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Based on interviews and clinical record review it was determined the facility staff failed to follow the physician's order regarding the 1-hour face-to-face assessment for four (4) of five (5) sampled patients who had documented restraint use, Patients #5, #6, #12, and #13.

The findings include:

On 03/29/18, the surveyors conducted a review of Patient #5's clinical record. On 03/20/18 at 8:04 a.m., restraint orders for violent behavior was obtained. "Restraint type: 5-point ... Reason for restraints: danger to self and danger to others ... Duration: 4 hours ... The MD must conduct a face to face assessment within 1 hour of initiation of restraint order and every 8 hours thereafter." A physician did not complete the 1-hour face-to-face assessment.

On 03/29/18, the surveyors conducted a review of Patient #6's clinical record. On 03/26/18 at 7:27 p.m., Restraint orders for violent behavior obtained. "Restraint type: polyurethane 5-point ... Reason for restraints: danger to self and danger to others ... Duration: 4 hours ... The MD must conduct a face to face assessment within 1 hour of initiation of restraint order and every 8 hours thereafter." A physician did not complete the 1-hour face-to-face assessment.

On 03/29/18, the surveyors conducted a review of Patient #12's clinical record. On 03/26/18 at 5:42 a.m., Orders for seclusion obtained. "Restraint type: Seclusion ... Reason for restraints: danger to others ... Duration: 4 hours ... The MD must conduct a face to face assessment within 1 hour of initiation of restraint order and every 8 hours thereafter." A physician did not complete the 1-hour face-to-face assessment.

On 03/29/18, the surveyors conducted a review of Patient #13's clinical record. On 03/14/18 at 8:25 p.m., Orders for seclusion obtained. "Restraint type: Seclusion ... Reason for restraints: danger to self and danger to others ... Duration: 4 hours ... The MD must conduct a face to face assessment within 1 hour of initiation of restraint order and every 8 hours thereafter." A physician did not complete the 1-hour face-to-face assessment.

0 n 03/29/18 at 6:00 p.m., the surveyors conducted an interview with Staff Member #13. He/she stated, that the hospital software does not allow the staff to change the order.

Based on interviews, personnel records and document review it was determined the facility failed to provide specific education/training that qualifies Registered Nurses to conduct the 1-hour face-to-face evaluation for two (2) of five (5) Staff Members. Staff Members #21 and 22.

The findings include:

On 03/29/18, the surveyor conducted a reviewed of Staff Member #21's personnel record, a Registered Nurse. There was no evidence that SM #21 received education/training that qualified him/her to conduct the 1-hour face-to-face evaluation.

On 03/29/18 at 6:00 p.m., the surveyors conducted an interview with Staff Member #13. Staff Member #13 stated, SM #21 has been with the facility for four (4) years and has worked on the Behavior Health Unit during that time. He/she felt that SM #21 had the experience to conduct the 1-hour face-to-face evaluation.

On 03/29/18, the surveyor conducted a reviewed of Staff Member #22's personnel record, a Registered Nurse. There was no evidence that SM #22 received education/training that qualified him/her to conduct the 1-hour face-to-face evaluation.

On 03/29/18 at 6:00 p.m., the surveyors conducted an interview with Staff Member #13. Staff Member #13 stated, SM #22 had been with the facility for five (5) to six (6) years and had worked on the Behavior Health Unit during that time. He/she felt that SM #22 had the training in the past to conduct the 1-hour face-to-face evaluation but was unable to provide evidence of that training.

During the interview with SM #13 on 03/29/18, he/she acknowledged that SM #21 and 22's personnel record did not contain the education/training for them to conduct the 1-hour face-to-face evaluation.

The Facility's policy and procedure titled, "Restraint and Seclusion" (revision date 07/17) contained the following: "8. Training ... Violent or Self-Destructive Behavior (Behavioral) ... Education: Currently licensed RN or currently licensed crisis prevention worker ... Training: Triennial successful documented completion of all sections of the restraint/seclusion written test, including the trainer section/competency. Experience: A minimum of two years functioning as an acute care RN and/or two years functioning as a behavioral health RN."

"10.13 Face to Face Assessment ... Notify physician, designee, or qualified RN of requirement to see patient and perform a face-to-face assessment within 1 hour of the initiation of the use of restraints or seclusion and consult with the physician regarding the patient's physical and psychological condition."

Based on interviews and review of hospital quality program documentation, it was found that in the review of an adverse event, facility staff failed to a) identify all areas in the hospital at similar risk, b) failed to implement preventative actions for the issues identified and c) failed to collect and report preventative action data through the hospitals quality program.

The findings include:

Review of the hospital's quality program included the review of the analysis of an adverse event which occurred on 12/04/17. The quality review conducted by the hospital's staff identified multiple areas that may have contributed to the event including but not limited to: the failure of hospital staff to conduct safety checks every 15 minutes on a behavioral health patient, failure of hospital staff to document and complete the CIWA-Ar (Clinical Institute Withdrawal Assessment from Alcohol) score, and staff involved in a code blue situation being unfamiliar with the location of supplies in the code cart.

The analysis of the event and the actions taken by the hospital were reviewed with Staff Member (SM) #1, SM #2 and SM #13 on 3/29/18 at 11:00 AM. The surveyor asked if other departments of the hospital that might be conducting safety checks (ex. medical/surgical and emergency) were evaluated or reviewed. SM #1 stated that they were not. SM #13 stated that he/she has been conducting "spot checks" to see if safety checks are being documented but this data was not being collected and/or reported to the Quality Council.

Surveyor review of actions related to the event failed to provide evidence of education, training or monitoring of the completion and documentation of the CIWA-Ar score. SM #1 confirmed this had not been addressed or implemented. The failure of hospital staff to complete and documentation of the CIWA-Ra score was noted during review of sampled medical records.

Surveyor review of actions related to the event found evidence of the standardization of code carts across the hospital but failed to provide evidence of any mechanism of monitoring the effectiveness of the change. SM #1 stated there would be practice "codes" but this had not been implemented at the time of the survey.

The hospital's quality review and response to the adverse event was discussed with SM #1 on 3/29/18. Although the hospital quality program staff had reviewed the adverse event, they (quality staff) had failed to identify all areas at risk, implement preventative actions for identified issues and failed to collect data to be presented to the Quality Council; SM #1 acknowledged this was correct.

The above findings were shared with the management team prior to exit on 3/29/18. No further evidence was provided to the survey team.

Based on interviews and review of documents it was determined hospital staff failed to administer drugs in accordance with the orders of the practitioner for 2 of 13 sampled patients (Patient #9 and Patient #2).

The findings include:

1. Patient #9 was admitted to the hospital's General Behavioral Health unit on 2/10/18 with diagnoses to include alcohol dependence with alcohol-induced mood disorder and hyperglycemia due to type 1 diabetes mellitus. Patient #9's electronic health record (EHR) was reviewed on 3/28/18 with the assistance of a navigator provided by the hospital.

An order was placed on 2/12/18 at 11:28 AM for CIWA-Ar (Clinical Institute Withdrawal Assessment from Alcohol) monitoring. The following was found in the "Comments" section of the order: "CIWA-AR MONITORING - Monitor and document CIWA-Ar score a minimum of every 4 hours. If the CIWA-Ar greater than 8, increase to every 2 hours while the patient is awake and every 4 hours while asleep. Once the score is less than 4 without requiring any benzodiazepine administration for 48 hours, the CIWA-Ar will be monitored and documented once every shift. If the score is less than 4 for the following 72 hours, monitoring can be discontinued."
Review of the EHR for Patient #12 revealed CIWA-Ar scores documented at 8:19 PM on 2/10/18, and at 5:09 AM and at 9:00 PM on 2/11/18. There were no CIWA-Ar scores documented from 9:00 PM on 2/11/18 until the patient's discharge on 2/13/18.

The CIWA-Ar score is used to determine the initiation of symptom triggered dosing ordered by the physician. For this patient (Patient #9) the physician had ordered diazepam (a benzodiazepine sometimes used for the treatment of acute alcohol withdrawal) 10mg every hour as needed for a CIWA-Ar score of 8-11, and diazepam 20mg every hour as needed for a CIWA-Ar score greater than or equal to 12.

Hospital policy "Alcohol Withdrawal, Management of" dated 02/05/18 reads in part as follows: "The CIWA-Ar score will be monitored and documented a minimum of every 4 hours until the patient's > 8. At that point the monitoring will increase to every 2 hours while the patient is awake and every 4 hours while asleep. Once the score is less than 4 without requiring any benzodiazepine administration for 48 hours, the CIWA-Ar will be monitored and documented once every shift. If the score is less than 4 for the following 72 hours, monitoring can be discontinued."

The hospital staff's failure to monitor and record CIWA-Ar assessments and/or provide medications based on the CIWA-Ra assessment was discussed with Staff Member (SM) #1 the afternoon of 3/28/18 and again prior to exit on 3/29/18. No further information was provided to the survey team.


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2. Facility staff members failed to follow Patient #2's orders related to medication administration.

Patient #2's clinical record included an order for CIWA assessments dated 12/3/17 at 11:40 p.m. The comments section of this ordered included: "CIWA-AR MONITORING - Monitor and document CIWA-Ar score a minimum of every 4 hours. If the CIWA-Ar greater than 8, increase to every 2 hours while the patient is awake and every 4 hours while asleep. Once the score is less than 4 without requiring any benzodiazepine administration for 48 hours, the CIWA-Ar will be monitored and documented once every shift. If the score is less than 4 for the following 72 hours, monitoring can be discontinued." The CIWA assessment is used to determined what medication dose should be provided to address withdrawal symptoms.

Patient #2's clinical record also included an order for "RT-OXIMETRY, SPOT CHECK" dated 12/3/17 at 11:40 p.m. The comments section of this ordered included: "Prior to initiation of sedation. Continuous pulsed oximetry if SpO2 less than 92% and contact physician." (SpO2 is the abbreviation used when reporting the results of the oximetry checks.)

Patient #2's clinical record was reviewed on 3/27/18 starting at 1:34 p.m. with Staff Member (SM) #24 then changing to SM #13. During this record review it was noted that Patient #2 did not have a CIWA assessment documented and did not have an oximetry check documented prior to the administration of a medication with sedative properties. Patient #2 had been administered two (2) doses of Lorazepam. The first dose was 1 mg given on 12/4/17 at 12:05 a.m. The second dose was 1 mg given on 12/4/17 at 12:32 a.m. No documentation of an oximetry check was found by or provided to the surveyor. (Lorazepam is a benzodiazepine with a common side effect of sedation.)

The failure of the facility staff to members to ensure implementation of Patient #2's orders to guide medication administration was discussed with SM #1 and SM #2 on the afternoon of 3/27/18. No evidence of Patient #2 having a CIWA assessment was provided to the surveyor. No evidence of Patient #2 having an oximetry check completed prior to the administration of lorazepam was provided to the surveyor.