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Based on observation, review of clinical records, hospital policies and procedures and interviews for one of three patients receiving end-of-life care, Patient #2, the hospital failed to implement a plan of care that included facilitating contact with support systems including clergy. The findings include:
Patient #2 was admitted to the hospital on 11/10/14 on in-patient hospice level of care with diagnoses that included bladder cancer and a history of dementia. The patient had been receiving hospice homecare services prior to admission. A coordinated care plan between the hospital and the hospice provider dated 11/10/14 identified the problem of Patient/Family Coping with an intervention of involving hospice and/or community spiritual support for the patient and family. The hospital plan of care dated 11/10/14, identified the problem of terminal illness with interventions that included to assess for spiritual values and facilitate contact with appropriate support systems. A hospital form entitled Interdisciplinary Assessment Indicators documented by an RN on 11/11/14 identified that the patient had spiritual concerns that included a request for Sacrament of the Sick with directions that included to request a visit by the chaplain.
Interview with Patient #2's family member on 03/29/16 at 2:00 PM identified that he/she had requested that the Sacrament of the Sick be administered, however, the patient was not visited by a chaplain and did not receive the sacrament of the sick prior to expiration on 11/12/14.

Based on clinical record review and interview for 1 (P#23) of 3 patients reviewed for allegations of abuse the facility failed to follow the facility abuse policy. The findings include:
P#23 with diagnoses that included dementia, anxiety and manic behaviors was admitted to the facility on 12/9/15 for evaluation of major depression and manic episodes. Facility documentation indicated on 12/13/15 P#23 made the accusation that staff was providing care to him/her in a rough manner resulting in a skin tear to P#23's hand and forearm. The facility documentation further indicated an investigation was initiated immediately and NA#3 and NA#4 were reassigned to another patient care area.
During a review of the incident and facility Abuse Policy with the Director of Acute Medical and Psychiatric Services on 3/29/16 at 2:10 PM he/she indicated NA#3 and NA#4 had been reassigned to another patient care unit the day the incident occurred. The Director of Acute Medical and Psychiatric Services indicated NA#3 and NA#4 should have been removed from the facility, not reassigned according to the facility Abuse Policy. He/she indicated upon completion of the investigation the allegation was determined to be unsubstantiated.
The facility Abuse Policy indicated in the even an allegation of abuse/neglect occurs, the employee will be removed from patient care areas while preliminary information is being obtained, and will then be suspended during the investigation process and conclusion of the investigation.

Based on clinical record review for 2 (P#9, P#20) of 3 patients reviewed for restraint use the facility failed to follow the facility restraint policy. The findings include:
1. Patient (P) #9 was admitted to the facility on 3/4/16 for psychiatric evaluation related to exacerbation of dementia with behavioral disturbances. A restraint assessment dated 3/19/16 indicated P#9 required placement in seclusion for behaviors such as striking out at staff, throwing furniture and banging his/her fists on the wall. A physicians order for seclusion was entered into the medical record on 3/19/16 at 3:31 PM. P#9 was removed from seclusion on 3/19/16 at 6:15 PM. In addition, a restraint assessment dated 3/20/16 indicated P#9 required placement in seclusion for striking/grabbing staff, breaking furniture and banging his/her hands on the walls. A physicians order for seclusion was entered into the medical record on 3/20/16 at 2:36 PM. P#9 was removed from seclusion on 3/20/16 at 5:45 PM.
2. P#20, with a history of a traumatic brain injury, was admitted to the facility on 2/11/16 for psychiatric evaluation after he/she exhibited behaviors such as increased agitation and aggressive behavior. A restraint assessment dated 3/8/16 indicated P#20 required the use of an airlift belt for behaviors such as striking out at staff, trying to stand without assistance and other unsafe behaviors. The airlift belt was applied at 9:30 PM and removed at 11:45 PM. A physician's order was entered on 3/8/16 at 9:39 PM.

Review of P#9's and P#20's medical records with the Director of Medical and Psychiatric Services on 3/24/16 failed to identify documentation indicating P#9 and P#20 had been evaluated by a LIP after restraint/seclusion according to facility Restraint policy.
Facility restraint policy indicated that a patient must be seen for evaluation by a LIP within one hour of restraint application or placement in seclusion.

Based on clinical record review and interview for 1 (P#22) of 3 patients reviewed for pain management the facility failed to formulate a comprehensive patient care plan (PCP) addressing pain management. The findings include:
P#22 was admitted on 4/9/15 to the facility for psychiatric evaluation due to aggressive behavior and psychotic symptoms. Diagnoses included mental retardation, bipolar disorder and borderline personality disorder According to a discharge summary dated 5/1/15 by Medical Doctor (MD) #2, P#22's admission assessment identified he/she was noted to have significant pain and dysfunction of his/her left shoulder and swelling and pain in the right arm. X-rays completed on 4/15/14 identified an old displaced fracture of the left humerus and a more acute displaced fracture of the right humerus. Medical record documentation identified pain assessments were completed and pain medications including Oxycodone were ordered by MD#2 and administered for pain control however review of the medical record failed to identify P#22's active pain issue was addressed in the PCP.
During an interview with MD#2 on 3/24/16 at 9:00 AM, MD#2 indicated P#22 had severe pain issues when first admitted to the facility. MD#2 further indicated P#22's change in behaviors may have been affected by the degree of pain he/she was experiencing.
During an review of P#22's PCP the Director of Medical and Psychiatric Services on 3/29/16 at 11:00 AM the Director of Medical and Psychiatric Services indicated P#22 did have an active problem of pain and the care plan should have included pain as an issue including updated interventions.
Facility Patient Care Plan policy indicated the facility would ensure that a plan of care for each patient is developed that is appropriate to his/her specific needs and the severity level of his/her disease, condition, impairment or disability.

Based of observation, review of clinical records, review of hospital documentation, hospital policies and procedures and interviews for one of three patients (Patient #1) receiving hospice care, the hospital failed to ensure that the patient received the correct dose of medication as ordered. The findings include:
Patient #1 was admitted to the hospital on 01/29/16 for in-patient hospice care with diagnoses that included end-stage heart failure and chronic kidney disease. Physician's orders dated 01/29/16 directed to administer Diazepam 5 mg sublingually, every 4 hours as needed for respiratory seizure and/or terminal agitation.
Review of the electronic medication administration record (eMAR) identified the original order as Diazepam Oral Concentrate 5 mg/ml (5 mg) with a dose of 5 mg sublingual q4hr prn for seizure or terminal agitation.
A nursing note documented by RN #1 on 02/02/16 at 12:01 AM identified that at 8:05 AM Patient #1's family member reported that the patient had experienced a seizure. Upon assessment, RN #1 identified that there was no visible sign or symptom of seizure activity, however, RN #1 administered Diazepam 25 mg sublingually instead of the prescribed 5 mg.
Review of the clinical record identified that the nursing supervisor as well as PA #1 were notified of the medication error. On 02/02/16 at 12:04 AM, PA #1 documented that RN #1 had administered the incorrect dose of Diazepam. PA #1 assessed the patient and discussed the patient's condition and medication error with family members and the Power of Attorney (POA) at the bedside. Although there was an option to reverse the effects of the excessive dose of Diazepam, the POA opted for no reversal of the Diazepam, and to continue comfort measures. Patient #1 continued to receive comfort measures, including additional medications until 02/02/16 at 2:51 PM when the patient was pronounced expired.
Interview with RN #1 on 03/21/16 at 2:45 PM identified that he/she had misinterpreted the medication dose as 5 ml (25 mg) instead of 5 mg (1 ml). medication dose. RN #1 recognized during administration that the volume of the medication was not consistent with sublingual administration notified the supervisor and PA #1 immediately.
Interview with the Director of Pharmacy on 03/21/16 at 3:15 PM identified that Diazepam concentrate was dispensed as a stock bottle containing 30 to 60 ml's of concentrate. Subsequent to the occurrence, Diazepam concentrate was dispensed in individual pre-filled 0.5 ml (2.5mg) or 1 ml (5 mg) syringes.
Hospital policy on medication administration identified that, for all medications, check the medication against the MAR and/or physician order and read the label 3 times. Check for right patient, right medication, right dose, right time, and right route. Use the scan, pour, chart, pass method.

Based on review of the clinical record, review of policy and interview, the hospital failed to ensure that the clinical record, completed in the Gastrointestinal (GI) Clinic, was complete and accurate for 2 of 3 records reviewed (Patients #11 and #13). The findings include:
a. Patient #11 underwent an esophagogastroduodenoscopy (EGD) and colonoscopy on 1/29/16. Review of the procedure report identified that the nurse failed to document the time that the patient had recovered sufficiently to discharge. Review of the policy for the Standard Operating Procedure (for colonoscopy), while identifying that the patient should be monitored post-procedure, the policy does not identify documentation parameters regarding documentation in the clinical record for times of discharge.
b. Review of the record for Patient #13, who underwent a screening colonoscopy on 1/18/16, identified that the history and physical (H&P) was completed the morning of the procedure and failed to be comprehensive, in that the cardiovascular assessment was lacking and only identified that the patient was "within normal limits." Additionally, this record failed to (1) reflect the time that a post anesthesia assessment was completed and (2) failed to reflect that during the post procedure monitoring phase of respiratory, the patient required oxygen or utilized room air.

1. The Hospital failed to ensure that the physical environment was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others.

During tour of the Geriatric Medical Psychiatric Program on 04/05/16 at approximately 11:00 AM, the surveyor along with the Facilities Director & Maintenance Supervisor, observed that the headwall cabinetry in patient rooms had openings that could be used as a ligature point and were not safeguarded, interview of facilities staff identified that the openings had been safeguarded previously and it was unknown who had removed the safeguard, but that they would be immediately safeguarded


2. Based on observation on the Geriatric Medical/Psychiatric Program (GMPP), review of hospital policy and procedures, and staff interviews, the hospital failed to ensure that the hospital environment was maintained in a manner conducive to the safety of patients. The findings include:

a. Tour of the Geriatric Medical Psychiatric Program (GMPP) on 03/22/16 at 11:00 AM with MD #2 and the Director of the Acute Care Unit (ACU) and the GMPP identified that one of thirty beds presented with an electric cord plugged into the wall that extended approximately five feet and plugged into the back of the bed. The plug could be manually removed from the wall and the bed lacked any mechanism (zip ties) to shorten the cord and decrease the ligature risk. Review of environmental safety rounds and work orders failed to identify that the hazardous cord had been identified as needing an intervention to ensure patient safety. Other similar cords were observed to be secured with zip ties.
b. Observation of the seclusion room on 03/22/16 at 11:20 AM identified that the painted floor in front of the seclusion room door was worn and deteriorating. Paint chips were loose, creating a risk for ingestion. Loose paint chips were also visible on the wall around a square, padded plate approximately 5-6 feet above the floor. Additionally, the ceiling near the access door appeared to be splashed with a brownish substance.
c. One patient room was appointed with a small, low, light-weight, square wooden table with one removeable rectangular drawer. The table was not affixed to the floor, nor was the drawer locked to prevent removal. The table and/or drawer could be utilized as a weapon.
Although patients assessed as at risk for self-injurious behavior and/or suicide were placed on one to one observation; patients with a history of aggression, psychosis, and/or self-injurious or suicidal behaviors remain at risk if they experience a sudden change in condition in an unsafe environment.
The hospital policy for unit safety rounds identified, in part, that any items that should not be in the rooms such as sharps, contraband, cords, etc, should be removed, and the room, furniture, and safety of the physical environment should be reported to the Registered Nurse (RN) immediately.

Based on review of the clinical record for one of five patients (P#18) reviewed for appropriate discharge timing and interview, the discharge planning failed to be flexible/appropriate secondary to poor communication between entities involved with the patient's discharge destination. The finding includes:
Review of the clinical record for Patient #18 identified that the patient was a resident of an affiliate of the same hospital organization prior to admission to the hospital. It was identified that early upon admission that Patient #18 would be moving into another apartment within the affiliate. The patient was deemed ready for discharge, however, secondary to poor communication with the affiliate, the patient was unable to be discharged into his/her new apartment secondary to readiness, thus causing the delay in discharge from the hospital as well as the patient being discharge to an intermediary location.
During interview on 3/24/16 at 3:30 PM, the Social Worker stated that upon review, the hospital had realized that the delay in discharge and placement of the patient was due to poor knowledge and communication with the affiliate and it's policies and is currently working to improve in those areas.