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The Hospital failed to ensure that the Condition of Patient Rights was met. Based on clinical record reviews, staff interviews, observations, and review of hospital policies and procedures, the hospital failed to ensure that care was provided in a safe setting when the hospital failed to identify and remediate environmental safety hazards observed on the psychiatric unit, for five of five sampled patients reviewed for the administration of sedative hypnotic medications the hospital failed to titrate Versed and Propofol in accordance with the hospital protocol and/or physician order, and for six of six patients reviewed for observational checks the facility failed to conduct patient safety observations in accordance with the physician's order.

Please refer to A144, A395 and A701

Based on clinical record reviews, staff interviews, observations, and review of hospital policies and procedures, the hospital failed to ensure that care was provided in a safe setting when the hospital failed to identify and remediate environmental safety hazards observed on the psychiatric unit, for five of five sampled patients reviewed for the administration of sedative hypnotic medications (Patient #26, #27, #28, #29 and #30), the hospital failed to titrate Versed and Propofol in accordance with the hospital protocol, and for six of six patients reviewed for observational checks (Patient #41, #42, #43, #44, #45 and #46), the facility failed to conduct patient safety observations in accordance with the physician's order and hospital policy. The findings include:


1. On 07/16/14 at 1:00 PM, while touring the adult psychiatric unit with the Vice President of Facilities and Support Services the following was observed:
Shower controls, door hinges and window locks contained in patient rooms, could be used as a ligature point posing a potential hanging hazard and were not designed to a psychiatric/ institutional standard. The hand washing sinks contained within patient rooms and patient bathroom/shower rooms throughout were not provided with paper towel holders, toilet paper dispensers, and soap dispensers that were designed and approved as psychiatric/ institutional standard in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used. The patient rooms and common areas had screw type fasteners that were not designed to a psychiatric/ institutional standard i.e. not security/tamper resistant.
Hospital inspection reports for the in-patient psychiatric unit were reviewed and included a General Workplace Inspection dated 1/23/2013 and Environmental Safety Rounds Checklists dated 1/22/2014 and 7/16/14. The General Workplace Inspection and the two Environmental Safety Rounds Checklists failed to include a review and inspection of the environment for the above mentioned items that would pose potential hanging hazards and equipment with the potential to be used in a harmful manner. Weekly Safety Inspection reports dated 6/21/14, 6/29/14, 7/6/14, and 7/13/14 also failed to include a review and inspection of the environment for the above mentioned items that would pose potential hanging hazards and equipment with the potential to be used in a harmful manner.
Interviews with the Regulatory Director of Behavioral Health and the VP of Facilities on 7/16/14 at 2:00 PM identified that the hospital had not identified shower controls, door hinges, window locks, paper towel holders, toilet paper dispensers, soap dispensers or screw type fasteners as potential hazards prior to the State Agency observations. Based on the State Agency's observations, the hospital developed and implemented hourly environmental rounds to monitor the safety hazards existing in the psychiatric unit and identified that these rounds would continue until all identified safety hazards were remediated.

2. Review of the clinical record identified Patient #26 was admitted to the hospital on 7/12/14 with a poly substance abuse overdose and aspiration pneumonia. Patient #26 was transferred to intensive care for respiratory distress that required intubation. Physician orders dated 7/15/14 directed sedation with Versed at 100 milligrams (mg) in 100 milliliters (ml) Normal Saline 0.9% intravenous (IV) solution. The order further directed Versed to be administered at 0.5 mg/hour (hr) and titrate by 0.5mg/hr every fifteen minutes to a Ramsey Sedation Scale between 2 (cooperative, oriented and tranquil), and 3 (responds to commands only). A maximum rate of 12mg/hr was directed. Review of vital signs record identified on 7/15/14 at 4:30 PM Versed was infusing at 0.5mg/hr and the patient's Ramsey Scale was 1. At 5:00 PM the Ramsey score was 3. At 6:30 PM Versed was infusing at 1.5 mg/hr absent a Ramsey score or a titration in increments of 0.5 mg/hr in accordance with the physician orders and/or hospital protocol. At 7:00 PM the Versed was infusing at 2mg/hr absent a Ramsey score. At 8:00 PM Versed was infusing at 3mg/hr with a Ramsey Scale of 3. Interview with the Director of Critical Care on 7/16/14 at 10:00 AM indicated the nursing staff did not titrate and/or conduct a Ramsey assessment with each titration and/or did not titrate in increments of 0.5mg/hr in accordance with the hospital protocol and should have.

3. Review of the clinical record identified Patient #27 was admitted to the hospital on 7/15/14 for abdominal pain that required emergency repair of an incarcerated ventral hernia. Postoperatively, the patient was noted to have acute respiratory failure and remained intubated in the Intensive Care Unit. Physician orders dated 7/15/14 directed sedation with an infusion of Propofol at 5 micrograms (mcg) per Kilogram (kg) per minute (min) intravenously and a titration of 5 mcg/kg/minute every 5 minutes to a Ramsey Sedation Scale between 3 and 4. Review of the vital signs record identified Propofol was initiated on 7/15/14 at 4:00 PM at 15 mcg/kg/min. A Ramsey score was not conducted until 8:00 PM which was documented as 4. Propofol was titrated at 5:00 PM to 10 mcg/kg/min and continued at this dose until 4:30 AM on 7/16/14. A subsequent Ramsey score was documented as 2 at 10:00 PM on 7/15/14. Interview with MD #5 on 7/15/14 at 10:08 AM indicated nursing determined the initiation rate of the Propofol based on their assessment. Interview with the Director of Critical Care on 7/16/14 at 10:10 AM identified nursing should have followed the physician's orders for the initiation of Propofol and did not. Further interview with the Director of Critical Care indicated if a different initiation rate was needed the nurse should have notified a prescriber for an order that reflected the dose required to achieve sedation and Propofol dosing should have been decreased at 8:00 PM when the Ramsey score was above the desired level of sedation as directed by the physician order. Furthermore, the Director of Critical Care identified the titration of Propofol should have corresponded to the Ramsey score in accordance to the hospital protocol and did not.

4. Review of the clinical record identified Patient #28 was admitted to the hospital on 7/11/14 with a history of achalasia and presented with shortness of breath. Patient # 28 underwent an esophagoscopy for the removal of a foreign body with a right neck exploration and a repair of an esophageal perforation on 7/11/14. Following surgery Patient #28 was received in Intensive Care from the Post Anesthesia Care Unit after a surgical procedure on a ventilator. Physician orders dated 7/11/14 directed sedation with a Propofol infusion at 5 mcg/kg/min intravenously and a titration of 5 mcg/kg/min every 5 minutes to a Ramsey Sedation Scale between 3 and 4. Review of the vital signs record identified Propofol was initiated on 7/11/14 at 1:00 AM at 5mcg/kg/min with a Ramsey score of 1. Propofol was titrated from 1:05 AM to 1:20 AM every 5 minutes for a total dose of 25 mcg/kg/min absent Ramsey scores throughout the titration. Interview with the Director of Critical Care on 7/16/14 at 10:20 AM identified nursing should have conducted the Ramsey Score prior to each titration to justify increasing the dose of Propofol and did not.

5. Review of the clinical record identified Patient #29 was admitted to the hospital on 7/2/14 with changes in mentation and a history of chronic respiratory failure. Blood gas changes required intubation. Physician orders dated 7/2/14 directed sedation with a Propofol infusion at 5 mcg/kg/min intravenously and a titration of 5 mcg/kg/min every 5 minutes to a Ramsey Sedation Scale between 3 and 4. Review of the vital signs record identified Propofol was initiated on 7/11/14 at 4:10 PM at 20mcg/kg/min with a Ramsey score of 1. Subsequent titrations were documented as 40 mcg/kg/min at 5:00 PM and 8:00 PM with a Ramsey score of 4 respectively absent titration dosing in increments that were ordered in accordance with the Ramsey Score. Additionally the Ramsey score was above the level of sedation at 5:00 PM and 8:00 PM. Interview with APRN #1 on 7/16/14 at 10:30 AM identified the nursing staff determine the initiation rate and titration of Propofol according to their assessment and judgment. Further interview with APRN #1 indicated the practitioner is not notified by nursing to obtain an order for an alternate initiation rate for Propofol when sedation cannot be achieved at the prescribed dose. Interview with the Director of Critical Care on 7/16/14 at 10:35 AM identified if the initiation rate of Propofol is different than the standing order the practitioner is responsible to provide the correct order for the administration of the medication. Further interview with the Director of Critical Care identified Propofol dosing should have been decreased at 5:00 PM when the Ramsey score was above the desired level of sedation as directed by the physician order and was not.

6. Review of the clinical record identified Patient #30 was admitted to the hospital on 6/3/14 with a long history of alcohol dependence who presented with hepatic failure and ascites. On 6/19/14 Patient #30's medical condition deteriorated and was transferred to the Intensive Care Unit and intubated. Physician orders dated 6/19/14 directed sedation with Versed 100 mg in 100 ml Normal Saline 0.9% intravenous solution. The order further directed Versed to be administered at 0.5 mg/hr and titrate to a Ramsey Sedation Scale between 2 and 3. Versed was to be titrated by 0.5 mg/hr every fifteen minutes to a maximum rate of 12mg/hr. Review of the vital signs record identified on 6/19/14 at 1:30 AM Versed was infusing at 0.5mg/hr and the patient's Ramsey Scale was 1. Versed was titrated every half hour through 4:30 AM by 0.5 mg/hr however at 2:00 AM the Ramsey score was 3 and a subsequent Ramsey score was not documented until 4:00 AM at which time the Ramsey score was 4. Further review of the clinical record identified the Ramsey score was titrated again at 4:30 AM by 0.5 mg/hr when the Ramsey score was above the recommended level of sedation. Interview with the Director of Critical Care on 7/16/14 at 10:45 AM indicated the nursing staff did not titrate and/or conduct a Ramsey assessment with each titration in accordance with the hospital protocol and should have. In addition the Versed dosing should have been decreased at 4:00 AM when the Ramsey score was above the desired level of sedation as directed by the physician order and was not. The hospital protocol entitled Medication Sedation of Ventilated Critical care Patients directed in part that Versed's initial dose would be 2 to 5 mg IV every fifteen minutes however the policy failed to direct titration in accordance with the Ramsey scale. The hospital policy entitled Propofol for Sedation in the Adult Ventilated Patient directed in part to initiate Propofol at 5 mcg/kg/minute and titrate up slowly every 5 to 10 minutes until adequate sedation is achieved using the Ramsey Sedation Scale.

7. Review of the clinical record identified Patient #41 was admitted to the hospital on 7/11/14 with diagnoses of borderline personality disorder, chronic pain and suicidal ideations. Physician's orders dated 7/13/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:00 AM.

8. Review of the clinical record identified Patient #42 was admitted to the hospital on 7/8/14 with a diagnosis of major depression with suicidal ideation. Physician's orders dated 7/11/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:00 AM.

9. Review of the clinical record identified Patient #43 was admitted to the hospital on 6/26/14 with a diagnosis of major depression with suicidal ideations. Physician's orders dated 6/27/14 directed observational checks to be conducted every fifteen minutes. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:45 AM.

10. Review of the clinical record identified Patient #44 was admitted to the hospital on 7/14/14 with a diagnosis of major depression with suicidal ideations. Physician's orders dated 7/15/14 directed observational checks to be conducted every fifteen minutes. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:45 AM.

11. Review of the clinical record identified Patient #45 was admitted to the hospital on 7/7/14 with a diagnosis of bipolar illness with suicidal ideations. Physician's orders dated 7/13/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:00 AM.

12. Review of the clinical record identified Patient #46 was admitted to the hospital on 7/10/14 with diagnoses of schizophrenia and suicidal ideations. Physician's orders dated 7/11/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM indicated checks were last completed at 9:00 AM.

Interview with RN #6 on 7/15/14 at 10:30 AM identified he/she was responsible for the observational checks on 7/15/14 between 9:30 AM through 10:30 AM. RN #6 indicated the checks were not conducted timely as he/she was busy completing nursing documentation in the electronic medical record. Interview with Nurse Manager #6 on 7/15/14 at 10:45 AM identified the patient safety checks should have been visually conducted by RN #6 and were not. The hospital policy entitled Patient Safety Check form directed in part, that safety checks would be conducted through observation of a patient's behavior and activity. The patient observer would document on the patient safety form every fifteen minutes or as ordered by the physician. The policy further directed documentation may be completed less frequently for example every thirty minutes or hourly as specified in the physician order.

Based on a clinical record reviews, staff interviews, and a review of the hospital policies and procedures for five of five sampled patients reviewed for the administration of sedative hypnotic medications (Patient #26, #27, #28, #29 and #30), the hospital failed to titrate Versed and Propofol in accordance with the hospital protocol, for six of six patients reviewed for observational checks (Patient #41, #42, #43, #44, #45 and #46), the facility failed to conduct patient safety observations in accordance with the physician's order and hospital policy, and for two of five patients reviewed for pain management (Patient #2 and P#3), the facility failed to complete pain reassessments according to facility policy. The findings include:

1. Review of the clinical record identified Patient #26 was admitted to the hospital on 7/12/14 with a poly substance abuse overdose and aspiration pneumonia. Patient #26 was transferred to intensive care for respiratory distress that required intubation. Physician orders dated 7/15/14 directed sedation with Versed at 100 milligrams (mg) in 100 milliliters (ml) Normal Saline 0.9% intravenous (IV) solution. The order further directed Versed to be administered at 0.5 mg/hour (hr) and titrate by 0.5mg/hr every fifteen minutes to a Ramsey Sedation Scale between 2 (cooperative, oriented and tranquil), and 3 (responds to commands only). A maximum rate of 12mg/hr was directed. Review of vital signs record identified on 7/15/14 at 4:30 PM Versed was infusing at 0.5mg/hr and the patient's Ramsey Scale was 1. At 5:00 PM the Ramsey score was 3. At 6:30 PM Versed was infusing at 1.5 mg/hr absent a Ramsey score or a titration in increments of 0.5 mg/hr in accordance with the physician orders and/or hospital protocol. At 7:00 PM the Versed was infusing at 2mg/hr absent a Ramsey score. At 8:00 PM Versed was infusing at 3mg/hr with a Ramsey Scale of 3. Interview with the Director of Critical Care on 7/16/14 at 10:00 AM indicated the nursing staff did not titrate and/or conduct a Ramsey assessment with each titration and/or did not titrate in increments of 0.5mg/hr in accordance with the hospital protocol and should have.
2. Review of the clinical record identified Patient #27 was admitted to the hospital on 7/15/14 for abdominal pain that required emergency repair of an incarcerated ventral hernia. Postoperatively, the patient was noted to have acute respiratory failure and remained intubated in the Intensive Care Unit. Physician orders dated 7/15/14 directed sedation with an infusion of Propofol at 5 micrograms (mcg) per Kilogram (kg) per minute (min) intravenously and a titration of 5 mcg/kg/minute every 5 minutes to a Ramsey Sedation Scale between 3 and 4. Review of the vital signs record identified Propofol was initiated on 7/15/14 at 4:00 PM at 15 mcg/kg/min. A Ramsey score was not conducted until 8:00 PM which was documented as 4. Propofol was titrated at 5:00 PM to 10 mcg/kg/min and continued at this dose until 4:30 AM on 7/16/14. A subsequent Ramsey score was documented as 2 at 10:00 PM on 7/15/14. Interview with MD #5 on 7/15/14 at 10:08 AM indicated nursing determined the initiation rate of the Propofol based on their assessment. Interview with the Director of Critical Care on 7/16/14 at 10:10 AM identified nursing should have followed the physician's orders for the initiation of Propofol and did not. Further interview with the Director of Critical Care indicated if a different initiation rate was needed the nurse should have notified a prescriber for an order that reflected the dose required to achieve sedation and Propofol dosing should have been decreased at 8:00 PM when the Ramsey score was above the desired level of sedation as directed by the physician order. Furthermore, the Director of Critical Care identified the titration of Propofol should have corresponded to the Ramsey score in accordance to the hospital protocol and did not.
3. Review of the clinical record identified Patient #28 was admitted to the hospital on 7/11/14 with a history of achalasia and presented with shortness of breath. Patient # 28 underwent an esophagoscopy for the removal of a foreign body with a right neck exploration and a repair of an esophageal perforation on 7/11/14. Following surgery Patient #28 was received in Intensive Care from the Post Anesthesia Care Unit after a surgical procedure on a ventilator. Physician orders dated 7/11/14 directed sedation with a Propofol infusion at 5 mcg/kg/min intravenously and a titration of 5 mcg/kg/min every 5 minutes to a Ramsey Sedation Scale between 3 and 4. Review of the vital signs record identified Propofol was initiated on 7/11/14 at 1:00 AM at 5mcg/kg/min with a Ramsey score of 1. Propofol was titrated from 1:05 AM to 1:20 AM every 5 minutes for a total dose of 25 mcg/kg/min absent Ramsey scores throughout the titration. Interview with the Director of Critical Care on 7/16/14 at 10:20 AM identified nursing should have conducted the Ramsey Score prior to each titration to justify increasing the dose of Propofol and did not.
4. Review of the clinical record identified Patient #29 was admitted to the hospital on 7/2/14 with changes in mentation and a history of chronic respiratory failure. Blood gas changes required intubation. Physician orders dated 7/2/14 directed sedation with a Propofol infusion at 5 mcg/kg/min intravenously and a titration of 5 mcg/kg/min every 5 minutes to a Ramsey Sedation Scale between 3 and 4. Review of the vital signs record identified Propofol was initiated on 7/11/14 at 4:10 PM at 20mcg/kg/min with a Ramsey score of 1. Subsequent titrations were documented as 40 mcg/kg/min at 5:00 PM and 8:00 PM with a Ramsey score of 4 respectively absent titration dosing in increments that were ordered in accordance with the Ramsey Score. Additionally the Ramsey score was above the level of sedation at 5:00 PM and 8:00 PM. Interview with APRN #1 on 7/16/14 at 10:30 AM identified the nursing staff determine the initiation rate and titration of Propofol according to their assessment and judgment. Further interview with APRN #1 indicated the practitioner is not notified by nursing to obtain an order for an alternate initiation rate for Propofol when sedation cannot be achieved at the prescribed dose. Interview with the Director of Critical Care on 7/16/14 at 10:35 AM identified if the initiation rate of Propofol is different than the standing order the practitioner is responsible to provide the correct order for the administration of the medication. Further interview with the Director of Critical Care identified Propofol dosing should have been decreased at 5:00 PM when the Ramsey score was above the desired level of sedation as directed by the physician order and was not.
5. Review of the clinical record identified Patient #30 was admitted to the hospital on 6/3/14 with a long history of alcohol dependence who presented with hepatic failure and ascites. On 6/19/14 Patient #30's medical condition deteriorated and was transferred to the Intensive Care Unit and intubated. Physician orders dated 6/19/14 directed sedation with Versed 100 mg in 100 ml Normal Saline 0.9% intravenous solution. The order further directed Versed to be administered at 0.5 mg/hr and titrate to a Ramsey Sedation Scale between 2 and 3. Versed was to be titrated by 0.5 mg/hr every fifteen minutes to a maximum rate of 12mg/hr. Review of the vital signs record identified on 6/19/14 at 1:30 AM Versed was infusing at 0.5mg/hr and the patient's Ramsey Scale was 1. Versed was titrated every half hour through 4:30 AM by 0.5 mg/hr however at 2:00 AM the Ramsey score was 3 and a subsequent Ramsey score was not documented until 4:00 AM at which time the Ramsey score was 4. Further review of the clinical record identified the Ramsey score was titrated again at 4:30 AM by 0.5 mg/hr when the Ramsey score was above the recommended level of sedation. Interview with the Director of Critical Care on 7/16/14 at 10:45 AM indicated the nursing staff did not titrate and/or conduct a Ramsey assessment with each titration in accordance with the hospital protocol and should have. In addition the Versed dosing should have been decreased at 4:00 AM when the Ramsey score was above the desired level of sedation as directed by the physician order and was not. The hospital protocol entitled Medication Sedation of Ventilated Critical care Patients directed in part that Versed's initial dose would be 2 to 5 mg IV every fifteen minutes however the policy failed to direct titration in accordance with the Ramsey scale. The hospital policy entitled Propofol for Sedation in the Adult Ventilated Patient directed in part to initiate Propofol at 5 mcg/kg/minute and titrate up slowly every 5 to 10 minutes until adequate sedation is achieved using the Ramsey Sedation Scale.
6. Review of the clinical record identified Patient #41 was admitted to the hospital on 7/11/14 with diagnoses of borderline personality disorder, chronic pain and suicidal ideations. Physician's orders dated 7/13/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:00 AM.
7. Review of the clinical record identified Patient #42 was admitted to the hospital on 7/8/14 with a diagnosis of major depression with suicidal ideation. Physician's orders dated 7/11/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:00 AM.
8. Review of the clinical record identified Patient #43 was admitted to the hospital on 6/26/14 with a diagnosis of major depression with suicidal ideations. Physician's orders dated 6/27/14 directed observational checks to be conducted every fifteen minutes. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:45 AM.
9. Review of the clinical record identified Patient #44 was admitted to the hospital on 7/14/14 with a diagnosis of major depression with suicidal ideations. Physician's orders dated 7/15/14 directed observational checks to be conducted every fifteen minutes. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:45 AM.
10. Review of the clinical record identified Patient #45 was admitted to the hospital on 7/7/14 with a diagnosis of bipolar illness with suicidal ideations. Physician's orders dated 7/13/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM identified checks were last completed at 9:00 AM.
11. Review of the clinical record identified Patient #46 was admitted to the hospital on 7/10/14 with diagnoses of schizophrenia and suicidal ideations. Physician's orders dated 7/11/14 directed observational checks to be conducted hourly. Review of the patient safety checks on 7/15/14 at 10:30 AM indicated checks were last completed at 9:00 AM.

Interview with RN #6 on 7/15/14 at 10:30 AM identified he/she was responsible for the observational checks on 7/15/14 between 9:30 AM through 10:30 AM. RN #6 indicated the checks were not conducted timely as he/she was busy completing nursing documentation in the electronic medical record. Interview with Nurse Manager #6 on 7/15/14 at 10:45 AM identified the patient safety checks should have been visually conducted by RN #6 and were not. The hospital policy entitled Patient Safety Check form directed in part, that safety checks would be conducted through observation of a patient's behavior and activity. The patient observer would document on the patient safety form every fifteen minutes or as ordered by the physician. The policy further directed documentation may be completed less frequently for example every thirty minutes or hourly as specified in the physician order.

12. Patient (P) #2 was admitted to the hospital for surgical intervention related to sigmoid diverticulitis with a contained perforation. A physicians order dated 7/10/14 identified P#2 was to receive Dilaudid 1 milligram (mg.) intravenous (IV) push every 2 hours as needed for pain.
The medication administration record (MAR) indicated P#2 received Dilaudid IV push for pain on 7/11/14 at 6:30 AM with a pain reassessment at 8:00 AM, 1 hour (hr.) 30 minutes (min.) later and at 10:27 AM with a pain reassessment at 12:22 PM, 1 hr. 55 min. after the dose was administered.
On 7/12/14 P#2 received Dilaudid at 6:39 AM with a pain reassessment at 8:14 AM, 1 hr. 50 min. later and 8:52 PM with a reassessment at 9:55 PM, 1 hr. 3 min. later. In addition P#2 received Dilaudid IV push on 7/12/14 at 9:23 AM and 7/13/14 at 12:13 AM with no documented pain reassessment.
On 7/13/14 P#2 received Dilaudid at 5:56 AM with a pain reassessment at 7:31 AM, 1 hr. 35 min. after the dose was administered, 9:47 AM with a reassessment 10:52 AM, 1 hr. 5 min. later, 12:10 PM with a pain reassessment at 1:52 PM, 2 hr. 2 min. later, 6:25 PM with a reassessment at 7:57 PM, 1 hr. 32 min. later and 11:47 PM with a pain reassessment at 1:00 AM, 1 hr. 13 min. after the dose was administered.
On 7/14/14 P#2 received Dilaudid at 6:10 AM with a pain reassessment at 7:00 AM; 55 min. after the dose was administered.
13. P#3 was admitted to the hospital for surgical repair of a perforated appendix. Physician's orders dated 7/8/14 indicated P#3 was to receive Tylenol with Codeine 10 milliliters (ml.) by mouth every 6 hours or Morphine 2 mg. IV push every 2 hours as needed for pain.
The MAR indicated P#3 received Tylenol on 7/11/14 at 3:53 PM with a pain reassessment at 5:39 PM; 1 hour 46 min. after the dose was administered.
On 7/12/14 P#3 received Tylenol at 5:13 AM and 1:35 PM with no pain reassessment documented in the medical record. In addition on 7/12/14 P#3 received Tylenol at 5:24 PM with a pain reassessment at 8:10 PM, 2 hrs. 14 minutes after the dose was administered.
On 7/13/14 P#3 received Tylenol at 6:01 PM with a pain reassessment at 7:50 PM; 1 hr. 49 minutes after the dose was administered.
In addition the MAR indicated P#3 received Morphine 2 mg. IV push on 7/9/14 at 6:57 AM with a pain reassessment at 9:00 AM, 2 hrs. 3 min. after the dose was administered.
During a review of the medical records with Unit Manager #1 on 7/14/14 at 9:45 AM, Unit Manager #1 verified that pain reassessments were either not documented or not completed according to hospital policy. Upon surveyor inquiry Unit Manager #1 indicated pain reassessment for effectiveness of pain medication should be done within 1 hour after the medication is administered.
Facility pain management policy indicated reevaluation of the patient's pain intensity and level of sedation will be 30 minutes after parenteral drugs and 60 minutes after oral analgesic or non-pharmacological interventions




29049

Based on a review of the clinical records and staff interviews for four of four sampled patients reviewed for disposition at the time of discharge (Patient #47, #48, #49, and #50), the hospital failed to obtain a discharge order and/or failed to ensure the legiblity of practitioner notes that reflected the plan of care and/or the rationale for the discharge. The findings include:
1. Review of the clinical records for Patient #47, #48, #49 and #50 failed to identify a physician's order that directed the discharge of all four patients. Interview with the Medical Director of the Emergency Department on 7/17/14 at 4:00 PM indicated a physician's order should be clearly identified in the clinical record and was not.
2. Review of the clinical records for Patient #47, #48, #49 and #50 failed to ensure the legiblity of practitioner notes that documented the plan of care and/or the rationale for discharge. Interview with the Director of the Emergency Department on 7/17/14 at 4:10 PM indicated the clinical record should be legible and all providers and staff members should be able to discern the written plan of care that included discharge planning.

The Hospital failed to ensure that the Condition of Physical Environment was met.
Based on a tour of the inpatient psychiatric unit, review of hospital inspection reports and interviews with staff, the Hospital failed to identify and ensure that the physical environment was constructed, arranged, and maintained to ensure the safety of the patients.



Please refer to A 701

Based on a tour of the hospital, observations, review of hospital inspection reports and staff interviews, the hospital failed to ensure that the psychiatric care sleeping rooms and unit were maintained in such a manner as to promote the safety and well-being of patients. The findings include:

1. On 07/16/14 at 1:00 PM, while touring the adult psychiatric unit with the Vice President of Facilities and Support Services the following was observed:

a. The shower controls, door hinges and window locks contained in patient rooms, could be used as a ligature point posing a potential hanging hazard and were not designed to a psychiatric/ institutional standard.

b. That the hand washing sinks contained within patient rooms and patient bathroom/shower rooms throughout were not provided with paper towel holders, toilet paper dispensers, and soap dispensers that were designed and approved as psychiatric/ institutional standard in construction and are deemed not appropriate for use in the environment in which they are installed; i.e. commercial-style, plastic-resin type dispensers can injure patients or others if mis-used.

c. The patient rooms and common areas had screw type fasteners that were not designed to a psychiatric/ institutional standard i.e. not security/tamper resistant.

Hospital inspection reports for the in-patient psychiatric unit were reviewed and included a General Workplace Inspection dated 1/23/2013 and Environmental Safety Rounds Checklists dated 1/22/2014 and 7/16/14. The General Workplace Inspection and the two Environmental Safety Rounds Checklists failed to include a review and inspection of the environment for the above mentioned items that would pose potential hanging hazards and equipment with the potential to be used in a harmful manner. Weekly Safety Inspection reports dated 6/21/14, 6/29/14, 7/6/14, and 7/13/14 also failed to include a review and inspection of the environment for the above mentioned items that would pose potential hanging hazards and equipment with the potential to be used in a harmful manner.

Interviews with the Regulatory Director of Behavioral Health and the VP of Facilities on 7/16/14 at 2:00 PM identified that the hospital had not identified shower controls, door hinges, window locks, paper towel holders, toilet paper dispensers, soap dispensers or screw type fasteners as potential hazards prior to the State Agency observations. Based on the State Agency's observations, the hospital developed and implemented hourly environmental rounds to monitor the safety hazards existing in the psychiatric unit and identified that these rounds would continue until all identified safety hazards were remediated.