HospitalInspections.org

Based on review of the hospital's complaint and grievance files it was determined that in two cases the response to the complaint was not made in a timely manner.

Review of complaint #142038 indicates that the complaint/grievance was received by the hospital on December 20, 2013 indicating a concern with the physician's management of care. The complaint was sent to Risk/Utilization Management for review on the same date and a letter of acknowledgement was sent to the complainant. However, the letter of resolution was not sent to the complainant until February 26, 2014. There is no documentation of notification to the complainant that the investigation was ongoing, extended, or would be resolved within a specific time frame.

Review of complaint # 142030 indicates that the complaint/grievance was received by the hospital on December 13, 2013 indicating that the complainant had developed pain and infection of a surgical wound after discharge. A letter of acknowledgement was sent to the complainant on December 13, 2013 and the investigation was started on the same date. However, the letter of resolution was not sent to the complainant until February 26, 2014. There is no documentation of notification to the complainant that the investigation was ongoing, extended, or would be resolved within a specific time frame prior to the resolution letter two months later.

In addition, as part of the "Patient Rights" assessment it was determined that the hospital's policy and procedure titled: "Patient Complaint Policy and Procedure" Effective date 5/17/12 revised 01/14/13, lacked documentation that when an investigation is not or will not be completed within 7 days, the hospital will inform the patient or the patient's representative that the hospital is still working to resolve the grievance.

Based on review of the hospital policy "Behavioral Health Restraint" and medical record reviews, it was determined that the hospital failed to obtain the order for restraint or seclusion prior to application of restraint/seclusion and in emergency application situations.

In 1 out of 16 open medical records, patient's # 1's medical record review revealed the hospital failed to obtain the order for restraint/seclusion.

Patient #1 was being evaluated in the main ED when she began banging her head and hitting, spitting, and kicking staff who intervened to prevent injury to the patient. Per the medical record less restrictive alternative interventions were attempted without success. The patient was placed in four point restraint at 1900 (7:00 PM). The medical record review revealed no order. Per the hospital investigation, the physician felt he/she could not leave the room given the agitation of the patient and gave a verbal order to the nurses at time of care and assessed the patient after placement of the restraints. He/she later forgot to place the order in the electronic system before leaving. The order was entered in the medical record as a late entry on 4/15/14 at 11:55 AM.

During observation of the facility and interview of the licensed staff during the facility tour on 04/15/14, it was determined that the facility is not consistently maintained in a manner to ensure an acceptable level of safety and quality. This was evident by the following findings:
1) 3T Floor/Unit-Room 3304 (Soiled Holding and Oxygen Storage Room) with a badge swipe entry, was observed unlocked or not locking.
2) 3T Floor/Unit- Room 3208 (Clean Supply/Utility Room) with a badge swipe entry, was observed unlocked or not locking.
3) 3T Floor/Unit- Room 3204(Soiled Holding and Oxygen Storage Room) with a badge swipe entry, was observed unlocked or not locking.
4) 3T Floor/Unit-Alcove across from Room 3143(where equipment is stored) at 9am had an EKG machine stored there that was observed with a bottle of Nitrostat 0.4mg(H62362, expires 07/16) resting in the plastic handle of the device. The bottle contained at least 12 pills and appeared to have been opened, but this could not be confirmed by staff on interview by the surveyor. The medication was in an open and unsecured area traveled by staff, visitors, and patients. Medication left unsecured creates the potential for: a) the medication to be ingested/taken by an individual who may be confused or have other psychiatric issues and 2) does not ensure that the medication remained in an untampered state.
5) 3T Floor/Unit-Room 3212-is a Housekeeping Closet was found unlocked with the housekeeping staff observed down the hall (~70feet or more away) cleaning in the hall. The Housekeeping Closet contained a wall mounted chemical dispensing unit ( Disinfectant Cleaner, Glass Cleaner, and Bathroom Cleaner). A repeat finding.
6) 5T Floor/Unit-Room #5308(Clean Supply/Utility Room) was observed unlocked at 11:30am.
Observation of the 3T Floor Nursing staff during the findings of the unlocked Clean and Soiled Storage Rooms revealed that the nursing staff would enter the rooms without swiping their badges. One nurse interviewed by the surveyor revealed that she had not noticed that the doors were not locking.
Observation revealed that storage rooms are not always within the staffs' view and can create a safety hazard for patients who may mistakenly wander into a room without staff knowledge or accidently become locked in. In addition, patients could access fluids and other supplies contained in the storage rooms for ingestion creating a potential swallowing or choking hazard.

Based on review of the medical record for patient #2 and patient #10, it was determined that the hospital failed to assess the patient's self-care needs in relation to discharging the patients back to their homes in the community. Patient #2 was initially brought to the Emergency Department on 4/7/14 by her children after being found outside standing in the rain in the backyard with no shoes on and very confused. Per the daughter the patient has progressively de-compensated since December 2013. She has delusions about a baby and money. The patient per the medical record lives independently with the children checking in on the patient. Per the medical record, one of the aftercare recommendations for the patient was day hospitalization which was refused by the family. No indication in the medical record of determining the patient's self-care needs and referral to services that will provide the patient and family with support other than the day program. No notation in the record regarding family meetings with the children, coordination of community services with her mental health community provider and no referral to Adult Protective Services. The referral to Adult Protective Service would potentially provide an assessment of the community resources and home environment from a safety stand-point.

In addition, during a Federal survey at another acute care hospital and review of the medical record of the patient #10 at the center of the complaint revealed the patient was discharged from MedStar Franklin Square Hospital Center on 3/26/14. The patient was being driven home by her daughter and attempted to jump out of the car. The daughter took the patient to the nearest Emergency Department where she was evaluated and admitted to the inpatient behavioral health unit. After treatment the patient was transferred into another facility for further treatment on 3/26/14. It is of concern that the patients were discharged from Med Star Franklin Square Hospital Center and were admitted either back into the hospital or another area acute care hospital for treatment and eventual discharge. Of concern is the failure of the hospital in their discharge of two patient's within two weeks of each other to determine the ability of the patient to safely return to environment from which they entered the hospital.

Patient #10 was admitted to the Behavioral Health Unit at MedStar Franklin Square Hospital Center on 3/14/14 complaining of anxiety, thinking the TV was talking to her and non-compliant with medication. The hospital started discharge plans on the day of admission for more long-term inpatient psychiatric care. Per the medical record the hospital contacted another facility for an inpatient bed from 3/14/14 to 3/19/14. There is a note by the discharge planner on 3/19/14 that the patient has been accepted by the other inpatient facility but the transfer was no longer needed. The treatment team per the medical record felt the patient had stabilized and no longer needed the inpatient services.

Although the patient had improved she was still refusing medications or taking half the dosage as evident by progress notes of 3/23/14 1700 and 3/24/14 at 2200. By 3/25/14 the hospital contacted the partial hospital program since patient had changed her mind and now was interested in the program. On the day of discharge 3/26/14, the patient was described as irritable, demanding, refusing to leave, and dismissive to staff. " I'm not leaving until Friday". The patient was assessed by the psychiatrist who documented that she denied suicidal/homicidal ideations/psychosis. "Patient feels safe and stable". The assessment revealed her thoughts were clear/abstract, speech articulate and coherent, mood stable but irritable, cognitively intact, insight fair, judgment good, no self-destructive behaviors, delusions or hallucinations. The patient had started back on her medications and appeared to have some improvement. Again, patient #10 was discharged home but in this case never made it to home and had to be seen at another area hospital, admitted for treatment and discharged to an inpatient unit for further care and treatment. In fact the facility the patient was transferred to on 3/26/14 was the same facility that MedStar Franklin Square Hospital had initially applied for admission and the patient had been accepted on 3/19/14.