HospitalInspections.org

Based on review of the hospital's policies and procedures, medical records and staff interviews, it was determined that the administrator failed to require that informed consent was obtained prior to administering psychotropic medications for patient #7 and for seven of eight (7/8) records reviewed for patients admitted to the [Juniper] Unit. This deficient practice posed the risk that patient and/or patient representatives were not properly informed of the potential risks associated with taking psychotropic medication.

Findings include:

The hospital policy titled, "Informed Consent" requires the following: "...All patients who have a psychotropic medication ordered and guardian of patients who have a psychotropic medication ordered will be informed of the benefits and risks involved in taking prescribed medication...Consent to take medications will be given in writing and witnessed by a licensed nurse, physician or pharmacist...When guardian is not physically available, telephone consent will be obtained...When telephone consent is obtained the following shall occur: Notation will be made on the medication education sheet...The Licensed Staff Member who supplied the information regarding prescribed medications will sign the statement...The guardian will countersign the document when they come in...A second Staff Member will witness the phone approval of the guardian...."

Documentation in the clinical record revealed that the physician ordered a new psychotropic medication [Risperdal] for patient #7 on 5/4/17. There was no documentation in patient #7's medical record that informed consent for psychotropic medication was obtained.

Interview with RN #8 and RN #9 confirmed that informed consent was not obtained in 7 of the 8 medical records for current patients admitted to the Juniper Unit on 12/14/17 (patient #'s 22, 23, 25, 26, 27, 28, and 29. RN #8 indicated that the consent forms were not signed because they were "inadvertently put back in the patient chart by a nurse on a different shift."

Based on review of hospital policies and procedures, medical records and staff interviews, it was determined that the nurse executive failed to require that the nursing staff provide appropriate care to meet daily needs of patient #7. This deficient practice posed the risk that patients would not receive appropriate needs.

Findings include:

The policy titled, "Oral Health" requires the following: "...Take a brief history of dental concerns and determine habits of care...assist or encourage patient with oral care as needed..."

Patient #7's medical record confirmed the following: oral care was not documented on 5/2/17, 5/4/17 or 5/7/17 and only one time each day on 5/3/17, 5/5/17 and 5/6/17.

The Nursing Assessment completed on 5/2/17 at 21:30 identified oral care: "...brush 2 x daily...."

RN #8 confirmed in an interview conducted on 12/14/17 that, "...oral care was not done very often...one of the things that falls through the cracks...."

BHT #14 confirmed in an interview conducted on 12/14/17 that s/he was, "too busy to provide oral care all the time...."

Based on review of hospital policies and procedures, patient #7's medical record and staff interviews, it was determined that the administrator failed to require that nursing documentation be completed on the "Daily Graphics Sheet". This deficient practice posed the risk that the physician is inaccurately notified of the patient's sleeping pattern and oral intake.

Findings include:

The hospital policy titled, "Documentation Protocol, #2396641" requires the following: "...All medical records are to be accurate, truthful and complete...Staff are to document accurately our services provided, patient interactions...."

The hospital policy titled, "Vital Signs, #2768844" requires the following: "...intake and output will be documented on the graphic form. Any nutritional supplements given will have total amount given and written next to nutritional supplements...."

The hospital policy titled, "Hydration & I&O, #2468296" requires the following: "...at the end of your shift total the amounts of all liquids the patient consumed...the following information is recorded in the patient's graphics sheet...the amount of liquid consumed..if the patient refuses the offer of fluids the RN is to document this in the RN progress notes..."

Review of Patient #7's medical record and the "Patient Observations" form confirmed the total number of hours spent "in room, quiet and/or asleep with chest rising or falling" increased each day.

On 5/3/17, the patient spent a total of 9.5 hours in the room quiet or asleep.
On 5/4/17, the patient spent 13.75 hours in room quiet or asleep and on 5/5/17, the patient spent a total of 18 hours in room, quiet and/or asleep.
On 5/6/17, a total of 21 hours was spent in the room quiet or asleep.
On 5/7/17, the patient spent 15 hours in the room, quiet and/or asleep.
According to the Patient Observations Log, the patient remained in the room, quiet and / or asleep from 5/6/17 at 13:15 through 5/7/17 at 1500 (a total of 25.75 hours).

The Daily Graphic Sheet "hours slept" was completed for the night shift as follows:
5/3/17: 5.25
5/4/17: 6.5
5/5/17: 6.5
5/6/17: 6.75
5/7/17: 6.75

The "Hours Slept" was blank for the "1st" and "2nd" shift on 5/3/17, 5/4/17, 5/5/17, 5/6/17 and 5/7/17.

Hydration Intake / Output (I&O) form contained the following documentation:
:
5/2/17: "0" (Zero)
5/3/17: Breakfast: 100% and 240 mls fluid intake, Lunch: 50% and 240 mls fluid intake, Dinner 75% and 480 mls of fluid.
5/4/17: Breakfast: 50% and 240 mls fluid intake, Lunch 40% and 120 mls fluid intake, Dinner 5% and 0 (zero) fluid intake.
5/5/17: Breakfast: Refused, Lunch: Refused, Dinner: Refused. No fluid intake documented on 5/5/17.
5/6/17: Breakfast: Refused, Lunch: Refused and 120 mls fluid intake, Dinner: Refused.
5/7/17: Breakfast: Refused, Lunch: Refused and 240 mls fluid intake.

The following Practitioner Orders were documented in patient #7's medical record following the "hydration protocol" order that was written on 5/3/17 at 11:03 am:

5/3/17 at 11:03 am: "...Push H20 500 ml po TID (three times a day)...."
5/3/17 at 11:03 am: "...1 can Glucerna TID with meals...."
5/5/17 at 14:13 pm: "...D/C Glucerna Shake...1 can Boost TID with meals...."

The Medication Administration Record (MAR) contained the following documentation:

#1: "Push H20 500 ml by mouth TID"
5/3/17: initialed as complete at 15:00 and 21:00 only
5/4/17: The nurse initialed as completed at 21:00 (the MAR was blank at 09:00 and 15:00)
5/5/17: The patient refused the water at 09:00 and the nurse initialed as completed at 15:00 and 21:00
5/6/17: The patient refused the water at 09:00 and 15:00. The nurse initialed as completed at 21:00
5/7/17: The patient refused at 09:00 and completed at 15:00 only

#2: "1 can Glucerna TID with meals"
5/3/17: The nurse initialed as completed at 17:00 only
5/4/17: The patient refused the Glucerna at 07:30. The MAR was blank at 12:00 and 17:00
5/5/17: This order was discontinued on 5/5/17 at 14:13.

#3: " 1 can Boost TID with meals"
5/5/17: The nurse initialed as completed at 17:00 and 20:00 only
5/6/17: The patient refused the Boost supplement at 07:30. The nurse initialed as completed "1/2 can" at 12:00 and 17:00 and completed at 20:00.
5/7/17 completed at 07:30, 12:00 and 17:00.

Physician #1 confirmed in a private interview conducted on 2/8/18, that the "Daily Graphics Sheet" is utilized when reviewing the patient's oral intake and the length of time the patient is sleeping.

Staff failed to document consistently/accurately on the I &O and MAR, patient response to ordered treatments as required.