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Based on review of hospital policy, medical record review and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A-0144: Failure to ensure a patient receive care in a safe setting. Specifically, an immediate jeopardy situation was identified including a patient receiving medication they were allergic to and a patient not being evaluated for a change in condition and being found two hours later unresponsive.

The egregious nature of this deficient practice resulted in harm to two patients and therefore the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on observation, document review, medical record review, and interview, it was determined the Administrator and Nurse Executive failed to ensure patients receive care in a safe setting. Specifically, an immediate jeopardy situation was identified including a patient receiving medication they were allergic to and a patient not being evaluated for a change in condition and being found two hours later unresponsive.

Findings:

Immediate Jeopardy situation #1

Facility policy titled "HIM Organizational Plan for Information Management" revealed "...Patient Care Services...1. Medical staff, nursing staff, and other hospital clinical departments require comprehensive consistent information to conduct their work...Data Accuracy...A. Integrity of the patient information data must must be accurate, valid and useful. Ensuring the accuracy of patient information is essential..."

Facility document titled "QRBH Hospital Medication Error/Variance Report," identifying Patient #13 and dated 8/24/24, revealed "...Description of Error: ...Per collateral packet and patient report, patient has allergy to Haldol. Per collateral packet s/s of allergy is rash, per pt. personal report s/s of allergy is akathesia which is not an allergy reaction, possibly adverse reaction..."

Facility document titled "9/11/23-Complaint Received from (Employee #23)-Unreported Medication Error" revealed "...The patient did receive Haldol IM as a chemical restraint. (Employee #11) did look into the matter when (Employee #23) brought it to his/her attention. The collateral information indicated pt had reported he/she would get a rash from Haldol. After the administration of the Haldol here he/she did not develop a rash/hives. Pt complained 13 hrs after the injection of jerky movements and discomfort. The symptoms he/she was having at this time could not be connected to the Haldol injection. The patient is a known epileptic...Spoke with (Employee #31) who indicated this is not an allergy. There is no med error. Any mention of allergy should be removed from the record...."

Medical record for Patient #13 revealed the following:

Document titled "ED Summary" states "...haloperidol [From Haldol] Allergy (verified 08/22/24 04:21)...Rash..."

Document titled "Medication Administration Record" states "...Allergies: HALOPERIDOL (Hives, Akathesia), PROMETHAZINE (Akathesia)...haloperidol SOLUTION 5mg...Administered 9:16 8/24/24..."

Document titled "Physician Progress Note" states "...Assessment/Recommendation: ...2. Haldol - drug allergy...8/25/24 0830..."

Document titled "Discharge Summary" states "...Discharge Date: 08/27/2024...History and Physical was completed upon admission where the patient reported ALLERGIES TO HALDOL AND PROMETHAZINE..."

Employee #6 confirmed during interview conducted on October 2, 2024, that the medical record for Patient #13 contains references of medication allergies to Haldol and Promethazine, confirmed Employee #31 determined administration of Haldol on 8/24/24 was not a medication error and that references of Patient #13 allergy to Haldol should be removed from the medical record.

Immediate Jeopardy Situation #2

Facility policy #12741903 titled "Risk Management Plan" revealed "...Occurrence or Incident Follow Up:...A. Four Step Approach to Incident Follow Up:...Immediate Response...Further Investigation...Step 1: Immediate Response:...Verify that the patient now is receiving appropriate medical management...Review the documentation for completeness, contradictions and clues to the cause...Interview those involved...Involvement of medical staff, department directors, supervisors, and administration as appropriate...."

Facility incident report "(RM) LOG#: 24-272504, dated 10/8/2024 identified Patient #33 and revealed "...On Tuesday 10/08/24 @1745 Pt. Climb on kitchen cabinet onto the fridgerator [SIC] into the ceiling roof. Pharametics [SIC] were called to get pt. down. Pt was assisted by Pharametics [SIC] to come down from the ceiling....

Facility investigation of the incident documented in "(RM) LOG#: 24-272504" was requested, none was provided.

A review of Patient #33 medical record revealed no nursing assessment, clinical assessment or medical assessment after climbing into the ceiling and being up there for approximately 30 minutes, in which there were times where no staff were observing the patient. A request was made for evidence that the patient was assessed for injury or self harm while unobserved in the ceiling was requested. None was provided.

Interview with employee #41 on October 17, 2024, confirmed that the internal area of the ceiling that Patient #33 was in had multiple items in which a patient could self harm or injure themselves. Interview with Employee #1 on October 17, 2024 confirmed that no clinical, nursing or medical staff evaluated the patient after the incident.

Based on review of facility policy and procedure, facility documents, document request, and employee interview, the Department determined the facility administrator failed to ensure the facility implemented its policy pertaining to incident reporting and the incident resolution process in order to measure, analyze and track adverse patient events. This deficient practice poses a risk to the health and safety of patients if incidents involving patient care are not reported and investigated according to policy, enabling the implementation of corrective actions to prevent incidents from recurring.

Findings include:

Facility policy #12741873 titled "Critical Incident Reporting" revealed "...After completing guidelines set forth in policy Critical Incident/Untoward Event Response, Quail Run Behavioral Health will report as necessary and required the following:...A. Holds, serious injuries, abuse, neglect, need for emergency services, death, major facility incident, injury of unknown origin unexpected outcomes or any other event as required by outside agencies or by facility discretion...."

Facility policy #12741903 titled "Risk Management Plan" revealed "...Occurrence or Incident Follow Up:...A. Four Step Approach to Incident Follow Up:...Immediate Response...Further Investigation...Step 1: Immediate Response:...Verify that the patient now is receiving appropriate medical management...Review the documentation for completeness, contradictions and clues to the cause...Interview those involved...Involvement of medical staff, department directors, supervisors, and administration as appropriate....Step 1: Further Investigation:...Gather all pertinent facts about the incidents...Scene - where, when, was equipment involved, patient and circumstances at the time...Parties - names and addresses of all those involved...Description - include quotes of described events....

Facility incident report "(RM) LOG#: 24-272504, dated 10/8/2024 identified Patient #33 and revealed "...On Tuesday 10/08/24 @1745 Pt. Climb on kitchen cabinet onto the fridgerator [SIC] into the ceiling roof. Pharametics [SIC] were called to get pt. down. Pt was assisted by Pharametics [SIC] to come down from the ceiling....

Facility investigation of the incident documented in "(RM) LOG#: 24-272504" was requested, none was provided.

Employee #15 confirmed in interviews conducted from October 11, 2024 to October 16, 2024, that no investigation of the incident documented in "(RM) LOG#: 24-272504" was conducted.

Based on the review of records and staff interviews, it was determined that the Medical Staff failed to implement a process to provide quality patient care as stated in the by-laws as evidenced by:

0340: Failed to implement and conduct periodically conduct appraisals of its members.

0358: Failed to ensure a History and Physical examination was completed within the timeframe determined by medical staff rules and regulations.

The substantial lack of oversight of medical staff resulted in the medical staff's inability to ensure the provision of quality patient care.

Based on review of Medical Staff Bylaws, policy, credential files and staff interviews, it was determined the medical staff failed to periodically conduct appraisals of its members. This deficient practice can result in practitioners not being provided oversight resulting in inappropriate patient care and operating outside their scope.

Findings include:

Document titled "Medical Staff Bylaws" states, "...The Medical Director, or his designee, shall have responsibility for oversight of the care provided by the professional, and for the assignment and management of duties. this shall be done through the monitoring of medical records..."

Policy titled "Performance Improvement Plan & Policy" Policy #12741919, dated September 2024, states "Peer Review-OPPE/FPPE...The Medical Executive Committee, through the Medical Director, is responsible to investigate, verify and consider each application for appointment or reappointment to any staff status and each request for modification of staff status and to make recommendations to the governing body...Ongoing Professional Practice Evaluation (OPPE) is a proactive practice of establishing a monthly assessment of performance along an established set of measures...."

Evidence of the monthly OPPE assessments was requested for the past year for Employee #35, #36, #37, #38, #39 & #40. A spreadsheet was provided for Employee #35, #36, #37, #38, #39 & #40 detailing a list of measures per month that were were completed including peer review results, timeliness of documentation among other quality measures. For Employee #35, #36, #37, #38, #39 & #40, the months of January, February, March, April, June 2024 were blank. For Employee #35, #36, #37, #38, #39 & #40 the months of July, August, and September had two of five measures completed.

Interview with Employee #15 on October 17, 2024, confirmed that the Medical Director or designee has not been completing the required oversight and OPPE as required in the Medical Staff Bylaws and Performance Improvement Plan & Policy for Employee #35, #36, #37, #38, #39 & #40.

Based on facility medical records and employee interview, the Department determined the administrator failed to ensure a History and Physical examination was completed within the timeframe established in regulation. This deficient practice poses the risk that patients will not receive timely healthcare services, leading to potential injury or death.

Findings include:

Facility medical record for Patient #37 documented an admission date and time of October 14, 2024 at 15:50. Review of document titled "History and Physical Examination" revealed a completion date and time of October 15, 2024 at 16:20.

Employee #15 confirmed during interviews from October 11, 2024 to October 18, 2024, that the date and time of completion of the History and Physical Examination for Patient #37 was October 15, 2024 at 16:20, more than 24 hours from date and time of admission.

Based on record reviews and staff interviews, it was determined the hospital failed to provide organized nursing services assessed the individual needs of each patient, and deliver and supervise the care required in accordance with physician orders, policies and procedures, and nursing standards of care.

Findings include:

The Condition level deficiency is the result of the standard deficiencies found in the following tags:

Cross reference A-0395: The facility failed to ensure nursing care for each patient was implemented with regard to ensuring a patient suicide risk assessment was completed according to guidelines and training.

Cross reference A-0396: The facility failed to ensure patient nursing care plans include planning for discharge.

Cross reference A-0405: The facility failed to implement changes to medication administration based on new guidance given by the Medical Executive Committee on April 24, 2024, with regard to PRN (As needed) medication for sleep.

Cross reference A-0411: The facility failed to identify, investigate and determine if reporting was necessary for an adverse drug reaction and errors in administration of drugs.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Nursing Services.

Based on review of facility medical records, training curriculum and employee interview, the Department determined the Nursing Executive failed to ensure nursing care for each patient was implemented with regard to ensuring a patient suicide risk assessment was completed according to guidelines and training. This deficient practice poses the potential risk that patient suicide risk would not be assessed, placing patients at risk of harm or death.

Findings include:

Facility medical records revealed the following:

Patient #34 - Document titled "Daily Nurse Progress Note," dated 10/10/24, revealed AMSR (Assessing & Managing Suicide Risk) Daily Screen missing one (1) of two (2) shift assessments completed.

Patient #35 - Document titled "Daily Nurse Progress Note," dated 10/11/24 and 10/14/24, revealed AMSR Daily Screen missing one (1) of two (2) shift assessments completed for both dates.

Patient #36 - Document titled "Daily Nurse Progress Note," dated 10/11/24 and 10/13/24, revealed AMSR Daily Screen missing one (1) of two (2) shift assessments completed for both dates.

Facility training curriculum titled "Assessing & Managing Suicide Risk Core Competencies for Behavioral Health Professionals - AMSR" revealed "...The "When" of Getting the Right Information: Routine Assessment Touch Points (Inpatient)...Reassessment (shift/daily)...Review precautions and info from previous shift; reflect changes and new information..."

Employee #6 confirmed during interviews conducted from October 11, 2024 to October 16, 2024, that Daily Nursing Progress Notes contained missing AMSR assessments.

Based on facility policy and procedure, reference to State Operations Manual (SOM) Appendix A Section 482.23 Condition of Participation: Nursing Services, medical records and employee interview, the Department determined the facility administrator failed to ensure that patient nursing care plans include planning for discharge. This deficient practice poses a potential risk to the health and safety of a patient when a nursing care plan does not address post-hospital needs.

Findings include:

Facility policy titled "Nursing Standards of Practice" revealed "...Standard IV Planning...1. Nursing collaborates with other health team members and participates in the development of the Initial and Master Treatment Plan...7. Criteria for discharge are identified...18. The plan includes appropriate discharge planning...."

State Operations Manual (SOM) Appendix A Section 482.23 Condition of Participation: Nursing Services states "...Nursing care planning starts upon admission. It includes planning the patient ' s nursing care to meet the patient ' s needs and interventions toward meeting patient treatment goals while in the hospital as well as planning for discharge to meet post-hospital needs...."

Facility medical records revealed the following:

Patient #5 - Document titled "Initial Nursing Treatment Plan," dated September 28, 2024, did not include discharge planning.

Patient #6 - Document titled "Initial Nursing Treatment Plan," dated September 22, 2024, did not include discharge planning.

Patient #10 - Document titled "Initial Nursing Treatment Plan," dated October 8, 2024, did not include discharge planning.

Patient #34 - Document titled "Initial Nursing Treatment Plan," dated October 4, 2024, did not include discharge planning.

Patient #35 - Document titled "Initial Nursing Treatment Plan," dated October 16, 2024, did not include discharge planning.

Patient #36 - Document titled "Initial Nursing Treatment Plan," dated October 11, 2024, did not include discharge planning.

Patient #37 - Document titled "Initial Nursing Treatment Plan," dated October 14, 2024, did not include discharge planning.

Employee #15 confirmed during interviews conducted from October 11, 2024 to October 18, 2024, that facility Initial Nursing Treatment Plans do not include patient discharge planning.

Based on facility document review, medical record review and interview the Nursing Executive failed to implement changes to medication administration based on new guidance given by the Medical Executive Committee on April 24, 2024, with regard to PRN (As needed) medication for sleep. This deficient practice resulted in patients receiving PRN medication contraindicated by the Medical Executive Committee and can result in hypersedation of patients causing harm or death.

Findings include:

A review of the Medical Executive Committee on April 24, 2024, notes indicate that patients are no longer to be given "...PRN for sleeping should not be given within 2hrs of scheduled medication...." Evidence that this direction was implemented and incorporated into policy for evaluated further to not be implemented was requested. None was provided.

Patient #1 was prescribed Hydroxyzine, 50mg "PRN" for "Insomnia." Patient #1 Medication Administration Record (MAR) reveals Patient #1 was administered PRN Hydroxyzine at the same time as their standard medication on the following dates: September 24, September 25, September 26, 2024. Hydroxyzine PRN for insomnia was administered at the same time as Lithium oral 300mg and Prozosin 1mg.

Interview with Employee #6 on October 11, 2024, confirmed that the direction from the medical executive committee was not implemented and patient#1 was given PRN medication for sleep at the same time as their scheduled night medication.

Based on facility policy and procedure, facility medical records, hospital emergency department records, and employee interview, the Department determined that the administrator failed to identify, investigate and determine if reporting was necessary for an adverse drug reaction and errors in administration of drugs. This deficient practice resulted in Patient #14 requiring emergency department assessment for adverse effect to medication provided and the facility failing to identify and investigate it.

Findings Include:

Policy titled "Assessment of Allergies" revealed "...Upon admission, the nurse will obtain a history of any known allergies from the patient, family or both...Once the nurse obtains an allergy history, the nurse will: ...Document patient allergies in the Nursing Assessment...."

Policy titled "Medication Administration Policy" revealed "...Medication Administration Policy...Before administering a medication, the authorized individual administering the medication completes the following: ...Verifies there is no contraindication with respect to allergy, sensitivity or diagnosis...."

Medical record for Patient #14 revealed the following:

Document titled "Standardized Intake Assessment," assessment date 8/2/24, assessment time 1829, revealed "..Allergies: ...Olanzapine..."

Document titled "Seclusion/Restraint/Chemical Restraint Order" revealed "...Date and Time of Order: ...8/2/24...2010...Type of Intervention...Chemical Restraint (box checked)...involuntarily (box checked)...Olanzapine 2.5mg IM..."

Document titled "Seclusion/Restraint/Chemical Restraint Order" revealed "...Date and Time of Order: ...8/3/24...0045...Type of Intervention...Chemical Restraint (box checked)...involuntarily (box checked)...Olanzapine 2.5mg IM..."

Document titled "Medication Administration Record" revealed "...Allergies...OLANZAPINE...Olanzapine INJ PWD 2.5 mg...scheduled 21:00 8/2/24...Administered 1:39 8/3/24...Olanzapine INJ PWD 2.5 mg...scheduled 2:00 8/3/24...administered 1:40 8/3/24..."

Emergency Department document titled "ED Provider Note" revealed "...Date of Service" 8/3/2024...Time Seen: 8/3//2024 2:22 AM...Chief Complaint...Patient present with...agitation...Pt BIBA from Quail Run for agitation following administration of olanzapine. Patient repeatedly grating jaw and combative per Quail Run staff...presenting to the ED with reported adverse effect to medication provided...was provided with 2.5 mg of olanzapine at 8:15 pm...subsequently ay 0045 patient awoke and was agitated again, at this point provided with additional 2.5 mg of IM olanzapine...Diagnoses...Extrapyramidal reaction...Agitation..."

Employee #6 confirmed during interview conducted on October 3, 2024, that Patient #14 had been administered a medication that was identified in the medical record that Patient #14 is allergic to twice and it has not been identified and investigated.

Based on review of facility policy and procedure, medical records and employee interview, the Department determined the facility administrator failed to ensure adequate documentation to justify treatment and activities was carried out by ensuring a patient interdisciplinary treatment plan was updated at a minimum every seven (7) days. This deficient practice poses a potential risk to the health and safety of a patient when a treatment plan is not re-evaluated and updated regularly and after a qualifying event to determine whether the current treatment plan is effective or needs to be modified, per facility policy.

Findings include:

Facility policy #12743793 titled "Interdisciplinary Patient Centered Care Planning" revealed "...The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days.

Facility medical records revealed the following:

Patient #5 - Document titled "Interdisciplinary Master Treatment Plan" dated October 2, 2024 identified "Date of Next Treatment Plan Update" as October 7, 2024. No update was found in the medical record.

Patient #6 - Document titled "Interdisciplinary Master Treatment Plan" dated September 24, 2024 identified "Date of Next Treatment Plan Update" as October 2, 2024. No update was found in the medical record.

Patient #34 - Document titled "Interdisciplinary Master Treatment Plan" dated October 6, 2024 identified "Date of Next Treatment Plan Update" as October 14, 2024. No update was found in the medical record.

Employee #15 confirmed during interviews conducted from October 11, 2024 to October 18, 2024, that Interdisciplinary Master Treatment Plans for Patients #3, #6, and #34 were not updated by the required dates.

Based on review of facility policy, medical record review and interview, the Department determined the Director of Social Services failed to ensure that treatment provided by the social services department was carried out and documented according the a patient's care plan. This deficient practice results in patients not obtaining therapeutic care necessary for their treatment at the hospital in order to be stabilized and discharge.

Findings include:

Policy titled "Interdisciplinary Patient Centered Care Planning, Policy #12743793, last reviewed July 2024, states "...It is the policy of Quail Run Behavioral Health Hospital to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed... Each patient's written Treatment Plan must include: ...Short-term and long term goals for each active problem, developed with patient input;...."

Patient #1 care plan dated September 26, 2024, states "...Social service will provide patient with daily processing group ...." Review of Patient #1's medical record revealed no social work processing group notes with patient attendance or a reason why the patient did not attend on the following dates: September 29, October 2, October 9, October 11, October 13, 2024. Evidence that Patient #1 was offered a process group on these dates was requested. None was provided.

Patient #5 care plan dated September 30, 2024, states "...Social services will meet with Patient #5 to develop goals for treatment...Modality...Process Group...Frequency of Intervention...Daily...." Review of Patient #5's medical record revealed no social work processing group notes with patient attendance or a reason why the patient did not attend on the following dates: September 29, September 30, October 2, October 5, October 6, and October 9. Evidence that Patient #5 was offered a process group on these dates was requested. None was provided.

Patient #6 care plan dated September 24, 2024, states "...Social services will facilitate a daily psychoeducation or process group...." Review of Patient #6's medical record revealed no social work processing group or psyschoeducation notes with patient attendance or a reason why the patient did not attend on the following dates: September 26, September 27, September 29, October 5, October 6 and October 9, 2024. Evidence that Patient #6 was offered a process group on these dates was requested. None was provided.

Interview with Employee #6 on October 16, 2024, confirmed that evidence of daily social work groups were offered to patients was not available for Patient #1, #5, and #6.