HospitalInspections.org

Based on facility observations and staff interviews it was determined the facility failed to ensure the facility was free from environmental risks which included ligature risks.

These deficient practices had the potential to negatively affect all patients admitted to the facility.

Findings include:

1. A tour was conducted on 5/3/22 at 1:15 PM of the facility 300 and 400 Unit. During a tour, a hospital bed with 2 side rails attached, which would pose a risk of ligature, were observed in rooms 301, 401 and 402.

An interview was conducted on 5/6/22 at 10:53 AM with Employee Identifier (EI) # 7, Administrator, confirmed the side rails on the above hospitals beds were not designed to collapse with weight and would be a ligature risk.



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2. A tour was conducted on 5/3/22 at 1:00 PM of the facility 200 Unit. During the tour, a hospital bed with a fixed open metal bar attached with bolts to the head of the bed and a fixed open metal bar attached with bolts to the side of the head of the bed, which would pose a risk of ligature, was observed in room 206 .

An interview conducted on 5/4/22 at 2:10 PM with EI # 8, Registered Nurse 200 Unit confirmed the metal bars on the above hospital bed were fixed to the bed with bolts and not collapsible with weight and would be a ligature risk.

Based on Medical Record (MR) review, facility policy and procedure and staff interview the facility failed to document a written modification to the patient's Plan of Care with the use of seclusion and/or restraints.

This deficient practice did affected 1 of 2 MR reviewed with a restraint, including Patient Identifier (PI) # 15, and 3 of 3 inpatient MR's reviewed with seclusion including, PI # 7, PI # 5, and PI # 3. This deficient practice had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy: Treatment, Treatment Plan and Review
Policy Number: CTS 1.2
Revised Date: 2/15

Policy:

In order to ensure the appropriateness of care, treatment plans and reviews will be conducted for all Consumers...

Procedure:

...2. The treatment plan will include clinical issues to be addressed in treatment and the survives to be provided...

...12. The treatment plan is reviewed when major changes occur..presenting problems... and is revised as necessary.

1. PI # 15 was admitted to the facility on 10/27/21 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the facility Incident Volume Report dated 11/1/21, time not documented, revealed documentation of "writer observed consumer throwing coffee on staff, then trying to hit staff. Consumer was brought to ground, vertical restraint... Med (medication) nurse administered prn (as needed) medication: Haldol and Benadryl IM (intramuscular)... Security was present at time of restraint and injection..."

Review of the Nursing Progress Note dated 11/1/21 at 10:58 AM revealed documentation of "writer observed consumer throwing coffee on staff, then trying to hit staff. Consumer was brought to ground, vertical restraint... Med (medication) nurse administered prn (as needed) medication: Haldol and Benadryl IM (intramuscular)... Security was present at time of restraint and injection..."

Review of the eMAR (Electronic Medication Administration Record) revealed PI # 15 was administered Benadryl 50 mg (milligrams) and Haldol 5 mg IM on 11/1/21 at 10:58 AM.

Review of the Hospital Treatment Plan Update dated 11/16/21 revealed no documentation of the restraint used for prn administration of psychotropic medications on 11/1/21.

Review of the facility Seclusion and Restraint Policy revealed no documentation of a timeframe for the modification of the patient's treatment plan after placement of a patient in seclusion and/or restraints.

An interview was conducted with Employee Identifier (EI) # 6, Director of Compliance, who confirmed there was no documentation PI # 15's treatment plan was updated on 11/16/21 for the use of the restraint on 11/1/21.

2. PI # 7 was admitted to the facility on 2/24/22 with the diagnosis of Schizoaffective, Disorganized.

Review of the MR revealed the patient was placed in seclusion on 2/25/22 from 12:55 PM to 2:30 PM.

Review of the Hospital Treatment Plan Update dated 2/25/22 at 3:42 PM revealed no documentation of the patient's seclusion on 2/25/22.

An interview was conducted on 5/6/22 at 9:02 AM with EI # 1, Director of Nursing, confirmed there was no documentation of the 2/25/22 seclusion.



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3. PI # 5 was admitted to the facility on 4/6/22 with an admitting diagnosis of Schizophrenia Disorganized, Chronic With Acute Execration.

Review of the physician orders dated 4/18/22 at 10:48 AM revealed an order to place PI # 5 in seclusion. Start Date and Time: 4/18/22 at 9:45 AM and Stop Date and Time: 4/18/22 at 1:44 PM.

Review of the Seclusion/Restraint Observation form revealed the patient was released from seclusion at 11:00 AM on 4/18/22.

Review of the Hospital Treatment Plan dated 4/22/22 revealed no documentation in the treatment plan which stated patient had been placed in seclusion on 4/18/22.

An interview was conducted on 5/5/22 at 3:25 PM with EI # 1 who confirmed the treatment plan was not updated.



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4. PI # 3 was admitted to the facility on 4/19/22 at 11:55 AM with diagnosis including Schizoaffective Disorder, Bipolar Type.

Review of the MR revealed the patient was placed in seclusion on 4/25/22 from 5:30 PM to 9:30 PM.

Review of the Hospital Treatment Plan Update dated from 4/25/22 to 5/4/22 revealed no documentation of the patient's seclusion on 4/25/22.

An interview was conducted on 5/5/22 at 3:00 PM with EI # 1, who verbalized the Plan of Care is not "updated everytime, not unless there is something different" and verbalized the seclusion would be under the problem of aggression. EI # 1 did confirm there was no documentation of the 4/25/22 seclusion under the aggression problem section of the Plan of Care.

Based on review of the facility Incident Volume Report, medical records (MR), facility policy and procedure, and staff interview the facility failed to have a documented physician notification and physician order for the use of the restraint used for the administration of psychotropic medications.

This did affect Patient Identifier (PI) # 15, 1 of 2 MR's reviewed with a restraint and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Use of Seclusion and Restraint
Policy Number: CTS 4.2
Review Date: 9/21

Policy: ...When...restraint...are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights and well-being.

...Definitions

...2. Physical Restraint - the direct application of physical force to an individual served with or without the patient's permission to restrict the patient's freedom of movement by utilizing MindSet Techniques and Principles.

Procedure:

...D. Initiation and Ordering of Seclusion/Restraint

1. ...Restraint may be initiated only by order of a Licensed Independent Practitioner (LIP) who is primarily responsible for the individual's care...or in an emergency when a LIP may not be immediately available...other trained staff members...may initiate the use of restraint...before an order is obtained from the LIP.

2. A LIP...include: MD (Medical Doctor), DO (Doctor of Osteopathic Medicine), Certified Nurse Practitioner, and a Physician Assistant.

3. As soon as possible, but no longer than 1 hour after the initiation of (a) restraint...in the absence of a LIP...Trained and qualified staff:

Notifies and obtains an order (verbal or written) from the LIP and consults with the LIP about the individual's physical and psychological condition.

The LIP...supplies an order...

1. PI # 15 was admitted to the facility on 10/27/21 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Physician Progress Note dated 11/1/21 at 10:25 AM revealed documentation of "...given PRN Benadryl 50 mg (milligram) IM and Haloperidol 5 mg IM for behavioral issues today..." There was no documentation the physician was aware a restraint was used to administer the PRN psychotropic medication.

Review of the Nursing Progress Note dated 11/1/21 at 10:58 AM and the facility Incident Volume Report dated 11/1/21, no time documented, revealed documentation of "writer observed consumer throwing coffee on staff, then trying to hit staff. Consumer was brought to ground, vertical restraint... Med (medication) nurse administered prn (as needed) medication: Haldol and Benadryl IM (intramuscular)... Security was present at time of restraint and injection..." There was no documentation the physician was notified of the use of a vertical restraint for prn administration of psychotropic medications.

Review of the MAR (Electronic Medication Administration Record) revealed PI # 15 was administered Benadryl 50 mg and Haldol 5 mg IM on 11/1/21 at 10:58 AM.

Review of the MR revealed no documentation the LIP was notified nor provided and order for the use of the restraint on 11/1/21.

An interview was conducted with Employee Identifier # 6, Director of Compliance, who confirmed there was no documentation the LIP was notified nor provided and order for the use of the restraint on 11/1/21.

Based on review of the facility Incident Volume Report, medical records (MR), facility policy and procedure, and staff interview the facility failed to document a patient face-to-face assessment following the use of a restraint for the administration of psychotropic medications.

This did affect Patient Identifier (PI) # 15, 1 of 2 MR's reviewed with a restraint and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Use of Seclusion and Restraint
Policy Number: CTS 4.2
Review Date: 9/21

Policy: ...When...restraint...are used, the interventions protect the health and safety of the patients while preserving his or her dignity, rights and well-being.

...Definitions

...2. Physical Restraint - the direct application of physical force to an individual served with or without the patient's permission to restrict the patient's freedom of movement by utilizing MindSet Techniques and Principles.

Procedure:

...F. In-person Face to Face Evaluation

1. The patient must receive an in-person face to face evaluation within 1 hour of initiation of...restraint...

2. The evaluation must include:

...Appropriateness of the intervention measures

...The reaction to the intervention

The patient's medical...and behavioral condition/psychological condition....

...The need for immediate changes to the patient's course of care such as the need for timely follow-up by the patient's primary clinician or the need for medical, psychiatric, or nursing evaluation for needed medication changes.

3. Each in-person evaluation of the patient must be signed by the staff person who provided the evaluation.

4. When a Qualified Registered Nurse (RN) or PA (Physician Assistant) conducts the in-person evaluation, the attending physician treating the patient or other licensed independent practitioner must be consulted as soon as possible.


1. PI # 15 was admitted to the facility on 10/27/21 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the facility Incident Volume Report dated 11/1/21, no time documented and the Nursing Progress Note dated 11/1/21 at 10:58 AM revealed documentation of "writer observed consumer throwing coffee on staff, then trying to hit staff. Consumer was brought to ground, vertical restraint, without incident and no injury occurred. Med (medication) nurse administered prn (as needed) medication: Haldol and Benadryl IM (intramuscular)... without incident in bedroom. Consumer to remain in bedroom until calm and cooperative. Security was present at time of restraint and injection. No harm noted to consumer. Consumer alert and oriented x 4 and in no acute distress at time of injection and restraint as well."

Review of the eMAR (Electronic Medication Administration Record) revealed PI # 15 was administered Benadryl 50 mg (milligrams) and Haldol 5 mg IM on 11/1/21 at 10:58 AM.

Review of the MR revealed no documentation of a face to face evaluation which included the appropriateness of the intervention measures, PI # 15's reaction to the interventions and the patient's medical and behavioral condition/psychological condition.

An interview was conducted with Employee Identifier # 6, Director of Compliance, who confirmed there was no documentation of a face to face evaluation which included the appropriateness of the intervention measures, PI # 15's reaction to the interventions and the patient's medical and behavioral condition/psychological condition.

Based on review medical records (MR), facility policy and procedure and facility staff interviews, it was determined the nursing staff failed to:

1. Document patient complaint and/or result of as needed (PRN) medication(s)

2. Follow the physician's order for administration of PRN medication(s).

3. Document the dosage administered of PRN medication.

This deficient practice did affected 4 of 8 current inpatient MR reviewed including, Patient Identifier (PI) # 7, PI # 8, PI # 6 and PI # 4 and had the potential to affect all patients served by the facility.

Findings Include:

Facility Policy Number: CTS 3.0
Subject: Medication Storage, Control, Assistance and Administration
Revised Date: 7/16/21

Procedure:

...C. Medication Administration/Assistance

...8... staff must document information related to a patient receiving PRN...medications including: ...complaint...results.

1. PI # 7 was admitted to the facility on 2/24/22 with the diagnosis of Schizoaffective, Disorganized.

Review of the physician's order dated 2/24/22 revealed an order for Benadryl 50 mg (milligrams) every 6 hours prn for EPS (Extrapyramidal Symptoms) and/or stiffness, Desyrel 50 mg at bedtime prn for insomnia and Haldol 5 mg every 6 hours prn for psychotic agitation and/or aggression.

Review of the eMAR (Electronic Medication Administration Report) revealed:

On 2/28/22 at 10:23 PM, Desyrel 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 3/1/22 at 9:13 PM, Desyrel 50 mg was administered. There was no documentation of the result of the prn administration.

On 3/2/22 at 3:45 AM, Benadryl 50 mg and Haldol 5 mg was administered for anxiety and having bad thoughts, which was not documented as an indication of use per the physician order. There was no documentation of the result of the prn administration.

On 3/6/22 at 10:15 PM, Desyrel 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 3/14/22 at 10:52 PM, Desyrel 50 mg was administered. There was no documentation of the patient's complaint and result of the prn administration.

On 3/15/22 at 11:12 PM, Desyrel 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 3/18/22 at 10:56 PM, Haldol 5 mg was administered. There was no documentation of the result of the prn administration.

On 3/29/22 at 9:31 AM, Benadryl 50 mg was administered. There was no documentation of the patient's complaint.

On 3/31/22 at 11:30 PM, Benadryl 50 mg was administered for a complaint of itching, which was not documented as an indication of use per the physician order. There was no documentation of the result of the prn administration.

On 4/6/22 at 10:56 PM, Benadryl 50 mg was administered. There was no documentation of the result of the prn administration.

On 4/8/22 at 3:38 PM, Benadryl 50 mg was administered. There was no documentation of the result of the prn administration.

On 4/10/22 at 3:14 PM, Benadryl 50 mg was administered. There was no documentation of the result of the prn administration.

On 4/13/22 at 11:18 PM, Benadryl 50 mg was administered. There was no documentation of the patient's complaint.

On 4/14/22 at 3:45 PM, Benadryl 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 4/15/22 at 10:00 PM, Haldol 5 mg was administered. There was no documentation of the result of the prn administration.

On 4/19/22 at 12:32 PM, Desyrel 50 mg was administered. There was no documentation of the result of the prn administration.

On 4/22/22 at 10:41 PM, Benadryl 50 mg was administered. There was no documentation of the result of the prn administration.

On 4/24/22 at 12:04 AM, Benadryl 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 4/26/22 at 12:06 AM, Benadryl 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 4/28/22 at 11:24 PM , Benadryl 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

Review of the physician's order dated 4/7/22 revealed an order for Benadryl 50 mg at bedtime PRN for sleep.

Review of the eMAR revealed Benadryl 50 mg was administered:

On 4/9/22 at 11:00 PM, there was no documentation of the patient's complaint and result of prn administration.

On 4/12/22 at 12:02 AM, there was no documentation of the patient's complaint.

On 4/15/22 at 10:00 PM, there was no documentation of the patient's complaint and the result of prn administration.

An interview was conducted on 5/6/22 at 9:02 AM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the facility staff failed to follow the facility policy and procedure and/or physician orders for prn administration on the above dates.

2. PI # 8 was admitted to the facility on 4/20/22 with a diagnosis of Major Depressive Disorder, Recurrent Episode with Anxious Distress.

Review of the Physician orders dated 4/20/22 revealed orders for Acetaminophen 650 mg every 4 to 6 hours prn for headache and Ibuprofen 400 mg to 600 mg every 8 hours prn for pain.

Review of the eMAR revealed:

On 4/20/22 at 9:19 PM, Acetaminophen 650 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

On 4/24/22 at 10:02 PM, Ibuprofen was administered for "leg pain". There was no documentation of the result of the prn administration.

On 5/2/22 at 8:00 PM, Acetaminophen 650 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

An interview was conducted on 5/6/22 at 8:48 AM with EI # 1 who confirmed the facility staff failed to follow the facility policy and procedure for prn administration on the above dates.

3. PI # 6 was admitted to the facility on 4/28/22 with a diagnosis of Unspecified Mood Disorder.

Review of the Physician order dated 4/28/22 revealed an order for Desyrel 50 mg at bedtime prn for insomnia.

Review of the eMAR dated 4/29/22 at 8:08 PM revealed Desyrel 50 mg was administered. There was no documentation of the patient's complaint.

Review of the Hospital Nursing Progress Notes dated 4/30/22 at 11:58 AM, which was 14 hours and 50 minutes after Desyrel was administered, revealed a follow up assessment which stated the patient had slept 9.1 hours.

Review of the Physician order dated 5/2/22 revealed an order for Vistaril 50 mg three time a day prn. There was no documentation of the indication for the prn administration of Vistaril.

Review of the eMAR revealed:

On 5/2/22 at 8:50 PM, Vistaril 50 mg was administered. There was no documentation of the patient's complaint.

On 5/3/22 at 6:59 AM, Vistaril 50 mg was administered. There was no documentation of the patient's complaint.

On 5/4/22 at 8:29 AM, Vistaril 50 mg was administered. There was no documentation of the patient's complaint and the result of the prn administration.

An interview was conducted on 5/6/22 at 8:52 AM with EI # 1 who confirmed the facility staff failed to follow the facility policy and procedure for prn administration on the above dates. EI # 1 was asked after the administration of a prn medication, in what timeframe should the result of the prn administration be documented per the facility protocol. EI # 1 verbalized within 2-3 hours following the prn administration. EI # 1 was asked if the indication for the adminsitration of a prn medication should be documented on the physician's order. EI # 1 stated, "yes."



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4. PI # 4 was admitted to the facility on 4/27/22 with an admitting diagnosis of Bipolar Disorder, Current Episode Depressed.

Review of the physician order dated 4/27/22 on the eMar and Orders Active Form dated 4/27/22 revealed an order for Acetaminophen 325 mg oral tablet give 650 mg every 4-6 hours as needed for headache.

Review of the physician order dated 4/27/22 on the eMar and Orders Active form dated 4/27/22 revealed an order for Ibuprofen 200 mg tablet give 400-600 mg every 8 hours as needed for pain.

Review of the eMar dated 5/2/22 at 6:50 AM revealed the nurse administered acetaminophen 650 mg for pain.

Review of the nursing progress notes for 5/2/22 revealed no documentation of the patient's complaint for acetaminophen being administered and the result of the prn administration.

Review of the eMar the patient was given Ibuprofen on 5/2/22 at 11:27 AM and on 5/3/22 at 1:00 PM. Further review of the eMar reveled no documentation of how much medication was given. The order stated 400 to 600 mg every 8 hours PRN.

Review of the nursing documentation revealed no documentation of a result of pain relief after the administration of a PRN pain medication.

An interview was conducted on 5/3/22 at 3:15 PM with EI # 1 who confirmed the nurse failed to document the patient's complaint, what strength of Ibuprofen was given and failed to document a follow up for pain relief.

Based on observations, review of policies and procedures, and staff interviews, it was determined the facility failed to ensure the staff cleaned and disinfected consumer rooms per facility policy.

This did affect 1 of 1 observation conducted for terminal cleaning of a consumers room.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Cleaning of Patient Care Equipment and the Environment
Policy #: IC 3.7
Update: 3/18

Policy:

Each AltaPointe Health...program will ensure...environment is maintained in a clean and sanitary condition. The accumulation of...microbial contaminants on environmental surfaces is...a potential source of healthcare-associated infections...
Employees and housekeeping personnel share responsibility for maintaining a safe and sanitary environment for consumers...

Procedure:

7. Equipment cleaning guidelines include:

N. Housekeeping staff will clean and disinfect high touch surfaces (door knobs...light switches...in consumers room)...

R. Any area contaminated with...other body fluids shall be cleaned promptly...

Facility Policy: Jani King Eastpointe Hospital Cleaning Schedule
Policy Number: Version 3.3
Date Created: 1/30/2014

Patient Room Discharge:

...Clean high touch areas such as switches and handles using Betco #4 PH7Q Ultra Neutral pH Disinfectant, Detergent and Deodorant and a Green microfiber cloth...

1. An observation was conducted on 5/4/22 at 1:30 PM to observe Employee Identifier (EI) # 9, Jani King Supervisor clean a room after consumer discharge.

During the observation, EI # 9 bent down to clean the toilet base and EI # 9's ID badge touched the rim of the toilet multiple times during the cleaning. EI # 9 then completed the room cleaning and exited the room without cleaning the light switches and door handles or removing and cleaning his/her ID badge.

An interview was conducted on 5/4/22 at 2:00 PM with EI # 8, Registered Nurse 200 Unit who verified the door handles and light switches should be cleaned on consumer discharge and the light switches and door handles were not cleaned per policy. EI # 8 also confirmed employee badges should be kept free from contamination.

Based on review of the facility Antibiotic Stewardship Program and staff interviews the facility failed to document the evidence-based use of antibiotics in all departments and services of the hospital

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 5/5/22 at 2:19 PM with Employee Identifier (EI) # 6, Director of Compliance.

EI # 6 was asked to provide documentation of the evidence-based use of antibiotics throughout the facility. EI # 6 stated, "we haven't gotten that far yet" and expressed the facility ASP was still in it's early development.

Based on review of the facility Antibiotic Stewardship Program and staff interviews the facility failed to document improvements, including sustained improvements, in proper antibiotic use.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 5/5/22 at 2:19 PM with Employee Identifier (EI) # 6, Director of Compliance.

EI # 6 provided the surveyor with the Summary of Antibiotic Usage for July to September 2021 and January to March 2022, which contained the name and dose of the antibiotic, the illness the antibiotic was used for and which facility in the hospital system the antibiotic was used at.

Review of the Summary of Antibiotic Usage for July to September 2021 revealed documentation of "Macrobid 100 mg (milligrams) BID (twice daily)...Amoxicillin ?" were both used at the facility for urinary tract infections. Further review revealed documentation of "Amoxicillin most frequently used antibiotic in the FQs (Federally Qualified Health Centers). Antibiotics multi use in 24 hrs (hours) facilities. To help promote antibiotic stewardship at our facilities we are closely monitoring prescribed amounts of antibiotics and we encourage our providers to use wisely."

EI # 6 was asked to provide documentation of improvement in antibiotic usage. EI # 6 stated, "we haven't gotten that far yet" and expressed the facility ASP was still in it's early development.

Based on review of the facility Antibiotic Stewardship Program and staff interviews the facility failed to document competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 5/5/22 at 2:19 PM with Employee Identifier (EI) # 6, Director of Compliance.

EI # 6 was asked to provide documentation of the competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. EI # 6 stated, "we wouldn't have that" and expressed the facility ASP was still in it's early development.