HospitalInspections.org

Based on staff interview, medical record review, observation, and review of policies and procedures, it was determined that the facility failure to ensure that patient's rights are protected and promoted.

Findings include:

1. The facility failed to ensure that the patient or the patient's legal representative had the right to make an informed decision in the development of the plan of care for medicinal treatments. (Refer to Tag A-0131)

2. The facility failed to ensure that surveillance cameras were maintained. (Refer to Tag A-0144)

3. The facility failed to ensure that security safety rounds were being performed hourly. (Refer to Tag A-0144)

4. The facility failed to ensure that skin integrity was assessed for patients in restraints. (Refer to Tag A-0175)

5. The facility failed to ensure that vital signs were assessed for patients in restraints. (Refer to Tag A-0175)

6. The facility failed to ensure that a face-to-face evaluation was conducted for patients in restraints. (Refer to Tag A-0184)

Based on staff interview, medical record review, and the review of facility policies and procedures, it was determined that the facility failed to ensure that the patient or the patient's legal representative had the right to make an informed decision for medicinal treatments in seven (7) out of seven (7) medical records reviewed for medication consent.

Findings include:

Reference #1: Facility policy titled "Consent, Informed" states: " ...To establish a mutual understanding between the patient and the physician or other licensed practitioner who provides care, treatment, or services about the care, treatment, and services the patient receives ... ... Informed Consent: ...1. Disclosure: providing adequate information to make an informed decision ....."

Reference #2: Facility policy titled "Admission to Inpatient Psychiatric Service, Minors" states: "...With respect to minors, the primary function of the Child and Family Crisis Clinician is to provide off-site clinical assessment for children and adolescents and refer them for treatment to the most clinically appropriate, least restrictive setting... Minors assessed by... Child and Family Crisis Clinician, in consultation with the on-call Child Psychiatrist... will be admitted in collaboration with parent/legal guardian consent....."

1. On 10/9/20, seven (7) medical records were reviewed from the Alexander Pavilion 2nd Floor (AP2) Unit. A consent form titled, "Behavioral Health: Children's Crisis Intervention Services Medication Consent" was identified in six (6) out of the seven (7) medical records. An interview with Staff #25 revealed that the "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form is obtained by the treating physician in correlation with the patient's family and is used for the consent of standing and prn (as needed) medications to be given for the treatment of the patient's condition.

a. Medical Record #1 identified standing medications that would be administered to the patient, but the form was incomplete in the following areas:

(i) Top section indicating patient name, date of birth, physician, patient's authorized representative, phone number, additional phone number, and the relationship of the authorized representative.

(ii) Section #1 denotes the relationship of the name filled in as the authority to consent for the patient. The patient's name was left blank.

(iii) Section 2. B. indicates which as needed medications would be administered for certain conditions.

(iv) Section 3 indicates a signature for the consent but does not indicate the relationship with the patient.

b. The medication consent of Patient #1 was signed by Staff #35 on 9/27/20. The medication consent was signed by an authorized patient representative on 10/2/2020. This consent only identified the standing medications to be given to Patient #1.

c. Review of Medical Record #1 on 10/9/20, identified a physician evaluation dictated on 9/28/2020 at 10:08 AM by Staff #35. The evaluation stated the plan of treatment with standing medications was discussed, but lacked evidence that treatment with prn (as needed) medications were discussed with the family.

d. The medical record of Patient #1 lacked evidence of the discussion with the patient's family of prn medications being used for treatment. Patient #1 was administered a prn medication for agitation on 10/1/2020.

e. Medical Record #20 "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form was not filled out or signed by a patient's authorized representative and the physician/LIP (Licensed Independent Practitioner). Patient #20 was admitted on 10/1/2020 and was being discharged at the time of the survey on 10/9/2020.

f. Review of the medication orders for Patient #20 noted both standing medication orders as well as prn medication orders. Patient #20 had received a standing medication order for the medication Abilify 2.5 milligram orally at bedtime during the hospitalization.

g. Review of the medical record of Patient #20 on 10/9/20, identified a physician evaluation dictated on 10/3/20 at 11:08 AM by Staff #36. The evaluation stated the plan of treatment with a standing medication was discussed, but lacked evidence that treatment with prn medications were discussed with the family.

h. Medical Record #21 "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form was not filled out or signed by the physician or the patient's authorized representative. Patient #21 was admitted on 10/7/2020 and was still an inpatient at the time of the survey on 10/9/2020.

(i) The Medication Administration Record (MAR) indicated that the patient had orders for both standing medications and prn medications.

(ii) Review of Medical Record #21 on 10/9/20, identified a physician evaluation dictated on 10/8/2020 at 5:15 PM by Staff #35. The evaluation stated the plan of treatment with standing medications was discussed, but lacked evidence that treatment with prn (as needed) medications were discussed with the family.

i. Medical Record #22 "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form was not filled out or signed by the physician or the patient's authorized representative. Patient #22 was admitted on 10/8/2020 at 2:00 AM and was still an inpatient at the time of the survey on 10/9/2020.

(i) A physician note written by Staff #35 on 10/8/2020 at 4:40 AM indicated that the physician had spoken with the family regarding standing medication orders, but did not address the use of prn medication.

(ii) The Medication Administration Record (MAR) indicated that the patient had orders for both standing medications and prn medications.

j. Medical Record #4 "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form was not signed by the patient's authorized representative. Patient #4 was admitted on 9/8/2020.

k. Patient #4's "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form identified standing medications that would be administered to the patient, but the form was incomplete in the following areas:

(i) Top section indicating patient name, date of birth, physician, patient's authorized representative, phone number, additional phone number, and the relationship of the authorized representative.

(ii) Section #1 denotes the relationship of the name filled in as the authority to consent for the patient. The patient's name was left blank.

(iii) Section 2. B. that indicates which as needed medications would be administered for certain conditions.

(iv) Section 3 indicates a signature by the physician but was incomplete in the following areas: consent or refuse treatment; time period that consent is valid for; parent signature; relationship to patient; and witness.

l. Medical Record #19 "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form was not filled out or signed by the physician and the patient's authorized representative. Patient #19 was admitted on 10/4/2020 and was still an inpatient at the time of the survey on 10/9/2020.

(i) A physician note written by Staff #35 on 10/5/2020 at 3:54 PM indicated that the physician had spoken with the family regarding standing medication orders, but did not address the use of prn medication.

(ii) The Medication Administration Record (MAR) indicated that the patient had orders for both standing medications and prn medications.

m. Medical Record #8 "Behavioral Health: Children's Crisis Intervention Services Medication Consent" form was not included in the medical record.

n. A MAR was in the medical record of Patient #4 that identified both standing and prn medications.

2. The above findings were confirmed with Staff #25, Staff #34, Staff #35, and Staff #36 on 10/9/2020 at 1:22 PM.

A. Based on staff interview, observation, and review of facility documentation, it was determined that the facility failed to ensure that security staff can effectively monitor patients via surveillance camera due to a darkened screen.

Findings include:

1. On 10/8/2020 at 1:41 PM, a review of the surveillance footage from 10/1/2020 of the security camera that monitors the Quiet Room of the AP2 Unit was conducted in the main security office in the presence of Staff #19, Staff #22, Staff #26, and Staff #27. The images from the 10/1/2020 recordings of the camera were observed to be dark, thus making it difficult to see the recordings on the screen.

a. An interview with Staff #27 at 1:41 PM revealed that the surveillance camera that monitors the Quiet Room of AP2 had been "glitchy" recently and a work order had been placed prior to the state of the survey for maintenance of the camera.

2. On 10/8/2020 at 1:44 PM, an interview with Staff #26 confirmed the above findings that a work order should have been placed for the camera when it was discovered it was not functioning properly.

3. On 10/8/2020 at 10:13 AM, a tour of the AP2 Unit was conducted in the presence of Staff #22 and Staff #25. The Quiet Room was observed on this tour, and it was confirmed with Staff #25 that a patient recently had used the quiet room the night of 10/7/2020 to the morning of 10/8/2020.

a. Staff #25 confirmed on 10/8/2020 at 10:44 AM that the quiet room had been in use for multiple patients after Patient #1 had been discharged from the facility on 10/2/2020.

4. Upon request to Staff #3 on 10/9/20 at 9:10 AM, the facility provided a copy of the work order placed for the surveillance camera that was dated 10/8/2020, which was the date of the survey.

B. Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure that security safety rounds are performed hourly on the AP2 psychiatric unit.

Findings include:

1. Upon request, Staff #26 provided a copy of the handbook titled: "Security Orientation Checklist." An item of the checklist stated: " ...Alexander Pavilion ...Conduct hourly tours through: AP1, AP2 & AP3 ... ."

2. Staff #26 confirmed that this orientation checklist is completed by each member of security upon hire and orientation to the facility. By completing the checklist, each member of security acknowledges the understanding of the task and responsibility that their job requires.

3. A tour of the AP2 unit was conducted on 10/8/2020 at 10:10 AM to 10:52 AM in the presence of Staff #19, Staff #22, and Staff #25. During the tour an "AP Safety Rounds Log" was identified at the front desk. An interview with Staff #22 at 10:44 AM stated that security guards are to sign in the log when the guards are entering the unit to do hourly rounds.

4. Upon review of the Safety Rounds Log from 9/26/2020 to 10/2/2020, it was noted that the security guard was not signing in each hour, therefore it was unable to be determined if hourly rounds were being conducted on the AP2 unit.

5. An interview with Staff #26 on 10/8/2020 at 2:50 PM confirmed the above findings and that security guards should be signing in the Safety Rounds Log when conducting safety rounds of each unit of the Alexander Pavilion.

A. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that nursing assessed and monitor the patient for signs of injury in two (2) out of four (4) medical records reviewed for patients placed in behavioral restraints (Medical Record #1 and #3).

Findings include:

Reference: Facility policy titled: "Restraint/Seclusion" states: " ...V. Monitoring/Care of the Patient While in Restraint: Rights, dignity and the patient's well-being will always be protected while the patient is in restraint. This includes: ...Behavioral Management use: The RN (Registered Nurse) will: a) Assess the patient at the initiation of restraint or seclusion and then every 15 minutes. This assessment includes ... the following: -Signs of injury associated with application ... -Physical and psychological status and comfort ...".

1. On 10/9/2020, the Medical Record of Patient #1 was reviewed. The following was identified:

a. Staff #33, a nurse, documented placing Patient #1 in 4-Point restraints on 10/1/20 at 7:30 PM.

(i) Staff #33 did not document any signs of injury at the point of contact with the restraints on the patient at the initiation of the restraints.

(ii) The restraints flowsheet lacked documentation of an assessment of any signs of injury associated with restraint application at each of the 15 minute checks while the patient was in restraints.

2. Upon review of Medical Record #3 on 10/9/20 at 9:38 AM in the presence of Staff #1, the following was identified:

a. Staff #38, a nurse, documented placing Patient #3 in "4 Point" restraints on 9/17/20 at 12:00 PM.

(i) Staff #38 did not document any signs of injury at the point of contact with the restraints on the patient at the initiation of the restraint.

(ii) The restraints flowsheet lacked documentation of an assessment of any signs of injury associated with restraint application at each of the 15 minute checks while the patient was in restraints.

3. An interview with Staff #25 on 10/8/20 at 12:15 PM stated that the staff do not assess for signs of injury with restraints usage.


B. Based on staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to ensure that vital signs were monitored per facility policy in four (4) out of four (4) medical records reviewed of patients in behavioral restraints (#1, #3, #4, #8).

Findings include:

Reference: Facility policy titled: "Restraint/Seclusion" states: " ...V. Monitoring/Care of the Patient While in Restraint: Rights, dignity and the patient's well-being will always be protected while the patient is in restraint. This includes: ...Behavioral Management use: The RN (Registered Nurse) will: a) Assess the patient at the initiation of restraint or seclusion and then every 15 minutes. This assessment includes ... the following: ...-Vital signs and interpreting relevance to safety of the patient ... -Physical and psychological status and comfort ...".

1. On 10/8/2020 at 11:15 AM, the medical record of Patient #1 was reviewed in the presence of Staff #25. The following was identified:

a. There was documentation by Staff #33, a nurse, that Patient #1 was placed in 4-Point restraints on 10/1/2020 at 7:30 PM. It was identified that Staff #33 also documented the 4-Point restraints were discontinued on 10/1/2020 at 8:47 PM. The medical record lacked evidence that vital signs were taken upon the initiation of restraints and every 15 minutes in accordance with facility policy.

2. On 10/8/2020 at 11:15 AM, Staff #25 confirmed the above findings.

3. On 10/9/2020 at 9:38 AM, a review of Medical Records #3, #4, and #8 revealed the following:

a. On 9/17/2020 at 11:57 AM, an order was entered for Patient #3 by Staff #38, a physician, for "Restraint Initiate Behavioral 18 Years and Older" with a type of "4 Point Locked."

(i) At 12:00 PM, Staff #40, an RN, documented in the "Restraints Information" flowsheet that 4 point locked restraints were initiated on Patient #3.

(ii) At 1:45 PM, Staff # Staff #40 documented in the "Restraints Information" flowsheet that the restraint was discontinued.

(iii) On 9/17/2020 in the "Vital Signs" flowsheet, the only documented vital signs for Patient #3 were at 8:00 AM, four hours before the restraints were ordered. The medical record lacked evidence that vital signs were taken upon the initiation of restraints and every 15 minutes in accordance with facility policy.

b. On 9/14/2020 at 4:30 PM, an order was entered for Patient #4 by Staff #34, a physician, for "Restraint Initiate Behavioral 9-17 Years" with a type of "4 Point Locked."

(i) At 5:33 PM, the Restraint order was discontinued by Staff #41, a physician.

(ii) On 9/14/2020 in the "Vital Signs" flowsheet, the only documented vital signs for Patient #4 were at 8:12 PM, 2 hours and 39 minutes after the restraints were discontinued. The medical record lacked evidence that vital signs were taken upon the initiation of restraints and every 15 minutes in accordance with facility policy.

c. On 8/2/2020 at 10:56 AM, an order was entered for Patient #8 by Staff #36, a physician, for "Restraint Initiate Behavioral 8 Years and Younger" with a type of "4 Point Locked."

(i) At 11:11 AM, the Restraint order was discontinued by Staff #36.

(ii) On 8/2/2020 in the "Vital Signs" flowsheet, there were no documented vital signs for Patient #8 on that day, including the time of restraint application.

4. The above findings were confirmed by Staff #1, #25, and Staff #42 on 10/9/2020 at 11:20 AM.

Based on staff interview, review of four (4) medical records for behavioral restraints use, and review of facility policy and procedure, it was determined that the facility failed to ensure that documentation of a face-to-face medical and behavioral evaluation is completed within one hour in one (1) out of four (4) medical records (Medical Record #3).

Findings include:

Reference: Facility policy titled, " Restraint/Seclusion" states, "...Physical Holding for Forced Medications... The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered restraint. ...If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply. ..."

1. On 10/8/2020 at 1:39 PM, a review of Medical Record #3 revealed the following:

a. On 9/16/2020 at 10:46 PM, an order was written by Staff #38, a physician, for "Restraint Initiate Behavioral 18 Years and Older" with "Reason for Restraint: Violence/Threatening Behavior, Type: Therapeutic Hold."

(i) At 10:58 PM, in the "Restraints Information" flow sheets, Staff #39, a registered nurse (RN), documented use of a physical hold for less than one minute to administer a medication.

(ii) There was no documentation of a face-to-face medical and behavioral evaluation of the patient within one (1) hour of the therapeutic hold.

2. The above findings were confirmed by Staff #1 on 10/8/2020 at 1:48 PM.

A. Based on three (3) out of three (3) observations of patient rooms dedicated to positive COVID-19 patients, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure that infection prevention and control practices used to mitigate the spread of COVID-19, are implemented.

Findings include:

Reference #1: Facility policy titled, "Standard and Isolation Precautions for Inpatients and Outpatients" states, "... 2. Transmission Based Precautions: Transmission based Precautions are used for patients known to be infected or colonized with epidemiologically important pathogens that can be transmitted by Airborne, Contact, Enteric-Contact or Droplet transmission. ... Procedure... 3. Place sign on door. Appropriate signs which denote isolation/precautions contain necessary instruction for staff and visitors are to be displayed on the door of the patient's room for both cohorted and private rooms. ... ."

Reference #2: Facility document, "COVID-19 Isolation/PPE Guidelines" state, "3. Asymptomatic... Status: COVID +... PPE to be worn: N95 mask, Procedural facemask (covers N95 mask), Face shield, Isolation Gown, Gloves... Isolation: Droplet Contact. ... 4. Symptomatic ... Status: COVID + or Suspected... PPE to be worn: N95 mask, Procedural facemask (covers N95 mask), Face shield, Isolation Gown, Gloves ... Isolation: Droplet Contact. ... ."

1. During the Entrance Conference conducted on 10/8/20 at 10:07 AM, Staff #2 confirmed that Stanley 4 is the facility's dedicated COVID-19 unit. He/she stated that patients who are PUI (persons under investigation) or confirmed positive for COVID-19 are housed on Stanley 4, unless they require critical care services, whereupon they are transferred to the Intensive Care Unit (ICU).

2. During a tour of Stanley 4 on 10/8/2020 at 10:50 AM, the following was observed:

a. Upon interview, Staff #14 confirmed that the unit had a bed capacity of six (6) with a current census of three (3). Staff #14 indicated that all the patients on the unit were confirmed COVID-19 positive.

b. Contact Precautions and Droplet Precautions isolation signs were observed outside of Room #438, Room #439, and Room #441. The isolation sign for Contact Precautions indicated that persons entering the room must wear gloves and a gown. The isolation sign for Droplet Precautions indicated that persons entering the room must wear a "Standard surgical mask" to enter the room.

(i) Neither of the isolation signs indicated that persons entering the room must wear an N95 mask covered by a surgical mask and a face shield, as indicated in facility guidelines for caring for COVID-19 positive patients.

c. Upon interview on 10/8/2020 at 11:05 AM, Staff #2 confirmed that all Droplet Isolation signage is the same throughout the facility. He/she stated that the signage "needs to be updated."

3. Staff #2, Staff #3, and Staff #39 confirmed the above finding on 10/8/20 at 2:55 PM.

B. Based on observation, review of nationally recognized guidelines, and staff interviews, it was determined that the facility failed to adhere to Centers for Disease Control and Prevention (CDC) recommendations to mitigate the transmission of COVID-19.

Findings include:

Reference: Centers for Disease Control and Prevention (CDC), The National Institute for Occupational Safety and Health (NIOSH), Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings, https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html#risksextended, March 27, 2020 states, " ... Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients are infected with the same respiratory pathogen and patients are placed together in dedicated waiting rooms or hospital wards ... Extended use is favored over reuse because it is expected to involve less touching of the respirator and therefore less risk of contact transmission ... If extended use of N95 respirators is permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination ... and consider additional training and reminders (e.g., posters) for staff to reinforce the need to minimize unnecessary contact with the respirator surface ... ."

1. During a tour of Stanley 4 on 10/8/2020 at 10:50 AM, the following was revealed:

a. Upon interview at 10:55 AM, Staff #14 indicated that he/she was caring for the patient in Room #441, a confirmed COVID-19 positive patient. Staff #14 was wearing a surgical mask but was not wearing an N95 mask.

b. When asked why he/she was not wearing an N95 mask, Staff #14 stated that he/she does not continuously wear his/her N95 mask. Staff #14 stated that he/she dons an N95 mask covered by a surgical mask when he/she is going into the patient's room, and immediately removes the N95 mask when he/she exits the room. Staff #14 stated that he/she puts the N95 mask in a paper bag and stores it in a cabinet until he/she needs it.

(i) Staff #14 confirmed that he/she goes into the patient's room "about every 2 hours and whenever I'm called."

c. The excessive donning and doffing of the nurse's N95 mask increases the potential for contact transmission of COVID-19.

2. Staff #2, Staff #3, and Staff #39 confirmed the above finding on 10/8/2020 at 2:55 PM.