HospitalInspections.org

Based on policy and procedure review, patient medical record review, and interview, the facility failed to implement its policy related to updating the treatment plan for patients after an ESI (emergency safety intervention), for 3 of 3 restrained/secluded patients (pts. N5, N6 and N7).

Findings:
1. At 4:40 PM on 6/16/11, review of the policy RM1140, "Seclusion, Restraint, and Emergency Intervention Procedures - Inpatient", indicated:
a. in the section "Procedure: Emergency Intervention", in item 1.9 (on page 6), it read: "All episodes of Emergency Interventions will be reviewed by the treatment team and revisions made to the treatment plan as appropriate to minimize the need for using Emergency Interventions to protect the patient or others."

2. Review of patient medical records at 10:45 AM on 6/16/11 indicated:
a. on 5/18/10, pt. N5 was placed in the seclusion room at 2100 hours, after a physician order was given
b. pt. N5 lacked any update to the treatment plan after the 5/18/10 seclusion event
c. at 0758 hours on 1/6/11, pt. N6 was placed in a physical restraint while a chemical restraint was administered
d. the treatment plan for pt. N6 was not updated after the ESI of 1/6/11
e. on 1/21/11 at 0720 hours, pt. N6 was placed in a physical restraint while a chemical restraint was administered
f. the treatment plan for pt. N7 was not updated after the ESI of 1/21/11

3. Interview with staff members NA and NB at 3:40 PM on 6/16/11 indicated:
a. additions or changes to the treatment plans after ESIs for pts. N5, N6 and N7 could not be found
b. it cannot be determined that updates to the treatment plans is occurring per policy requirements, after the implementation of emergency safety interventions

Based on policy and procedure review, patient medical record review, and interview, the facility failed to implement its policy related to physician orders for restraint or seclusion for 1 of 3 patients who were restrained/secluded (pt. N7).

Findings:
1. At 4:40 PM on 6/16/11, review of the policy RM1140, "Seclusion, Restraint, and Emergency Intervention Procedures - Inpatient", indicated:
a. on page 3 in the "Procedure: Restraint or Seclusion for Behavior Management" area, in section 2.0 "RN Assesses for Patient Safety...2.2.3 Notifies the physician immediately of the need to restrain or seclude and obtains an order..."

2. Review of patient medical records at 10:45 AM on 6/16/11 indicated:
a. pt. N7 had a form titled "Original Order to Restrain/Seclude" with a date of 1/21/11 and time of 0720 hours, that lacks:
I. the name of the ordering practitioner
II. any authentication by a practitioner of the order to restrain pt. N7
b. pt. N7:
I. had nursing notes of 1/22/11, on the "Nurse's Progress Notes" page, at 1900 hours that read: "[writer] was called to 300 side by other staff to help with pt. Deputy [named] with other staff were alongside pt. who was on [their] stomach laying on the floor...pt. was agitated and shouting then attempted to roll over from [their] stomach to [their] side.."
II. lacked a physician order to restrain pt. N7, notify local authorities and remove the patient from the facility

3. Interview with staff member NB at 3:00 PM on 6/16/11 indicated :
a. the nurse failed to write the name of the ordering practitioner
b. there is no physician authentication of the order to restrain pt. N7 on 1/21/11
c. there is no physician order to restrain pt. N7 on 1/22/11 or to notify local police to have the patient removed from the facility

Based on policy and procedure review, personnel file review, and interview, the facility failed to ensure the competency related to restraint and seclusion techniques for 1 of 2 LPNs (licensed practical nurses). (staff member P4)

Findings:
1. At 4:25 PM on 6/16/11, review of the policy number RM1140, "Seclusion, Restraint, and Emergency Intervention Procedures - Inpatient", indicated:
a. in the "Policy Statement" section, it read: "...All direct patient care staff will be trained in patient assessment, recognition, and treatment of the problems causing the need for restraint, seclusion, and emergency intervention. Training...through the use of Non-Abusive Psychological and Physical Intervention (NAPPI) training,..."

2. Review of the personnel file for P4, a LPN, at 4:15 PM on 6/15/11, indicated the competency in NAPPI (Non-Abusive Psychological and Physical Intervention) had expired in February of 2011

3. Interview with staff members NB and ND at 5:05 PM on 6/15/11 indicated the NAPPI competency for staff member P5 was required to fulfill their duties as a LPN, and that their competency had expired in February of this year

Based on personnel file review and interview, the facility failed to ensure CPR (cardiopulmonary resuscitation) competency for 1 of 3 RNs (registered nurses). (staff member P5)

Findings:
1. At 4:15 PM on 6/15/11, review of personnel files indicated CPR competency for staff member P5, a RN, had expired 3/11

2. Interview with staff members NB and ND at 5:05 PM on 6/15/11 indicated CPR certification for staff member P5 was required per their job expectations, and that certification had expired in March

Based on policy and procedure review, patient medical record review, incident report review, and interview, the quality assurance coordinator failed to ensure the implementation of the facility policy related to completion of an incident report after an emergency situation for one patient (pt. N7) and failed to monitor quality indicators for one service (laboratory) in their Quality Assessment and Performance Improvement program.

Findings:
1. At 4:40 PM on 6/16/11, review of the policy RM1140, "Seclusion, Restraint, and Emergency Intervention Procedures - Inpatient", indicated:
a. under "Procedure: Emergency Intervention", on page 6 in section 3.0, it reads: "A complete and thorough incident report shall be completed within 24 hours following any incident involving use of time-limited emergency interventions and forwarded to the Risk Management Nurse..."

2. Review of patient medical records at 10:45 AM on 6/16/11 indicated pt. N7:
a. had nursing notes of 1/22/11, on the "Nurse's Progress Notes" page, at 1900 hours that read: "[writer] was called to 300 side by other staff to help with pt. Deputy [named] with other staff were alongside pt. who was on [their] stomach laying on the floor. The deputy was kneeling over the pt with left knee in [pt's] back and two tazer prongs were stuck on [pt's] upper back. pt. was agitated and shouting then attempted to roll over from [their] stomach to [their] side. Deputy [named] again tazed the pt...Officer [named] joined Deputy [named] towards the tail-end of the incident."

b. had a note written by nursing at 1915 hours that stated: "pt escorted off unit by an [city] policeman et (and) a sheriff's deputy. [pt] was handcuffed and crying. Report called to [other acute care psychiatric hospital]"

3. Review of facility incident reports for the past 12 months indicated there was none present related to the events of 1/22/11 for pt. N7

4. Interview with staff members NC at 2:00 PM on 6/16/11 indicated:
a. the incident of 1/22/11 for pt. N7 was unknown by this staff member
b. there was no incident report completed by staff related to the ESI (emergency safety intervention) event, tazing, and police intervention for pt. N7 on 1/22/11
c. the restraint/tazer event of 1/22/11 for pt. N7 was not reported to the quality assurance/risk management staff person for review by the quality assurance committee

5. The Quality Improvement (QI) report for 2010 lacked performance measurements for the contracted laboratory services provided to the facility.

6. During an interview on 06-16-11 at 1345, employee #A3 confirmed that laboratory services are not evaluated through the QI program.




29550

Based on observation, manufacturer's recommendation, and interview, the facility failed to ensure patient safety related to possible incorrect glucometer results and oximeter results, due to expired products.

Findings:
1. Review of the manufacturer's recommendation for glucometer control solutions ("MediSense Glucose Control Solution") at 4:00 PM on 6/16/11 indicated:
a. in the section "Storage and Handling", it reads: "...when you open a new bottle, write the date of opening on the bottle label..."
b. in the section "Precautions and Warnings", it reads: "Do not use control solutions 90 days after opening or if they are expired..."

2. While on tour of the nursing station, in the company of staff members NB and NF, at 4:00 PM on 6/16/11, it was observed that:
a. the control solutions for the glucometer were not dated when opened or when they expire (90 days after opening, as per manufacturer recommendation)
b. 4 packages of Oxi max oxygen sensors (to test oxygen saturation levels) had expired 12/10

3. Interview with staff members NB and NF at 4:10 PM on 6/16/11 indicated:
a. it was unknown that the manufacturer recommended expiration of the control solutions 90 days after opening
b. it cannot be determined when the current control solutions were opened, or when the 90 day expiration date is/was
c. the oxygen sensors that expired were for a previous machine and should have been purged from the supply area

Based on observation and interview, the facility failed to ensure an acceptable level of sanitation was maintained by the housekeeping department at the facility.

Findings:

1. During a facility tour on 06-15-11 at 1540, the following was observed in a housekeeping storage area: one gallon containers of a cleaning concentrate Wayne PQ-64. The product labeling failed to indicate it was a hospital grade disinfectant and indicated a dilution ratio of 2 ounces per gallon water used.

2. During an interview on 06-16-11 at 0935 hours, employee #A6 indicated the product Wayne PQ-64 was used throughout the facility for floor mopping. The employee indicated they were instructed to use one capful of the product diluted with 4.5 gallons water for mopping and indicated they did not use a 1 ounce unit measure pump observed with the stored cleaning products.

3. During an interview on 06-16-11 at 1630, employee #A2 indicated the Infection Control committee had not been consulted prior to the selection and use of the cleaning product by the housekeeping department to ensure a hospital grade disinfectant was selected for use at the facility.

Based on policy and procedure review, personnel file review, and interview, the facility failed to ensure an effective program to identify communicable disease history for 5 of 9 staff members (P2, P3, P4, P7 and P9).

Findings:
1. At 9:00 AM on 6/16/11, review of policy number FA0448, "Immunization Record - IP" (in patient), indicated:
a. under "Summary", it read: "To meet necessary state and federal mandates, all inpatient staff that provides direct care must provide documentation of immunizations for, or antibodies to, MMR (measles, mumps, rubella) and Varicella (Chicken Pox), by having the attached form completed on their behalf, or by submitting a copy of an official State Immunization Form which indicates immunization."
b. under "Statement of Information:", it read in section 2.0, "[facility] Inpatient Services employees shall secure evidence from their general practitioner they they have either had the required immunizations, a titer test indicating immunization, have had the inquired about disease, or have secured the official State Immunization form as evidence of immunization."

2. Review of personnel files at 2:55 PM and 4:15 PM on 6/15/11 and 8:15 AM on 6/16/11, indicated:
a. P2, P3, P4 and P7 (all hired between January 2008 and November 2010) were lacking documentation related to immunization status for Varicella
b. staff members P4 and P7 were lacking documentation of a 3rd Hepatitis B injection (had documentation of #1 and #2 in the series of 3)
c. P9 had a document/health history form with self reported immunity to measles, mumps, rubella and varicella that was lacking physician authentication of the declaration

3. Interview with staff members NB and ND at 4:50 PM on 6/15/11 and 9:55 AM on 6/16/11, indicated:
a. staff members P4 and P7 never presented to the nurse for their last Hepatitis B injection in the series of 3, but there is no documentation in their files of contact made with these staff members and their failure to connect with the nurse/employee health
b. it is unclear why varicella immunity documentation for staff members P2, P3, P4 and P7 was not obtained at the time of hire
c. human resources failed to ensure that staff member P9 had physician authentication on the appropriate health history form

Based on document review, observation and interview, the facility failed to have policies/procedures for the provision of respiratory therapy ensuring that medications were administered according to accepted standards of practice by the nursing staff.

Findings:

1. On 06-15-11 at 1030 hours, employee #A1 was requested to provide policies/procedures for respiratory therapy services and none was provided prior to exit.

2. During a facility tour on 06-15-11 at 1210 hours, several aerosol nebulizer pieces were observed drying on a paper towel in the medication room. Employee #A7 indicated the nursing staff administered aerosol treatments to patients and documented on the patient medication administration record.

3. During an interview on 06-15-11 at 1250 hours, employee #A2 indicated nursing staff did not document breath sounds, heart rate, respiratory rate and/or oxygen saturation before and after aerosol treatment administration.

4. During an interview on 06-16-11 at 1610, employee #A1 confirmed the facility lacked policies/procedures for aerosol nebulizer administration to patients by licensed nursing staff.