HospitalInspections.org

Based on document review, medical record (MR) review and interview, emergency department (ED) staff did not obtain accurate and current patient medication histories for 6 of 21 ED patients. This could cause ED staff to lack awareness of a patient's current medications.

Findings include:

-- The hospital policy and procedure (P&P) titled "Medication Reconciliation," last revised 10/2015, indicated that with patient involvement, nursing staff should obtain and document a complete list of patient's home medications during the medication reconciliation process. The medication list should be initiated by nursing in outpatient areas, including the emergency department.

-- Review of Patient #1's MR revealed that the patient presented to the ED with self inflicted neck laceration and suicidal ideation on 1/18/18 at 12:07 pm. Patient #1's MR contained a list of medications titled "Active (Home) Medications". (This medication list prepopulated for previous hospital visits.) The last date that Patient #1's medications had last been reviewed and confirmed by nursing staff was 12/15/17 (approximately 1 month earlier). Staff C (Psychiatrist) documented being aware that the patient was due for her monthly aripiprazole (Abilify Maintena) injection however the last injection date was not documented. On 1/19/18 at 2:50 pm, Patient #1 was discharged to Tompkins County Mental Health Clinic (TCMHC) to receive her Abilify Maintena injection. Patient #1's discharge information contained a "Home Medication List" which listed the same unreviewed medications with dates last taken as "unknown." Patient #1's Home Medication List did not contain the monthly Abilify Maintena injection.

Patient #1 again presented to the ED with suicidal ideation on 1/19/18 at 4:33 pm. Staff C documented that the patient had been discharged earlier to TCMHC where she was due to receive her monthly Abilify Maintena injection. There was no documentation in Patient #1's MR indicating whether the patient received the monthly Abilify at TCMHC. Patient #1 was discharged at 8:54 pm with the same incomplete and unconfirmed Home Medication List.

There was no documentation in Patient #1's MR indicating that a current medication history had been obtained and/or reviewed by ED staff during either of the 1/18/18 or 1/19/18 ED presentations.

-- Review of Patient #2's MR revealed that he presented to the ED on 8/26/17 after falling from a ladder. Patient #2's medications were listed in the MR. The last date noted in the MR that Patient #2 medications had been reviewed and confirmed by nursing staff was 4/24/17 (4 months earlier). There was no documentation in Patient #2's MR indicating that a current medication history had been obtained by ED staff during this ED presentation.

The same lack of documentation of current medication history was also found in the MRs of Patient #3, Patient #4, Patient #5, and Patient #6.

-- During interview of Staff I (IT Director of Applications and Consultations) on 2/20/18 at 2:00 pm, he/she acknowledged the above findings regarding lack of ED staff confirmation of current medications in patient MRs.

Based on medical record (MR) review, interview, and document review, the hospital did not ensure that a Registered Nurse (RN), Staff J, functioning in the role of a Psychiatric Evaluator in the ED (Flex unit), was qualified to perform mental health evaluations (MHE) of patients that presented to the ED with psychiatric symptoms. This could lead to inadequate patient evaluations.

Findings include:

-- Review of Patient #1's MR revealed that she presented to the ED on 1/18/18 at 12:07 pm with a self inflicted neck laceration and suicidal ideation. At 5:32 pm, (after a medical clearance exam) Staff J documented performing a MHE for Patient #1.

-- Review of Patient #7's MR revealed she presented to the ED on 2/9/18 at 12:33 pm for a MHE with suicidal ideation. At 3:17 pm, (after a medical clearance exam) Staff J documented performing the MHE for Patient #7.

-- Per interview of Staff J on 2/16/18 at 3:30 pm, he/she was a "new nurse" since 5/2017 and had been employed at the hospital 3 months. Staff J indicted he/she had no psychiatric nursing experience. He/she acknowledged performing MHEs for patients in the ED (Flex unit).

-- Per review of Staff J's personnel file, he/she was offered a position as a Registered Nurse, Behavioral Health Unit on 10/6/17. His/her file contained a "Behavioral Services Unit - Registered Nurse" orientation checklist indicating that the form should be completed during the employees initial orientation period. The form contained multiple responsibilities and performance criteria areas and was signed and dated by Staff J on 2/21/18. The form did not address responsibilities and performance criteria for a Mental Health Evaluator (Psychiatric Evaluator). The file also contained a form titled "Position Description Performance Evaluation; Registered Professional, Nurse Behavioral Services," dated and signed by Staff J on 2/21/18. This form did not address performance standards related to Mental Health Evaluator (Psychiatric Evaluator) (e.g., Patient Assessment - Clinician is responsible for independent behavioral health emergency evaluations of acute psychiatric / addiction patients in emergency department, Crisis Intervention - provides assessment, interventions and supportive social work services to help patients / families deal with health problems and psychosocial needs, Risk Management - Ability to recognize symptoms of behavior of potentially dangerous situations and intervenes appropriately.)

-- During interview of Staff K (Director of Behavioral Services) on 2/21/18 at 2:05 pm, he/she acknowledged lack of documentation indicating Staff J was competent to perform MHE. He/she also acknowledged that Staff J's RN orientation checklist was not completed or signed by Staff J until that day (2/21/18).

There was no documentation in Staff J's personnel file indicating that he/she had been hired to perform as a Psychiatric Evaluator (Mental Health Evaluator). He/she lacked experience and training to work in the ED and to perform MHE (e.g., previous psychiatric experience and one year of clinical experience).