a time of intubation.

In conclusion, due to inconsistencies in documentation, a lack of supportive evidence including positive toxicologies, and a lack of documented withdrawal symptoms, it was unclear if the patient met criteria for inpatient alcohol detox for and treatment with Methadone for opioid dependence.

Despite DOH receiving a certified copy of a complete medical record for MR # 25 on April 30, 2010, the medical record was missing significant parts of both the electronic and paper medical record. The following were missing:
- Computerized copy of the History and Physical done on January 17, 2010
- Computerized Anesthesia note after intubation on January 20, 2010
- Complete list of Physician Orders
- Emergency Department record for January 16, 2010
- CPEP record for January 17, 2010
- Cardiac Resuscitation sheet from January 20, 2010

Please see additional findings related to the facility's internal investigation of this case cited under A0289.
MR # 24:
This case involves the death of a 20 year-old with head trauma. Review of this case revealed multiple lapses in appropriate and timely care; clinical assessments; timely clinical follow-up; and the impact of miscoding psychiatric disorders; and potential bias against an individual with a history of a psychiatric disorder.
This 20 year-old was brought to the ED by ambulance on 3/31/10 at 9:28 PM after being found on the ground by friend after waiting in front of a store while he went inside. EMS described him as having + alcohol on breath, disoriented with an abrasion and hematoma to the left occipital region, able to obey commands, and bladder incontinence complaining of a constant (acute) headache. Other medical history obtained by EMS included a history of bipolar disorder and Cogentin and Zyprexa medications. He was assigned a Trauma Score of 12; GCS (glasgow coma score) # 1 score of 14; and GCS# 2 score of 15.
The ED evaluation revealed evidence of a direct blow to the head just prior to arrival, loss of consciousness, loss of bladder function and a history of bipolar disorder. He was noted to have normal vital signs, be alert and oriented x 3 with normal mood/affect. His cranial nerve exam, gait, and deep tendon reflexes were documented as normal but the patient had a head contusion and abrasion that was mildly tender in the occipital area. Nursing notes describe the patient as well nourished with similar findings. At 11:23 PM, an ED Quick Note describes the patient as having a " GCS of 15, recent ETOH (1 drink) without signs of intoxication, + contusion/abrasion. No anticoagulants. Ambulatory in ED. Will CT head and reassess. "

A head CT scan at 11:41 PM showed an acute parenchymal hematoma involving the right lateral frontal lobe and frontal operculum. The hematoma measures roughly 2.3 x 1.8 cm. Minor adjacent subarachnoid hemorrhage is present. There is no current mass effect, midline shift, or hydrocephalus. No significant subdural or epidural hematoma is identified. There is a single tiny focus of intracranial air noted near the left lamboid suture. No significant diastases of the adjacent suture is seen. " It should be noted that the diagnosis on the CT scan report reads " other and unspecified injury to an unspecified site " . Serum alcohol level on admission was 25mg/dL. The report notes that the findings were discussed with a physician at "11:42 PM CDT " . (The central daylight time designation is found throughout multiple reports and notes in the electronic medical record)
On 4/1/10 at 1:33AM he was evaluated by inpatient neurosurgery. He was described as s/p (status post) fall, questionable loss of consciousness, complaining of headache. This is inconsistent with EMS and ED evaluation. "Subsequently a head CT showed a small R sided frontal contusion. Exam showed a GCS of 15 with cranial nerves and sensory nerves grossly intact. Head CT finding discussed with neurosurgeon on call " and recommended repeat head CT in AM or earlier if mental status deteriorates.
He was admitted to KCMC Surgical ICU with the diagnosis of subarachnoid bleed on 4/1/10 at 1:40 AM for further observation and management.
At 2:19 AM, the SICU resident evaluated the patient and documented " Per EMS report " " combative " with " alcohol on board " and a GCS 4/5/6, a past medical history of " bipolar disease " with medication history " denied " . This description is completely inconsistent with the EMS report, ED evaluation, and neurosurgery consult reviewed by surveyor. On exam, the patient was described as awake, alert, orientated, and in no acute distress, a GCS 4/5/6, left posterior scalp hematoma, with no obvious abrasion and laceration defined, and extremities having full range of motion. The ETOH level at 25 and CT scan results were noted. He was admitted to the SICU for monitoring and neurocheck, and placed on DT and DVT prophylaxis.
At 3:20AM he was given Morphine 4mg IVP for headache with a pain scale scored at 10/10.
At 3:20AM, the SICU physician noted s/p assault with a diagnosis of subarachnoid hemorrhage, R frontal intraparietal bleed and a history of bipolar disorder " not taking medications " .
At 4:20 AM the Trauma attending brief admit note describes the patient as having a head injury with scalp laceration, and GCS 15/15 on arrival in ED, with LOC unclear and neurologically intact without focal or lateralizing signs. Admitted to SICU for neuro-observation and repeat CT in the AM.
At 4:22 AM, the nursing admit note described the patient as " alert and oriented " with " minor head injury ", a Glasgow scale noting " opens eyes spontaneously " , noting "patient lacks interest in learning" and having received smoking cessation counseling with MD help at 3:40AM.
At 4:30 AM, a nursing note states the " patient refused to talk " .
The SICU Transfer Acceptance Note was documented with an " event Time " of 4/1/10 at 8:21 AM although documented by physician on 4/2/10 at 10:29 AM. The problem Plan states: Neuro: inebriated, history of bipolar disorder, repeat CT in AM; consider psych consult and medical treatment if pat becomes agitated; Tylenol prn for headache; consider Ativan if patient shows signs of alcohol withdrawal, as ETOH history is unclear.
Nursing notes document the patient was taken to radiology for a CT scan of the head at 9:40AM and having returned to unit at 10AM. According to the medical record, a CT scan of the head was performed at 10:22AM which showed increased parenchymal hemorrhage involving the R frontal and anterior temporal lobe; increased mass effect with right-to-left midline shift. The radiologist documented contacting a member of the SICU team at 9:22 CDT (Central Daylight Time), however, there was no evidence in the medical record that the new CT scan findings were communicated to the appropriate SICU staff.
The medical record has two timeframes associated with a psychiatric consult on 4/1/: 10:15AM and 11:43AM CDT. The 10:15AM timeframe noted by the psychiatrist is in conflict with the time of the repeat CT scan of the head illustrating a worsening clinical picture ( " increased mass effect and a midline shift " ). The psychiatrist documented the chief complaint as "I have bipolar disorder" and noted that the computerized record indicated that the patient was previously admitted to KCMC and diagnosed with " psychotic disorder NOS not bipolar disease" an example of the diagnostic inconsistencies in diagnosis found on all charts reviewed.
The psychiatrist described the patient as having a hostile attitude; paranoid toward medical staff and psychiatry; an " irritable and angry mood; and oriented x2. The impression acknowledged " hemorrhage over frontal lobe, confused, disoriented and agitated, complaining of headache and trying to get out of bed. He was also described as " non-compliant with meds " with " on-going alcohol dependence " . The psychiatric assessment was " delirium due to traumatic brain injury and r/o delirium tremens " . The psychiatrist ordered Haldol and Ativan to be given in one syringe in AM and prn q4 for agitation, as well as Depacon stat and TID for agitation.
4/1/10 Patient Observation Record documents the patient as " awake/restless " from 1:30PM through 7:15 PM; " agitated " from 7:30 to 8:00PM; " sedated " from 8:15 to 8:30PM; and asleep from 8:45PM to 9:15PM when taken to OR. However, Nursing notes document restlessness as early as 11AM with Tylenol administered. A stat order of Haldol and Ativan were administered at 6:10PM. At 7:00PM the patient was noted having a right fixed pupil and sluggishly reactive left pupil. Haldol and Ativan were administered again at 7:45PM for agitation. At 7:51 a Code 88 was called. The patient was taken to the OR for emergency craniotomy and decompression. At 8:29PM, a post operative nursing note documents manual restraints for violent and assaultive " behavioral health " reason in imminent danger to self. The patient never recovered and sustained a cardiac arrest on 4/7/10.


Based on review of documents and patient's medical records, it was determined that the facility did not address diagnostic inconsistencies for patients during various hospital admissions which have the potential for adverse outcomes.
Review of medical record #26 demonstrated diagnostic inconsistencies between patient hospital admissions that could impact on coordination of care and has the potential for negative impact on patients. For example, a review of MR #26 for 6/29/09-7/24/09 and 8/26/09 -9/24/09 admissions showed several principal diagnoses assigned to the patient within a three month period. Diagnoses include:
1. Unspecified Psychosis
2. Chronic undifferentiated schizophrenia
3. Bipolar Disorder with Acute Psychotic Behavior
4. Chronic Schizophrenia, Catatonic Type
Medical record progress notes do not document the rationale or bases for arriving at each diagnosis and do not document concerns or process to reconcile the inconsistencies in diagnosis. For example, there was no evidence in the 8/26/09 CPEP evaluation and assessment on admission that significant inconsistencies existed when compared to the previous admission just one month earlier. During tour of the unit this pattern of diagnostic inconsistencies was brought to the attention of an attending physician and the chief of clinical services. Both attributed the problem to the hospital ' s use of ICD-9 codes rather than the use of DSM IV diagnostic codes. The attending physician described the use of progress and discharge notes to document the working diagnosis in the electronic health record. However, as observed throughout the survey process, information in the electronic health record is not fully accessible to all health professionals. This practice did not prevent the possibility of a misdiagnosis having an unintended negative impact on the acute clinical management and long term care planning of patients.
These diagnostic inconsistencies were also noted in MR #s 17, 24, and 25.


Based on review of records and staff interviews, it was determined that the hospital's governing body failed to provide a safe and secure environment to a patient with special needs who was a victim of alleged sexual assault by an employee while receiving inpatient psychiatric care.

Findings include:
MR#17
Review of MR # 17 on 4/21/10 determined that the hospital did not properly evaluate, plan, or adequately supervise the care and treatment provided to a 28 year old male patient admitted to the hospital on 12/28/09 with mental retardation, hearing impairment, and intermittent explosive disorder. It was alleged by the patient on 2/12/10 that he was the victim of alleged sexual assault by a hospital employee while taking a shower.

The record indicates a systematic failure to properly assess and monitor this patient from admission that did not meet standards of care as follows:
-staff did not accurately assess the patient's risk of sexual victimization from admission prior to the event, resulting in inadequate assignment of monitoring levels;
-failure to develop and implement an appropriate plan to ensure effective ongoing interpretation and communication for this hearing impaired patient who had coexisting mental retardation.
-failure to modify the treatment plan immediately following the alleged event;
- inaccurate documentation of patient identification that has the potential to lead to errors in treatment and care.

Specific findings include:

The patient was admitted to CPEP on 12/28/09 via EMS after a report received that he hit his mother. The CPEP nursing progress note dated 12/28/09 indicate the patient has mental retardation and does not communicate resulting in no completion of the risk or patient care assessments. The sexual risk assessment dated 12/29/09 indicates a sexual victimization score of 0, representing no risk. It was significant that the patient was rated as not experiencing a cognitive impairment, resulting in the overall score of not being at sexual risk. It is unclear how the patient could have been rated as having no impairment of cognition, given the history of retardation and communication impairment.

Review of the record indicates that on 12/31/09, the physician noted that during communication with the mother via interpreter, it was reported the patient had been a victim of past sexual abuse at the age of 17 years. This significant history did not result in an accurate reassessment of the patient's sexual risk; the patient continually scored as no risk until the incident occurred on 2/12/10. The patient was consequently monitored on less frequent level 2 observation every 15 minutes for risk of sexual victimization and mental retardation shortly after admission to the inpatient unit until after the event occurred. Inconsistent documentation of observation level remained following the event in that on 2/12/10, the treatment plan for patients at risk of sexual victimization form checked "patient on 1:1 or q15 minutes". The section for alert level had been left blank. Furthermore, inconsistent documentation of observation persisted in that on 2/17/10, the nursing progress note recorded the patient is on level I observation for sexual victimization and mental retardation and is maintained on Q15 minute observation and hourly observation. The reference to three different observation levels is unclear.

The staff did not properly assess the patient's communication and language needs. The record contained inconsistent documentation of the patient's language ability and interpretation needs. The record continually documented the patient's difficulty in communicating . In the emergency room on 12/28/09, the patient was not willing to answer questions and referred all questions to his mother, who was not present at that time. Due to the cognitive limitation, the patient was unable to explain any details and could only request to call his mother. The psychiatrist in CPEP noted the ability to communicate adequately in English. However, the Mental status exam indicated the patient is aphasic. On 12/30 the record noted the patient would need two interpreters because he has limited formal signing skills.

The record did not contain sufficient information to explain how the staff was able to ascertain the patient's response to treatments and interventions. Staff relied on use of a communicard to communicate with this patient, which is limited. For example, on 2/6/10, prior to the allegation, the nurse documented the patient is encouraged to " express all concerns via the use of communicard." Reliance on exclusive use of this card does not explain how the staff was able to assess the patient's response to complex psychiatric treatment.

The record did not indicate any modification to the patient's treatment plan immediately following the alleged event. The event occurred on 2/12/10, yet the treatment plan was not updated until 2/16/10.

The record did not describe and ensure consistent or accurate patient identification of the patient's race and ethnicity, which has the potential to lead to errors in treatment. For example on 12/28/09, the physician notes in CPEP that the patient is a "28 year old African American male". However, on 12/31/09, the MD described the patient on the unscheduled IP formulation as a "28 year old deaf MR, Hispanic male, admitted for threatening behavior." Yet on 12/31/09, the inpatient psychosocial assessment documented by the social worker described the patient as a "28 year old African American male with moderate MR". Additional discrepancy in patient description was recorded on 1/4/10 in which the inpatient social worker records the patient as a 28 year old African American male.

Based on review of medical records, observations, and staff interviews, it was determined the facility did not consistently ensure that patients or their representatives were advised of patients' rights as hospital patients in order to exercise their rights in accordance with regulatory requirements. This deficiency was noted in 15 of 23 applicable inpatient psychiatric records reviewed.

This finding is a repeat of a deficiency noted for 482.13(a), tag # A116 during a previous survey conducted at the facility on 11/9/09.

Findings include:
The facility failed to ensure that each patient or the patient's representative is informed of their rights as a hospital patient upon admission.

During tours conducted of inpatient adult and pediatric units on 4/19, 4/20, and 4/21/10, 15 of 23 inpatient adult and adolescent inpatient psychiatric records did not contain any documentation of the patient and/or the legal representative's written acknowledgment of patients' rights information as required by the hospital's policy and practice. In instances where the completion of the form was deferred, there was no follow-up evident.

During a tour of the inpatient adolescent unit on 4/21/10 at 10 AM it was noted that eight (8) of 12 records lacked evidence of acknowledgement and receipt of patients' rights information. This omission was acknowledged by the Director of the Adolescent unit and supervisory nursing staff during review of patient records on the inpatient adolescent unit 6W on 4/21/10 at 10:05 AM. Staff reported the practice is that the parent will sign the patients' rights acknowledgement form in the CPEP and again upon arrival to the unit. A second form that is utilized on the adolescent unit for acknowledgement of patients' rights was blank in applicable records reviewed. Staff was unable to explain the reasons for these incomplete acknowledgement forms.

Hospital staff did not implement a process for follow up when the condition of the patient or circumstances on admission precludes acknowledgement of patients' rights information by either the patient or appropriate representative. The hospital did not afford patients a follow-up opportunity to receive and sign acknowledgement of patients' rights during a later point of the inpatient hospitalization, when patients might be more receptive to receive and understand this information following provision of further treatment and stabilization.

Examples include:

MR #4:
During a treatment team meeting at 11:30 AM on 4/20/10, this patient , who was approaching discharge, was verbal and discussed his discharge plans with staff. The patient was offered his treatment plan to sign. Upon subsequent review of the patient's medical record at noon on unit R5 East, it was noted that upon admission on 1/24/10, the patients' rights acknowledgement form was deferred due to the patient's psychiatric condition at that time. However, at the time of survey, the patient was cooperative, alert, and participated actively in the team meeting. The staff did not consider this treatment plan meeting discussion as a follow up opportunity for the patient to receive the patient rights acknowledgement.


16399


MR#15:
The acknowledgement of patients' right information was deferred for MR #15 in CPEP on 4/3/10 due to substance induced psychosis. The patient was admitted to inpatient psychiatry on 4/3 and discharged on 4/16/10. The patient was not provided another opportunity to receive and acknowledge his rights before discharge.

MR #18:
The patient was admitted on 3/8/10, but there was no indication that the patient received patient rights information until 4/16/10. The patient, however, refused to acknowledge his rights on 4/16 and on 4/19.

MR #23:
The patient was admitted to inpatient psychiatry on 3/15/10 with a diagnosis of posttraumatic stress disorder, pre-senile dementia with delusional features. The patient was allowed to acknowledge her rights on 3/15 even though her Comprehensive treatment Plan developed on 3/16/10 noted she was disorganized and out of touch with reality; she mumbles, was incomprehensible and incoherent. Although facility staff met with the patient ' s daughter during her visit with her mother, there was no indication she received patients ' rights information.

Refer to medical record #s 1, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 23, 28.

#1.
Based on record reviews and staff interviews, it was determined the hospital did not formulate effective treatment plans that incorporated significant patient factors and information, which resulted in incomplete assessments. These assessments contributed to unsafe discharge plans that did not include appropriate referrals to address relevant needs. Findings of incomplete treatment and discharge plans were evident in four of seven applicable medical records reviewed for discharge planning.

Findings include:

Review of the following medical records on 4/19/10 and 4/21/10 determined the hospital did not effectively incorporate significant information about patients in treatment care plans in order to coordinate post-discharge follow up activities to address outstanding legal matters, child welfare investigations, or unmet housing needs. Consequently the lack of safe discharge plans impacted on the facilities ability to ensure continuity of treatment and care provided to these patients.

Examples include:

MR # 15:
The care planning for this patient was deficient because it did not incorporate the housing need of the patient or an assessment of the patient's capacity in his refusal to plan for this issue. This 47 year old male was admitted for inpatient psychiatric treatment surrounding hallucinations and suicide attempt in the setting of usage of alcohol and illicit substances. The patient was homeless. He had history of past noncompliance with medication and multiple prior admissions with documented poor family support. The patient submitted a 72 hour letter requesting discharge into his own custody. An appointment for outpatient mental health follow up was provided at discharge on 4/16/10. While the patient refused shelter options, the discharge plan indicated the patient provided a name and address to be called by Koskinas staff for follow up. The plan did not include a practical discussion of where the patient would reside. The patient refused housing referral but the staff failed to assess the safety of this discharge plan and did not reassess the patient's insight, judgement, and reality testing with respect to lack of housing. The discharge aftercare service plan contained contradictory documentation in that the patient did not release a name to be contacted in case of emergency.

Staff failed to incorporate significant information into care plans, which resulted in inadequate discharge plans. Specifically, treatment plans dated 4/5 and 4/12/10 did not incorporate the outstanding issues related to homelessness and need for housing.

MR # 9:
The care planning for this patient was deficient as it did not incorporate outstanding issues about the need to follow up with child protective authorities prior to discharge. This 16 year old male was admitted on 4/5/2010 for assessment and stabilization of disorganized and aggressive behavior with report of auditory hallucinations. Noted behavior included cannabis abuse. The child reported on 4/6/10 he had been hit by his father on the leg with a wooden stick and fist. Investigation by child protective authorities was noted and under investigation. The Social worker noted the mother reported the Agency for Children's Services (ACS) worker had visited the home and denied abuse, citing the origin of the bruise was unknown and that the child had been assaulted in school during a fight a few weeks prior. The plan was for the inpatient social worker to follow up with ACS for disposition. The child was not reassessed for physical evidence of abuse; initial physical exam on 4/5/10 prior to the report noted normal skin with no lesions.

During a tour of the unit on 4/21/10 at approximately 11 AM, the record noted the physician's order and discharge plan had already been written for 4/21/10 for the child to be discharged in the afternoon. No follow up with ACS was evident at the time of this review at approximately 11AM on 4/21/10.

An interview with the psychiatrist and the social worker by the surveyor on 4/21/10 at approximately 11AM revealed that the ACS worker had called on 4/16/10 stating she would come to the hospital to coordinate plans because there was a report from the school concerning physical abuse and marks. Staff reported that ACS did not follow up.

After the interview with staff, documentation was entered into the record on 4/21/10 at 12:45 PM by the MD that noted the staff contacted ACS and left a message that the child would be discharged home that day before 3 PM and to call with any concerns about sending him home. The physician noted he would call ACS again and will discharge the patient "today".

Final nursing documentation reviewed on 4/21/10 showed the patient was discharged at 2:20 PM on 4/21/10 with no report of ACS disposition or approval of the plan. There was no validated follow up by hospital staff to ensure ACS approval of the plan to return home and to verify safe discharge planning.

Staff failed to incorporate significant information into care plans, which resulted in inadequate discharge plans. Specifically, treatment plans dated 4/8 and 4/15/10 did not incorporate the outstanding issues with ACS regarding the need for child welfare agency clearance for this minor prior to discharge.

MR #20:
The facility failed to incorporate issues into the care plan to ensure patient safety. The care planning for this patient was incomplete because it did not incorporate the housing need of the patient along with outstanding legal issues and also did not include assessment of the patient's capacity in her refusal to plan for these matters. This 28 year old undomiciled patient was discharged on 4/9/10 with an unsafe plan. She was homeless and was discharged without evidence of validated housing arrangements. The patient was admitted on 4/2/10 for treatment of symptoms of psychosis, including response to internal stimuli and auditory hallucinations. The patient's decompensation and disorganized behavior was attributed to noted noncompliance with medication. The patient's history was significant for chronic disorganized type schizophrenia and cocaine dependence.

The discharge planning assessment was inadequate. The concrete needs assessment in the medical record, which included an assessment of forensic history, was not recorded for the current admission. A previous assessment on 5/13/09 recorded the patient had a history of incarceration for 10 assaults. This matter was not appropriately followed up during the current admission and this significant issue was not properly incorporated into care planning.

It was noted during the current admission the patient had been in jail for one year and was recently released three days prior to the current hospitalization. The patient was required to attend inpatient MICA ( Mentally Ill Chemical abusers) treatment but had admitted she never presented for treatment. The patient has a parole officer but expressed she was afraid she would have to go back to jail if the parole officer learned that she failed to show for treatment.

The patient was converted to voluntary status during hospitalization and submitted a 72 hour notice for discharge. The patient advised the social worker at 0846 on 4/19/10 that she would either stay with a friend or go to a shelter; she could not provide the name or contact information for the friend. The patient refused shelter or residential MICA treatment and refused to grant permission for the social worker to contact the parole officer. This deficit in planning should have triggered a more comprehensive reassessment of the patient's reality testing, insight and judgement.

The psychiatrist assessed the patient at 10:12 AM on 4/19/10 and found the patient stable for discharge to the community. No information was included about the lack of housing or the safety of discharge to the community. The patient's refusal to follow up with the parole officer was significant secondary to lack of compliance with the treatment directives from parole. The legal status of the patient should have been reassessed for safety in allowing this patient to leave on voluntary basis without a viable discharge plan. The patient's refusal to plan for safe housing was not clinically correlated with her psychiatric condition to determine if discharge was feasible.

The aftercare plan dated 4/19/10 included an outpatient mental health appointment with a calendar date. However, there was no appointment for medical follow up given the patient's history of hypertension and the aftercare plan noted for health care services that "no referral was necessary." This aftercare services plan noted "none" under the section for identification of safety concerns. This reassessment was inadequate given the patient's lack of safe planning for housing and to establish if a safety risk was presented by the failure to consider the legal consequences of failing to coordinate with parole.

At interview with the social worker and psychiatrist on 4/19/10 at 3 PM, it was reported to the surveyors that the patient refused shelter placement and refused permission to contact her parole officer.

On 4/21/10, a supplemental record was provided to the surveyors indicating a social work note had been added to the record on 4/20/10 at 0947 hours. This note indicated that an attempt was made to contact the MICA day treatment program on 4/14/10. The social worker was advised to call back on 4/19/10 due to the worker's absence. The note indicated the patient refused to wait for (Program Referral Unit) "PRU" shelter placement, stating that she could just walk into a shelter or stay with a friend. At that time, there is no evidence the social worker intervened to identify that applicants for shelter do not walk into PRU and that this statement issued by the patient was not a safe or viable discharge plan. The PRU unit places patients who have been cleared medically by a medical review team contracted by the New York City Division of Homeless Services and this process requires a paper referral by the provider and clearance in advance of discharge.

According to the medical record, the patient left the unit on 4/19/10 at 1135 AM. There is no evidence, either from record review or interview with the social worker, that follow up contact was made with the MICA program staff. As a result, there was lost opportunity for follow up. There was no documented way to contact this patient.

Staff failed to incorporate significant information into care plans, which resulted in inadequate discharge plans. Specifically, treatment plans dated 4/7 and 4/12/10 did not incorporate the outstanding issues related to housing, MICA treatment, parole, and legal concerns. The patient's unwillingness to cooperate with efforts to contact parole were not included in care planning. The 4/7/10 care plan did not contain input from all professional staff, including lack of social work input. The 4/12/10 updated treatment plan lacked input by nursing and social work.


16399

MR #22:
This patient was admitted on 4/7/10 with a diagnosis of depressive disorder due to general medical condition. The aftercare services plan dated 4/14/10 indicated the patient expressed concerns about her husband's potential for domestic violence. There was no evidence the psychosocial needs of the patient were recognized and appropriate interventions were provided. The issue of concern about domestic violence was identified prior to discharge but not addressed. The patient's discharge plan did not include appropriate referrals to provide counseling, education and assistance to the patient.

#2.
Based on observation, interview, and record review, it was determined the facility staff did not ensure accurate monitoring and record keeping of patients on special observation levels. An instance of charting a patient observation in advance by staff was observed during unit tours.

Findings include:

MR # 21:
This is a patient with a long history of multiple psychiatric hospitalizations who was admitted on 3/19/10 for depression and suicidal ideation. The patient was maintained on level I precautions from 3/20 to 4/2/10 and on level II from 4/2/10.

The patient was interviewed on 4/20/10 at 11:00 AM in the Quiet Sensory Modulation Room in the presence of the unit psychiatrist and social worker. At 11:02 AM, the Patent Care Technician was approached in the hallway; it was observed the staff had documented her observation of the patient in advance for 11:15 AM.

Staff was interviewed after this occurrence and confirmed this event. The observation of the patient had been charted in advance of the time actually noted on the observation form.

This is a repeat deficiency from the November 2009 survey. The facility was to have implemented corrective measures to assure that observation forms are accurately documented.

#3.
Based on record review and staff interviews, it was determined that the hospital failed to provide a safe environment free from harm for two patients who were discovered to have inappropriate sexual contact while on the inpatient unit.

Findings include:
MR's # 18 and 19
The hospital did not ensure appropriate monitoring to prevent adverse patient outcomes.
During an inpatient tour conducted on 4/19/2010, it was noted during reviews of MR #s 18 (male patient) and #19(female patient), that both patients had been discovered by staff in the female patient's bathroom on 4/15/10. Both patients subsequently acknowledged oral sexual contact had occurred on 4/15/2010.

Additional review of MR #19 revealed the facility failed to maintain a safe level of observation for this patient upon transfer from the emergency CPEP unit to the inpatient unit. The patient's observation level was downgraded to level 2 observation every 15 minutes upon inpatient admission, despite a clinical indication to maintain a continuous level I observation.

The patient was triaged in CPEP on 4/14/10 at 1:14 PM. The patient called 911 because she was hungry and was in need of evaluation as she had not taken medication. The patient's history is significant for schizoaffective disorder, hypertension, and diabetes. She presented with disorganized, illogical thought and pressured speech. It was significant that on 4/15/10 at 3:07 AM, the patient became physically assaultive, necessitating the application of 4- point restraints and 1:1 monitoring. At that time the BROSET violence checklist rating scale assessment was scored as 7. This tool helps to predict violent behavior during the next 24 hours. It requires reassessment daily until the patient scores less than 2. At 8:47 AM , the patient was reassessed and scored 2. The patient scored 0 on the sexual risk assessment. However, according to the BROSET guidelines, the patient should have been maintained on a level I observation for the next 24 hours, until scoring less than 2. However, prior to the incident of sexual contact, the patient was maintained on a less frequent level 2 (15 minute) observation for assaultive, aggressive, and disorganized behavior.

The staff failed to provide an adequate level of monitoring to the patient referenced in MR # 19, despite evidence of earlier behavior involving interaction with a male patient that was observed by staff prior to the event. Staff did not take immediate action to monitor this patient, following an observation made that she was interacting with a male peer that resulted in a need for redirection from staff.

The staff did not intervene to monitor this patient appropriately upon noticing an inappropriate interaction with a male peer on the unit prior to the event. The female patient was approached by staff at that time and redirected. The staff was instructed to perform an immediate sexual risk assessment in order to place the patient on continuous monitoring. Several minutes later, at 7:10 PM, the staff discovered both patients in the female patient's bathroom. The patient was found by staff in her bathroom seated on the toilet wearing her hospital gown with the male patient hiding behind the bathroom door. The female patient described she was asked by the male patient for a sexual favor and provided oral sex. While the male patient initially denied the sexual contact, he subsequently acknowledged both had engaged in consensual oral sex.

Following the incident, a nursing note documented at 22:39 hours on 4/15/10 reported that the patient had been observed on the unit restless and anxious. She was medicated. The note indicated the client was interacting with patient referenced in MR #18. At that time, the staff was instructed to perform a sexual risk reassessment on the patient, in order to start her on 1:1 observation.

The facility's incident report and report of investigation was incomplete. The report failed to document an investigation to determine how the male patient was able to enter the room of the female patient when a hallway monitor was assigned to patrol the corridors leading to patient bedrooms at all times.

#4.
Based on review of records, the hospital did not ensure that accurate monitoring of patient observation levels were properly implemented in accordance with physician orders. Specifically, there was a lack of correlation identified between observation level orders, nursing assignment records, or progress notes.

Findings include:

Review of nursing assignment records on 4/20/10 determined there was lack of monitoring of patient safety due to lack of coordination to ensure accurate observation levels were implemented.

Two instances were identified for inaccurate entries of patient observation levels which did not match physician orders or bed list records. An additional instance was identified for a discrepancy in observation level assigned between physician order and progress notes. Consequently, inconsistencies noted between assignments, orders, or progress notes for observation levels has the potential to compromise patient safety as it may lead to a higher risk of errors in monitoring.

Specific reference is made to review of assignment records during a tour of unit R5 East at 12:05 PM on 4/20/10. It was noted on the tour II nursing assignment record that two patients were assigned to the nurse to be monitored every 30 minutes (MR #s 16 , 18) However, review of bed list records determined that both patients were assigned to level 2 monitoring, which requires more frequent monitoring every 15 minutes.

Examples :

MR #16:
This patient was assigned to the nurse for monitoring every 30 minutes during tour II on 4/20/10 per the nursing assignment sheet. However the bed list noted the patient was assigned to level 2 monitoring every 15 minutes for aggressive, assaultive, and sexual risk.
Review of the physician orders on 4/23/10 determined that this patient was required to have level 2 monitoring for assaultive and sexual preoccupation.

MR #18:
This patient was assigned to the nurse for monitoring every 30 minutes during tour 2 on 4/20/10. However, the bed list sheet determined the patient was supposed to receive level 2 monitoring every 15 minutes as required for sexual risk precautions. Review of physician orders from the medical record on 4/23/10 determined the patient was ordered by the physician to require level 2 monitoring every 15 minutes due to sexual risk.

MR#2:
During tour of unit R5 West on 4/19/10 at 3PM, it was determined there was a discrepancy noted between the physician observation order and the progress notes in patient MR #2. The patient was admitted to the hospital for assessment of suicidal risk after being raped by a friend. The patient's history is significant for bipolar depression and OCD. The patient had been on level I continuous observation which was downgraded to level 2 observation for sexual precautions/victimization. The physician's orders dated 4/19/10 indicated that the patient would receive level 2 (every 15 minutes) monitoring from 8 AM to 8PM and then be upgraded to level I continuous monitoring 8 PM to 8 AM. However, review of progress notes indicated the patient's would be on level II from 8 am to 8 PM and again on level II from 8PM to 8 AM. When this discrepancy was brought to the attention of staff by the surveyor, the psychiatrist acknowledged this inaccuracy and documented a corrected note at 3:04 PM, which indicated the change to level I observation level at night as originally ordered.

THIS IS A REPEAT OFA DEFICIENCY FROM A PRIOR SURVEY CONDUCTED OF THE FACILITY ON 11/9/09, WHERE IT DETERMINED UNDER 482.13(C)(3), TAG # A145 THAT THERE WERE GAPS IN STAFF ASSIGNMENTS WHICH FAILED TO ENSURE PROPER MONITORING OF PATIENTS.

Please refer to findings noted under tag # A291 that relate to the facility's failure to monitor corrective action plans effectuated from prior surveillance activities on 11/9/09 related to inconsistencies in staff assignment for patient monitoring and care.

#5.
MR#3
Review of this record identified a lack of and inconsistencies in documentation that could impact patient care and safety. Specific reference is made to lack of clarity in documentation of patient observation levels. Additionally, treatment plans were not complete and staff failed to follow procedures related to the care of potentially violent patients.

There is not a treatment plan in the patient's medical record. A treatment plan update signed by the patient and team members on April 14, 2010, lacked date of review, current legal status, evidence that the KPC (Kingsbrook Psychiatric Center) application had been submitted, and current risks. The second page that includes areas of focus, current medications, patient adherence to medications, group and other activities, etc is blank.

Staff members did not use the same standard documentation to indicate the level of observation. Staff interchangeably used different characters to denote observation levels. Facility staff used both numeric and. alphabetic characters, which could potentially affect patient safety.

There is a notation in the medical record for Thursday April 15th at 1530 indicating that the patient in on "q15 observe level II (q 15 minute)". Nursing documentation on this date at 1416 and 2224 noted that the patient was maintained on "q 30 minute observations".

On April 16 at 1001, the physician documented that the patient exhibited disorganized behavior, hostile, agitated and loud and was noted to be a danger to self and others. The patient was medicated with intramuscular Haldol and Ativan. Observation level was noted as "11 for assault". It is not clear based on the documentation, if this meant the patient was on one to one observation or a level two observation. There is a notation on the same page of the medical record, that appears to be an order resolved on Sunday April 18 at 0028, that the patient is on "observe Che Level II (q 15 min)". At 1302 when the RN documented the incident at 9AM, the nurse noted that the patient was placed on " Level II" observation for assaultive/aggressive behavior. At 1339, the psychologist noted that the patient, who is male, was maintained at a "Level I" observation for her safety. At 1357, the RN noted that the patient was placed on "Assault level II" observation. At 1629, the physician noted the patient's threatening behavior and that a team meeting was held. The plan was that patient will be monitored on "one to one" for his assault/agitative and disruptive behavior. There is a notation timed at 1510 on April 16 that the observation level is Level I, (1:1). However, there is no indication that this plan was implemented. The patient observation record for this date of service noted that the patient is on observation level: assault II, "2 q15 minutes observation".

On Sunday April 18, there is a notation at 0905, that the observation level is "II". On April 18 at 1322, the nurse documented that the patient is now "level 2" for assaultive and aggressive behavior.

On 4/21/10, at 1805, the MD noted that a code orange was called. The physician documented that the patient lacks insight and judgment. The patient is a danger to self and others. The patient was medicated with Haldol and Ativan, and the plan was to start level "11" observation for assaultive and disorganized behavior. On 4/22/10 at 0046, the RN documented that the patient remains on assaultive "level 2", patient is unmanageable and very dangerous.

During a tour of the unit R3E on 04/21/10, at approximately 1130, this patient was observed to be increasingly agitated and began speaking very loudly to members of the survey team who were standing at the nurses' station. Several staff members were at the station but failed to implement specific calming measures as outlined in the facilty's policy "The Assessment and Management of High Violence Risk Patients".

Based on observation, interview and review of MR # 27, facility staff failed to provide appropriate care for this patient. Specifically, the hospital staff did not monitor restraints to ensure they were implemented using safe and appropriate techniques and in accordance with accepted standards of practice.

Findings:

The patient was observed in the CPEP on 4/19 and 4/20/10 in forensic restraints. During tours of the units on both dates, the patient was noted to be lying flat with his left arm handcuffed to the stretcher base. A police officer and staff member were observed sitting near the patient.

The medical record lacked documented evidence of on-going and appropriate assessments and provisions of care including nutrition and hydration, circulation assessment and range of motion in the patient's extremities; deep vein thrombosis assessment and prevention; vital signs; hygiene and elimination; assessment for signs of injury, physical and psychological status and comfort, and assessment of the forensic restraint. Specifically, nursing staff failed to document on-going patient monitoring and assessment of the physical and psychological well-being of the patient who was in a forensic restraint.

On 4/21/10, an interview was conducted with the CPEP's head nurse and the Assistant Director of Nursing. Both confirmed that the medical record lacked evidence of appropriate care and assessments.

Based on staff interview and review of quality improvement reports and meeting minutes for Behavioral Health for 2010, it was determined the facility did not fully review and analyze incidents involving unexpected adverse patient outcomes.

Findings:

The hospital did not ensure that incidents occurring in the Behavioral Health division were thoroughly reviewed and analyzed to determine if standards of medical and psychiatric care were met.

During review of Special Incident Review Committee (SIRC) meeting minutes on 4/22/10 for 1/20/2010 and combined reports for 2/17/10& 3/11/10, it was determined the facility is not ensuring thorough and complete incident review analysis as noted below.

The facility's internal investigation is not consistent with information in the patient's medical record. The internal investigation noted that patient was found by a PCT (patient care technician), unresponsive at 4:17 AM, an RN evaluated the patient and a code was called, CPR was initiated at 4:24 AM. However, the medical record documentation states that the patient was found unresponsive at 4:30 AM and CPR (cardio-pulmonary resuscitation) was started at 4:30 AM.

The facility's Quality Assurance review noted that nursing reported that the patient had loud snoring which disturbed his roommate and the roommate was moved to a different room in the early hours of January 20, 2010. There was no documented evidence in the patient's progress notes regarding this finding. It is not clear based on documentation when the patient started exhibiting loud snoring respirations. There is a nursing note dated January 20, 2010 and timed 3:30 AM, however, after this entry, there is a lack of nursing documentation describing the circumstances surrounding the cardiac arrest when the patient was found unresponsive and actions taken prior to arrival of the code team.

Both the facility's internal quality assurance investigation and SIRC minutes failed to identify that the patient was not started on his psychiatric medications that were taken at home for bipolar disease and depression as well as the potential clinical consequences of not continuing these medications.

Both the facility ' s internal quality assurance investigation and SIRC minutes did not identify that the nursing documentation was not on the standardized Cardiac Resuscitation Form and that the hand written note on patient ' s Progress/Communication Record regarding resuscitation did not include the following documentation: cardiac rhythm strips, cardiac rhythm at start, during, and at end of resuscitation efforts, dosages and routes for all emergency medications given (atropine, epinephrine, sodium bicarbonate, and calcium chloride), rate of IV fluids, date of arrest, labs drawn besides arterial blood gas at 04:39, the staff involved in resuscitation by name and title, the percentage FIO2 and route of oxygen supplied to the patient including times, and signature of person documenting note.

The facility 's internal quality assurance investigation failed to identify that the patient was not resuscitated per ACLS guidelines due to both a delay in CPR and inaccurate, incomplete documentation by nursing and members of the resuscitation team.

The facility's internal quality assurance also did not explore whether a reversal agent such as Narcan should have been considered prior to arrest or during the resuscitation of this patient.

Both the facility's internal quality assurance investigation and SIRC minutes did not identify that the vital signs were not taken as ordered per protocol every 8 hours. Vital signs on January 19, 2010 at 1700 were BP 137/77, pulse 90, RR 18, TEMP 97.8. No vital signs were documented after 1700. The patient was found unresponsive 04:17 on January 20, 2010; 11 hours and 17 minutes after the last set of vital signs.

The facility's internal quality assurance investigation was not thorough and credible.
It did not include a comprehensive timeline, identification of all causal and contributing factors, identification of all actions that would greatly reduce or eliminate the causes, all appropriate measures for monitoring the actions, and a complete literature search.

Based on interview with facility staff including the nurse manager of R2 E, documentation of vital signs in a hybrid medical record can be done in either the paper and/or electronic-health record. This could be a potential care issue for clinical staff since, it could result in an inability to trend changes in vital signs over time, unless a clinician reviews both the electronic and hardcopy record. It is also difficult to assure that vital signs are taken per Q 8 hour intervals as ordered by protocol. This could potentially impact patient care/safety on R2East. These issues with the hybrid medical record were not identified in the quality assurance review or SIRC minutes.

Based on medical record review, there were 5 sets of vital signs recorded electronically.
Some vital signs were documented in both the e-HR (electronic health record), and the progress notes, but the times were discrepant. Vital signs taken at 10:59 on 1/19/2010 per e-HR were BP 159/86, Pulse 115, Resp 21, TEMP 98. The same BP and TEMP were documented in the progress notes at 14:00 on 1/19/2010. Vital signs at 17:00 on 1/19/2010 per the e-HR were BP 137/77, Pulse 90, Resp 18, TEMP 97.8. The same vital signs were documented in the progress notes at 00:20 on 1/19/2010. According to the chronology of the progress notes the date should have been 1/20/2010. Upon interview, the nurse manger stated this set of vital signs were taken around 18:00 on 1/19/2010 but charted at the end of the RN's shift.

Both the facility's internal quality assurance investigation and SIRC minutes did not identify that there is not a standardized documentation process for nurses and physicians to record physical and psychological assessments of the patients on R2East Detox, on a every 8 - 24 hour basis including: absence, presence, intensity, frequency and specifics of withdrawal symptoms, and response to detoxification treatment regimen.

The facility's internal quality assurance investigation did identify that the patient was on both Methadone and Kaletra, medications that can cause PR and QT interval prolongation and cardiac arrhythmias. Despite being on multiple medications that can cause cardiac arrhythmias, the treatment plan did not identify the possibility of life threatening cardiac arrhythmias and changes to both the monitoring and medical management of this patient. Corrective actions were not identified by the facility except for obtaining a baseline EKG on all Methadone patients. The facility failed to identify how the treatment plan could be modified in the future for patients that are on one or more medications that can cause PR and QT interval prolongation and cardiac arrhythmias that have EKGs that actually show either will be monitored and have their treatment plan modified based on the EKG results.

The facility's review also failed to note the abnormal laboratory results that were obtained during the resuscitation or consideration of other factors regarding this patient's demise including cardiac arrest from a prolonged QT interval, arrhythmias, sleep apnea, hyperkalemia, seizures, oversedation.



16323

Based on review of the facility 's incident reports for the behavioral health program, the facility failed to provide evidence that the overall problems were assessed and that corrective measures were implemented.
Findings:
On 01/28/2010, three incident reports were completed (one report for each patient involved in the incident) indicating that a pair of scissors was not accounted for at the end of art therapy on the adolescent unit, (R6E). The facility provided surveyors with e-mails that occurred between behavioral health staff addressing the incident and immediate actions taken to assure patient safety; however the facility's investigation of these incidents lacked discussions/conclusions regarding implementation of measures that would prevent reoccurrence of the same situation.
Additionally, the facility's Plan of Correction for the deficiencies cited as a result of surveillance activities in November 2009, stated that an Incident Investigation Summary Sheet will be used to provide for a comprehensive systemic approach for incident investigations. There was no evidence that this was done. A blank Incident Investigation Summary Sheet was attached to these three incident reports. Further review of the facility's incident reports identified multiple incidents with blank Investigative Summary Sheets.

Based on review of documents and records, it was determined that the facility failed to monitor the effectiveness of corrective actions implemented for previous deficiencies issued for inconsistent staffing assignments and patient observations. Repeat deficiencies were identified during the current survey for inaccurate patient monitoring, gaps and inconsistencies in staffing assignments.

The facility failed to monitor corrective measures planned to address previous deficiencies regarding inconsistencies in patient assignments and observation levels identified during a prior survey ending on 11/9/09 for regulations 482.13(c)(2) and 482.13(c)(3)(tag #s A144 and A145).

The facility's POC included multiple activities, including collaboration between charge or head nurses with attending psychiatrists to ensure the accurate assignment of patient observations on assignment sheets. Additionally they planned to ensure monitoring by the ADN during each tour for proper patient monitoring and supervision.

Recent surveillance activities ending on 4/23/10 determined the facility failed to effectively ensure implementation of their plan of correction.

Repeat deficiencies include:
-inaccurate observation of patient care;
-inconsistencies between staffing assignments and physician orders for patient monitoring and observation levels;
-incomplete staffing assignments that did not include specific staff allocated for patient needs.
Cross-refer to deficiencies listed under tag #s A144 and A291.


16323

Based on document review and interview, the facility failed to assure that corrective measures instituted in January 2010 were implemented. Specifically, unit assignment sheets lacked a responsible staff member for glucose monitoring on two units.

Findings:

The facility's plan of correction submitted to CMS following a federal allegation survey conducted in November 2009, noted that the Assistant Director of Nursing would ensure that the unit assignment sheets would reflect coverage for responsibilities and tasks. During a tour of R3E on 4/21/10 at 1100, it was noted that the morning blood glucose monitoring was not assigned for 0800. This was confirmed with the ADN. The monitoring sheets done by the ADN to assure completeness of the assignment sheet were requested by survey staff, but was not received.

During a tour of R2E at 1500 on 4/21/10, it was also noted that the blood glucose monitoring had not been assigned for Tour II. The head nurse was questioned regarding this omission. The head nurse indicated that no one on the unit required blood glucose monitoring, however, a review of the clinical daily report for that day indicated that there was a diabetic patient on the unit.




16399


Based on review of documents the hospital did not ensure compliance with the monitoring of planned corrective action activities for provision of required patients' rights notification.

Findings include:

The hospital's plan of correction submitted on 12/23/09 planned to prospectively monitor a random sample of 30 medical records monthly to ensure fulfillment of compliance with patients' rights requirements. However, the facility did not ensure that monitoring included validation that patients' rights information was actually received and understood by the patient or the designated representative.

The results of the facility's review for March 2010 noted one hundred percent compliance with placement of the Status of Rights form in the sampled medical records. The facility, however, did not track the medical records for compliance with notification of rights and for follow-up of patients who were psychiatrically unstable on admission, in order to validate notification of the patients' rights were provided when deemed appropriate.

Based on observation, interview and review of medical records, the facility failed to assure that patients who presented to the CPEP seeking treatment were afforded the rights to receive treatment consistent with standards of care for emergency services and that requirements for the emergency department are met.

Findings:

During observation and interviews conducted on 4/19/10, it was observed that patients who present to the CPEP are not evaluated/triaged by nursing staff upon presentation to the facility. Patients are first met by hospital security staff and are entered into a log maintained by the the security staff. The patients are then directed into a Salliport where a "mini-registration" is done. Patients are escorted into a room for a pre-search. Based on interview with CPEP staff, patients are then triaged within thirty minutes of arrival.

Presentation of a patient to the CPEP was observed by survey staff on 4/19/10 at approximately 11:30. The patient had been transported to the hospital by EMS. Information was given to the security staff by EMS, the patient was then brought in to the Salliport area where information was obtained by the registration clerk. The patient was taken to the examination room for the initial search. EMS was still accompanying the patient at this time. The patient was taken from the examination room to the triage area. There was no evidence that the patient had been assessed by nursing staff up to this point. EMS staff was interviewed by survey staff regarding the report of the patient's condition to nursing staff. EMS staff responded that they needed to have "the paperwork signed" before they could leave but had not yet reported any information about the patient to nursing staff.

Based on observation and interview, the hospital has limited signage at the main entrance of the R building regarding the location of the CPEP for patients who present through the main door seeking emergency medical care. Additionally, based on interview, it was not evident that all hospital staff are trained on the procedure for patients who present to the facility seeking emergency medical (psychiatric care) or that patients would be able to readily access help for an emergent condition.

Findings:
Hospital police, who are seated at the main door of the R building, were interviewed on 4/19/10 at approximately 1500 regarding presentation of patients through the main door who are seeking treatment for an emergency psychiatric condition. Survey staff were informed that those patients would be directed to the CPEP. Survey staff were directed to a long corridor with limited signage to the CPEP. There are doors to the CPEP from the hallway that are locked, a speaker on the wall is intended as a means of communication with the security staff in the CPEP, but it was not labelled as such on 4/19/10.
This was brought to the attention of facility staff during a tour on 4/19/10. The facility had added signage for the speaker when the survey staff returned on 4/20/10.

Based on observation, the CPEP failed to comply with Federal regulations regarding posted notices and patient logs.

Findings:

During the tour of the CPEP on 4/19/10, it was noted that the facility failed to post conspicuously in the CPEP department (i.e., entrance, admitting area, waiting room, treatment areas, etc) a notice outlining the rights of all patients in compliance with the Emergency Medical Treatment and Labor Act.

Survey staff reviewed the CPEP's patient log. It was noted that the patient log did not include a chief complaint. This finding was brought forth to facility staff. This was corrected while survey staff were on-site.

Based on observation and interview, the CPEP lacked an effective process to assure that staff were aware of their specific tasks and assignments.

Findings:

During a tour of the CPEP on 4/20/10, it was noted that no one was assigned the task/responsibility of checking the crash cart. The crash cart logs were reviewed. The logs lacked evidence of routine monitoring on 4/18 and 4/19/10 and a defibrillator check on 4/19 and 4/20/10. The AED,automatic external defibrillator, lacked evidence checks on 4/18, 4/19 and 4/20/10 during tour 1 and 4/19 and 4/20 on tour 3.

It was confirmed during interview with the head nurse on 4/20/10, that a staff member had not been assigned the responsibility for the checks.

The assignment sheet also failed to note assignments for 15 minute observations checks. The head nurse had a personal copy of staff assignments for the checks but there was not a unit sheet available so all staff could readily check assignments and responsibilities.

These findings were brought forth to facility staff at the time of survey. The assignment sheet for the CPEP is in the process of being revised to include specific tasks and assignments.