HospitalInspections.org

Based on medical record review, Facility policy and document review and staff interview, it was determined that the Facility failed to obtain consent from the patient, or the patient representative, before the administration of a psychotropic medication (refer to A 117); failed to provide care in a safe setting (refer to A 144); and failed to act to keep patients free from neglect (refer to 145). The cumulative effect of these deficient practices resulted in the Facility's inability to protect patient rights and ensure that patients received care in a safe setting.



Cross reference:
482.13(a)(1) Patient Rights: Notice of Rights
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(c)(3) Patient Rights: Free From Abuse/Harassment

Based on medical record review, facility policy review and staff interview, it was determined that for 1 of 9 patients (MR4) sampled, the Facility failed to obtain consent from the patient before the administration of psychotropic medication. Findings include:

Review of facility policy "Patient Rights & Responsibilities" revealed "...Consent-You have the right to know how certain treatments could affect you and what other choices you have..."

Review of facility policy "Consent for Treatment with Psychiatric Medication", effective October 2017, revised June 2023, revealed "MeadowWood Behavioral Health System obtains the informed consent from the patient...prior to initiating psychotherapeutic medications...This specifically includes any medication whose primary purpose in this use is the treatment of a psychiatric/mental health disorder..."

MR4

- The "Practitioner Order Sheet" dated 12/31/23 at 11:00 AM documented an order for:
Haldol 30 mg (milligram) PO (by mouth) X (times) 1 dose for severe agitation/physical fight.
- The "Practitioner Order Sheet" dated 1/1/24 at 9:50 AM documented an order for:
Haldol 40 mg PO X 1 now for severe agitation.
- The "Medication Administration Record" documented the following medication administered:
Haldol 30 mg PO X 1 on 12/31/23 at 11:00 AM.
Haldol 40 mg PO X 1 on 1/1/24 at 9:50 AM.

There was no evidence of patient consent for treatment with this medication.

This finding was confirmed with EMP5 on 4/9/2024 at 12:30 PM.

Based on observation, medical record review, facility policy and document review, and staff interviews, it was determined for 6 of 9 patients (MR1, MR2, MR5, MR6, MR7, and MR8) sampled, the Facility failed to ensure that patient safety rounds and observations were completed as ordered, failed to ensure a patient was transferred to another unit as ordered, and failed to provide proper staff supervision resulting in patient elopements. Findings include:


I. Observations

Review of facility policy "Routine Observation of Inpatients", effective June 2002, revised September 2020, revealed "In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...Documentation of 5 minute observations occurs q [every] 5 minutes..."

The facility document titled "Patient Observation Sheet" states, "...(M) in front of the Observer Name shows that the observation was part of a 1:1 - Minder Session."

A. MR1; Admitted on 9/28/23 with a mental health diagnosis of Disruptive Mood Dysregulation Disorder; eloped on 10/17/23.

Medical Record Review revealed:
- "Practitioner orders" dated 10/25/23 at 12:48 AM included orders for "every 5-minute observations while awake."

- The "Patient Observation Sheet" showed no evidence that patient observations were completed every 5-minutes while awake on the following dates:
10/25 - 10/31/23 (7 days)
11/4 - 11/7/23 (4 days)
11/15/23
11/23/23
11/26 - 12/13/23 (18 days)

These findings were confirmed by EMP4 on 4/10/24 at 10:30 AM.

B. MR2; Admitted on 9/22/23 with a mental health diagnosis Disruptive Mood Dysregulation Disorder; eloped on 10/17/23.

Medical Record Review revealed:
- The "Facility Practitioner Order Sheet" dated 10/17/23 at 2:15 PM included orders to begin "every 5-minute checks while awake."

- The "Patient Observation Sheet" showed no evidence that patient observations were completed every 5-minutes while awake on the following dates:
10/27/23 - 10/29/23 (3 days)
11/2/23 - 11/6/23 (5 days)
11/8/23 - 11/9/23 (2 days)
11/13/23
11/15/23

These findings were confirmed by EMP5 on 4/9/24 at 2:15 PM.

C. MR5; Admitted on 3/1/24 with a diagnosis of unspecified psychosis and alleged sexual misconduct by a peer on 3/4/24.

Medical record review revealed:
- Practitioner orders on 3/4/24 at 9:45 PM included orders to stop every 15-minute observations and to start every 5-minute observations.

- The "Patient Observation Sheet" showed no evidence that patient observations were completed every 5 minutes from 3/5/24 at 2:45 AM to discharge on 3/8/24 at 1:15 PM (82.5 hours).

During an interview on 4/10/24 at 1:45 PM, EMP4 confirmed these findings.

D. MR6; Admitted on 3/4/24 with a diagnosis of schizophrenia with exacerbations of auditory hallucinations and worsening symptoms who reported that a peer sexually assaulted him/her on 4/4/24.

Medical record review revealed:
-Practitioner admitting orders on 3/4/24 at 2:08 PM included an order for every 15-minute observations which were discontinued on 4/4/24 at 8:00 PM. Orders on 4/4/24 at 8:00 PM stated to change to every 5-minute observations.

-The "Patient Observation Sheet" showed no evidence that the patient was observed every 5 minutes between 4/4/24 at 8:00 PM and 4/5/24 at 2:00 AM (approximately 6 hours).

These findings were confirmed by EMP4 on 4/10/24 at 1:52 PM.

E. MR7; Admitted 2/19/24 with a diagnosis of major depressive disorder with suicidal ideations with a plan, who was accused of sexual misconduct by a peer on 3/4/24.

Medical record review revealed:
- Practitioner admitting orders on 2/19/24 at 11:15 PM included an order for 1:1 observation which was discontinued on 2/20/24 at 10:47 AM.
- Practitioner orders on 3/4/24 at 8:45 PM included orders to stop every 15-minute observations and to start every 5-minute observations.

- The "Patient Observation Sheet" showed no evidence that MR7 was placed on 1:1 observation between 2/19/24 at 11:15 PM to 2/20/24 at 10:47 AM (approximately 10.75 hours).
- The "Patient Observation Sheet" showed no evidence that MR7 received observations q 5 minutes from 3/4/24 at 9:00 PM to discharge on 3/6/24 at 9:30 AM (36.5 hours).

During an interview on 4/10/24 at 2:15 PM, EMP4 confirmed these findings.

F. MR8; Admitted on 3/30/24 at 7:28 AM with a diagnosis of opioid abuse, uncomplicated who was accused by a peer of sexual assault on 4/4/24.

Medical record review revealed:
- Practitioner admitting orders on 3/30/24 at 7:27 AM included an order for every 15-minute observations which was discontinued on 4/4/24 at 8:00 PM.
- Practitioner orders on 4/4/24 at 8:00 PM included an order to change to every 5-minute observations.
- Practitioner orders on 4/5/24 at 7:20 AM included orders to discontinue every 5-minute observations and begin 1:1 observation until discharge.

-The "Patient Observation Sheet" showed no evidence that the patient was observed every 5 minutes between 4/4/24 at 8:00 PM and 4/5/24 at 7:20 AM (approximately 11 hours and 20 minutes).
-The "Patient Observation Sheet" showed no evidence that the patient was on 1:1 observation from 4/5/24 at 7:20 AM until discharge at 11:45 AM (approximately 4 hours and 25 minutes).

These findings were confirmed by EMP4 on 4/10/24 at 2:27 PM.

II. Safe Environment

Review of facility policy, "Nursing Accountability," effective August 1993, revised June 2023, revealed "Each nursing staff member is responsible for providing care to assigned patients...To provide nursing care in which all nursing staff have accountability...All Licenses [sic] Nursing Staff are responsible for ...Careful execution of all applicable physician ...orders ..."

Review of facility policy "Inpatient Precautions - Sexual Acting Out Precautions", effective December 1995, reviewed/revised April 2019, revealed " ...Staff members will take reasonable steps to prevent the opportunity for sexual contact between patients ...Patients may be moved to a different unit ..."

MR7

Medical record review revealed:

- "Nursing Note" dated 2/28/24 at 11:50 AM documented that the patient made "...threats towards male peer..."

- Practitioner order on 2/29/24 at 2:35 PM stated that the patient "may be transferred to Unit E when bed was available" and was signed off by nursing staff on 2/29/24 at 3:00 PM.

- "Nursing Note" dated 3/3/24 at 10:22 PM documented the patient had "...poor boundaries with a female patient on the unit..."

- Practitioner order on 3/4/24 at 9:30 AM stated to "please transfer to Unit E" and was signed off by nursing staff on 3/4/24 at 9:40 AM.

- "Nursing Note dated 3/4/24 at 7:16 PM documented patient with " ...poor boundaries c [with] female peer. Redirected several times ..."

- "Progress Notes" dated 3/5/24 "late entry for 3/4/23 [at 9:30 PM]" documented, "Allegations of unconsensual sexual activity with another peers [sic] received ..."

- There was no evidence in the medical record that an attempt was made to transfer MR7 to Unit or that MR7 refused to be transferred to Unit E.

During an interview on 4/11/24 at 9:10 AM, EMP4 stated the maximum census for Unit E is 17 patients and that if a patient did not want to be transferred and exhibited behavior that could result in a code (behavioral code) being called, the transfer would not occur unless there was a safety issue.

Facility census reports documented that the census of Unit E on 2/29/24 was 16, 3/1/24 was 13, and 3/4/24 was 15, below the maximum census of 17 for Unit E.

During an interview on 4/11/24 at 10:00 AM, EMP4 confirmed the patient was not transferred to Unit E as ordered and that a bed was available in Unit E on 3/1/24 and 3/4/24. He/she also confirmed there was no evidence of documentation in the medical record of why the patient was not transferred.


III. Code Blue Drills

Facility policy titled "Medical Emergencies" revised 8/2014 stated, "...The DON [Director of Nursing] will assign Nurse Coordinator to perform - MOCK Code Blue drills each shift, minimum quarterly on each shift..."

During an interview on 4/8/24 at 11:35 AM, EMP4, DON, stated the Facility's Code Blue drills are held once a month so that each shift will have a drill quarterly, and, if an actual Code Blue is called, this will be used as a drill.

A review of the Facility's 2024 First Quarter Code Blue log revealed an actual Code Blue was called on 1/7/24 at 4:16 AM, an actual Code Blue was called on 2/26/24 at 8:53 AM, and a MOCK Code Blue drill was completed on 3/11/24 at 11:00 AM. There was no evidence that an actual or MOCK Code Blue was called or completed during the evening shift hours of 3:00 PM to 11:00 PM.

During an interview on 4/11/24 at 9:05 AM, EMP4 confirmed a Code Blue drill was not held or an actual Code Blue was not called during the evening shift for the first quarter of 2024.

Based on medical record review, facility policy review, and staff interview, it was determined that for 3 of 9 patients (MR1, MR2, and MR3) sampled, the Facility failed to prevent neglect of patients leading to patient elopements. Findings include:

Review of facility policy "Inpatient Precautions - Elopement Precautions," effective December 1995, reviewed/revised April 2019, revealed "...A patient on Elopement Precautions (EP) must be maintained on a 1:1, Line of Sight (LOS), or a Unit Restriction...Place patient room in close proximity to the nurse's station and away from exit doors...Awareness of unit activity which will result in doors to unit being open...Patients on EP are not permitted to leave the locked inpatient unit except if a physician has determined there is a therapeutic benefit..."

Review of facility policy "Routine Observation of Inpatients," effective June 2002, revised June 2023, revealed "...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds...Q [every] 15 Minute Rounds ...Make direct visual contact; look for signs of danger or distress ...Remain vigilant for specific risks for patients on Special Precautions ...A staff member must always accompany a patient while off the unit ..."

MR1 and MR2

Medical record review of MR2 revealed:

- "Progress Note" dated 10/17/23 at 2:10 PM documented, "At approximately [1:00 PM], pt [patient] eloped from facility through exit door during fire alarm testing ..."

A review of the Facility document "Incident Investigation Report" dated 11/21/23 related to the 10/17/23 incident involving MR1 and MR2 documented, " ...Two ...patients, [MR1 and MR2] had eloped from the unit during a fire alarm system testing event ..." The investigation determined a lack of communication between Facility departments, regarding the planned fire alarm system testing.

During an interview on 4/8/24 at 10:30 AM, EMP4 stated that, currently, staff do not monitor unit exit doors during fire drills and confirmed the 10/17/24 elopement of MR1 and MR2.

MR3
Medical record review revealed:
- "High Risk Notification Form" dated 11/17/23 identified patient as an elopement risk.
- "MeadowWood Behavioral Health Admission Order" dated 11/17/23 at 7:07 PM included orders for Elopement Precautions and every 15-minute level of observations.
- "Admission Psychiatric Evaluation" dated 11/18/23 documented, Patient "...started on elopement...precautions with q [every] 15 minute checks."
- "Practitioner Order Sheet" dated 11/20/23 at 11:19 AM included orders for patient to be on "HR [house restrictions]."

Review of surveillance video on 4/11/24 of the 11/22/23 5:20 PM elopement revealed:

- 5:15:14- the receptionist is sitting at the front desk while another employee (not identified) is
standing to the left of the desk.
- 5:20:05- the unidentified employee leaves the lobby by entering through a facility door to the left
of the front desk.
- Between 5:20:05-5:21:17- the receptionist is looking at a cell phone, answers the desk phone,
then hangs up.
- 5:21:18- the receptionist gets up and walks around the desk to the right side and enters
through a door (identified as the restroom).
- 5:21:56- visible through the interior hallway window from the lobby is one individual (identified
as EMP15) who approaches the glass lobby door, which is locked. A second individual (identified as MR3), is visible through the hallway window running in the hallway towards EMP15. While EMP15 unlocks the lobby door, MR3 pushes past them and enters the lobby. MR3 is seen running through the lobby and exiting through the front doors of the Facility while EMP15 is walking through the lobby and exits from the facility through the front doors. Outside video surveillance footage shows EMP15 walking from the building to the parking lot. MR3 is no longer visible on the footage.
- 5:23:51- the receptionist returns to the front desk.
- 5:25:00- a nursing employee (identified as EMP14), enters the lobby through the
interior glass doors from the hallway and walks to the front desk where the receptionist is sitting.
- 5:26:30- the receptionist uses the front desk telephone with EMP14 standing at the front desk next to her.
- Video ends.

The review of the video surveillance revealed no evidence that MR3 was within "Line of Sight" of nursing staff, as stated in the hospital's elopement precautions policy. This finding was confirmed by EMP3 on 4/11/24 between 12:45 PM and 1:30 PM.

Based on medical record review, facility policy reviewand staff interview, it was determined that for 1 of 9 patients (MR4) sampled, the Facility failed to ensure nursing documented the effectiveness of medications administered as an urgent order or to authenticate their medication administration according to their policy. Findings include:

Review of facility policy "Medication Administration and Documentation", original date of issue August 2020, revealed "...All ordered medications administered to patients will be documented on the Medication Administration Record...One (1) hour after administration of medication, reassess the patient and document effectiveness of medication on the PRN [as needed] Effectiveness Record...All medications must be charted on the Medication Administration Record immediately following administration...Sign each patient's Medication Administration Record..."

MR4

a."Practitioner Order Sheet" dated 12/31/23 at 11:00 AM documented an order for:
-Haldol 30 mg PO (by mouth) X (times) 1 dose and Ativan 3 mg PO X 1 dose for severe agitation/physical fight.

- The "Medication Administration Record" (MAR) documented the following medication administered:
Haldol 30 mg PO X 1 on 12/31/23 at 11:00 AM.
Ativan 3 mg PO X 1 on 12/31/23 at 11:00 AM.

No evidence of documentation of the effectiveness of the medication within 1 hour noted in the Medication Administration Record or in a progress note.

This finding was confirmed with EMP5 on 4/9/2024 at 12:35 PM.

b. "Practitioner Order Sheet" dated 1/4/24 at 2:30 AM documented an order for:
-Ativan 2 mg IM (intramuscular) X 1, Thorazine 100 mg IM X 1, and Benadryl 100 mg IM X 1 for psychosis.

- The "Medication Administration Record" documented the following under "One Time Medication Administration":
Thorazine 100 mg IM X 1 now at 3:00 AM on 1/4/24.
Ativan 2 mg IM X 1 now at 3:00 AM on 1/4/24.
Benadryl 100 mg IM X 1 now at 3:00 AM on 1/4/24.

No evidence of nursing authentication via initials or signature was found on the MAR for the above medications when administered as ordered.

No documentation of the effectiveness of the above medications within 1 hour of administration noted in the Medication Administration Record or in a progress note.

This finding was confirmed by EMP5 on 4/9/24 at 12:38 PM.

Based on medical record review, facility policy review and staff interview, it was determined that for 1 of 9 patients (MR4) sampled, the Facility failed to ensure staff reviewed and reassessed the multidisciplinary treatment plan according to their policy. Findings include:

Review of facility policy "Treatment Planning", effective May 1996, revised June 2023, revealed "The Multidisciplinary treatment plan will...identify the specific needs and goals of the patient and the specific interventions...A review and reassessment of the progress and or lack of progress toward the Treatment Plan Goals identified...The review and reassessment is done every 7 days..."

MR4

-Registration Admission Form stated, "...Admission Date & Time, 12/26/23 at 3:14 PM... Discharge Date & Time, 1/07/24 at 5:40 AM...Admitting diagnosis, bipolar disorder...Severe with Psychosis..."
-The Interdisciplinary Treatment Plan Medical Problem Sheet identified the following problems:
"...Problem: Health Maintenance...Birth Control/Family Planning...Date Initiated, 12/26/23..."
"...Problem: Ineffective airway management related to Asthma...Date Initiated, 12/26/23..."
"...Problem: Impaired Metabolism related to Diabetes...Date Initiated, 12/26/23..."
"...Problem: Altered Tissue Perfusion related to HTN [hypertension], Hyperlipidemia [high cholesterol] ...Date Initiated, 12/26/23..."
"...Problem: Impaired metabolism related to Diabetes...Date Initiated, 12/26/23..."
"...Problem: Altered Health Maintenance related to infectious disease as manifested by medical history of herpes...Date Initiated, 12/26/23..."
"...Problem: Manic Mood with Psychosis...Date Initiated, 12/26/23..."

There is no evidence the multidisciplinary treatment plan was reviewed or reassessed between 12/27/23 and 1/6/24 (11 days).

This finding was confirmed with EMP5 on 4/9/24 at 12:23 PM.