HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 1 patient (Patient #1's) written grievance/complaint was investigated. The facility failed to provide Patient #1 the results of the grievance/complaint he filed.

Findings included:

Patient #1's Integrated Psychosocial Assessment dated 04/08/15 timed at 1926 reflected, "Patient suicidal and was depressed because lost wife and sister...reported he has had issues with alcohol...drinks a 12 pack of beer per night...patient chronic obstructive pulmonary disease...reported he falls frequently because he is unsteady on feet...tachycardia, irritability, cramps, agitation, cravings, weakness..."

The Hospital Patient Advocate Communication Form dated 04/17/15 timed at 1120 reflected, "Patient #1's written complaint/grievance...my health is in danger because of a lack of medical equipment and medication and equipment necessary for my care...my medications for pain are not being dispensed when I request...I have not received help for any of my problems...I need my medications, my equipment....the section of the document entitled, "Direct care staff intervention"....support given, referred to the DON (Director of Nurses)." No follow-up and/or findings regarding the patient complaint was addressed.

The April 2015 Complaint/Grievances log reflected, "Complaint date 04/17/15...unit...complaint/grievance...equipment and medications necessary for care...comments unsubstantiated (closed)....letter needed...N (no)...letter sent...N (no)."

On 08/14/15 at 1210 Personnel #2 was interviewed. The surveyor asked Personnel #2 if she investigated Patient #1's complaint/grievance. Personnel #2 stated she could not remember.
The hospital policy and procedure entitled, "Grievance Policy" with review date of 11/2014 reflected, "Policy statement...to ensure every patient, family member and/or legally appointed representative [LAR] hold legitimate and reasonable expectation of appropriate care and service...with the right to file complaint and/or grievance when the patient and/or family members has cause to believe breech of reasonable expectations has occurred...final resolution of all complaints will occur within 30 days and the complainant shall receive a written response including the review of the complaint, the outcome of the review and corrective actions taken...documentation regarding all complaints including final disposition, are maintained by the Patient Advocate."

Based on interview and record review the hospital failed to ensure 1 of 10 patients (Patient #1) gave informed consent for psychoactive medications prior to being administered psychoactive medications.

Findings included:

Patient #1's Integrated Psychosocial Assessment dated 04/08/15 timed at 1926 reflected, "Patient suicidal and was depressed because he lost wife and sister...reported he has had issues with alcohol...drinks a 12 pack of beer per night...patient...chronic obstructive pulmonary disease...reported he falls frequently because he is unsteady on feet...tachycardia, irritability, cramps, agitation, cravings, weakness..."

The 04/09/15 physician's orders reflected, "Celexa 20 mg (milligrams) po (by mouth) daily..."

The 04/10/15 physician order reflected, "Vistaril 50 mg po at hour of sleep prn (as needed)."

The 04/11/15 physician order reflected, "Prozac 10 mg po every day..."

The Medication Administration Records (MAR) revealed the following psychoactive medications were administered without consent:

Celexa 20 mg po daily was administered on 04/09/15, 04/11/15, 04/12/15 and 04/13/15.

Prozac 10 mg po QD (every day) administered on 04/12/15, 04/13/15.

Vistaril 50 mg po administered on 04/13/15, 04/17/15, 04/18/15, 04/19/15 and 04/20/15.

On 08/14/15 from 1456 to 1545 Personnel # 2 was interviewed. Personnel #2 was asked to review Patient #1's psychoactive medication consents. Personnel #2 stated she could not find medication consents for Celexa, Prozac and Vistaril.

The Hospital Consent to Treatment with Psychoactive Medication Form reflected, "The nature and purpose of treatment with the medication (s) checked on the back of this form have been fully explained to me...the nature and seriousness of the mental condition for which the medication is recommended...reason for using the medication...potential side effects...patients treated with antidepressants may have an increase in suicidal behaviors especially when initiated or dosage adjusted...I have the right to accept or refuse this medication treatment... have read (or had read to me) and understand the foregoing..."

There were no signed medication consents for Vistaril, Prozac and Celexa in Patient #1's medical record.

Based on interview and record review the hospital failed to ensure Registered Nurses evaluated/assessed the care needs for 1 of 1 patient (Patient #1) in that

1) Registered Nurses did not initiate a CIWA (clinical institute withdrawal assessment) for Patient #1 who was admitted for alcohol detoxification. The Registered Nurses further failed to complete a CD (chemical dependency) assessment for Patient #1 upon admission to the facility.

2) Physician ordered neurological checks for Patient #1 were not completed and/or documented.

Findings included:

1) Patient #1's Integrated Psychosocial Assessment dated 04/08/15 timed at 1926 reflected, "Patient suicidal and was depressed because he lost wife and sister...reported he has had issues with alcohol...drinks a 12 pack of beer per night...patient...chronic obstructive pulmonary disease...reported he falls frequently because he is unsteady on feet...tachycardia, irritability, cramps, agitation, cravings, weakness..."

The 04/08/15 Initial Nursing Assessment timed at 2200 for Patient #1 reflected, "Page 2 CD (chemical dependency assessment) Date of Last Substance Usage (blank), what was used? (blank)...Amount that was used (blank)...if patient uses Alcohol, complete CIWA (Clinical Institute Withdrawal Assessment)...health history/chronic conditions (blank)..." No documentation was found which indicated a CIWA was completed for Patient #1 and/or a complete nursing assessment was done.

On 08/14/15 from 1456 to 1545 Personnel #2 was interviewed. Personnel #2 verified after review of Patient #1's nursing assessment the CD (chemical dependency) section was left incomplete on page 2. Personnel #2 was asked to provide evidence of the CIWA document. Personnel #2 stated the CIWA was not in the medical record.

The policy and procedure entitled, "Detoxification" with a review date of 07/2012 reflected, "It is the policy that each person entering treatment for chemical dependency that requires detoxification shall be admitted on a prescribed detox protocol...detoxification can range from 24 hours to 5 to 7 days or longer...the following symptoms are commonly found and are to be observed for...nervousness, agitation, tremulousness, anxiety, diaphoresis, elevated vital signs, seizures, delirium tremens...nursing will provide close monitoring and comfort measures for detoxing patients...patients on Alcohol Detox Protocol will have a Clinical Institute Withdrawal (CIWA) completed on them a minimum of each shift, while awake...the clinical tool assesses 10 common withdrawal signs..."

2) Patient #1's 04/12/15 nursing progress note timed at 1820 reflected, "Was called by other patients...noted patient lying on his left side...assessed patient stated lost balance and fell...I did not hit my head ...no apparent injuries...Dr. notified...neuro checks every four hours times 24 hours...appropriate staff notified..." No further documentation was found from nursing which addressed neurological checks were completed every four hours for 24 hours for Patient #1.

On 08/14/15 from 1456 to 1545 Personnel #2 was interviewed. Personnel #2 stated the medical record did not address Patient #1's fall. Personnel #2 stated she could find no neurological checks for Patient #1.

The hospital Neurological Assessment Flow Sheet reflected, "Document the date and time of each assessment...level of consciousness, pupils response, motor function, pain response, vitals...use observation column to note the presence or absence of specific, resident conditions." No completed neurological flowsheet was found in Patient #1's medical record.

Based on interview and record review the hospital failed to ensure 1 of 1 patient (Patient #1's) treatment plan was individualized to address (medical) needs such as oxygen therapy, COPD (chronic obstructive pulmonary disease), and non-compliance in regard to smoking.

Findings included:

Patient #1's History and Physical dated 04/12/15 reflected, "COPD (chronic obstructive pulmonary disease)...numerous leg surgeries...chronic left leg malunion...continues to smoke...recommendations...COPD medications have been addressed..."

The 04/17/15 physician Orders for Patient #1 reflected, "Medical consult COPD/Asthma/Cough/Wheezing...at 2000 Oxygen two liters as needed..."

The 04/20/15 physician's orders timed at 1640 for Patient #1 reflected, "Patient is not to smoke until compliant with supplemental oxygen, hold all medications...nebulizer Ventolin every four hours as needed...at 1715..."

Patient #1's Interdisciplinary Individualized Treatment Plan with an initiation date of 04/09/15 reflected, "Detox, problem 1...alteration in mood, problem 2...alcohol dependence...problem 3...risk to fall...problem 4...history of hypertension, problem 5...history of GERD (Gastrointestinal esophageal reflux disease)...problem 6...pain."

Patient #1's Interdisciplinary Treatment Plan/Update-Inpatient dated 04/16/15 reflected, "Very depressed...adjusting medications."

Patient #1's Interdisciplinary Treatment Plan/Update-Inpatient dated 04/20/15 reflected, "Doing little better today SI (suicidal ideations) decreasing...adjusting medications." The above Individualized Treatment Plan did not address Patient #1's non-compliance regarding smoking related to his COPD (Chronic Obstructive Pulmonary Disease, and the need for supplemental oxygen and nebulizer treatments.

On 08/14/15 from 1456 to 1545 Personnel # 2 was interviewed. Personnel #2 was asked to review Patient #1's medical record. Personnel #2 reviewed Patient #1's treatment plan and verified Patient #1's COPD and the use of inhalers; supplemental oxygen was not addressed in Patient #1's treatment plan. Personnel #2 further stated she could not find a treatment plan which addressed Patient #1's non-compliance related to smoking.

The hospital policy and procedure entitled, "Master Treatment Plan/Master Treatment Plan Review with a review date of 05/2010 reflected, "The initial treatment plan will contain...initial problem list...both psychiatric and medical if applicable...initial goals and objectives to address, appropriate nursing interventions...any Axis III diagnosis admitting nurse will complete problem/goal sheet...any identified problems that will not be the focus of treatment documentation by the treatment team...treatment team will review and discuss the initial treatment plan with each discipline, adding additional goals, objectives..."

Based on interviews and record review the hospital failed to ensure the physician discharge summary for 1 of 1 patient (Patient #2) recapitulates the patient's hospitalization. Patient #2's inappropriate sexually acting out behavior was not addressed in the discharge summary.

Findings included:

Patient #2's Integrated Psychosocial Assessment dated 05/01/15 timed at 1500 reflected, "Conflicts with teachers, peers, unable to focus...sexually active no...no abuse history."

Patient #2's 05/01/15 physician's preadmission examination orders and preliminary plan of care timed at 2343 reflected, "Precautions assaultive, suicide...every fifteen minute level of observation."

Patient #2's physician's orders dated 05/08/15 timed at 2110 reflected, "Place patient on SAO (sexually acting out) precautions due to inappropriate sexual behavior..."

The Nursing Progress Note dated 05/08/15 timed at 2130 for Patient #2 reflected, "MHT (mental health technician) reported when rounded on patient MHT saw peer on his knees facing patient...patient and peer were segregated and discussed and processed incident with the patient...patient tearful...reported his pants were down and peer performed...when MHT walked in on peer and patient...stopped...placed in room alone..."

The Psychiatric Progress Note (physician) for Patient #2 dated 05/09/15 timed at 0730 reflected, "Patient seen...was sexually acting out with peer."

The Hospital Case Management Notes for Patient #2 dated 05/09/15 timed at 1330 reflected, "Therapist had a one to one with patient...patient reported he did not want to think about what had happened...patient reported that he felt ashamed, surprised, and unhappy...at 1540...had session with patient, stepfather, mother...patient reported he had consented, and the idea for...was the other patient's...patient reported he regretted the act..."

The non-dated Physician Discharge Summary for Patient #2 reflected, "Depression, anger, impulsive...treatment progress ...medication and therapy...gradually improving...stable at discharge..." No documentation was found which indicated the patient had a sexual encounter with his roommate in the discharge summary.

On 08/14/15 at 1210 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #2's medical record which included the discharge summary. Personnel #2 verified the physician discharge summary did not address Patent #2's sexually acting out behavior.