HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 1 patient (Patient #1's) treatment plan/plan of care addressed a seizure Patient #1 sustained during inpatient stay. The treatment plan was not signed by Patient #1 nor did it address the seizure Patient #1 suffered.

Findings included:

Patient #1's Integrated Intake and Psychosocial Assessment dated 08/12/17 timed at 1400 reflected, "Reports she stopped taking her Depakote today because it caused her to urinate "Foam"...pharmacist told her to stop it...has a primary care physician thinks he is trying to kill her out of negligence...reports she is psychic and can read minds...feels angels around her...reports she often rocks, sways back and forth...husband states she is not taking her medication ...sons says she is good at hiding things from people...mania and mild psychosis...arthritis, hypothyroidism, connective tissue disorder, migraine..."

The Interdisciplinary Master Treatment Plan with a start date of 08/13/17 and target date of 08/20/17. The treatment plan did not address the seizure the patient experienced while inpatient on 08/14/17 nor addressed patient involvement.

The 08/14/17 Nursing Progress Note timed at 1445 reflected, "Patient was sitting in dayroom at 0720...RN was called into dayroom to find patient sitting in chair having what appeared to be a seizure...lasted 30 seconds to 45 seconds...Ativan 1 mg (milligram) given per physician orders..."

The 08/15/17 Nursing Progress Note non-timed reflected, "Anxious because of experience yesterday with seizure..."

The 08/16/17 non-timed Case Management Note reflected, "...expressed concern about the seizure patient had and the fact that she bit her tongue..."

The 08/17/17 Nursing Progress Note timed at 0300 reflected, "Patient drank ensure plus...complains of mouth sore..."

On 09/06/17 at 1630 Personnel #2 was interviewed by telephone. Personnel #2 verified Patient #1's treatment plan did not address the seizure the patient suffered and was incomplete.

Based on interview and record review the hospital failed to ensure Registered Nurses assessed and evaluated 1 of 1 patient (Patient #1's) needs after sustaining a seizure and biting her tongue. Patient #1 complained of mouth pain repeatedly. Nursing personnel failed to assess Patient #1's mouth and document their findings.

Findings included:

Patient #1's Integrated Intake and Psychosocial Assessment dated 08/12/17 timed at 1400 reflected, "Reports she stopped taking her Depakote today because it caused her to urinate "Foam"...pharmacist told her to stop it...has a primary care physician thinks he is trying to kill her out of negligence...reports she is psychic and can read minds...feels angels around her...reports she often rocks, sways back and forth...husband states she is not taking her medication ...sons says she is good at hiding things from people...mania and mild psychosis...arthritis, hypothyroidism, connective tissue disorder, migraine..."

The 08/14/17 Nursing Progress Note timed at 1445 reflected, "Patient was sitting in dayroom at 0720...RN was called into dayroom to find patient sitting in chair having what appeared to be a seizure...lasted 30 seconds to 45 seconds...Ativan 1 mg (milligram) given per physician orders...full range of motion in all extremities...medical consult was ordered and completed...safety precautions in place..." No documentation was found which indicated an assessment of the patient's mouth was completed after the seizure.

The Physician's Orders dated 08/14/17 timed at 0730 reflected, "Ativan 1 mg IM (Intramuscular) now for seizure..."

The 08/15/17 Nursing Progress Note non-timed reflected, "Anxious because of experience yesterday with seizure..."

The 08/16/17 non-timed Case Management Note reflected, "...expressed concern about the seizure patient had and the fact that she bit her tongue..."

The 08/17/17 Nursing Progress Note timed at 0300 reflected, "Patient drank ensure plus...complains of mouth sore..."

The 08/17/17 Nursing Progress Note timed at 0950 reflected, "Patient not eating well due to sore in her mouth...order received for ensure one can twice a day..." No actual assessment of mouth was documented to determine severity of mouth soreness.

On 09/06/17 at 1505 Personnel #6 was interviewed. Personnel #6 was asked to review Patient #1's medical record. Personnel #1 verified Patient #1 had a seizure. Personnel #6 was asked if he assessed Patient #1's mouth for injury. Personnel #6 stated he did not.

Based on interview and record review the hospital failed to ensure 1 of 1 patients (Patient #1's) treatment plan identified and addressed actual seizure activity which occurred during inpatient stay. No specific treatment approaches were identified.

Findings included:

Patient #1's Integrated Intake and Psychosocial Assessment dated 08/12/17 timed at 1400 reflected, "Reports she stopped taking her Depakote today because it caused her to urinate "Foam"...pharmacist told her to stop it...has a primary care physician thinks he is trying to kill her out of negligence...reports she is psychic and can read minds...feels angels around her...reports she often rocks, sways back and forth...husband states she is not taking her medication ...sons says she is good at hiding things from people...mania and mild psychosis...arthritis, hypothyroidism, connective tissue disorder, migraine..."

The Interdisciplinary Master Treatment Plan with a start date of 08/13/17 and target date of 08/20/17. The treatment plan did not address the seizure the patient experienced while inpatient on 08/14/17 nor addressed patient involvement.

The 08/14/17 Nursing Progress Note timed at 1445 reflected, "Patient was sitting in dayroom at 0720...RN was called into dayroom to find patient sitting in chair having what appeared to be a seizure...lasted 30 seconds to 45 seconds...Ativan 1 mg (milligram) given per physician orders..."

The 08/15/17 Nursing Progress Note non-timed reflected, "Anxious because of experience yesterday with seizure..."

The 08/16/17 non-timed Case Management Note reflected, "...expressed concern about the seizure patient had and the fact that she bit her tongue..."

The 08/17/17 Nursing Progress Note timed at 0300 reflected, "Patient drank ensure plus...complains of mouth sore..."

On 09/06/17 at 1630 Personnel #2 was interviewed by telephone. Personnel #2 verified Patient #1's treatment plan did not address the seizure the patient suffered and was incomplete.