HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to investigate, take action or have a method to identify incidents or patterns to protect patients.

Findings:

1. The hospital's policy titled "Incident reporting" stipulates any unusual occurrence, adverse reaction, negative response or out come, untoward event, or variance from approved policy and procedure must be documented. The policy further stipulates "any individual witnessing a possible incident will consult the Risk Manager within three calendar days of the occurrence".

2. Patient #2 was admitted for physically aggressive behavior and dementia. During the course of the patient stay several occurrences were documented in nursing notes. Within two days of admission nursing staff document "four staff escort combative hit and kick, notify MD (physician) DR HS (House Supervisor) called and maintenance stat". The documentation further stipulated "in another patients room trying to get in bed, became combative, hitting one nurse in arm, kicked Staff in knee, punched Staff , 5 milligram (mg) Zyprexa given". There was no documentation staff filed this occurrence as a incident.

There are multiple instances of Patient #2 wandering throughout the unit and into other patient's rooms. In one particular instance staff documented Patient #2 took another patient's dentures. On another occasion Pt #2 was found in bed with a female patient. There was no documentation staff filed these occurrences as incidents.

Later during the same patient stay the nursing staff document "combative banging doors with fist, went to quiet room." Over the course of the next few days, nurses document" turned shower water on in kitchen/bathroom area flooded kitchen, environmental services called. Will continue to observe". There was no documentation staff filed this occurrence as an incident. Later in the patient stay the documentation reflects the patient "closed self in bathroom, shower on and flooding floor, would not allow staff to enter several times". There was no documentation staff filed this occurrence as a incident.

Documentation by medical staff stipulated Patient #2 had been taken off anticoagulation medication on admission. Later in the stay medical staff document nursing spoke with facility patient had been transferred from and should be on "life long" anticoagulants. Medical staff documentation patients need for anticoagulant. No documentation a medication incident or incident report was generated by staff.

3. On 12/19/2011 surveyors reviewed August through November 2011 incident log. The log stipulated Patient #1 had a fall. Review of the Patient#1's medical record did not record any notes on Patient #1 falling. An order for a hip x-ray was written. There was no documentation indicating what had happened to the patient. Review of the log indicated multiple falls on the geropsychiatric unit during the same admission time as Patient #1. There was no review, analysis, or rationale for the number of falls documented. This finding was reviewed with Staff A on 12/19/2011.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to include, analyze and track all incidents as part of the quality process to improve patient care and hospital services.

Findings:

Review of the quality meeting minutes for 2011 and incident reports for August 2011 to December 2011 did not demonstrate all incidents were part of the quality improvement program with analysis to improve hospital practices. Two of two patient charts reviewed included multiple instances of occurrences meeting the definition of a incident.

1. Patient #2 was admitted for physically aggressive behavior and dementia. During the course of the patient stay several occurrences were documented in nursing notes. Within two days of admission nursing staff document "four staff escort combative hit and kick, notify MD (physician) DR HS (House Supervisor) called and maintenance stat". The documentation further stipulated "in another patients room trying to get in bed, became combative, hitting one nurse (Initials of Staff) in arm, kicked Staff in knee, punched Staff , 5 milligram (mg) Zyprexa given. There was no documentation staff filed this occurrence as a incident.

There are multiple instances of Patient #2 wandering throughout the unit and into other patient's rooms. In one particular instance staff documented Patient #2 took another patient's dentures. On another occasion Pt #2 was found in bed with a female patient. There was no documentation staff filed these occurrences as incidents.

Later during the same patient stay the nursing staff document "combative banging doors with fist, went to quiet room." Over the course of the next few days, nurses document" turned shower water on in kitchen/bathroom area flooded kitchen, environmental services called. Will continue to observe". There was no documentation staff filed this occurrence as an incident. Later in the patient stay the documentation reflects the patient "closed self in bathroom, shower on and flooding floor, would not allow staff to enter several times". There was no documentation staff filed this occurrence as a incident.

Documentation by medical staff stipulated Patient #2 had been taken off anticoagulation medication on admission. Later in the stay medical staff document nursing spoke with facility patient had been transferred from and should be on "life long" anticoagulants. Medical staff documentation patients need for anticoagulant. No documentation a medication incident or incident report was generated by staff.

2. In an interview 12/19/2011 Staff A told surveyors none of the above incidents had been reported through the incident reporting process. Staff A was not aware of these occurrences.


3. Review of Quality Meeting Minutes and Incident reports from August 2011-November 2011 indicate a high rate of falls in the behavioral health unit. There was no documentation the facility trended, analyzed, and improved processes based on reports of incidents.

Based on review of medical records, nursing policies and procedures and interviews with hospital staff, the hospital failed to ensure the registered nurse supervised and evaluated patient nursing care. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. In two of two patient medical records (Records #1,2) reviewed for nursing assessments and care, the nurse did not perform complete assessments so that care needs could be identified and did not supervise nursing staff to ensure accuracy and completeness of documentation.

Findings:

1. Patient #1 - Patient admission from 7/29/2011-8/10/2011. The patient was admitted to the HOPE unit for suicidal ideation, depression, dementia, physical aggression, behavior issues. Nursing took a picture of Patient #1's sacral area showing a skin disruption and weeping lesions. Also pictures were taken of the patient's bilateral heels and lower leg. There was no date or time indicated on the pictures. Documentation in the chart did not include specific information as to location of skin issues. The documentation did not include information on Patient #1's fall. During the course of the patient stay the documentation would stipulate "no difficulty" and later documentation stipulated "difficulty". There was no other documentation as to location or what the difficulty was. Patient #1's medical record included a observation log with every 15 minute documentation. Multiple blanks were found on the log. Staff also wrote over earlier documentation. These findings were confirmed with Staff A on 12/19/2011.

2. Patient #2-Patient admission from 8/8/2011-8/23/11. The patient was admitted to the HOPE unit for physical aggression at the nursing home, dementia, and behavior issues. Documentation by medical staff stipulated Patient #2 had been taken off anticoagulation medication on admission. Later in the stay medical staff document nursing spoke with facility patient had been transferred from and should be on "life long" anticoagulants. Documentation on the initial intake did not reflect the patient needed anticoagulation medication. Medication reconciliation records did not reflect the patient's need for anticoagulation. Patient #2's medical record included a observation log with every 15 minute documentation. Multiple blanks were found on the log. Staff wrote over earlier documentation. These findings were confirmed with Staff A on 12/19/2011.

3. The above findings were reviewed with administration during the exit conference. No further documentation was provided.