HospitalInspections.org

Based on record review and interview the hospital failed to insure the medical staff was accountable to the Governing Body for the quality of care provided to patients. This deficient practice was evidenced by 2 (#1, #2) of 2 patients determined by a physician to be a danger to themselves or others not receiving a psychiatric evaluation prior to discharge while being treated for acute medical conditions.
Findings:


Review of an Internet website for Lakeview Regional Medical Center, an offsite campus of Tulane Medical Center, revealed in part under services the following: Behavioral Health, Emergency Care, Heart Care, Maternity & Obstetrics, Orthopedic Care, Rehabilitation, Stroke Care, Surgery, and Women's Care.


Patient #1
Review of Patient #1's medical record revealed he was a 94 year old sent to the ED 5/15/19 from his residence, a nursing home, for inappropriate sexual behavior. He was PEC'd at that time and a CEC was signed 5/15/19 at 9:03 p.m. The ED physician diagnosed new onset Atrial Fibrillation and the patient was admitted to the acute care hospital to evaluate and stabilize his Atrial Fibrillation. Further review revealed a Psychiatric consult was ordered and S5MD's (psychiatrist) office was called and a message was left. The EMR documented that the physician was not taking new patients. The order for a psychiatric consult was canceled. The patient's PEC/CEC remained in place throughout his inpatient admission. He was discharged 7 days later, on 5/22/19 to an inpatient psychiatric facility, also an offsite campus of Tulane Medical Center. No psychiatric consult was done during the patient's 7 day inpatient stay.


Patient #2
Review of Patient #2's medical record, with S7RN and S8RN, revealed he was admitted to the Lakeview Behavioral Health, an offsite facility of Tulane Medical Center located on the same property as the acute care facility. Patient #2 was transferred from [Facility B's] ED under a PEC/CEC for depressive symptoms and suicidal ideation 2/11/19. Review of a patient evaluation dated 2/11/19 and signed at 9:09 a.m. by S9PMHNP, from the Behavioral Facility, documented the following:
"This is an 84 year old male who reported to [Facility B] due to positive SI, decreased appetite, decreased sleep. It is noted that patient was very active until last week, riding bike and walking, patient complained of should pain and hip last week and insomnia, went to (sending facility name) for Angio last week, patient had stent placed, ever since discharged, patient has become more withdrawn, poor appetite, no interest in activities, son was called to his parents' house this evening by his mom, she told him that his dad said 'I can't live like this anymore, just let me kill myself'. On 2/11, (Patient #2) was admitted to LVR Behavioral Health for further treatment and evaluation. Upon evaluation on 2/11 (Patient #2) was seen with some acute distress...as he appears to be SOB, but calm and cooperative. Staff discussed findings with Medical Team, with EKG ...etc. and (S3MD, Medicine) reports that he would be sent to Telemetry for further medical treatment, as he is in Heart Failure and has edema. At this time, he is not medically stabilized per (S3MD), with Direct admit to Telemetry, with Cardiology Consult... He reports Depression, Anxiety, rating them both at 9/10, but cannot further explain why. He reports that he has had poor appetite for about 6 days, no weight loss reported, and poor sleep for the past 5-6 days. He reports being 'weak and tired' and HOH, only able to hear in the left ear. He still reports being Suicidal, with a plan to kill himself, 'any way he could', so he will have the proper procedures in place, with him being high risk, on the medical floor. He reports 'I just don't want to do it anymore, I'm just tired, beat up'". His problem list was documented as: 1) Suicidal ideation, 2) Depression, 3) Major depressive disorder, recurrent episode, severe with anxious distress, 4) Depressive disorder due to another medical condition with major depressive-like episode. The plan documented was 1) Continue to monitor symptoms of Depression, SI. No Psych Meds per Reconciliation Record. At this time, will be a Direct Admit to LVR Medical Center per (S3MD). Recommendations to help with Depression, SI: At this time, I think once he is medically stabilized, with adequate sleep and appetite, along with the support of his wife, his Depression, is likely to improve. Start Remeron 15 mg po every hs for Insomnia, Start Lexapro 10 mg po Daily for Depression/Anxiety. 2. Consult Internal Medicine to follow all acute and chronic needs."

Patient #2 was admitted to Lakeview Regional Medical Center's acute care campus, under the services of S4MD with the diagnosis of CHF, with his PEC/CEC in place 2/11/19. Further review of Patient #2's medical record revealed the patient remained as an inpatient in the acute care hospital from 2/11/19 to 2/22/19 at 6:00 p.m. (11 days) when he was discharged to Hospital "A" for skilled nursing and rehabilitation (Physical Therapy/Occupational Therapy). Further review of the medical record revealed a physician's order dated 2/11/19 for a Psychiatry Consult, with the reason for the consult documented as Suicidal Ideation. Noted on the detail portion of the order, was that the consulted physician's office (S5MD) was notified 2/11/19 at 4:36 p.m. and a message left. A physician's order dated 2/22/19 at 9:38 a.m. by S4MD documented an order to rescind the patient's PEC, CEC. Further review of the record revealed no progress note or other documentation by S4MD regarding an assessment or rational for the order to rescind the PEC/CEC.

Review of Patient #2's progress note by S6FNP dated 2/22/19 at 9:48 a.m. revealed the patient's chief complaint as CHF and elevated Troponin. The progress note also noted the patient had also been placed on PEC for SI and since felt not to have any SI. The patient was documented as having a flat affect, delayed speech. Under Diagnosis, Assessment, and Plan documentation for the documentation included, "Depression/ Suicidal Ideation/Insomnia- PEC with suicide precautions; Psych consult still pending ...Patient had a reported episode a few days ago of AMS/unresponsiveness. He has not been acting himself and recently had SI. Psych consult pending ..."

Review of Patient #2's progress noted, dated 2/22/19 at 1:41 p.m. and authored by S6FNP, revealed the patient was discharged to a Nursing Home for skilled nursing care for rehabilitation.

Review of discharge instructions sent with the patient included discharge to SNF, Cardiac diet, PT/OT 5 times a week, physician follow up appointment - PCP not known in 1-2 weeks, S4MD's name and phone # provided. Further review of Patient #2's record revealed no documentation of a psychiatric consultation during his inpatient admission or a cancellation of a Psychiatric Consult.


The findings from Patient #1's and Patient #2's medical records were verified by S7RN and S8RN, reviewing the medical records with the surveyor.

In an interview 5/22/19 at 1:10 p.m. S4MD verified he was the admitting physician for Patient #1 and for Patient #2. The physician confirmed he practiced in Medicine, not in Psychiatry. S4MD reported Patient #1 was PEC/CEC'd from a nursing home for inappropriate sexual behaviors. He also reported the patient was in his 90's and had dementia. He said he didn't find the patient to be a risk of harm to himself or others. He verified the psych consult was canceled. He said he would have rescinded the PEC/CEC, but he spoke with the patient's family and his son wanted his father to go to the inpatient Behavioral hospital. He said he thought the son was fearful that the nursing home would kick his father out of the nursing home if he didn't get treatment. S4MD said there wasn't much that could be done for this patient because of his dementia, as far as cognitive behavior therapy, but he could be medicated to control his behavior. S4MD verified Patient #2 was admitted to his service. After a brief review of the medical record with S10FNP, also present for the interview, S4MD reported Patient#2 was sent to the Geri-psych for having SI, but when he got there they realized he was not medically cleared to be admitted there because of some cardiac problems/symptoms and he was admitted to the acute care hospital. He reported the patient had [cardiac] stents placed recently at another facility, and had another Cardiac Cath during this inpatient admission. He reported there was an episode where they thought he had a stroke and Patient #2 was transferred to the ICU, and then moved back to the medical surgical floor after that for the rest of his admission. S4MD confirmed he did rescind the CEC order because he did not feel the patient was still suicidal, and thought that his depression and SI was probably a result of his worsening medical conditions. He verified that he did not document any assessment or rationale for his order to remove the CEC. When asked about the patient not having a psychiatric consult during his 11 day admission, S4MD confirmed the patient did not and reported he did not feel the patient needed a psychiatric evaluation any longer as the patient's mood was improved with medication adjustment. He reported the patient was prescribed Remeron and Lexapro on admission. The physician reported he did not feel the patient was still suicidal. As to the order for a psychiatric consult, he said it "slipped through," not getting canceled. He reported he did not always get a psychiatric consult on a patient if they were admitted with a PEC/CEC in place.

Review of a LDH/HSS OTIS report investigative findings submitted by Facility "A" 2/28/19 revealed that on the morning of 2/24/19, the 2nd day after his discharge from Lakeview Regional Medical Center, Patient #2 was found in the bathroom of Facility "A" with a cord wrapped around his neck and tied to the grab bar, without respirations or a pulse. Further review revealed the report documented the patient was transported to a hospital via EMS, but expired at the hospital.

Based on record review and interview the hospital failed to ensure the nursing staff developed and kept current a nursing care plan as part of the patient's medical record. This deficient practice was evidenced by the documented nursing plans including only the nursing needs for the admitting diagnosis/diagnoses, and not including other nursing needs for 5 of 5 (#'s 1-5) medical records reviewed for nursing care plans from a total sample of 5.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed he was a 94 year old sent to ED 5/15/19 from a nursing home for inappropriate sexual behavior and was PEC'd/CEC'd. He was admitted to the acute care facility for 7 days as an Inpatient, to treat Atrial Fibrillation diagnosed in the ED, before being discharged to an inpatient behavioral health facility of the hospital. Review of a transfer summary for Patient #1, found on his medical record, from the Long Term Care Nursing Facility in which the patient resided included the following diagnoses, in part: Osteoarthritis, Hypertension, Sicca Syndrome (Dryness of the exocrine glands, particularly the eyes and mouth) Dementia, Cognitive communication deficit, muscle weakness, lack of coordination, Unsteadiness on feet, Alzheimer's disease, Constipation, and Insomnia. Review of a hospitalist note titled, "Brief Discharge Note" by S11FNP 5/21/19 at 11:25 a.m., revealed his problem list to include 1) Dementia with behavioral disturbance, and 2) Afib with RVR. Further review revealed the following diagnoses under hospital course: 1) Dementia with behavioral disturbance, 2) A-fib- chronic, 3) Alzheimer's dementia, 4) constipation, 5) hyperlipidemia, 6) Hypertension. Further review of the medical record revealed a case management report with notes under discharge planning evaluation that documented: ADL Limits: Mobility or ambulation, Dressing, Bathing, Toileting, and Durable Medical Equipment used as a walker. Review of the patient's care plan, provided by S7RN, revealed Patient #1's care plan did not address actual or potential problems related to his hypertension, Sicca syndrome, Alzheimer's/dementia, his cognitive communication deficit, lack of coordination/unsteadiness on his feet, or his need for assistance with ADLs. Further review of the care plans revealed they were not individualized to Patient #1, did not provide measurable goals, or individual interventions. The care plan for Patient #1 included the following:
-Diagnosis/Problem: Facility Standard of Care, Outcome: Standard of Practice will be met
-Diagnosis/Problem: Cardiac Output Alteration, change in or modification of the pumping action of the heart or blood vessels; Outcome: See Health Plan of Care ---- Diagnosis/Problem: Sexuality Pattern Alteration, change in or modification of a person's sexual response; Outcome: See Health Plan of Care
-Skin Integrity Alteration: Change in or modification of skin conditions; Outcome: See Health Plan of Care
-Medication Risk, Increased chance of negative response to medicinal substances; Outcome: See Health Plan of Care. No interventions were listed.


Patient #2
Review of the medical record for Patient #2, with S7RN and S8RN, revealed he was admitted to the Lakeview Behavioral Health, an offsite facility of Tulane Medical Center located on the same property as the acute care facility. Review of a patient evaluation dated 2/11/19 and signed at 9:09 a.m. by S9PMHNP, from the Behavioral Facility documented the following::
"This is an 84 year old male who reported to [Facility B] due to positive SI, decreased appetite, decreased sleep. It is noted that patient was very active until last week, riding bike and walking, patient complained of shoulder pain and hip last week and insomnia. He was not medically stabilized per (S3MD), with Direct admit to Telemetry, with Cardiology Consult... He reports Depression, Anxiety, rating them both at 9/10, but cannot further explain why. He reports that he has had poor appetite for about 6 days, no weight loss reported, and poor sleep for the past 5-6 days. He reports being 'weak and tired' and HOH, only able to hear in the left ear. He still reports being Suicidal, with a plan to kill himself, 'any way he could', so he will have the proper procedures in place, with him being high risk, on the medical floor. His problem list was documented as: 1) Suicidal ideation, 2) Depression, 3) Major depressive disorder, recurrent episode, severe with anxious distress, 4) Depressive disorder due to another medical condition with major depressive-like episode. The plan documented was 1) Continue to monitor symptoms of Depression, SI. No Psych Meds per Reconciliation Record. At this time, will be a Direct Admit to LVR Medical Center per (S3MD). Recommendations to help with Depression, SI: ;Lexapro 10 mg po Daily for Depression/Anxiety. 2. Consult Internal Medicine to follow all acute and chronic needs." Under Diagnosis, Assessment, and Plan, documentation included, "Depression/ Suicidal Ideation/Insomnia- PEC with suicide precautions; Psych consult still pending ...Patient had a reported episode a few days ago of AMS/unresponsiveness. He has not been acting himself and recently had SI. Psych consult pending ..." Review of a progress noted, dated 2/22/19 at 1:41 p.m. and authored by S6FNP, revealed The patient was discharged to a Nursing Home for skilled nursing care for rehabilitation. Review of discharge instructions sent with the patient included discharge to SNF, Cardiac diet, PT/OT 5 times a week, physician follow up appointment - PCP not known in 1-2 weeks, S4MD's name and phone # provided.
S7RN, reviewing care plan with surveyor, verified there was no documentation of a care plan for patient needs related to diagnoses that included Anorexia, Diabetes (requiring accuchecks after each meal, insulin, and a diabetic diet), Hypertension, AKI/Chronic Kidney Disease, Stage III-IV/Hyponatremia, Anemia, and Right hip pain/Left wrist pain and edema , as listed in physician and NP progress notes.


Patient #3
Review of the medical record for Patient #4 revealed she was admitted 4/06/19 through the ED from home with auditory and visual hallucinations. The patient had been discharged from an inpatient psychiatric facility, the day before presenting to ED, for treatment of exacerbation of her schizophrenia. Listed in the in past medical history of the ED physician's notes were the diagnoses of Arthritis, Diabetes mellitus, Hypertension, Seizure disorder, HIV positive, anxiety and Bipolar Disorder. The ED physician's notes included, " ... Initial workup shows dehydration and acute renal insufficiency ...she had wheezing and a COPD exacerbation. Patient was given nebulizer treatments. Was unable to fully clear patient for psychiatric admission due to renal insufficiency and concerns that she may have nephrotoxicity related her HIV medications. She will require IV rehydration, monitoring of renal function, neb treatments, and further evaluation. Review of a brief discharge note by S6FNP 4/10/19 at 10:48 a.m. revealed problems listed and treatments as follows:
-COPD exacerbation- nebulizers, O2 as needed, decrease steroids, monitor
-Seizure disorder-seizure precautions, PRN benzodiazepines
-Bipolar Mood disorder/schizophrenia-psych consulted, adjust meds as needed
-auditory hallucinations-psych consulted, social services consulted, adjust meds, once medically cleared can go to IP rehab
-Acute kidney injury-possibly related to HIV meds, improved, continue current treatment, monitor intake and output
-Hypothyroid- elevated TSH, started on oral meds
Diabetes mellitus II- accuchecks before meals and at bedtime, medications ordered, including insulin.
-Hypertension- continue current treatment, adjust meds as needed, and
-Hyperkalemia- medication as ordered, monitor in AM.
The patient was medically cleared for inpatient psychiatric placement.
Psych consult done 4/6/19 by Dr. Sureshkumar Bhatt; recommendation: inpatient psych after medically stabilized.

Review of the care plan, provided by S12QA, revealed the patient's care plan included"
-alteration in respiration, Outcome: See Health Plan of Care;
-"Facility Standard of Care/Facility Standard of Practice", outcome: Standard of practice will be met;
- Decreased Independence/Self Care/A -decreased functional independence with self-care and daily living related to injury, surgery, or disease process. Potential for injury related to decreased function and safety awareness, Outcome: See OT initial Evaluation;
-Decreased physical Function/Mobility/A Decreased physical function/mobility related to injury, surgery, or disease process. Potential for injury related to decreased function. Potential for skin breakdown related to decreased mobility, Outcome: See PT initial evaluation. STG and LTG; and
-Thought process alteration, A change in or modification of thought and cognitive processes, Outcome: See Health Plan of Care.
Further review of the care plan revealed no care plans related to the patient's seizure disorder, her acute kidney injury, her Hypothyroidism, her Diabetes, hypertension, her positive HIV status, anxiety, or medication monitoring. Care plan diagnoses were not individualized to the patient's diagnoses and/or symptoms, goals were not specific to the patient and measurable, and interventions weren't documented in the plan of care.


Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital from the ED 4/17/19, and discharged to an inpatient psychiatric facility 4/19/19. He was admitted to the telemetry floor, then moved to ICU for 1:1 monitoring when he became combative with staff. The patient was evaluated, and cleared by cardiology. Review of a History and Physical 4/17/19 at 11:10 p.m. revealed in part , his chief complaint was chest pain, and the patient , per the ED note reported he had visual hallucinations and felt very anxious and then progressed to some chest pain. The note documented the patient reported the chest pain resolved, but he continues to feel very anxious. The patient was discharged to an inpatient facility 4/19/19 on a cardiac diet, after he was medically cleared. Review of the care plan for Patient #3 revealed the following:
-Facility Standard of Care, Facility Standard of Practice; Outcome: Standard of Practice.
- Cardiac Output Alteration Change in or modification of the pumping action of the heart or blood vessels, Outcome: See health plan
-Comfort Alteration: Change in or modification of sensation that is distressing; Outcome: See Health plan of care
Further review revealed no specifics to define the patient's alteration in cardiac output, his discomfort (actual or potential), or his aggressive behavior. No interventions or measurable goals were noted.


Patient #5
Review of the medical record for Patient #5 revealed she was an 80 year old admitted to the hospital 4/1/19 after presenting to the ED, with family, for alteration in mental status. The patient was admitted for evaluation of an elevated Troponin and medical clearance for transfer to an Inpatient Psychiatric facility. The patient was PEC'd. Review of the History and Physical documented a history of Hypertension and Coronary Artery Disease, Transient ischemic attack, placement of a pacemaker, cardiac ablation, and Carotid endarterectomy. Review of a Brief Discharge Note revealed a problem list that included acute psychosis, Insomnia, Elevated troponin, and Hallucinations. Further review of the Brief Discharge Note revealed the patient was transferred to an inpatient geriatric psychiatric unit for further evaluation on a cardiac diet.

Review of the nursing care plan for Patient #5, provided by S12QA, revealed the following diagnoses, goals, without any interventions documented:
-Facility Standard of Care, Facility Standard of Practice, and Outcome: Standard of Practice will be met;
-Cardiac Output Alteration, Change in or modification of the pumping action of the heart or blood vessels; Outcome: See Health Plan of Care;
-Neurological Alteration, Change in or alteration of mental processes, Outcome: See Health Plan of Care ;( no documentation of what mental process was changed or altered)
-Injury Risk, Increased chance of danger or loss, Outcome: See Health Plan of Care.
(No documentation as to what risks or potential risk was identified)
Further review revealed the care plan was not individualized for Patient #5, had no documentation of measurable goals, or documented interventions.


In an interview 5/21/19 at 2:40 p.m. S7RN reported the hospital EMR no longer had interventions listed. She reported the interventions were embedded into the EMR, in that the interventions were the physicians' orders for treatments and medications, and the assessments done by the nurse. She reported it was the expectation that nurses are able to verbalize interventions. When asked about the outcome documented as "See health plan of care", S7RN reported," In the policy the nurse needs to be able to speak to what the plan is for each patient. Like what the doctor has ordered for that plan." S7RN reported they only care plan the patient's top priority diagnoses. An example was provided as: If a patient had Diabetes or chronic pain, but it is not one of the diagnoses for which they were admitted, they would say that it is not a problem and we can't measure any improvement while the patient is here, because we consider that diagnosis as their baseline. She confirmed this is the case even if the patient received diabetic medications including insulin, blood glucose monitoring, and diabetic diets, or if the person with chronic pain, or pain needs not related to their top admitting diagnoses. S7RN stated, "We only care plan the patient's top priority problems." When asked about the diagnoses not being specific to the patient, and the goals not being measurable, such as Patient #1's Skin integrity Alteration", S7RN provided no answer. S7RN reported that if a patient had to be turned every 2 hours to prevent skin breakdowns the intervention is not documented or care planned. She reported that the staff charts by exception, and that need would be captured by skin assessments done by the nurses every shift.