HospitalInspections.org

Based on review of records and interview, Emergency Department (ED) nursing staff failed to reassess psychiatric patients at the required intervals to ensure patient safety and stability of psychiatric condition in 4 out of 4 patients reviewed (Patient #s 1, 28, 29, 30).

Findings were as follows:

On 1-25-2017 a tour of the ED and interview was completed with Staff #18. Staff #18 stated the frequency of vital signs and reassessment is determined by the acuity assigned at the triage assessment. Staff #18 stated that a separate monitoring sheet is not required for psychiatric patients who are being evaluated or are waiting on placement. Staff #18 stated they do not always assign a sitter to psychiatric patients and, at times, will allow the family to sit with patient to ensure patient safety.

Review of the Palestine Regional Medical Center policy titled "Assessment Organization Wide", PolicyStat ID: 2312565, last revised 5-2016, expiration 5-2019 was as follows:

Page 9, Nursing Services, Section 2. Emergency Department, Item 2. "The triage RN will categorize patients as they present for triage as follows:
a. Level I
1. Initial assessment - The patient's condition may or does require immediate life saving (sic) medical intervention. The patient is very briefly evaluated by the triage nurse and immediately sent to the treatment room.
2. Vital signs are obtained every 5-15 minutes until stable then hourly.

...
b. Level II
1. Initial assessment - The patient's condition is potentially unstable. The patient should receive physician assessment as soon as possible.
2. Vital signs are obtained every 15-30 minutes until stable then every 2 hours.
3. Patient is reassessed at every hour until stable, then every 2 hours.

...
c. Level III
1. Initial assessment - The patient's condition is stable and no obvious distress noted.
2. Vital signs on admission. Reassess any abnormal vital signs every 2 hours. Reassess stable vital signs every 4 hours.
3. Patient's condition will be reassessed every 4 hours.

Review of Palestine Regional Medical Center policy titled "Standards of Practice and Care", PolicyStat ID: 1009165, last revised 11/2004, expiration 08/2017 was as follows:

Page 5, "Fundamental Emergency Department nursing interventions include, but are not limited to the following:

Priority 1 (Critical Care) - Initial assessment and reassessment (to include vital signs) documented every 15 minutes (more frequently if warranted by patient's condition).

Priority 2 (Emergent) - Initial assessment and reassessment (to include vital signs) documented every 15-30 minutes (more frequently if warranted).

Priority 3 (Urgent) - Initial assessment and reassessment (to include vital signs) documented every 30-60 minutes (more frequently if warranted).

Priority 4 (Non-Urgent) and Priority 5 (Routine care) - Initial assessment and reassessment (to include vital signs) documented every one hour (more frequently if warranted).

Vital signs will be repeated if not within normal limits, as follows:
Adult ranges:
Temp: 96.4 - 99.1 degrees F
BP: 95/60 -140/90 mm/Hg
Pulse: 60 - 80 bpm
RR: 12 - 24 / min"


Review of Palestine Regional Medical Center Policy titled "Suicide Risk Assessment and Suicide Precautions", PolicyStat ID: 2047947, last revised 01/2016, expiration 01/2019 was as follows:

Page 9, INTERVENTIONS, E. "An appropriate level of observation and monitoring shall be implemented. Regardless of the level of observation utilized for patients with suicidal risk, the patient's status (including mood, behavior, and location) must be documented at least every 15 minutes.

F. Reassessment of suicidal ideation and intent will be reassessed and documented at least every four hours.

Review of Patient #1's chart revealed the patient was a 21 year old female who was triaged on 1/23/2017 at 5:31 P.M. as and acuity level 3, Urgent. Her presenting complaint was that she was hearing voices and having suicidal thoughts for the past 3 days. Her husband had stopped her from taking pill, drowning self, and cutting self. The patient was transferred to another location by the sheriff's department on 1/24/2017 at 1:16 A.M. Patient #1 was in the ED care for 7 hours and 45 minutes.

Patient #1 had vital signs documented twice; once at 5:36 P.M. and once at 1:14 A.M. No nursing record was found documenting the patient status every 15 minutes or reassessing her suicidal ideation and intent.


Review of Patient #28's chart revealed the patient was a 25 year old male who was triaged on 1/23/2017 at 3:13 P.M. as and acuity level 2, Emergent. His presenting complaint was that he was "released from jail today after months in custody pt states has not been on his meds is hearing voices depressed and has anxiety issues pt denies suicidal or homicidal ideations." (sic) Patient #28 was transferred to another location by the sheriff's department on 1/24/2017 at 1:18 A.M. Patient #28 was in the ED care for 10 hours and 5 minutes.

Patient #28 had vital signs documented twice; once at 3:16 P.M. and once at 1:16 A.M. No nursing documentation of care, assessment, or reassessment was found between 3:58 P.M. when a urine drug screen was sent to the lab and the discharge assessment at 1:16 A.M the next morning (over 11 hours).


Review of Patient #29's chart revealed the patient was a 63 year old female who was triaged on 1/2/2017 at 9:52 A.M. as and acuity level 2, Emergent. Her presenting complaint was that "Spouse states: she has been hearing voices for 2 month patient states she doesn't want to stay here again those nurses down there are mean to me voices are telling me to pack up and leave, she packed up all her stuff on sat and put it on the porch" (sic) Patient #29 was admitted on 1/2/2017 at 2:29 P.M. Patient #29 was in the ED care for 4 hours and 37 minutes.

Patient #29 had vital signs documented twice; once at 9:58 A.M. and once at 2:23 P.M. (4 hours and 25 minutes)


Review of Patient #30's chart revealed the patient was a 24 year old female who was triaged on 1/17/2017 at 10:22 P.M. as and acuity level 3, Urgent. Her presenting complaint was that she was "very depressed and suicidal, on medication, Access will not see her until her appointment." The patient was admitted on 1/18/2017 at 3:22 A.M. Patient #30 was in the ED care for 5 hours.

Patient #30 had vital signs documented three times; once at 10:32 P.M. with an abnormal pulse of 121 beats per minute; once at 2:43 A.M.; and a third time at 3:20 A.M. No nursing record was found documenting the patient status every 15 minutes or reassessing her suicidal ideation and intent.

Based on observation, interview and review of documents, nursing staff failed to safely administer medication according to hospital policy in 6 (Patient #s 44, 62, 63, 66, 67, and 68) of 8 (Patient #s 44, 62, 63, 64, 65, 66, 67, and 68) patients reviewed.

This deficient practice could result in serious harm to all patients.

Findings are as follows:

On 1-25-2017 at approximately 4:00 P.M., a tour of the Intensive Care Unit was made with Staff #39. Upon reviewing Patient #63's chart on the computer, it was found that two medications had not been given as ordered. Buspar (an antidepressant) was scheduled at 1:00 P.M. and Neurontin (given for seizures or nerve pain) was scheduled at 2:00 P.M. Staff #53 was identified as the nurse caring for the patient. When interviewed, Staff #53 stated he had been busy during those times and hadn't given it, but would give it now.

On 1-26-2017 at approximately 10:15, a tour of the Medical/Surgical Unit medication room was made with Staff #22. A small paper cup was observed to contain 10 pills and was located in a plastic bin with room #328 on it. Staff #22 stated Staff #54 was the nurse caring for that patient. Interview with Staff #54 was conducted. First Staff #54 stated Patient #62 was asleep, so medications could not be given. Staff #54 stated he put the medication back in the medication room to give later. Staff #54 was asked to identify the medication to be given since none of it was marked. Staff #54 was not able to identify the medication in the cup on sight. Staff #54 had a medication list and stated he had not given Norvasc (for blood pressure), Lotensin (for blood pressure), Aspirin (blood thinner), Aricept (for dementia), Vitamin B-6 (supplement), Vitamin B-12 (supplement). It was noted on the Medication worklist that Patient #62 had 4 other medications due at 9:00 A.M. along with the medications not given. One was to be given intravenous (IV - in the vein). One was an injection through the skin. The other two were pills to be given by mouth. Staff #54 was asked how those medications were given when the others had not been given. Staff #54 the patient wasn't asleep, but drowsy. After giving the first 4 medications, he decided to hold the rest until later.

An interview was conducted with Staff #22. Staff #22 confirmed that Staff #54 had documented in the patient record that all medications had been given, including the medication found in the medication room. Staff #22 stated that medication opened at the bedside and not given is supposed to be wasted, not brought back into the medication room for dispensing at another time. Staff #22 confirmed that medication opened and out of the package should be labeled with the medication, dosage, and patient information. Staff #22 confirmed that Staff #54 had not followed procedures for safe medication administration.

Review of Patient #44's Medication Administration Record (MAR) revealed that on 1-25-2017, 4 medications were scheduled to be given at 9:00 A.M. but were given at 09:38 A.M. or later. Two medications scheduled for 9:00 P.M. were given at 7:50 P.M. and 8:00 P.M. No reason for early or late administration was found documented.

Review of Patient #66's MAR showed that Xarelto was scheduled to be given on 1-25-2017 at 5:30 P.M., but was administered at 4:56 P.M. No reason for early administration was found documented.

Review of Patient #67's MAR showed that Coumadin was scheduled to be given on 1-20 at 5:00 P.M. but was given at 4:17 P.M. On 1-23-2017, Coumadin was scheduled for 5:00 P.M. but was given at 5:42 P.M. No reason for early or late administration was found documented.

Review of Patient #68's MAR showed that Pepcid and Lovenox were scheduled to be given on 1-21-2017 at 9:00 A.M. but was given at 8:25 A.M. No reason for early administration was found documented.

Review of Palestine Regional Medical Center policy titled "Medication Administration Guidelines", last revised 04/2015 and expires 04/2018 was as follows:

"PROCEDURE

A. MEDICATIONS:

...

12. Medications are to be administered 30 minutes before or after designated time of administration

13. The following standardized times are used for medication administration only allowing for ½ hour before and after the time scheduled:

....

B. PATIENT SAFETY
3. Never give medication from an unmarked or poorly marked container.

...

19. The e-MAR (electronic Medication Administration Record) be first viewed. Then the Medication barcode and e-MAR (electronic Medication Administration Record) will be scanned using the Medhost HMS scanning system. Unit doses medications will remain unopened until time of administration to the patient at the bedside.

...

L. DOCUMENTATION FOR MEDICATION ADMINISTRATION

...
2 Medications are to be documented in the e-MAR with the date and time of administration.

...
c. If the medication is given outside of the scheduled time frame, the nurse must document on the e-MAR the reason for variance."

Based on reviews and interviews the facility failed to follow its own policy and procedure of blood administration and failed to;

a.) have completed blood consents and transfusion records in 2(#18 and 71) out of 4 (18, 71, 72, and 73) charts reviewed.

b.) have a physician order for a rate of transfusion in 3 (#71, 71, and 73) out of 4 (18, 71, 72, and 73) charts reviewed.

c.) have an order to transfuse blood in 1 (#73) out of 4 (18, 71, 72, and 73) charts reviewed.

d.) have an accurate process to determine if the person that picked up the blood from the lab, was the RN checking it with another nurse at the bedside before administration in 4 (#18, 71, 72, and 73) of 4 charts reviewed.

e.) document delays in blood administration in 2 (#71 and 73) of 4 (18, 71, 72, and 73) charts reviewed.


Review of the facility's policy and procedure "Blood Transfusions" Stated, 5.) There must be an informed consent for blood transfusion in the patient's medical record."

Review of the blood consents revealed the patient signed a consent that was not completed for the following patient;
Review of patient #71's chart revealed the consent had a blank for the physician's name, what product they were consenting to, and alternatives to treatment.

Review of the facility's policy and procedure "Blood Transfusions" Stated, "1. Blood transfusions, and /or blood products, i.e...FFP, platelets, must be ordered by the physician. *****The physician must order a rate of transfusion. *****"

Review of the patient charts revealed the following patients did not have an ordered rate for transfusion;
1. Patient #71
a.) 12/14/16 19:00 (7:00PM) Transfuse 2 units of PRBC's
b.) 12/14/16 at 18:27 (6:27PM) RBC Unit Order #2200
c.) 12/14/16 at 18:27 (6:27PM) RBC Unit Order #2300

2.) Patient #72
a.) 1/21/17 at 17:50 (5:50PM) Transfuse 1 unit of PRBC
b.) 1/23/17 at 9:29AM Transfuse 1 unit of PRBC

3.) Patient #73
a.) 1/16/17 at 10:31AM Transfuse 1 unit of PRBC



Review of the facility's policy and procedure "Blood Transfusions" Stated," 3. Blood Transfusions and /or products must be retrieved from lab, signed for and witnessed by two people before leaving the lab, have two licensed staff co-sign (one must be RN starting transfusion) as part of the patient identifier process at the bedside, started and monitored for the first 15 minutes by an RN." Blood units removed from the Laboratory may not be returned if it is out of the Laboratory Blood bank for more than 15 minutes, or if the seal is broken.

Review of the following patient charts #18, #71, #72, and #73 revealed there was no documentation in the patient charts on who picked up the blood from the lab and at what time.

Review of the Laboratory "Blood Bank Worksheet" revealed a section where the blood is retrieved from the lab. In the unit disposition section is a place for the date and time, if the unit was visually "ok", who it was issued to, and issued by.

The log revealed patient #71's blood was ready to be picked up on 12/14/16 at 19:52 (7:52PM). The log revealed the blood was not picked up from the lab until 2234 (10:34PM) a 2 ½ hour delay. The issued to and issued by was just initials. The initials were difficult to read and there was no authentication on the log to match the initials with the signature. Some of the dates and times on the log had been marked over and were not legible.

Review of patient #72's blood bank worksheet log revealed the blood was picked up in the lab on 1-21-17 at 2254 ( 10:54PM). There was just initials with no name or title verification on the log. Another unit was picked up on 1-23-17 at 1331 (1:31PM). The log revealed the initials "ok" on the issued to line. There is no nurse administering the blood with initials OK.

Review of patient 73's chart revealed blood was picked up in the lab on 1-16-17 at 1358 (1:58PM) and another unit on 1-17-17 at 0000 (12:00AM). There was only initials with no name or title verification on the log.

There was no way to accurately determine, if the person that picked up the blood from the lab, was the RN checking it with another nurse at the bedside before administration. There was no found documentation for the delay in blood administration.


Review of the Dialysis charts revealed the blood administration was done on a paper copy and not in the electronic record. The paper transfusion record for patient #18 was found to be incomplete.
Review of the paper blood record revealed the "issued date and time" from the lab was blank.
Review of patient #18's blood record under transfusion record section revealed on 9/28/16 blood was started at 10:45AM and the "Date/Time stopped was blank. Under the vital signs section revealed the blood was started at 2245 (10:45PM) and ended on 23:15 (11:15PM). The Medical History Report section was blank and required a physician/nurse signature.

Review of the second blood unit, under the transfusion record section, revealed there was not two people checking the blood at the bedside. The signature line for the transfusionist was blank. The date/time section was blank. Under the vital signs section the blood was shown started at 23:15 (11:15PM) and stopped at 20:45PM (8:45PM). Three hours before it was started. The Medical History Report section was blank and required a physician/nurse signature.

Review of Patient 73's chart revealed there was an order written on 1/16/17 at 8:22AM for a unit of RBC (blood). The priority on the order stated, "Stat" (now). There was no order found to transfuse the blood. Review of the blood blank log revealed that someone came and got the blood (initials illegible) on 1/16/17 at 1358(1:58PM); 5 ½ hours later. The Blood Administration Nurses Notes dated 1/16/17 revealed the blood was started on 1/16/17 at 1430 (2:30PM); 6 hours and 8 minutes after it was ordered. There was no documentation found on why the "stat" order was delayed. The blood was documented as completed at 1/16/17 at 1700 (5:00PM).

Review of patient #73's physician orders revealed the RBC unit was ordered ASAP on 1/16/17 at 10:31. An order was found that stated 1/16/17 at 10:31AM "Transfuse 1 unit or PRBC routine." According to the policy and procedure "Blood Transfusions" the time frame for administration of ordered blood is:
"Stat: 15 minutes after notification that it is ready.
ASAP: 30 minutes after notification that it is ready.
Routine: 2 hours after notification that it is ready."

Review of patient 73's blood administration record revealed the blood was not started until 1/17/16 at 00:12 (12:12AM) 13 hours and 42 minutes later. There was no documentation found on why the blood administration was delayed.

An interview with staff #22 was conducted on 1/25/17. Staff #22 confirmed the above findings. Staff #22 stated, "There is no proof that the nurse picked up the blood in the chart. The only place it's documented is in the lab and I see its just initials."