HospitalInspections.org

Based on interview and the review medical record, it was determined the facility failed to afford patient the right to care in a safe setting. This finding was noted in 1 of 6 applicable records reviewed (Patient #1).

Findings include:

Patient #1 is a 48-year-old female with a history of Multiple myeloma since 2012; End stage renal disease on hemodialysis three times a week; bipolar disorder and a history of non-compliance with treatment regimen.

The patient presented to the Emergency Department on 9/28/14 with hypertension, acidemia (increased acidity of the blood), hyperkalemic (high levels of potassium in the blood), and pancytopenia (a deficiency of all types of blood cells) due to non-compliance with hemodialysis. The patient was emergently dialyzed; she was treated for bacteremia (presence of bacteria in the blood) and her infected hemodialysis catheter was consequently replaced.

The facility failed to implement appropriate safety measures for Patient #1 who was at risk for elopement and had been deemed to lack capacity to leave the facility against medical advice.

An initial psychiatric consult on 9/29/14 notes the patient was not cognitively impaired, but had poor insight and judgment. The team impression was that she might have initially been delirious due to her metabolic abnormalities and that she was now back to baseline. No further psychiatric intervention was required at that time and there was no evidence of an acute psychiatric disorder requiring further treatment.

However, a second psychiatric consultation obtained on 11/26/14 to determine patient's capacity to sign out of the facility "Against Medical Advice (AMA)" notes the patient had been refusing medications and treatments. The patient attempted earlier on 11/26/14 to elope from dialysis and was now asking to leave AMA. The patient had been medically stable for weeks and was awaiting placement in an outpatient hemodialysis center for continued treatment. The physician notes, "Patient is currently unable to understand treatment options and risks, benefits and alternatives in the event that she leaves the hospital". He notes that the patient is amendable to staying and does not require capacity consult at this time. The physician added, "If the patient expresses a wish to leave AMA without a change in her understanding of treatment, there would be concern for lack of capacity".

On 11/28/14, another psychiatric consultation was requested, as the patient was again demanding to leave AMA without having secured placement in an outpatient hemodialysis center. The patient eloped on 11/28/14 prior to psychiatric evaluation and the determination of capacity.

At interview with Staff #1 on 1/16/15 at 12:00 PM, she stated, a psychiatric consultation was placed on 11/28/14 with normal priority. Staff #1 reported that she advised the treating physician to place the patient on 1-1 pending psychiatric evaluation, and that the patient could be medicated for agitation if indicated. She stated the patient had already eloped before the psychiatric evaluation on 11/28/14.

The patient was neither placed on 1-1 nor medicated for agitation in accordance with psychiatric recommendation. The patient eloped and she could not be reached on her home telephone number, which prompted the facility to notify the patient's family and the New York Police Department.

Based on interviews, the review of medical record and other documents, it was determined the facility failed to ensure that restraints are applied in accordance with the order of a physician. This finding is noted in 2 of 6 applicable records reviewed (Patients #2 & #3).

Findings include:

1. Patient #2 is a 61-year-old male with past medical history of liver cirrhosis (chronic disease of the liver), and ascites (excess fluid in the space between the membranes lining the abdomen and abdominal organs). The patient was admitted on 9/23/14 for treatment of hepatic encephalopathy (worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood).
Review of restraints flow sheet on 1/15/15 noted the patient had two episodes of restraints application on 10/17/14 and 11/22/14 for the entire hospital course ending on 12/12/14.

The Restraint Flow Sheet on 10/17/14 revealed bilateral soft limb restraints were applied from 7:30 AM and discontinued at 7:00 PM. The preventive strategies attempted prior to the initiation of restraint was documented on the flow sheet by nursing staff, however, the rationale for the use of the restraint was not noted.

The facility's policy titled care of the patient requiring restraint/seclusion, last revised December 2013, notes that restraints may be applied with a written order from a Licensed Independent Practitioner (LIP) after face-to-face assessment of the patient. However, in emergencies of immediate danger, restraints may be applied by a registered nurse. The registered nurse must document the circumstances requiring use of restraint and must notify the prescriber immediately. In addition, the policy notes, the nurse is responsible for ensuring that a written order is obtained within 30 minutes of restraint application, and the registered nurse is expected to escalate communication if needed.

There was no face-to-face assessment of the patient prior to the use of the restraint or within thirty minutes of restraint use. There was no physician order for the application of the restraint.

The Restraint Flow Sheet on 11/22/14 revealed restraints were applied from 4:25 PM and discontinued at 6:20 PM. The nurse initiating the restraint failed to document preventive strategies/alternatives attempted prior the use of restraints. Also not documented was the type of restraint used and the rationale for the use of the restraint.

A written order from LIP was not obtained within thirty minutes of initiation of the restraint. An order that reads "Restraint - Nonviolent Patient, 1, Now and qs (every shift)" was written by a physician on 11/22/14 at 6:25 PM. It was noted the order for restraint application was written two hours after restraint application and five minutes after it was discontinued by the patient's nurse.

At interview with Staff #2 on 1/14/15 at 2:30 PM, she acknowledged that there was no order for the application of restraint on 10/17/14. She stated the restraint order on 11/22/14 was not obtained timely in accordance with the facilities protocol, and the order should not have indicated "qs" (every shift) because restraint orders for nonviolent/non self-destructive patient expire after 24 hours.


2. Patient #3 is a 33-year-old female with a past psychiatric history of Major Depressive Disorder, prolonged posttraumatic stress disorder, borderline personality, prior suicidal attempts and psychiatric admissions.

The patient presented to the Emergency Department on 1/17/14 escorted by her psychotherapist after concluding a treatment session in which she admitted to frequent and intense urges for self-injury, decreased ability to function at home and at work, as well as worsening suicidality with active suicidal ideation and a plan to overdose on Dilaudid.

On 1/18/14 at 10:30 PM, nurse notes, "patient continued to be angry, uncooperative, poor insight, denying any need for treatment. Patient wants to sign self out, threatening to cause trouble. Patient refused to be transferred to another hospital when ambulance arrived. Nurse noted that Haldol 5 milligrams (mg) was given intramuscularly with security officers' assistance.

At interview with Staff #3, psychiatrist on 1/16/15 at 12:05 PM, he stated the patient required medication on 1/18/14 for management of extreme agitation. He added that safe administration of the medication was accomplished with the help of security staff.

However, the patient's record revealed there was no physician written order authorizing the application of force to physically hold the patient, in order to administer Haldol intramuscularly.

The facility's policy on Restraints or Seclusion notes, "Physical holding of a patient in order to conduct routine physical examination or tests is not considered restraints", however; the policy failed to provide a guideline for the implementation of physical holding for forced medication of a violent patient.

Based on interview, the review of medical records and other documents, it was determined the facility failed to develop and implement an individualized care plan to assure that the care needs of patients at risk for developing pressure ulcers are met. Specifically, nursing staff failed to implement and document preventive measures for a patient at risk for developing pressure ulcers. This finding was noted in 1 of 5 applicable patient records reviewed (Patient #4).

Findings include:

Patient #4 is an 83-year-old male with multiple medical conditions who was admitted on 10/6/14 for treatment of a perineal abscess.

The initial "Nursing Admission Database and Flow sheet" on 10/6/14 notes the patient had a stage II sacral/coccyx pressure ulcer that was 2.5 centimeters (cm) x 5 centimeters (cm) in dimension. The patient was also identified at risk for developing pressure ulcers.

The nursing care plan developed on 10/6/14 for the treatment and prevention of pressure ulcers was not individualized to ensure prompt treatment of the patient's existing sacral ulcer, and did not ensure the implementation of adequate measures to prevent the development of pressure ulcers in accordance with the facility's policy.

The facility's policy titled "Pressure Ulcer Prevention and Treatment", last revised August 2014, notes "...if a pressure ulcer is noted during skin inspection, a provider order for treatment is required, and the dressing is applied and maintained as per that order".

An order was not obtained timely for the management of the patient's stage II sacral ulcer that was present on admission on 10/6/14. A physician order for treatment of the sacral ulcer was written on the third day of admission on 10/9/14 at 10:53 AM.

During the course of the patient's admission, he developed a pressure related injury to his left heel that was noted in the nursing assessment tool on 10/14/14 as a "Deep Tissue Injury", 3 cm x 3.4 cm in dimension. Nursing documentation did not include preventive measures for the patient's heels until the day of his discharge on 10/14/14 when a nurse indicated in the progress note that the patient's heels were elevated.

The facility's policy titled Pressure Ulcer Prevention and Treatment notes that "Heels require elevation using heel relief device. The policy further notes that a therapeutic support does not provide adequate pressure redistribution for the heels.

At interview with Staff #4 on 1/15/15 at 1:45 PM, she stated that nursing assessment of patient's risk factors for pressure ulcer development is documented twice daily, but nursing progress notes might not include all the preventive measures implemented for patients at risk for developing pressure ulcer.