HospitalInspections.org

Based on a review of 15 medical records, it was determined the hospital failed to modify the care plan for one patient who required seclusion.

The review of patient #13's medical record revealed that the plan of care had not been modified to include the patient's behavior, alternative interventions and use of seclusion on 9/4/15. The hospital failed to meet the regulatory standard to update the care plan after the intervention of violent seclusion or restraint.

Based on observation and review of Patient#7's medical record, review of the hospital complaint investigation, and interview of the Risk Management Staff on 9/8/2015 and 9/9/2015, it was determined that the hospital failed to track and analyze the patient's potential negative response (Adverse Drug Event/ Reaction) to medications received during a hospitalization.

The findings were:
Patient #7 was referred by a community neurologist to the outpatient services to have a lumbar puncture on 02/20/14 for evaluation of hemiplegia (inability to move a group of muscles on one side of the body) and other neurological symptoms. The patient's past medical history included an auto-immune disorder (Hashimoto Thyroiditis), seizures, chronic pain syndrome after assault in 2013, fibromyalgia, and a T3 lesion.

The patient complained of pain after the procedure and was given pain medication (Oxycodone) orally. The medication failed to provide the patient any relief. A second pain medication (Dilaudid 1 milligram (mg) intravenous) was administered to the patient. The patient began to have shaking of the limbs which appeared to be seizure like. Ativan 0.5 (anti-anxiety agent) was administered to the patient. The patient was observed to have lateral nystagmus (involuntary oscillating eye movements) and a decreased level of consciousness. The patient was given an additional Ativan 2.5 mg. The patient's nystagmus ceased and the patient became unresponsive. The patient was transferred to the Intensive Care Unit (ICU) for monitoring.

The intensivist noted on 02/20/14 that the patient's altered mental state post the lumbar procedure and was likely due to the administration of the medication, Ativan, and not seizure activity.

Review of the hospital's documentation including quality improvement activities and interview of the Risk Management Staff on 09/08/15-09/09/15 confirmed that the patient may have experienced an adverse drug event due to a potential medication reaction. Further interview of the Risk Management Staff revealed that there was no investigation of the possible adverse drug event by the hospital.

Review of the hospital's documentation including quality improvement activities, and interview of the Risk Management Staff on 09/08/15-09/09/15 confirmed that the patient may have experienced an adverse drug event due to a medication reaction. Further interview of the Risk Management Staff revealed that there was no adverse drug event report generated which would have triggered an investigation and review by the pharmacy and other related entities.

Failure to investigate, track, and analyze adverse medication events potentially could impede the hospital 's efforts in maintaining patient safety and the reduction or prevention of adverse events.

Based on review of 15 medical records and staff interviews, it was determined that for two patients (patient #10 and patient #13) the nursing staff failed to accurately update and document identified changes in the care of the patients as evidenced by: .

Patient #10 (13 month old minor) was admitted to the hospital. The patient's father spoke English, Spanish and Portuguese but the hospital was informed the mother spoke Spanish but understood English. Based on the medical record review, it was determined that this information was not addressed in the progress notes or in the patient's care plan. To ensure that the all staff understood the specific communitaion needs of this patient and his parents this information should have been addressed as part of the plan of care.

Patient #13 is 33 year old admitted to Behavioral Health Unit. The patient was secluded on 9/4/15 at 10:10 PM. The record review revealed a failure to update the care plan to reflect that seclusion had been used as an intervention to address the patient's behavioral needs.