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Based on interviews, medical record review, and review of Hospital Bylaws, the Governing Body failed to assure the Attending Physician and Hospitalist accurately assessed and documented the condition of Patient Identifier's (PI #1)'s right eye, removed PI # 1's right contact lens before irritation developed, and obtain specialized Ophthalmology care in a timely manner for a patient (PI # 1) identified with limited vision, and the inability to communicate physical symptoms, who developed a contact lens associated corneal ulcer and infection resulting in vision loss during hospitalization.

Findings Include:

PI # 1, a patient with a history of Bipolar Disorder, presented to the Hospital's Emergency Department (ED) on 2/10/11 due to anxiety, depression and violent behavior (reported by family as throwing things and exhibiting childlike behavior). PI # 1 has been overly anxious which precipitated a manic episode. The history, obtained from the patient and family, is documented as "limited, due to severity of condition."

According to the ED Physician's Review of Systems, PI # 1 is "positive for vision loss and blind in left eye."

The Physical Examination of the eyes reveals PI # 1's pupils are "equal, round and reactive to light. Extraocular motion intact."

Orders written by the Emergency Physician, document PI # 1's case was discussed with the Attending Psychiatrist (Employee Number # 1), who approves admission orders and assumes care of the patient (PI #1) upon arrival to the floor.

According to the "Nurse's Summary of Admission," dated 2/10/11, PI # 1 was admitted to the Psychiatric Unit due to a manic episode. PI # 1 reports "troubling" religious and political thoughts and knew she was heading into a manic phase. PI # 1 is described as disorganized, hyperverbal and pressured. The Registered Nurse documents PI # 1 has a contact lens in the right eye.

The History and Physical, dated 2/13/11 and documented by the Attending Psychiatrist (Employee Number # 1), reveals PI # 1 was brought to the hospital due to worsening anxiety, agitation and manic episode.

History of Present Illness: Over the past several weeks, she (PI # 1) has become increasingly disorganized, agitated, manic and bizarre. She decreased her Lithium dose. She has had poor sleep, racing thoughts and has been out of control at times.

Past Psychiatric History: The patient has a long history of bipolar illness with multiple psychiatric hospitalizations.

Review of Systems (ROS): A 14 point review of systems was noncontributory. (ROS: An organized and complete examination of a patient's organ systems as part of the workup when patient is first seen by a physician; an ROS is an inventory of body systems obtained by verbal history, with the signs and/or symptoms which the patient is experiencing or had. McGraw-Hill Concise Dictionary of Modern Medicine ? 2002 by The McGraw-Hill Companies, Inc.)
Physical Examination: PERRLA (Pupils equal, reactive, round, reactive to light and accomodation). Fundi benign. (fundus of eye: the back portion of the interior of the eyeball, visible through the pupil by use of an ophthalmoscope. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ? 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

Mental Status Examination Includes: The patient (PI # 1) was pressured, intermittently agitated and emotionally labile. Alert and oriented to time, day and place. Her speech was markedly increased in rate and volume, decreased in latency and quite pressured. Mood was silly. Affect labile. Thought processes illogical with poor goal direction and loosening of association. Positive for auditory hallucinations and grandiose/ paranoid and religious delusions. Insight and judgement impaired. Cognition mildly impaired.

Diagnostic Impression:
Axis I: Bipolar Affective Disorder (manic type), recurrent, severe with psychotic features.
Axis II: Deferred.
Axis III: See Medical History.
Axis IV: Problems with primary support group.
Axis V: Global assessment of functioning on admission: 25.

Plan of Treatment:
1. Admit to psychiatry...
4. Resume home medications
5. Add Thorazine p.r.n. (as needed)
6. Increase Lithium and Seroquel.

Examination of Cranial Nerves by EI # 1 on 2/11/11: ...Optic II: Distinguishes number of fingers in central field: Yes.
Distinguishes movements in peripheral field: Yes.

A Nursing Note, dated 2/14/11 at 1:30 PM documents PI # 1, "C/O (complaint of) L (left) eye pain and discomfort. Some redness noted. Pt. (patient) was encouraged to keep her hands out? her face. L eye was cleaned with saline water. Make-up was removed and pt. was instructed not to put makeup on L eye."

A review of Verbal Orders dated 2/14/11 at 6:30 PM, received from the Attending Psychiatrist (EI #1) documents, "...Consult Hospitalist per Conjunctivitis."

A review of Progress Notes written by the Attending Psychiatrist (EI #1) documents: 2/14/11: "....conjunctivitis OD (right eye), rather
pressured bizarre and loose - no insight...."
2/15/11: "...still quite loose and labile. Positive flight of ideas. Disheveled. Awaits hospitalist eval (evaluation)..."

There is no documentation in the medical record that PI # 1's eyes were examined by the hospitalist as ordered by the attending psychiatrist (EI # 3) on 2/14/11.

A Nursing Note, dated 2/17/11 at 1:50 PM documents, "Pt. (patient) eye red and watery. Contact removed by writer from R (right) eye.
Dr. (name of Attending Psychiatrist (EI #1) notified."

A Physician Order dated 2/18/2011 documents, "...Tobradex eye drops ii OD (right eye) q (every) 4 hrs (hours) while awake..."

A Progress Note dated 2/21/11 by the Attending Psychiatrist(EI #1) reveals, "Pt. (patient seen)...very labile, pressured and disinhibited...decreased scleral injection..." (sclera: a clear tissue that covers the white of the eye) (?1996-2011 MedicineNet, Inc.) (injection: Congested. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ? 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved).

A Nursing Note dated 2/24/11 at 7:50 AM reveals, "...Eye redness noted...drooling, difficulty with ambulation, eye drainage from right eye. Blurred vision. MD (Medical Doctor) paged - order noted."

The first documented Physician's Order on 2/24/2011 is a verbal order received from the Attending Psychiatrist (EI # 1) at 4:00 PM for, "Tobradex Opth (Ophthalmic) 1 drop each eye qid (four times a day)."

According to a Progress Note documented by the Attending Psychiatrist (EI #1), and dated 2/24/11 at 4:00 PM, "Patient's eyes still draining, very injected..." (Injected: Congested. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ? 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved).

A Nursing Note dated 2/24/11 at 5:00 PM documents, " Lethargic and drooling. R (right) eye shut due to infection..."

The next Physician Order, dated 2/24/11, written by the Attending Psychiatrist (EI # 1), documents, "1. Resume Tobradex eye drops 1 gtt (drop) OD (right eye) QID (four times a day). 2. Consult hospitalist for eye infection..." (The order was not timed by EI # 1. However, the orders were signed off by a nurse at 5:45 PM.)

A Summary of the "Stat" (documented stat by the Hospitalist/EI # 4) Consultation dated 2/24/11, reveals eye infection as the reason for consultation. The Eye Examination Includes: The left pupil is round and reactive to light and accomodation. Conjunctiva is clear. No signs of redness or injection.

The right eye has "copious yellow purulent appearing discharge. Eyelid appears stuck due to discharge. The patient (PI # 1) states she has
photophobia and tries to keep her eye closed. Resists attempts to open it." Upon manual inspection of the eye, her conjunctiva is very red
and erythematous. The cornea is clear without any lesions. There is normal gross acuity. The entire eye exam is limited by lack of cooperation.
The patient states that her eye is painful.

Assessment: Bacterial Conjunctivitis. There is no evidence of keratitis as her cornea is clear without lesions.

Plan: Will treat with erythromycin ointment tonight for bacterial conjunctivitis and get a formal ophthalmology consult in the morning.

A review of an Ophthalmology Consultation dated 2/25/11 at 12:05 PM reveals: "Two week history of pain, redness and irritation OD (right eye). Examination of Right Eye: 2 + injected with mucopurulent discharge. Large K (corneal) ulcer with K thinning (10-20 %). C.L. (contact lens) associated K ulcer OD. Very concerning with K thinning and size of ulcer. Very poor prognosis that vision will recover. More concerning that cornea will perforate necessitating emergency K transplant. Will perform C&S (culture and sensitivity) and stains of K ulcer..."

An Ophthalmology Progress note dated 3/1/11 at 11:30 AM documents, "...Pseudomonas K (corneal) ulcer OD (right eye); Slightly better...See again in 2-3 days."

However, the next documentation in the medical record regarding an Ophthalmology evaluation is 3/7/11 (six days later).

During an interview on 4/7/11 at 10:20 AM, PI # 1's Attending Psychiatrist (EI # 1) indicated PI # 1 had been wearing a, "Left extended wear contact lens" that was removed by a staff member. Inflammation was noted on the second day of PI # 1's hospitalization. EI # 1 describes the patient (PI # 1) as, "Delirious, a more manic patient than I have seen in a while. "Unable to communicate physical symptoms," confused, disorganized, and very manic with hallucinations. EI # 1 stated he did not know the recommendations from the Hospitalist consultation that was ordered on 2/14/11. "Our nurses are anal retentive about consults." According to the Attending Psychiatrist (EI # 1) it looked like, "Pink eye..."

During an interview with Registered Nurse (RN/EI # 6) on 4/7/11 at 3:50 PM, the RN says he worked 3:00 PM to 11:00 PM on 2/14/11.
According to EI # 6, the on-call hospitalist who evaluated PI # 1 on 2/14/11 was a Hospital (EI # 3). The RN (EI # 6) reports the Hospitalist (EI # 3), "Briefly talked to the patient (PI # 1) and looked at her eye." The RN described EI # 3 as, "Overwhelmed, the Emergency Room was busy." Reportedly, EI # 3 (Hospitalist) said he planned to "formally" see PI # 1 the next day."

According to a Registered Nurse (EI # 5), during an interview on 4/8/11 at 10:25 AM, PI # 1 approached the nurses' station and said, "I got a contact lens in my eye and it's stuck." The RN reports the Attending Psychiatrist (EI #1) was notified and "advised" staff to flush the eye with saline and remove the contact. EI # 5 states she did not document this physician's order in PI # 1's medical record.

During an interview on 4/8/11 at 11:00 AM, the Ophthalmologist (EI # 2) (see ophthalmology evaluation dated 2/24/11), confirmed PI # 1's
right eye corneal ulcer is, "In all likelihood secondary to contact lens." According to EI # 2, PI # 1's eye was red and injected, but not swollen.
There was a mild to moderate amount of drainage. A pseudomonal infection, described by EI # 2 as, "Common for contact lens ulcers," was identified. PI # 1 has extensive scarring of the cornea and, "Will probably need a transplant after the eye is calm," according to the Ophthalmologist (EI # 2).

During an interview with a Hospitalist (EI #3) on 4/8/11 at 11:15 AM, the physician stated, "I went to see the patient. I examined her eye very quickly to make sure it was not life threatening. It looked like viral conjunctivitis." EI # 3 was identified by a staff nurse as the physician who allegedly responded to a hospitalist consultation ordered on 2/14/11 for PI # 1. According to EI # 3, he planned to return that night to complete a more thorough examination, but he was "too busy. I forgot the next day." The Hospitalist (EI # 3) confirms he did not document his evaluation in PI # 1's medical record. EI # 3 reports he did not see a contact lens in PI # 1's eye on 2/14/11. EI # 3 then asked the surveyor if PI # 1 had a contact.

A review of the Board of Trustees Bylaws, dated May, 2010, 3.10 Responsibilities....The responsibilities and obligations of the board shall include... 3.10(a) Assuming responsibility for Medical Staff Oversight....

During an interview on 4/12/11 at 3:00 PM, the Quality Manager (EI # 7), said the Governing Body is not aware of this complaint because the information was not reported at the last meeting on 3/10/11. The complaint is still under review and the Department Chair of the Medical Staff will determine the continued course of the investigation. The information will be presented to the Governing Body at the next scheduled meeting on 4/21/11.

On admission, PI # 1's thought processes were described as illogical. Her insight, judgement and cognition were impaired. PI # 1 had auditory hallucinations and delusions. Based on PI # 1's psychiatric impairment, the hospital failed to remove or assist PI # 1 in removing the contact lens until 2/17/11, seven days after admission at PI # 1's request. The hospital also failed to ensure the hospitalist consultation for evaluation of conjunctivitis, ordered 2/14/11, was done. Furthermore, PI # 1 did not receive an ophthalmology consultation until 2/25/11, when a contact lens associated ulcer and pseudomonal infection resulting in vision loss was identified. PI # 1 received an Ophthalmic Consultation on 3/1/11 and the documented plan was to follow up two to three days later. However, PI # 1 was not evaluated by Ophthalmology until 3/7/11 (six days after the 3/1/11 evaluation).

Based on interviews, medical record review, and review of Hospital Bylaws, the Governing Body failed to assure the Attending Physician and Hospitalist accurately assessed and documented the condition of Patient Identifier's (PI #1)'s right eye, removed PI # 1's right contact lens before irritation developed, and obtain specialized Ophthalmology care in a timely manner for a patient (PI # 1) identified with limited vision, and the inability to communicate physical symptoms, who developed a contact lens associated corneal ulcer and infection resulting in vision loss during hospitalization.

Findings Include:

PI # 1, a patient with a history of Bipolar Disorder, presented to the Hospital's Emergency Department (ED) on 2/10/11 due to anxiety, depression and violent behavior (reported by family as throwing things and exhibiting childlike behavior). PI # 1 has been overly anxious which precipitated a manic episode. The history, obtained from the patient and family, is documented as "limited, due to severity of condition."

According to the ED Physician's Review of Systems, PI # 1 is "positive for vision loss and blind in left eye."

The Physical Examination of the eyes reveals PI # 1's pupils are "equal, round and reactive to light. Extraocular motion intact."

Orders written by the Emergency Physician, document PI # 1's case was discussed with the Attending Psychiatrist (Employee Number # 1), who approves admission orders and assumes care of the patient (PI #1) upon arrival to the floor.

According to the "Nurse's Summary of Admission," dated 2/10/11, PI # 1 was admitted to the Psychiatric Unit due to a manic episode. PI # 1 reports "troubling" religious and political thoughts and knew she was heading into a manic phase. PI # 1 is described as disorganized, hyperverbal and pressured. The Registered Nurse documents PI # 1 has a contact lens in the right eye.

The History and Physical, dated 2/13/11 and documented by the Attending Psychiatrist (Employee Number # 1), reveals PI # 1 was brought to the hospital due to worsening anxiety, agitation and manic episode.

History of Present Illness: Over the past several weeks, she (PI # 1) has become increasingly disorganized, agitated, manic and bizarre. She decreased her Lithium dose. She has had poor sleep, racing thoughts and has been out of control at times.

Past Psychiatric History: The patient has a long history of bipolar illness with multiple psychiatric hospitalizations.

Review of Systems (ROS): A 14 point review of systems was noncontributory. (ROS: An organized and complete examination of a patient's organ systems as part of the workup when patient is first seen by a physician; an ROS is an inventory of body systems obtained by verbal history, with the signs and/or symptoms which the patient is experiencing or had. McGraw-Hill Concise Dictionary of Modern Medicine ? 2002 by The McGraw-Hill Companies, Inc.)
Physical Examination: PERRLA (Pupils equal, reactive, round, reactive to light and accomodation). Fundi benign. (fundus of eye: the back portion of the interior of the eyeball, visible through the pupil by use of an ophthalmoscope. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ? 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

Mental Status Examination Includes: The patient (PI # 1) was pressured, intermittently agitated and emotionally labile. Alert and oriented to time, day and place. Her speech was markedly increased in rate and volume, decreased in latency and quite pressured. Mood was silly. Affect labile. Thought processes illogical with poor goal direction and loosening of association. Positive for auditory hallucinations and grandiose/ paranoid and religious delusions. Insight and judgement impaired. Cognition mildly impaired.

Diagnostic Impression:
Axis I: Bipolar Affective Disorder (manic type), recurrent, severe with psychotic features.
Axis II: Deferred.
Axis III: See Medical History.
Axis IV: Problems with primary support group.
Axis V: Global assessment of functioning on admission: 25.

Plan of Treatment:
1. Admit to psychiatry...
4. Resume home medications
5. Add Thorazine p.r.n. (as needed)
6. Increase Lithium and Seroquel.

Examination of Cranial Nerves by EI # 1 on 2/11/11: ...Optic II: Distinguishes number of fingers in central field: Yes.
Distinguishes movements in peripheral field: Yes.

A Nursing Note, dated 2/14/11 at 1:30 PM documents PI # 1, "C/O (complaint of) L (left) eye pain and discomfort. Some redness noted. Pt. (patient) was encouraged to keep her hands out? her face. L eye was cleaned with saline water. Make-up was removed and pt. was instructed not to put makeup on L eye."

A review of Verbal Orders dated 2/14/11 at 6:30 PM, received from the Attending Psychiatrist (EI #1) documents, "...Consult Hospitalist per Conjunctivitis."

A review of Progress Notes written by the Attending Psychiatrist (EI #1) documents: 2/14/11: "....conjunctivitis OD (right eye), rather
pressured bizarre and loose - no insight...."
2/15/11: "...still quite loose and labile. Positive flight of ideas. Disheveled. Awaits hospitalist eval (evaluation)..."

There is no documentation in the medical record that PI # 1's eyes were examined by the hospitalist as ordered by the attending psychiatrist (EI # 3) on 2/14/11.

A Nursing Note, dated 2/17/11 at 1:50 PM documents, "Pt. (patient) eye red and watery. Contact removed by writer from R (right) eye.
Dr. (name of Attending Psychiatrist (EI #1) notified."

A Physician Order dated 2/18/2011 documents, "...Tobradex eye drops ii OD (right eye) q (every) 4 hrs (hours) while awake..."

A Progress Note dated 2/21/11 by the Attending Psychiatrist(EI #1) reveals, "Pt. (patient seen)...very labile, pressured and disinhibited...decreased scleral injection..." (sclera: a clear tissue that covers the white of the eye) (?1996-2011 MedicineNet, Inc.) (injection: Congested. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ? 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved).

A Nursing Note dated 2/24/11 at 7:50 AM reveals, "...Eye redness noted...drooling, difficulty with ambulation, eye drainage from right eye. Blurred vision. MD (Medical Doctor) paged - order noted."

The first documented Physician's Order on 2/24/2011 is a verbal order received from the Attending Psychiatrist (EI # 1) at 4:00 PM for, "Tobradex Opth (Ophthalmic) 1 drop each eye qid (four times a day)."

According to a Progress Note documented by the Attending Psychiatrist (EI #1), and dated 2/24/11 at 4:00 PM, "Patient's eyes still draining, very injected..." (Injected: Congested. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. ? 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved).

A Nursing Note dated 2/24/11 at 5:00 PM documents, " Lethargic and drooling. R (right) eye shut due to infection..."

The next Physician Order, dated 2/24/11, written by the Attending Psychiatrist (EI # 1), documents, "1. Resume Tobradex eye drops 1 gtt (drop) OD (right eye) QID (four times a day). 2. Consult hospitalist for eye infection..." (The order was not timed by EI # 1. However, the orders were signed off by a nurse at 5:45 PM.)

A Summary of the "Stat" (documented stat by the Hospitalist/EI # 4) Consultation dated 2/24/11, reveals eye infection as the reason for consultation. The Eye Examination Includes: The left pupil is round and reactive to light and accomodation. Conjunctiva is clear. No signs of redness or injection.

The right eye has "copious yellow purulent appearing discharge. Eyelid appears stuck due to discharge. The patient (PI # 1) states she has
photophobia and tries to keep her eye closed. Resists attempts to open it." Upon manual inspection of the eye, her conjunctiva is very red
and erythematous. The cornea is clear without any lesions. There is normal gross acuity. The entire eye exam is limited by lack of cooperation.
The patient states that her eye is painful.

Assessment: Bacterial Conjuncti