HospitalInspections.org

Based on document review and staff interview, the facility failed to ensure exercise of patients rights related to personal possessions for 1 of 5 (patient 1) closed patient medical records reviewed.

Findings:

1. Policy I-A.16, titled, "Psychiatric Patients Rights", revised/reapproved 10/2014, was reviewed on 7/14/15 at approximately 1600 hours, and indicated on pg. 2 of policy, section titled "You have the legal right to:", point 2., states "Keep and use personal possessions."

2. Review of patient 1's medical records on 7/13/15 at approximately 1350 hours, confirmed:
A. Patient Belongings Inventory record lists a vagal nerve stimulator (VNS) written above the Inventory Upon Admission column. The Inventory Upon Discharge column is blank.
B. Per Daily Nursing Record dated 6/29/15 at 1645 hours, "Vagus nerve stimulator given to ambulance personnel in envelope...left via stretcher with all belongings."
C. lacked documentation of when or who took the VNS or where it was placed.

3. Medical staff D1 (Medical Director) was interviewed on 7/13/15 at approximately 1430 hours, and confirmed patient 1 has a VNS with a magnet and the magnet was to be worn. During one of the periods of his/her agitation, one of the nurses became concerned patient would harm himself/herself or others and it was removed. When F1 came in and asked the Social Worker where it was, he/she was informed it was misplaced, but the issue was that this Social Worker just did not know that it had been put away for potential self harm. Patient did have this returned and left with it.

4. Staff 14 (Staff Nurse) and staff 15 (Staff Nurse) were interviewed on 7/14/15 at approximately 1435 hours, and confirmed not sure who removed patient 1's VNS from his/her possession or when. Patient belongings are documented on the Patient Belongings List. This patient's VNS was documented on the list, but unsure if this was at discharge or when it was put up for safe keeping. Not sure where VNS was put.

Based on document review and staff interview, the facility failed to ensure the use of restraint in accordance with hospital policy for 2 of 2 (patient 1 and 4) closed medical records reviewed of patients put in restraint.

Findings:

1. Policy II.C.16, titled, "Restraint or Seclusion Use", revised/reapproved 10/2014, was reviewed on 7/14/15 at approximately 1600 hours, and indicated on pg. 4 of policy, Provision of Care While Restrained section, point 7., states "Patients will be assessed for injuries as a result of the restraint and, any observed injury, will be reported promptly."

2. Review of medical records on 7/13/15 at approximately 1350 hours, confirmed patient:
A. 1, presented to the facility on 6/17/15 for symptoms of organic mental syndrome and was discharged on 6/29/15. Patient had an order for medical restraint dated 6/18/15 at 1240 hours and 6/29/15 at 1230 hours; and medical record lacked documentation of assessment of injuries.
B. 4, presented to the facility on 3/30/15 for anxiety disorder and major depressive disorder and was discharged on 5/20/15. Patient had an order for medical restraint dated 4/14/15 at 1000 hours and 4/30/15 at 1000 hours; and medical record lacked documentation of assessment of injuries.

3. Staff 3 (Director of Nursing) was interviewed on 7/13/15 at approximately 1500 hours,and confirmed there was no documentation of assessment for injuries per policy and procedure for the above-mentioned restraints.

Based on document review, medical record review, and staff interview, the facility failed to ensure the use of restraint was in accordance with the order of a physician for 2 of 5 (patient 1 and 4) closed medical records reviewed.

Findings:

1. Policy II.C.16, titled, "Restraint or Seclusion Use", revised/reapproved 10/2014, was reviewed on 7/14/15 at approximately 1600 hours, and indicated on pg. 3 of policy, Physician Orders section, point 1., states "A physician order for restraint - either med-surg or for violent or self-destructive behavior - is required prior to or, in an emergency situation, immediately after placing in restraints."

2. Review of medical records on 7/13/15 at approximately 1350 hours, confirmed patient:
A. 1, presented to the facility on 6/17/15 for symptoms of organic mental syndrome and was discharged on 6/29/15. Per Restraint Order: Medical:
a. dated 6/18/15 at 1240 hours was for a lap buddy for safety for a 24 hour period and:
i. stated "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lacked documentation of discontinuation.
b. dated 6/29/15 at 1230 hours was for a Posey bed for safety for a 24 hour period and:
i. stated "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lacked documentation of discontinuation.
iii. lacked physician authentication, date, or time.

B. 4, presented to the facility on 3/30/15 for anxiety disorder and major depressive disorder and was discharged on 5/20/15:
a. Restraint Order: Medical dated 4/14/15 at 1000 hours, was for a lap buddy for safety for a 24 hour period and:
i. states "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lacked of documentation of discontinuation.
b. Restraint Order: Medical dated 4/30/15 at 1000 hours, was for a Mitt for safety for a 24 hour period and:
i. states "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lack of documentation of discontinuation.
c. per Behavior Tracking form dated 4/17/15 from 0630- 1730 hours and 1830-2100 hours, "was found trying to slide under lap buddy" and "trying to stand despite lap buddy."
i. lacked physician order for medical restraint for 4/17/15.

3. Staff 3 (Director of Nursing) was interviewed on 7/13/15 at approximately 1500 hours,and confirmed Physician signature with date and time is not documented on medical restraint for 6-29-15. Also, there is no documentation of medical restraint discontinuation for the medical restraints mentioned above and a lack of physician order for medical restraint for patient 4 on 4/17/15.

Based on document review and staff interview, the facility failed to ensure discontinuation of restraint for 2 of 2 (patient 1 and 4) closed medical records reviewed of patients put in restraint.

Findings:

1. Policy II.C.16, titled, "Restraint or Seclusion Use", revised/reapproved 10/2014, was reviewed on 7/14/15 at approximately 1600 hours, and indicated on pg. 3 of policy, Discontinuation of Med-Surg Restraint section, states "Restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order."

2. Review of medical records on 7/13/15 at approximately 1350 hours, confirmed patient:
A. 1, presented to the facility on 6/17/15 for symptoms of organic mental syndrome and was discharged on 6/29/15. Per Restraint Order: Medical:
a. dated 6/18/15 at 1240 hours was for a lap buddy for safety for a 24 hour period and:
i. stated "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lacked of documentation of discontinuation.
b. dated 6/29/15 at 1230 hours was for a Posey bed for safety for a 24 hour period and:
i. stated "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lacked documentation of discontinuation.

B. 4, presented to the facility on 3/30/15 for anxiety disorder and major depressive disorder and was discharged on 5/20/15:
a. Restraint Order: Medical dated 4/14/15 at 1000 hours, was for a lap buddy for safety for a 24 hour period and:
i. states "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lacked of documentation of discontinuation.
b. Restraint Order: Medical dated 4/30/15 at 1000 hours, was for a Mitt for safety for a 24 hour period and:
i. states "discontinue restraints when patient demonstrates reduction in conditions necessitating the restraint use."
ii. lack of documentation of discontinuation.

3. Staff 3 (Director of Nursing) was interviewed on 7/13/15 at approximately 1500 hours and confirmed there is no documentation of medical restraint discontinuation for the medical restraints mentioned above.

Based on document review and staff interview, nursing service failed to ensure an adequate number of licensed registered nurses for 1 of 2 (Inpatient Care Unit 200) areas.

Findings:

1. Policy II-C.103, titled, "Staffing Precaution Plan", revised/reapproved 2/2015, was reviewed on 7/14/15 at approximately 1600 hours, and indicated on pg. 2 and 3 of policy, Procedure section, points 2.a. and b., state "There will be a minimum of one registered nurse in the unit at all times if the hospital has one patient...Under no circumstances shall there be less than one registered nurse and one additional nursing staff member in the unit if the hospital has more than one patient in a unit."

2. Nursing staffing pattern, acuity, and census for Inpatient Care Unit 200 for 6/14/15 through 6/27/15, was reviewed on 7/13/15 at approximately 1500 hours and facility did not follow sections of their policy/procedure, Staffing Precaution Plan, by not ensuring at least one Registered Nurse (R.N.) was staffed on each inpatient care unit (100 and 200) as required per facility policy and procedure. An R.N. was lacking for the 200 unit for 6/14/15, 6/16/15, 6/17/15, 6/18/15, 6/19/15, 6/21/15, 6/23/15, and 6/24/15. Patient census on these days was 16 for all days, except 15 on 6/23/15.

3. Staff 3 (Director of Nursing) was interviewed on 7/13/15 at approximately 1500 hours, and confirmed the Inpatient Care Unit 200 was lacking a Registered Nurse (RN) as required by facility policy and procedure on 6-14, 6-16-19, 6-21, 6-23, and 6-24-15.

4. Staff 1 (Staff Nurse) was interviewed on 7/14/15 at approximately 1312 hours, and confirmed an R.N. is not staffed on this unit today [7/14/15], but 1 R.N. is on the other unit (100).