HospitalInspections.org

Based on document review and interview, in one (1) of 10 complaint files reviewed, the facility did not implement its policy and procedure to ensure that patients received care in a safe environment. (Patient #1)


Findings include:

Review of Complaint file #1 notes that Patient #1 complained that Staff V, a Phlebotomist, answered a personal call on a hands free devise while he was in the patient's room drawing blood samples, on 5/17/16.

The facility policy and procedure titled "Cell Phone Usage, Manual Code EC-7," last reviewed May 2016 stated the following: "...all cell phones use is prohibited in patient rooms..."

A review of the employees' files revealed that Staff V did not receive education on Cell Phone Usage.

During interview with Staff A, Vice President of Critical Care/Surgical Services on 8/5/16 at 10:45 AM, she acknowledged the finding.

Based on medical record review, document review and interview, in one (1) of 6 medication incidents reviewed, nursing staff did not implement the facility's policy and procedure to ensure medications are administered timely to patients. Specifically, a time critical medication was not administered timely (Patient #1).

Findings include:

1. Review of the medical record for Patient #1 found a physician order on 5/17/16 at 4:00PM for "Pyridostigmine Bromide (Anti-nerve agent pill) 180 mgs orally (PO) every three hours for 30 days".

The patient's administration record on 5/17/16 revealed that a dose of Pyridostigmine Bromide due at 7:00 PM was not given until 8:21 PM, one hour twenty-one minutes after it was due.

On 5/17/16 at 11:00 PM, the physician changed the patient's medication to "Pyridostigmine Bromide 6 mg Intravenous Push every three hours for one (1) day. Medication Administration Record revealed that doses of the medication were given intravenously on 5/17/16 at 11:00 PM and on 5/18/16 at 1:39 AM and 5:36 AM. The dose given at 5:36 AM was approximately one hour late.

The facility policy and procedure (P/P) titled "Administration of Medication," last revised April 2015, stated the following: "Time-critical scheduled medications: Must be administered within thirty (30) minutes before or after their scheduled dosing time for a total window of 1 hour." Included in this category of medications are medications prescribed more frequently than every four (4) hours (every 1, 2, or 3 hours).

During interview with Staff F, Assistant Director Quality, and Patient Safety on 8/3/16 at 12:50 PM, he acknowledged the findings.

Based on document review, and staff interview, in two (2) of 11 incidents reviewed, the Director of Food and Nutrition Department did not manage the facility's dietary services to ensure timely delivery of meal trays to patients (Patient #1).

Findings include:

Review of complaint file #1 noted, Patient #1 complained that post operatively on 5/17/16, after she was cleared to eat; she did not receive a meal tray for several hours.

Review of the facility's investigation report completed on 8/5/16 revealed that as per nursing documentation, on 5/17/16 at 6:40 PM, a meal tray was requested from the kitchen upon the patient's arrival from surgery. On 5/17/16 at 8:15PM, the nurse escalated the request to her nursing supervisor who went to the kitchen to obtain a late tray.

Similar findings regarding untimely delivery of meals to patients was noted in Complaint file #2 where it was noted that nursing staff, on 4/15/16 at 12:45 PM called the kitchen repeatedly for a food tray for Patient #36 and by 3:19 PM, the tray had not been delivered.
The investigation report noted that the patient was aggravated and family purchased a meal from an outside vendor.

During interview with Staff H, Director of Food, and Nutrition Services on 8/5/16 at approximately 11:00 AM, he acknowledged that patient #1 and #36 were not timely provided with meal trays.

Based on document review and interview, in one (1) of 15 patients records reviewed, the facility did not ensure that each patient evaluated in the Emergency Department received a safe discharge (Patient #2).

Findings include:

Review of medical record for Patient #2 noted a 16-year-old female who presented to the Emergency Department on 6/5/16 at 9:26 PM with a chief complaint of self-inflicted lacerations of both forearms.

The patient had a medical screening examination completed on 6/5/16 at 10:50 PM with an initial clinical impression of suicide ideation. The patient was medically cleared and transferred to the Psychiatric Emergency Department at 10:50 PM. On 6/6/16, the patient was evaluated by a psychiatrist whose impression was depressive disorder, poor impulse, borderline personality, and conduct disorder. As per the Psychiatrist's evaluation, the patient denied having a suicide attempt. The patient stated that she cut herself because she was angry with her girlfriend after a break up.

On 6/6/16 at 4:35 PM, a nurse noted that the patient was cleared by the psychiatrist for discharge. The patient was discharged to the Children's Home on 6/6/16 at 4:42 P.M.

The patient's Treatment Plan noted the following: "The patient does not require hospitalization. The patient can return to the children's home. The patient's therapist was contacted and advised for the patient to be seen more frequently. The patient has been referred for mobile crisis team interventions. They can go tomorrow for a follow-up on the patient's condition at the time. We will add Risperdal (Antipsychotics) 0.5 milligram (mg) tablet daily in the a.m. Continue on all other medications as prescribed and follow up with the psychiatrist at the children's home".

The patient's discharge instruction and post hospital plan of care did not indicate the level of monitoring required for the patient and the provision of a protective environment to ensure her safety.

Consequently, the patient returned to the Emergency Department the next day, on 6/7/16 at 10:19 PM with multiple self-inflicted lacerations to the legs and torso, requiring medical treatment and transfer to another facility for inpatient psychiatric admission.

At interview with Staff G, Emergency Room Director on 8/3/16 at 11:45 AM, he stated that the staff therapist in the children's home was advised of the patient's return and that she agreed to take the patient back. Staff G stated there are no other placement options for this patient and the mobile crisis unit is the link between the Emergency Department and the children's home, to ensure the patient will be provided with adequate support and care.