HospitalInspections.org

Based on observation and interviews it was determined the facility failed to provide a safe environment when providing seclusion in one (1) of three (3) seclusion rooms located within the facility.

The findings were:

During a tour of the facility on 12/2/2014 at 11:00 am with the Director of Plant Operations in attendance, observation of the seclusion room in building six (6) revealed the window frame in the door had been broken with a piece of the metal frame hanging loose on the outside of the door with sharp edges creating the potential for a patient to be injured or pull the frame off and use the metal as a weapon. The Plexiglas window did not come all the way to the top of the frame. The open area at the top of the glass was big enough to put one-two fingers in and contained sharp edges creating the potential for injury. The door also contained a large opening for a door knob to be placed however; no knob had been added to the door and the opening was large enough for one-two fingers to be placed within the hole and the hole had rough edges where the wood had been cut out for the opening presenting another source of potential injury.

An interview with Director of Plant Operations at the time of the tour revealed a patient broke the door frame by banging on the glass while in seclusion. A new frame had been ordered and the facility was waiting on the knew glass to come in to repair the door. He/she stated a thicker glass had to be ordered to fit the frame. Screws had been placed in the current frame to hold it in place until repairs could be made.

An interview with Staff #13 on 12/2/14 at 2:20 p.m. revealed the door "initially broke on 10/23/14 and maintenance periodically checks it to tighten the screws. A work order was placed and the glass was ordered". "The last time the room had been used for seclusion was 11/20/14". Staff did not have the information on the unit and made several phone calls to obtain the information regarding, which patients had been placed in the seclusion room.

On 12/2/14 at approximately 3:30 p.m. a list was provided of the patients that had been in the seclusion room since the door had been broken. Four patients were on the list including the day the door had been broken. The patient who had been placed in seclusion on 11/20/14 did not appear on the list.

An interview with Staff #9 12/3/14 at 9:20 am revealed he/she did not know why the list did not contain the patient for 11/20/14. The risk manager joined the interview and confirmed a patient had been in seclusion on 11/20/14 but had not been added to the list yet.

The seclusion room had been used a total of four times since the window/door had been broken. Patient #20 who originally broke the door returned to the unsafe seclusion room on three separate days for aggressive behavior, 10/24/14, 11/15/14 and 11/20/14. Patient #21 had been in the unsafe seclusion room on one day 11/17/14.

Based on document review and interview, it was determined that the facility staff failed to administer medications per physician order in five (5) of 30 in the patient survey sample, (Patient #1, #14, #15, #18, and #26)

Findings included:

1. The medical record for Patient #1 was reviewed on 12/2/14 at 11:00 AM. Patient #1 was admitted on 11/10/14 with a diagnosis of Human Immunodeficiency Virus (HIV), Posttraumatic Stress Disorder (PTSD) and eating disorder. The medical record revealed that on 11/13/14, the 8:00 AM medications, Norvir-100 mg tab, Truvada-200/300 mg tab, and Prezista-800 mg tab, were not given as ordered. According to www. nim.nih.gov/medline plus, Norvir, Truvada, and Prezista are used to treat HIV.
On 12/2/14 at approximately 11:30 AM, Staff #19 reviewed the medication administration record (MAR) for Patient #1, for the date of 11/13/14, and stated, "I definitely gave those medications." Staff #19 initialed the Mar at this time, failing to add the current date and time.
2. The medical record for Patient #14 was reviewed on 12/2/14 at approximately 2:00 PM. Patient #14 was admitted on 12/3/13 with a diagnosis Diabetes Mellitus Type I, and PTSD with psychotic features. The medical record revealed the medication clonidine 0.3 mg tab was not given on 11/6/14 at 8:00 PM as ordered. The pulse rate was not documented to be less than 55, which would be an indication to hold the medication per physician order. According to www. Nim.nih.gov, clonidine is used to treat high blood pressure.
3. The medical record for Patient #15 was reviewed on 12/2/14 at approximately 3:10 PM. Patient #15 was admitted on 7/31/14 with a diagnosis of conversion paralysis, pseudoseizures, and dysthymia. The medical record revealed the medication Inderal-40 mg tab was not given on 10/19/14 at 8:00 PM, and 11/22/14 at 8:00 AM and 8:00 PM as ordered. The pulse rate was not documented to be less than 55, which would be an indication to hold the medication per physician order. According to www. nim.nih.gov/medline plus, Inderal (propranolol) is used to treat high blood pressure, abnormal heart rhythms, angina pain and migraine headaches.
4. The medical record for Patient #18 was reviewed on 12/2/14 at 2:50 PM. Patient #18 was admitted on 6/24/14 with a diagnosis of Diabetes Mellitus Type I, and conduct/emotional disorder. The medical record revealed that on 11/26/14 and 11/27/14, the 8:00 PM medication amoxicillin-250 mg capsule was not administered as ordered (with meals and bedtime until tooth extracted or repaired). On 11/28/14, the 8:00 PM medication fluoxetine-40 mg (2- 20 mg capsules) was not administrated as ordered. According to www. nim.nih.gov/medline plus, amoxicillin is an antibiotic used to treat certain infections caused by bacteria, and fluoxetine (Prozac) is used to treat depression, obsessive-complulsive disorder, eating disorders, and panic attacks.
5. The medical record for Patient #26 was reviewed on 12/3/14 at approximately 10:30 AM. Patient #26 was admitted on 9/17/14 with a diagnosis of anxiety disorder, and conversion symptoms (fatigue and syncope). The medical record revealed the medications clindamycin phosphate-1% solution (apply to clean, dry face) and famotidine-20 mg tab were not given on 11/11/14 at 8:00 PM as ordered. According to www. nim.nih.gov/medline plus, clindamycin topical solution is an antibiotic used to treat acne, and famotidine is used to treat ulcers and conditions where the stomach produces too much acid.
During review of medical records on 12/2/14 from approximately 9:30 AM to 3:45 PM, Staff #2 acknowledged that there were medications not administered on the medical records for Patients #1, #14, #15, and #18. During an interview conducted on 12/3/14 at approximately 11:30 AM, Staff #4 acknowledged the medications were not administered as ordered on the medical records for Patients #1, #14, #15, #18, and #26.

Based on document review and interview, it was determined that nursing staff failed to document their signature with title on the medication administration record (MAR) in order to authenticate their initials utilized to designate medication administration to nine (9) of thirty (30) patients included in the survey sample. (Patient #14, #15, #18, #19, #20, #26, #27, #29, and #30 )
The findings included:
1. The medical record for Patient #14, reviewed on 12/2/14 at 2:00 PM, revealed the MAR dated 11/1/14 thru 11/7/14, was not signed and initialed by all medical staff administering medications.
2. The medical record for Patient #15, reviewed on 12/2/14 at 3:10 PM, revealed the MARs dated 10/18/14 thru 10/24/14, and 11/22/14 thru 11/28/14, were not signed and initialed by all medical staff administering medications.
3. The medical record for Patient #18, reviewed on 12/2/14 at 2:50 PM, revealed the MAR dated 11/22/14 thru 11/28/14, was not signed and initialed by all medical staff administering medications.
4. The medical record for Patient #26, reviewed on 12/3/14 at approximately 10:30 AM, revealed the MARs dated 11/8/14 thru 11/14/14, and 11/22/14 thru 11/28/14, were not signed and initialed by all medical staff administering medications.
During an interview conducted on 12/3/14, at approximately 11:30 AM, Staff #4 acknowledged that medical staff did not sign and initial the medication administration record (MAR), to authenticate the initial designating responsibility in seven (7) out of 30 medical records in survey sample. (Patient #14, #15, #18, #26 )


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5. A review of the clinical record for patient #20 revealed medication administration records for the week of 11/15/14 through 11/21/14 and again the week of 11/22/14 through 11/28/14 in which someone with the initials LT signed off on medications to include famotidine, chlorpromazine, and propranolol without placing a signature to authenticate the initials at the top of the medication record. It is unclear who LT is or if LT is a nurse.


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6. Patient #27's medical record was reviewed on December 3, 2014 from 11:00 a.m. through 12:15 p.m.. Patient #27's medication administration record (MAR) dated the week of 11/22/2014 had documentation of the initials of three nursing staff members who administered Levothyroxine (used to treat low thyroid hormone levels) 0.1 mg po (by mouth) at 8:00 a.m., during the week. One staff member documented his/her full name authenticating the administration of the medication. No documentation was found on the MAR identifying the other two staff members who had administered the Levothyroxine at 8:00 a.m. on 11/25/2014, 11/26/2014, 11/27/2014, and 11/28/2014.

7. Patient #29's medical record was reviewed on December 3, 2014 from 11:00 a.m. through 12:15 p.m.. Patient #29's MAR dated the week of 10/25/2014 had documentation of three nursing staff's initials indicating the staff had administered Cetirizine (used to treat allergies) 10 mg po at 8:00 a.m. daily and Thorazine (anti-psychotic) 25 mg po at 7:00 a.m., 1:00 p.m., and 8:00 p.m. One nursing staff member failed to document his/her full signature authenticating the MAR.


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8. Review of Patient #19's medical record was conducted on December 3, 2014 at approximately 8:15 a.m., on the unit. Patient #19 was admitted to the facility on November 25, 2014. The review included Patient #19's medication administration record (MAR) for November 24 through 28, 2014, which had been included in the patient's medical record. Patient #19's medical record indicated the chart had been reviewed by staff for accuracy. Patient #19's MAR indicated the facility staff had administered medications and documented the administration via initials. The facility's MAR has six places at the top of the form for staff to sign with their title in order to authenticate their initials. The signature sections of Patient #19's MAR for November 24 through 28, 2014 pages 1 through 4 were blank.
The following medications were administered, per staff initials without authentication of staff: Omerazole D-R 20 mg (milligram) one capsule twice daily [a proton pump inhibitor to decrease stomach acid], Prednisone 5 mg one tablet daily [a synthetic corticosteroid], Ursodeoxycholic Acid 300 mg one capsule twice daily [secondary bile acid; a metabolic byproducts of intestinal bacteria], Azithromycin 250 mg one tablet Mon.-Wed.-Fri [an antibiotic], Mycophenolate 500 mg one tablet twice daily [an immunosuppressant drug], Cyclosporine 25 mg two capsules twice daily [an immunosuppressant drug], Cyclosporine 100 mg two capsules twice daily, Dapsone 25 mg three tablets once daily [an an antibacterial drug], Magnesium Oxide 400 mg two tablets twice daily [a naturally occurring mineral], and Creon 12 six capsules with meals and five capsules with snacks [Amylase/Lipase/Protease therapeutic aid to improve food digestion].
The following medications were handwritten on Patient #19's MAR VitadeK (no indication of dose or number of capsules) documented as given at "0800 and 200 [Sic]") [fat soluble vitamins], and "Heparin 100 unit flush mediport" -no indication of frequency. The two handwritten entries did not have a start or stop date.
An interview was conducted on December 3, 2014 at approximately 8:44 a.m., with Staff #18. Staff #18 reviewed Patient #19's November 24 through 28, 2014 MAR. Staff #18 verified the facility staff had failed to place their signatures and titles at the top of Patient #19's MAR. Staff #18 verified the top signature section for all four pages of Patient #19's MAR was blank.
9. Patient #30 was admitted to the facility on October 08, 2014. Review of Patient #30's "Treatment Administration Record (TAR)" and MAR revealed facility staff failed to authenticate their initials by signing the TAR and MAR for treatments and medications administered for the following dates: November 08 -14, 2014; November 13-19, 2014 and November 22-28, 2014.
An interview was conducted on December 3, 2014 at 11:00 a.m., with Staff #2. Staff #2 reviewed Patient #19's MAR and Patient #30's TAR and MAR with the surveyor. Staff #2 verified the facility staff should have signed each page of the MAR(s). Staff #2 verified the TAR and MAR contained initials that did not have authenticating signatures with titles. Staff #2 verified the staff failed to follow the facility's policy and procedure for documenting medication and treatment administration.
Review of the facility's policy and procedure titled "Nursing Services Policy and Procedure on Transcription of Physician's Orders" read in part under the section "Medication" "48. Enter the following onto the medication administration record... a. Routine medications (1) Date medication ordered ... (6) dosage, (7) Route of administration, (8) Frequency of administration ... 49. Enter nurse's initials, full signature and title on the upper portion of form [TAR and MAR] under the column marked signature..."

Based on the Life Safety Code Validation survey, completed on December 9, 2014, the Condition of Physical Environment is not met. Those deficient practices and the associated regulations can be found in the respective Life Safety Code survey (LTUP21).

Based on observations and interviews the facility staff failed to perform hand hygiene during medication administration for two of three medication passes.

The findings included:

An observation was conducted on December 2, 2014 at 11:46 a.m., with Staff #17 and Staff #6 present. Staff #17 performed hand hygiene then touched multiple potentially contaminated items in the environment including the metal rolling door to remove the medication cart from it position, handled keys in his/her pockets, removed the pen from behind his/her ear, handled papers on the top of the medication cart then obtained a medication cup. Staff #17 opened the medication container of Creon 12 and poured six capsules in the medication cup and handed it to Patient #19.

An observation was conducted on December 2, 2014 at 11:50 a.m. through 12:01 p.m., with Staff #19 and Staff #6 present. Staff #19 reviewed the medications for Patient #12. Staff #19 obtained the unit dose medication from the medication cart, holding the medications in his/her hand, while touching multiple potentially contaminated items in the environment (pen from pocket, medication keys, door handle, and a large medication crusher). Staff #19 crushed Patient #12's medications in the unit dose package, opened the unit dose packs, holding the medication cup with one finger inside the cup, poured the crushed tablets in a medication, and handed the medication cup to Patient #12.

An interview was conducted on December 3, 2014 at approximately 9:11 a.m., with Staff #6 after the third medication observation. The surveyor asked Staff #6 regarding his/her observations during the medication passes conducted on December 2, 2014. Staff #6 identified that Staff #17 did not perform hand hygiene prior to administering medication to Patient #19. Staff #6 verified the surveyor's observation related to the medications administered by Staff #19. Staff #6 reported the staff perform hand hygiene and contaminate their hands by handling potentially contaminated items in the environment and "seem to forget to sanitize" their hands again prior to administering medications.