HospitalInspections.org

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 2 of 5 sampled patients (Patient #6 and #7) as evidenced by failure to reassess patients after disruptive behaviors requiring medication administration and failure to implement additional measures to minimize physical altercations between patients.


The findings included:

Facility policy "Assessment and Reassessment of the Patient" last reviewed 02/18 documents "Reassessment: Each patient is re-assessed according to discipline specific guidelines. For all patients re-assessment is at specified, regular intervals related to: Patient response to treatment/procedures including medication administration."


Clinical record review conducted on 02/27/19 revealed Patient #7 was admitted to the facility on 12/05/18. Physician's admission orders dated 12/05/18 included Assault and Suicide precautions. Other precautions noted unpredictable behavior and monitor every fifteen minutes.

Nurses Notes dated 12/07/18 at 2:17 PM documents Patient #7 was in an altercation with peer (Patient #6). Staff intervened and separated the patients. No injuries or bruising noted on either patient. Department of Children and Families notified per protocol.

Review of document titled "Special Observation Record/15 Minute Patient Monitoring" dated 12/07/18 failed to document behaviors, it noted "patient sitting in milieu". The instructions on the form noted "This form is used for documentation of every 15 minutes checks. Document the patient location and behavior codes with your initials every 15 minutes."

The record indicates an Emergency Treatment/Medication Order for Geodon and Vistaril was obtained on 12/07/18. The drugs were administered to the patient at 4:34 PM. The record does not document the behaviors leading to the event or interventions implemented prior to placing the patient in the quiet room or prior to receiving the drugs.

Review of the Special Observation Record/15 Minute Patient Monitoring form and Nurses Notes dated 12/07/18 failed to provide evidence of a nursing reassessment after the medication was administered.

Nurses Notes dated 12/08/18 at 3:45 PM documents Patient #7 was "yelling and cursing, and knocking over chairs and tables. Unable to be redirected. Vistaril and Geodon given. Will continue to monitor."

The record indicates an Emergency Treatment/Medication Order for Geodon and Vistaril was obtained on 12/08/18. The drugs were administered to the patient at 3:38 PM.

Review of the Special Observation Record/15 Minute Patient Monitoring form dated 12/08/18 failed to provide evidence of a nursing reassessment after the medication was administered.

Nurses Notes dated 12/08/18 failed to provide evidence of a nursing reassessment after the medication was administered.

Approximately, an hour later at 4:38 PM, the nurse documents Patient #7 was again "involved in a physical altercation with another peer (Patient #6) in the unit. No injury received. Patient states my head was graced. Father was informed and call placed to DCF."

Special Observation Record/15 Minute Patient Monitoring form dated 12/08/18 documents the patient was in the milieu from 2:30 PM thru 4:15 PM and in his room reading from 4:30 PM through 5:45 PM. The patient monitoring form failed to document the patient's behavior.


Interview with Staff A, a Mental Health Technician, conducted on 02/27/19 at 3:19 PM revealed he recalls Patient #6 and #7. Patient #7 was angry and Patient #6 was the instigator. They were bickering all day; they sat by each other and that afternoon one of the boys was swinging from the desks. The other patient got angry and claimed he hit his hand and after that, they got into it. Staff A recalls he was standing by the door and separated the boys, the patients just did not mix well. He reported the incident and told the incoming shift. Staff A did not work in the adolescent unit the next day so he was not aware of the second altercation but explained the area is limited and is hard to separate the youth, as the common area is small. We try to separate the adolescent from the pewees and there is not much room left. Staff A explained assault precautions means to keep a close eye for behaviors or any signs of escalation leading to violence.


Interview with The Quality Coordinator, who navigated the electronic record, conducted on 02/28/19 at 11:13 AM confirmed the clinical record has no evidence of patient reassessment after the emergency medication administration on 12/07/18 and 12/08/18. There is no evidence of identified behaviors and interventions prior to administering psychotropic drug on 12/07/18 and there is no evidence the facility implemented additional measures to reduce the risk of further altercations between patient #6 and #7.

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure nursing care plans provided to each patient is in accordance with established Standards of Practice of Nursing Care, Chapter 464.003(5). This failure affected 1 of 5 sampled patients (Patient #7) as evidenced by failure to revise plan of care after multiple physical altercations with peers.


The findings included:

Facility policy titled "Standards of Care" last reviewed 08/18 documents "Standard of Care: Assessment
The priority of data collection activities is derived by the patient's immediate condition and anticipated needs.
Problem identification
Problems are prioritized in a manner that facilitates expected outcomes in the plan of care.
Outcome identification
Outcomes are derived from actual problems and mutually formulated with the patient and the health care team.
Planning
The plans developed collaboratively with the health careteam with each member contributing towards achieving expected outcomes and continuity of care
Implementation
Interventions are delivered in a manner that minimizes complications and life threatening situations.
Evaluation
Once initiated, interventions are evaluated by the healthcare team within an appropriate time frame."

Clinical record review conducted on 02/27/19 revealed Patient #7 was admitted to the facility on 12/05/18. Physician's admission orders dated 12/05/18 included Assault and Suicide precautions. Other precautions noted unpredictable behavior and monitor every fifteen minutes.

Nurses Notes dated 12/07/18 at 2:17 PM documents Patient #7 was in an altercation with peer (Patient #6). Staff intervened and separated the patients. No injuries or bruising noted on either patient. Department of Children and Families notified per protocol.

Emergency Treatment/Medication Orders for Geodon and Vistaril were obtained and administered on 12/07/18 at 4:34 PM.

Emergency Treatment/Medication Orders for Geodon and Vistaril were obtained and administered on 12/08/18 at 3:38 PM.

Nurses Notes dated 12/08/18 at 3:45 PM documents Patient #7 was "yelling and cursing, and knocking over chairs and tables. Unable to be redirected. Vistaril and Geodon given. Patient tolerated it well. Will continue to monitor."


Approximately, an hour later at 4:38 PM, the nurse documents Patient #7 was "involved in a physical altercation with another peer (Patient #6) in the unit. No injury received. Patient states my head was graced. Father was informed and call placed to DCF."

Care Plan initiated for Patient #7 on 12/05/18 documents Problem #1 Mood, patient with irritability and mood swings. Patient throwing furniture at school. No other problems were identified. Further review of the clinical record failed to provide evidence the staff updated Patient #7's nursing care plan addressing the recent physical behaviors and altercations with peer.


Interview with The Quality Coordinator, who navigated the electronic record, conducted on 02/28/19 at 11:13 AM confirmed the clinical record has no evidence of care plan revision addressing the physical altercations with peers.

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established Standards of Practice of Nursing Care, Chapter 464.003(5) for 2 of 2 sampled patients (Patient #8 and #9). This failure is evident by failure to assess and reassess patient's condition during and after completion of blood transfusions as specified in facility policy for Blood Product Administration.


The findings included:

Facility policy titled "Blood Product Administration" dated 07/18 documents "To provide guidelines for the safe administration of blood products within the facility. Procedure for Monitoring and Documentation:
All patient areas will document vitals and any transfusion reactions at the following intervals.
Baseline vital signs (blood pressure, pulse, temperature, respirations and oxygen saturation) must be taken 30 minutes prior to beginning transfusion.
5 minutes after initiation of transfusion and as patient condition requires
15 minutes after initiation of transfusion
30 minutes after initiation of transfusion
1 hour after initiation of transfusion
Every hour thereafter until transfusion is complete
A final set of vital signs should be documented 30 minutes after end time."



1) Clinical record review conducted on 02/28/19 revealed Patient #8 was prescribed a blood transfusion, one unit of red blood cells on 02/19/19 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 02/20/19 at 6:33 AM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence of the patient baseline, a complete set of vital signs was obtained 30 minutes prior to the infusion. Furthermore, there is no evidence the patient's temperature was reassessed thirty minutes after the completion of the blood transfusion.

Interview with The Director of Patient Safety and The Quality Coordinator, who were navigating the electronic documentation, on 02/28/19 at approximately 12 noon confirmed there is no evidence the nursing staff completed a baseline assessment including temperature thirty minutes prior to the initiation of the blood transfusion. There is no evidence the nurse monitored the patient's temperature post transfusion as mandated by the facility policies and procedures.


2) Clinical record review conducted on 02/28/19 revealed Patient #9 was prescribed a blood transfusion, one unit of red blood cells on 02/24/19 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 02/24/19 at 2:55 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation and blood administration record failed to provide evidence of the patient baseline, a complete set of vital signs was obtained thirty minutes prior to the infusion. Furthermore, there is no evidence the patient's temperature was reassessed at the five minutes and thirty minutes intervals. Subsequently, there is no evidence the patient vital signs were monitored hourly and there is no evidence of a reassessment thirty minutes after the completion of the transfusion.

Interview with The Director of Patient Safety and The Quality Coordinator, who were navigating the electronic documentation, on 02/28/19 at approximately 12:18 PM confirmed there is no evidence the nursing staff monitored Patient # 9's vital signs as specified by the facility policies and procedures.