HospitalInspections.org

Based on medical record reviews, facility documentation reviews, and staff interviews it was determined that the facility failed to:

1. Assure that current standing prn [as needed] orders are sufficiently prescriptive to direct nursing staff in their use. As written, standing prn orders allowed nursing staff to select one or another medication for ill-defined parameters such as "agitation" and "anxiety," or to use the same medication for a choice of symptoms (for example, "agitation/EPS")
2. Assure that when Chemical Restraints were utilized, there was a protocol in place to assess the effectiveness of Chemical Restraints and/or other sequelae to their usage.
3. Assure that staff followed the procedures for the use of Automatic External Defibrillator (AED) in Code Blue (medical emergency) situations.
4. Assure that facility protocol was followed for announcing a Code Blue so that all necessary personnel and equipment was available to aid a patient in a medical emergency
5. Assure that all physicians, especially those on call, were currently credentialed for CPR intervention.
These failures during both psychiatric and medical emergencies jeopardize the patient's right to receive the care needed in a safe environment. (Refer to B125).

Based on medical record reviews, document reviews and interviews, the facility failed to:

1. Assure that standing prn orders were sufficiently prescriptive to direct nursing staff in their use for 16 of 25 patients who were residing on Unit S3 on 2/22/2010 (S1, S2, S3, S4, S5, S6, S7, S8, S11, S13, S14, S16, S17, S19, S20 and S21). As written, standing prn orders allowed nursing staff to select one or another medication for ill-defined parameters such as "agitation" and "anxiety," or for a choice of symptoms ("agitation/EPS"), activities outside the scope of nursing practice.
2. Assure that when Chemical Restraints were utilized, an evaluation of their effectiveness and/or other sequelae was conducted for expired patient D1 on whom chemical restraints was used. This failure jeopardizes the safety of patients during and following a psychiatric emergency.
3. Protect patient rights by ensuring that staff followed the policy on use of the Automatic External Defibrillator (AED) during a Code Blue event for expired patient D1. Failure to utilize the AED per policy can potentially contribute to a negative patient outcome during a medical emergency.
4. Protect patient rights by ensuring that staff followed the hospital protocol for announcing a Code Blue; the failure resulted in a lack of equipment being available to provide emergency care for 1 expired patient, D1 Failure to have needed equipment jeopardizes patient safety during a medical emergency.
5. Assure that CPR certification for Physician 1, the Physician on Call, was current on 1/20/2010 when CPR was needed during a Code Blue for Patient D1. This failure jeopardizes patient safety during a medical emergency.
Findings are:
1. Assure indications for the use of prn medications are sufficiently prescriptive:
A. Medical Record Review:
Medication Administration Records (MARs):
On 2/22/2010 at 2:20 p.m., the surveyors requested the MARs for all of the patients residing on Unit S3 at that time. Of the 21 MARs obtained, for 16 patients (S1, S2, S3, S4, S5, S6, S7, S8, S11, S13, S14, S16, S17, S19, S20 and S21) the MARs showed standing po [oral] prn [as needed] medications for the ill-defined symptom of "agitation." Several of the medications were for a choice of symptoms, and in other instances, there was a choice of more than one medication for the same symptom (see the listing below). These findings were shared with the Risk Manager on 2/23/2010 at 1:55 p.m. who reviewed each patient's medical management to confirm this. The findings are as follows:
(1) S1: "Ativan 2mg agitation q [every] 4hrs."
(2) S2: "Ativan 2mg q4h anxiety" and "Ativan 1 mg qid [four times a day] anxiety po prn."
(3) S3: "Thorazine 50mg [P.O.] q4h agitation" and "Haldol 5mg [P.O.]q4h agit. NTE(not to exceed)/tid" (three times daily); "Ativan 2mg [P.O.] q4h/agit.NTE/TID;" and "Benadryl 50mg [P.O.] q4h/agit NTE/TID."
(4) S4: "Benadryl 50mg q4h agitation NTE/TID" and "Vistaril 5mg tid anxiety."
(5) S5: "Thorazine 100mg q6hrs acute agitation."
(6) S6: "Ativan 1mg tid anxiety/agitation."
(7) S7: "Vistaril 50mg q4hrs agitation."
(8) S8: "Benadryl liquid 50mg q4h EPS/agitation."
(9) S11: "Ativan 2mg q4hr agitation."
(10) S13: "Prolixin 5mg prn q4h(agitation)."
(11) S14: "Benadryl 50mg q4h agitation."
(12) S16 "Benadryl 50mg q4hrs agitation/insomnia."
(13) S17: "Vistaril 50 mg q4h agitation."
(14) S19: "Thorazine 50mg q4h prn agitation" and Benadry 50mg q4h prn agitation" and " Ativan 2mg q4h prn agitation." On 2/18/2010, the Thorazine had been administered X1, the Benadryl X2 and the Ativan X3.
(15) S20: "Benadryl 50mg q4h agitation."
(16) S21: "Ativan 1mg q4hrs prn anxiety."
B. Other document reviews:
Joint Commission Executive Summary -Survey 12/15-18/2009:

On Page 13 the report stated: "During patient tracer activity, it was noted that there were two drugs, Haldol and Thorazine, that were both prescribed for the same indication, agitation. There was no indication when to use which drug, so this is essentially a duplicate order."
C. Staff Interviews:
(1). On 2/21/2010 at 2:10 p.m., RN1 was interviewed with the facility's Risk Manager present. She told the surveyors that if 2 or 3 types of standing prn medication Orders were prescribed for the same indication for the patients on the Unit at that time, as described in the MARs above, it enabled the nursing staff to pick and choose the medication used. RN 1 stated "It allows us to have a tool to use to work effectively with the patient." She was unable to explain how an indication noted simply as "agitation" would be individualized or how different nurses on different shifts would agree exactly what "agitation" meant for each individual patient.
(2). In an interview with the Clinical Director on 2/23/2010 at 10:35 a.m. with the Risk Manager present, the findings of standing prn Orders for "agitation" was discussed. He was asked to comment on the charge nurse's comments noted above. He stated "We leave it to the nurse's judgment, leave it to her discretion about the level of med to give." Both he and the Risk Manager/RN stated that, in their opinion, this privilege to select a medication and/or a combination of them when written for the same ill-defined parameter ("agitation") was within the scope of nursing practice.
2. Lack of follow-up post usage of Chemical Restraints:
A. Documentation Records:
(1). Preliminary Root Cause Analysis related to the death of Patient D1, dated 2/01/2010
a. Patient D1, a 47 year old female, was sent from her community residence when she was perceived to be becoming more paranoid in her ideation and experiencing both auditory and visual hallucinations. Her medication compliance prior to admission was questionable. It was determined that she was hypertensive BP 178/110 and tachycardic with a pulse rate of 112. The temperature was elevated (99.5), weight was 202 lbs., and height was 67 inches. She was diagnosed as Schizoaffective Disorder, bipolar type, and a non-insulin dependent diabetic.
b. The admitting DOC (Doctor on Call) prescribed the following po medications at 12:00 a.m., which the patient accepted: Depakote 1000mg, Lopressor 50mg, Ativan 2mg, Risperdal 2mg, and Benadryl 50mg. He also began her on Glucophage 500mg and a Low Salt/1800Kcal diabetic diet to begin in the morning. The rationale for administration of further medication (Chemical Restraint) at 1:00 a.m. was "...intermittent periods of yelling and screaming hysterically from 11:30 PM to 1 AM." The one time only IM (intramuscular) administration consisted of Thorazine 50mg, Ativan 2mg, and Benadryl 50mg. The DOC had noted under Allergies that the patient was allergic to "phenothiazines" and when questioned by the Nurse (RN#1) he told her that this was not truly an allergy, and that it was all right to give the 3 meds noted.
c. Following interventions that included holding the patient briefly (Physical Restraint), the DOC assessed her [patient] within one hour and noted his findings. Patient D1 was observed coming out of her room 2-3 times and "...seemed sedated and was taken back to her room, last 2:30 AM." Every 15 minute checks by Unit staff (routine minimal observation protocol) were then conducted. The last check occurred at 3:50 a.m. and at 4:00 a.m. RN1 noticed that the side of the bed was wet and that Patient D1 was unresponsive.
d. The analysis included the following statement: "Reassessment of Vital Signs did not occur after the patient was given antihypertensive...and prn (give as necessary) medication...and medication restraint."
(2). Medical record review of Patient D1 confirmed the statement given above. In fact, the only Vital Signs taken for this patient occurred at admission.
(3) Joint Commission Executive Summary-Survey 12/15-18/2009:

On Page 14 the report stated "...it was noted that a first dose of a standing medication was not monitored for effects or side effect...there was no timing...and in conversation with staff, it was noted that follow up could be as much as 24 hours later."
B. Staff Interviews:
In an interview with the Clinical Director on 2/23/2010 at 10:35 a.m. with the Risk Manager present, both staff agreed that there was not presently any protocol in place for evaluating the effects of IM Chemical Restraints.
3. Assure proper usage of AED protocols:
A. Document/Record Review
(1). The policy, "Nursing Roles, Code Blue," number N-C6, revision number: 5 (9/05), under the AED section states that the RN will "Apply electrodes to patient after an initial assessment has been made that patient is in cardiac arrest."
(2). Review of the Progress Notes for Patient D1 revealed that in a note written by RN1 at 6:50 a.m. on 1/20/2010 about the Code Blue, there was no mention of the AED. RN1's note further stated that the Code started at 4:00 a.m. and the Nurse Supervisor was called. According to RN1's note, the Nurse Supervisor and Physician 1 arrived at 4:05 a.m. There was nothing to indicate that either the Nurse Supervisor or Physician 1 attempted to use the AED.
(3). In a 2/01/2010 document entitled, "[Draft] Root Cause Analysis" (for Patient D1), under the section examining "Human Factors" relevant to the outcome, Physician 1 and the Nurse Supervisor were reported as stating that they did not apply the AED because they were both waiting for the other "...to initiate when it should be applied per protocol in a Code Blue."
(4). In a 2/01/2010 document entitled " [Draft] Root Cause Analysis" (for Patient D1), under the section, "...steps in the process that did not occur as intended," was written "AED was not applied per policy." This document further revealed under the section "Equipment Factors," the statement "EMTs placed their AED on patient when they arrived."
(5). The Code Blue Record form for Patient D1, dated 1/20/2009, stated that the EMTs arrived at 4:15 a.m.
B. Interviews
(1). In a telephone interview on 2/23/2010 at 9:50 a.m., RN1 stated that she was so busy doing CPR on Patient D1 that she did not think about using the AED during the Code Blue. RN1 further stated that no one gave her the AED to attach the electrodes.
(2). In an interview on 2/22/2010 at 12:30 p.m., the Risk Manager/Nurse Executive stated that RN1 had not followed policy when she failed to use the AED during Patient D1's Code Blue. She further stated that the Unit Nurse Manager on S3 (South 3 where the Code Blue took place) met immediately with the staff of S3 and reviewed the Code Blue protocol. The Unit Nurse Manager put into writing for the surveyor at 11:17AM on 2/23/2010 that she had reviewed the Code Blue protocol on 1/22/2010 with the RNs present at the change of shift at 7:00 a.m. and 3:00 p.m. RN2, who was assigned to S3 the night of 1/20/2010 and participated in CPR, was not present for this meeting; there was no evidence that any other education of staff occurred on the unit. During this same interview when asked who was responsible for utilizing the AED during a code, the Risk Manager/Nurse Executive stated that the RN on the unit was responsible but that the physician or nurse supervisor should apply the AED if the RN had not done so when they arrived at a code.
(3). In an interview on 2/22/2010 at 3:25 p.m., the Hospital Educator stated that during the regularly scheduled Mandatory Education Days (annual renewing of CPR) she had now added training that speaks more clearly to the use of the AED. She further stated that she had only trained about 20 staff to date (there are approximately 320 staff members-not all of whom would need this training). She agreed that it would take a good amount of time to get everyone needing the class trained. The Hospital Educator also stated that she was in the process of scheduling more frequent Code Blue drills, from quarterly to monthly. This change had not occurred as of 2/23/2010.
4. Failure to follow hospital protocol for announcing a Code Blue:
A. Document/Record Review
(1). The policy, "Nursing Roles, Code Blue," number N-C6, revision number: 5 (9/05) states that the initial responder "Instructs staff to call Code Blue and/or 911 as indicated." The policy does not specify whether the call is to be made via phone or overhead page but does state "N2 staff will deliver Gomco (suction device) machine to the scene."
(2). In a 2/01/2010 document entitled "[Draft] Root Cause Analysis" (for Patient D1), under the section, "...steps in the process that did not occur as intended", it was written "Code Blue protocol was not followed-it was not announced over loud speaker (overhead page)." Under the section "Human Factors" relevant to the outcome, the failure to overhead page "...did not affect staff response to unit, but prevented N2 (North 2 Unit) staff from responding immediately with suction machine per policy." This document further included under the section "Equipment Factors," the statement, "Suction machine was requested by the EMTs when they arrived. Since Code Blue was not overhead paged, the suction was not immediately brought to S3 from N2 where it is kept." (N2 is on the floor below S3 and houses the only hospital suction machine.)
B. Interviews
(1). In a telephone interview on 2/23/2010 at 9:50 a.m., RN1 acknowledged that the Code Blue protocol was not followed. The Code Blue should have been paged overhead and not phoned directly to the Supervisor. RN1 stated that the EMTs asked for a suction machine when they arrived because Patient D1 sounded "gunky" as if she had aspirated. When asked if she had sounded like that during CPR, RN1 stated that the patient had sounded like that when CPR was begun.
(2). In an interview on 2/22/2010 at 2:00 p.m., the Risk Manager/Nurse Executive stated that the Code Blue had not been called per protocol. She stated that staff had been taught how to make the call overhead and knew that the N2 staff would bring the suction machine when they heard the announcement. She did not know why the code was not paged overhead and thought that it might have been due to the time (4:00 a.m. and not wanting to wake patients. The Risk Manager/Nurse Executive further stated that the Unit Nurse Manager on S3 met immediately with the staff of S3 and reviewed the Code Blue protocol. The Unit Nurse Manager put into writing for the surveyor at 11:17 a.m. on 2/23/2010 that she had reviewed the Code Blue protocol on 1/22/2010 with the RNs present at the change of shift at 7:00 a.m. and 3:00 p.m. Although Mental Health Associates can call Code Blue, and one actually did call the Code Blue on Patient D1, there were no Mental Health Associates present at the meetings; neither was RN2 who was assigned to S3 the night of 2/20/2010 and participated in CPR. There was no evidence that any other education of staff occurred on the unit.
(3). In an interview on 2/22/2010 at 3:25 p.m., the Hospital Educator stated that during the regularly scheduled Mandatory Education Days (annual renewing of CPR), she would remind staff of the proper way to call a Code Blue. She also stated that she was in the process of scheduling more frequent Code Blue drills, from quarterly to monthly. This change was not yet in effect as of 2/23/2010.
5. Assure Medical staff are current in credentialing for CPR:
On 2/23/2010 at 10:35 a.m., the Clinical Director and the facility's Risk Manager were interviewed. Concerning the matter of the DOC not being current in CPR certification, it was explained that the Medical Staff Coordinator keeps a "tickle-file," but at this time, they did not know if the fault of the physician not availing himself for training was his oversight or his not being notified.

Based on medical record reviews, facility documentation reviews and staff interviews, it was determined that the Clinical Director failed to assure that when prn medications were utilized, they were given for clearly defined indications, and that when Chemical restraints were utilized, patients were monitored afterward for assessment of the medication effectiveness and/or other sequlae. The Clinical Director also failed to ensure that when Automatic External Defibrillators are required and Code Blue situations occur, staff followed hospital protocol, and also failed to assure that physicians on call were current in their certifications to do CPR. (For the Findings, refer to B125).

Based on record review and interviews, the Director of Nursing failed to monitor nursing practice to ensure that:
1. Nursing staff monitored the vital signs for expired patient (Patient D1) on 1/20/2010 after the patient received Lopressor 50mg for high blood pressure, and also received medications as a chemical restraint. Failure to monitor a patient's vital signs can lead to a negative medical outcome. (Refer to B125-Part 2.)
2. Nursing staff followed the protocol for calling a Code Blue and for applying the AED during a Code Blue for expired patient (Patient D1) on 1/20/2010. Failure to respond according to policy and protocol during a medical emergency can jeopardize safety and lead to a negative outcome during a medical emergency. (Refer to B125-Part 3 & B125-Part 4.)
3. Nursing staff were re-educated calling a Code Blue, on the use of the AED, and taking vital signs after a chemical restraint. Failure to train staff in a timely manner can result in a repeat of the failures and impact negatively on the safety of patients.

Findings are:
In an interview on 2/22/2010 at 3:25 p.m., the Hospital Educator stated that during the regularly scheduled Mandatory Education Days (annual renewing of CPR) she had added training that speaks more clearly to the use of the AED. She further stated that she had only trained about 20 staff to date (there were approximately 320 staff members-not all of whom would need this training). She agreed that it would take a good amount of time to get everyone needing the class trained. The Hospital Educator also stated that she was in the process of scheduling more frequent Code Blue drills, from quarterly to monthly. This change had not occurred as of 2/23/2010.
In an interview on 2/22/2010 at 3:25 p.m., the Hospital Educator stated that during the regularly scheduled Mandatory Education Days (annual renewing of CPR), she would remind staff of the proper way to call a Code Blue. She also stated that she was in the process of scheduling more frequent Code Blue drills, from quarterly to monthly. This change was not yet in effect as of 2/23/2010.