HospitalInspections.org

1. Based on review of 12 medical records on 3/2/2016, it was determined that for 2 patients the hospital failed to have 2 physicians document and certify that the patients lacked capacity to make informed decisions. State law specifies that the patient must be examined by two physicians before certification of incapacity.

Patient #1 was admitted on 2/22/2016 for dementia, behavioral disorder and anxiety. On 2/22/2016, one physician documented that due to dementia, the patient lacked capacity to comprehend and make decisions. A second medical certification by a physician was not completed for patient #1.

Patient #2 was admitted on 2/26/2016 for schizophrenia relapse. On 2/26/2016 one physician documented that the patient was not able to comprehend or make decisions. A second medical certification by a physician was not completed for patient #2.

Failure to follow the process for determining a patient's capacity for decision-making prior to allowing a surrogate decision maker circumvents the patient's rights to fully participate in his or her own care.

2. Based on review of 12 medical records it was determined that the nursing staff failed to document that 2 patients were offered and then refused the oral (PO) form of Haldol or Ativan prior to intramuscular (IM) injection of the medications.

On 2/28/2016 at 1755 the nurse documented that the Patient #1 was "screaming about clothes, wanting to go downstairs, and was in and out of rooms. Ativan 0.5 mg IM given." The nurse documented that the Ativan was administered IM on 2/28/2016 at 1803. However, there was no documentation that the patient has offered the ordered medication PO nor was there an indication why the patient was given the medication IM as opposed to PO.

Patient #3 was admitted for suicidal ideation and agitation on 2/22/2016. The patient received 7 doses of Haldol 1 mg IM on the following dates: 2/24/2016 at 1643, 2/25/2016 at 0016, 2/26/2016 at 1425, 2/27/2016 at 0959, 2/28/2016 at 1643, 2/28/2016 at 2347, and 2/29/2016 at 1732. The nursing documentation did not indicate that the oral form of Haldol was offered and/or refused by the patient prior to administering the IM form of the medication.

For safety reasons more invasive routes of medication may be indicated, however staff must attempt the least invasive/restrictive measure and document that attempt prior to advancing to more invasive means of medication administration.

Based on review of 12 medical records it was determined that the hospital failed to properly identify the surrogate decision maker for one patient.

Patient #10 was admitted to the hospital on 6/26/2015 for altered mental status and dehydration. The patient's Admission Form listed his son-in-law as his Health Care Decision Maker and his daughter as the Alternate Contact. The patient's Maryland Medical Orders for Life-Sustaining Treatment (MOLST) also referenced the patient's surrogate. Patient #10 was certified as not capable of making and communicating decisions regarding medical care, financial decisions and code status by two physicians. The physicians signed the form on 7/1/2015 and 7/6/2015.

On 7/1/2015 Case Management contacted Patient #10's son-in-law who was listed as the patient's decision maker. The son-in-law requested the social worker to contact Patient #10's daughter who he stated was the decision maker. The social worker left a detailed voice mail with with the patient's daughter inquiring about the Power of Attorney.

A copy of the medical Power of Attorney was not found in Patient #10's medical record. The was no indication that the hospital had attempted to obtain the medical power of attorney to clarify who was the patient's medical decision maker.

Based on review of 12 medical records it was determined that nursing staff failed to document the assessment requiring the need for patients to be medicated with "as needed (PRN)" medications and/or failed to document the post administration assessment indicating if the medication was effective for 2 patients.

On 2/28/2016 at 1755 the nurse documented that Patient #1 was "screaming about clothes, wanting to go downstairs, and was in and out of rooms. Ativan 0.5 mg IM given." The nurse documented that the Ativan was administered IM on 2/28/2016 at 1803. There was no nursing reassessment documentation to indicate if the administration of Ativan was effective.

Patient #3 received 7 doses of Haldol 1mg IM on the following dates: 2/24/2016 at 1643, 2/25/2016 at 0016, 2/26/2016 at 1425, 2/27/2016 at 0959, 2/28/2016 at 1643, 2/28/2016 at 2347, and 2/29/2016 at 1732. The nursing progress note on 2/29/2016 at 1805 noted "patient agitated continues in wheelchair with lap buddy grabbing at staff and pushing at wheelchair." There was no nursing reassessment documentation to indicate if the administration of Haldol was effective.

Patients must be monitored for the therapeutically intended benefit to allow for early identification of adverse effects of medication administration and timely initiation of appropriate corrective actions.

Based on review of 12 medical records it was determined that nursing staff failed to document in the Medication record (MAR summary) that Haldol 1 mg intramuscularly had been administered on 2/28/16 at 1035 to one patient.

Patient #3 received 7 doses of Haldol 1 mg IM on the following dates: 2/24/2016 at 1643, 2/25/2016 at 0016, 2/26/2016 at 1425, 2/27/2016 at 0959, 2/28/2016 at 1643, 2/28/2016 at 2347, and 2/29/2016 at 1732. On 2/28/2016 at 2025 the nurse documented in a progress note that Haldol 1 mg IM was given at 1035 but was not effective.

The hospital uses the medication dispensing system Accudose. Review of the Accudose report for Patient #3's medications indicated that the nurse had to pull the Haldol for patient #3 from a different unit (Meisel 2) Accudose system. The records indicate that the Haldol was pulled on 2/28/2016 at 1030. Review of the medication summary, a record in which nurses document the administration of medications, it was revealed the nurse failed to document the medication administration using the barcode system required by the hospital policy.

Failure of staff to follow hospital policy in the administration of medications to patients places patients at risk for potential overmedication as well as the potential to not identify medication administration errors that scanning medication bar codes identify.

Based on review of 12 medical records it was determined that the hospital failed to document assessments justifying discontinuing the use of restraints.

Patient #11 was admitted on 1/26/2016. The patient required the use of a waist belt during his hospital stay. Restraints were initiated on 2/13/2016 at 1302. The restraints were ordered again on 2/14/2016 at 1018, 2/15/2016 at 1505, 2/17/2016 at 1244, 2/18/2016 at 1127, and 2/19/2016 at 1630 and 1753. They were ordered again on 2/20/2016 at 1751, 2/22/2016 at 1550, 2/23/2016 at 1653, 2/24/2016 at 1033, 2/25/2016 at 1425, 2/26/2016 at 1613, 2/27/2016 at 2001, 2/28/2016 at 1444, and 2/29/2016 at 0951. Patient #11 was released from the restraint belt during the night.

On 2/15/2016 at 0000 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/15/2016 at 1706.

On 2/18/2016 at 0214 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/18/2016 at 1143.

On 2/18/2016 at 2200 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/19/2016 at 1630.

On 2/20/2016 at 2200 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/22/2016 at 1800.

On 2/24/2016 at 0005 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/24/2016 at 1033.

On 2/25/2016 at 0205 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/25/2016 at 1449.

On 2/27/2016 at 0500 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/27/2016 at 2001.

On 2/28/2016 at 0000 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/28/2016 at 1444.

On 2/29/2016 at 0000 restraints were documented as an ongoing restraint. This was the last documentation for the night. Restraints were again documented as initiated on 2/29/2016 at 1000.

On 03/01/2016 at 0400 restraints were documented as an ongoing restraint. This was the last documentation for the night. There was no documentation as to whether restraints were discontinued or initiated again.

Without restraint assessment documentation of restraints being discontinued one is unable to determine whether the patient was still in restraints during these hours. Without this documentation it is unable to determine if the patient was released at the earliest possible time.