HospitalInspections.org

Based on bylaws review, meeting minutes review, and staff interview, the governing body failed to ensure the accountability of the medical staff by failing to hold meetings for 3 of the 5 required quarterly meetings (June 2012, September 2012, and March 2013) reviewed from January 2012 through May 2013. Failure to meet quarterly as required limits the governing body's ability to ensure the medical staff's accountability for provision of quality care to the Hospital's patients.

Findings include:

Review of the "North Dakota State Hospital Bylaws of the Governing Body" occurred on 06/03/13. These bylaws, dated 03/08/12, stated,
". . . Article I. . . .
II. Duties and responsibilities of the governing body.
1. The governing body functions as an oversight committee with authority for:
a. Quality of care . . .
2. Duties and responsibilities of the governing body are: . . .
f. Approving a program to assess and improve the quality of care provided, and appropriately addressing identified problems or opportunities to improve care, which include the medical staff . . .
V. Meetings.
1. The governing body shall meet quarterly. . . .
Article II. . . .
I. Governing body authority. . . . It [governing body] serves to . . . assure quality patient care . . .
Article III. . . .
II. Medical staff obligations to the hospital and governing body. . . .
8. The medical staff shall make reports to the governing body of identified problems, resolved problems, and identified opportunities to improve patient care.
9. The governing body reviews regular reports received regarding the provision of quality and appropriate services to patients by medical staff. . . ."

Review of the 2012-2013 governing body meeting minutes occurred on 06/04/13. These minutes lacked evidence the governing body met in June 2012, September 2012, and March 2013.

During an interview at approximately 4:25 p.m. on 06/04/13, an administrative assistant staff member (#29) stated she maintained the governing body meeting minutes and confirmed the governing body did not meet in June 2012, September 2012, and March 2013.

During an interview at approximately 4:55 p.m. on 06/05/13, an administrative staff member (#21) confirmed the governing body did not meet in June 2012, September 2012, and March 2013 and should meet quarterly.

THIS IS A REPEAT CONDITION FROM THE COMPLAINT SURVEY COMPLETED ON 04/11/13.

Based on observation, record review, policy and procedure review, and staff interview, the Hospital failed to protect and promote each patient's rights by failure to ensure the safety and security of a patient who eloped from the facility and required emergency treatment for an overdose (Refer to A142 and A144); failed to ensure patients received coffee at a safe temperature (Refer to A144); failed to ensure safety when staff transferred patients (Refer to A144); failed to ensure patients remained free of physical restraints (Refer to A154); failed to ensure the Hospital attempted less restrictive devices before using restraints (Refer to A164); failed to use physical restraints in accordance with a patient's plan of care (Refer to A166); and failed to use physical restraints in accordance with a physician's order (Refer to A168). This placed all patients in serious and immediate jeopardy for harm.

The survey team determined an Immediate Jeopardy situation existed on 06/05/13 at 12:10 p.m. related to the elopement of a patient from the facility who required emergency treatment for an overdose. At 12:30 p.m. the survey team notified administrative staff members (#1, #20, and #21) of the Immediate Jeopardy situation. The Hospital provided the following plan of correction on 06/05/13: effective immediately, the locked women's unit will eat meals in a secured dining room; effective 06/05/13, a daily report of key issues, including patient incidents, will be sent to all medical staff, charge nurses, supervising nurses, hospital administrators, and safety and security staff; and, effective 06/05/13, the nursing electronic hand-off communication form communicated at each shift report will include issues of ongoing risk (suicide, elopement, falls, assault, change of observation, and change of privileges). The survey team verified the Hospital's plan and determined the Immediate Jeopardy situation was abated on 06/05/13 at 4:45 p.m. Condition level noncompliance continued post abatement.

Based on record review, policy review, and staff interview, the Hospital failed to ensure care in a safe setting for 1 of 1 active suicidal inpatient (Patient #6) who eloped from the facility and required emergency medical treatment for an overdose. Failure to ensure a secure environment resulted in Patient #6 eloping from the Hospital and placed other patients at risk of elopement.

Findings include:

The Hospital failed to ensure Patient #6 ate in a secure dining room, staff completed timely and/or accurate safety checks on the patient, and staff communicated with all key staff members after Patient #6's licensed independent practitioner placed her off-unit privileges on hold. Refer to A144.

1. Based on record review, policy review, and staff interview, the Hospital failed to ensure care in a safe setting for 1 of 1 active suicidal inpatient (Patient #6) who eloped from the facility and required emergency medical treatment for an overdose. Failure to ensure a secure environment resulted in Patient #6 eloping from the Hospital and placed other patients at risk of elopement.

Findings include:

Review of the policy "Elopement Response Policy" occurred on 06/05/13. This policy, revised April 2013, stated, ". . . Procedures: I. Immediate Response: Step 1: a. When it is suspected a patient/resident might have eloped (after a brief ward search, but prior to a grounds search), staff will immediately contact the CC [Clinical Coordinator]/Supervisor and complete the Elopement Information sheet . . . c. If CC/Supervisor decides to declare the patient/resident eloped, the ward staff are to call operator (dial 122), request patient/resident be paged to return to their ward. At the same time the switchboard will immediately call [name of law enforcement agency] . . . give them the information that we have a suspected elopement and the patient/resident's description . . . e. CC/Supervisor will notify the attending LIP (licensed independent practitioner) and Program Director (after hours the On Call LIP and Administrator). Step 2: The Clinical Coordinator/Supervisor will determine if a ground search will need to be made . . . LIP enters an elopement and APB [all point bulletin] order . . . An All Point Bulletin will be requested of Law Enforcement by the Operator . . . Return from Elopement . . . 1. Hospital staff will return all patient/residents to the admissions room when found during a search. Staff will use precautions in dealing with resistant patient/residents and when necessary, will keep patient/residents in direct line of vision until additional help arrives. 2. The Clinical Coordinator/Supervisor will notify admissions staff if the patient/resident is not found and the search is called off. 3. Switchboard staff will notify Administrator on Call, Physician, [name of correctional center], County Sheriff, Human Service Center, and the [name of law enforcement agency]. 4. Care and placement of returned patient/resident will be the decision of the LIP assigned to the patient/resident or the LIP on Call . . . 5. Medical staff, in consultation with the Medical Director will review patient/residents who are not returned after five days to extend elopement status or discharge the patient/resident . . . Post-Incident Review Process. Within 24 hours of the time the patient/resident was reported missing, the nursing supervisor will complete the 1st part of the 'Elopement Post Incident Review Form' and submit it to the Treatment Team. The Treatment Team will review the circumstances of the elopement and subsequent action taken, complete the required documentation and submit it to the Program Director. The Program Director, in consultation with the Medical Director, will determine whether further review or other action is necessary, and if so, will assign staff to coordinate post-incident review and debriefing activities. . . ."

Review of the policy "Privilege System" occurred on 06/05/13. This policy, revised April 2010, stated, ". . . Privilege Level Expectations . . . Level 2B - Step 2 - Free Time 30 X 6 - Limited Off Ward . . . 3. Individual allowed free time without escort.
a. Client signs out when he/she leaves the unit or Treatment Mall & sign back in.
b. One hour at the library, in addition to free time. . . ."

Review of Patient #6's medical record occurred on 06/05/13 and identified a court order, dated 05/06/13, requiring the transfer and admission of the patient to the Hospital on 05/07/13 for treatment of mental illness, chemical dependency, history of suicide attempts, and risk for further suicide attempts. Patient #6's diagnoses included generalized anxiety disorder, major depressive disorder, borderline personality disorder, polysubstance dependence, and post traumatic stress disorder. The patient's scheduled medications included olanzapine (antipsychotic) 10 milligrams (mg) at bedtime, venlafaxine extended release (antidepressant) 300 mg daily, clonazepam (antianxiety) 0.5 mg three times daily, buspirone (antianxiety) 5 mg twice daily, trazodone hydrochloride (antidepressant and used for sleep) 100 mg at bedtime, and as needed medications included one dose of clonazepam 0.5 mg every 24 hours.

A "Precautions Checklist," completed upon Patient #6's admission, stated, ". . . Suicidal: Recent overdose reported to be in [sic] a suicide attempt shortly after discharge from North Dakota State Hospital (NDSH) 4-26-13 . . . Homicidal/History of Violence/Harm to Others: Reported history of putting a pillow over another patient's face while in bed in another hospital . . . Elopement Risk: History AWOL [absent without leave]. . . ." Patient #6's nursing treatment plan, dated 05/07/13, stated, "Ineffective Individual Coping related to suicidal ideation [as evidenced by] injested [sic] a bottle of Benadryl two days after discharge, was admitted to [name of a medical facility], was admitted to ACS [after care services] upon d/c [discharge] from [name of a medical facility] left after only an hour and reported to consuming multiple [over the counter] medications and was readmitted to [name of a medical facility] . . . [interventions] . . . Be aware of patient's whereabouts . . . Make contract with patient; notify staff if experiencing suicidal thoughts . . . Assess appropriateness of program . . . Observe for changes in mood/appetite/levels of energy/concentration . . . Communicate to all staff regarding patient's behavior; chart observations. . . ."

Review of Patient #6's progress notes identified the following:
*05/07/13 at 7:40 p.m. - ". . . Adm [admitted] urgent [discharge]/mental [name of county] on 3rd adm [with] last discharge 4-26-13. Client left ACS [after] 2 days drank 4 beers [and] took 100 Benadryl tabs left suicidal note adm to [name of a medical facility] 4-28-13 denies withdrawal s/s [signs/symptoms] at present verbally denies suicidal ideation at present med [medication] hx [history] alcohol w/d [withdrawal] seizures . . . pleasant socializes [with] peers. On escort privilege level. . . ."
*05/27/13 at 11:00 a.m. - ". . . Safety issues . . . is at risk to walk away from treatment and self-harm behaviors when highly anxious and emotional."
*06/03/13 at 6:05 p.m. - ". . . Requests [and] receives Clonazepam 0.5 mg . . . for [complaints of] 'very anxious' . . . Continue to monitor."
*06/03/13 at 7:30 p.m. - ". . . States nothing helps anxiety much. States does feel a little better. Using free time. . . ."
*06/03/13 at 8:00 p.m. - ". . . Returns from free time [with] [nursing] supervisor . . . was caught smoking and 'making out' [with] a male [patient]. Staff from crossroads observed this behavior. Free time suspended . . . Continue to monitor."
*06/04/13 at 2:30 p.m. - "[Patient #6] remained on the unit this a.m. She is disappointed her privileges were put to escort. She declined to go to tx [treatment] mall [therapy center in a different building] as she did not feel up to it. She was checked on frequently. She rested most of the a.m. She was up at 11:30 [a.m.] [and] walking in the hallway on the unit. She responded to staff when asked 'How you doing?" answered with 'Ok.' At [1:45 p.m.] [Patient #6] was not found. She was paged back to the unit. She did not respond. Information for elopement given to switch board. LEC [law enforcement center] informed and APB put out . . . Peer informed staff at 2 p.m. that [Patient #6] walked out the dining room door over the dinner mealtime."
*06/04/13 at 2:40 p.m. - "[Patient #6] went missing from L500 [Intensive Care Unit for Women] dining room w/o [without] staff awareness. Check was done at 2:00 [p.m.] and patient not on unit or tx mall. Peer then told staff [Patient #6] had left over lunch. Pt [patient] was seen this morning. She was depressed about developing relationships. Found with male 'making out.' Staff on unit are on hold. Seen at 9:00 a.m. by writer. She was feeling down, but denied being suicidal. She repeatedly [sic] several times she just wanted to go home. Was homesick. AWOL procedure followed. Order in. Ground search done. LEC called."
*06/04/13 at 4:15 p.m. - "[Patient #6] [and] this author on 5-30-13 in the tx mall as scheduled. [Patient #6] was more down than our previous meeting on 5/28. She mentioned going to [name of retail center] the night before on an outing with staff. [Patient #6] stated she was tempted to buy Benadryl but couldn't because she was 'being watched to close.' [Patient #6] identified several things she is grateful for yet didn't view these as positives. [Patient #6] kept saying she 'just wants to go home.' She recognizes she has done the same things to cope (drugs/alcohol) [and] has difficulty identifying anything different - a more healthy way to cope. [Patient #6] did let this author know she spoke with her ex-husband about the letter she wrote him [and] he did not agree with getting back together with her. She mentioned several times - 'I just want this to go away. It's getting harder [and] harder to fight the negative thoughts. This author left phone messages for [name of physician] [and] L500 nurses phone about my concerns on her mood. [Patient #6] did have assignments completed [and] turned them in - she did not want to take a Diary Card for this week stating, 'The numbers are confusing.' This author agreed to skip one week [and] stated we would be returning to it next week. [Patient #6] was not present for our meeting today at 4 PM as she went missing earlier this afternoon."
*06/04/13 at 5:00 p.m. - "[received] call from [name of administrative staff member] that [Patient #6] presented at the [name of medical facility]."
*06/04/13 at 5:30 p.m. - "[Patient #6] was seen walking on sidewalk at 12:45 p.m. in front of [name of hospital building Patient #6 resided] by security guard."
*06/04/13 at 5:40 p.m. - ". . . [name of nurse from medical facility] calls. States [Patient #6] came to ER. [Patient #6] stated she was from the NDSH [and] needed to check in every hour. [Patient #6] says she took 100 Benadryl [and] drank a 6 pack of beer. . . ."
*06/05/13 at 4:30 a.m. - ". . . @ [at] [11:30 p.m.], received verbal report from [name of ER physician] . . . [Patient #6] was medically cleared to return to NDSH. Per his report, Pt was brought to ER by . . . [name of companion] @ approx [approximately] [6:00 p.m.], [with] report that Pt consumed 100 gel tab Benadryl at approx [1:30 p.m.], [and] had 6 cans of beer [within] an hour. Labs, EKG [electrocardiogram - a test to check the electrical activity of the heart] [and] drug screen obtained . . . [with] abnormal HR [heart rate] as tachycardic [increased HR] varying 100-120 bpm [beats per minute]. Received 1 [liter] [normal saline], partial liter of lactated ringers. Ativan 0.5 mg [and] Zofran 4 mg . . . at [11:30 p.m.]. Pt returned to NDSH via authorities @ approx [12:10 a.m.] and received onto unit @ [12:15 a.m.]. Lower arms [and] hands extremely tremulous. Unable to hold [large] items. Rigidity noted of legs, back [and] neck. Assisted into [pajamas] . . . Placed in bed. [vital signs] monitored [and] did receive Klonopin 0.5 mg @ [12:35 a.m.]. Pt noted to lose focus on tasks easily but able to redirect. Klonopin deemed effective as pt less tremulous, more focused [and] reports feeling slightly better. HR [decreased] to 90 bpm @ [4:30 a.m.]. Was incontinent . . . during the night, [and] was assisted [with] cares . . . unstability [sic] when standing . . . [wheelchair] used for transportation. Remains on [nursing] [observation] for monitoring, pushing fluids [and] monitor for sedation."

Review of Patient #6's "Hourly Checklist" for 06/04/13 identified the patient eloped sometime between 12:00 p.m. and 1:00 p.m. Review of information the facility provided on 06/03/13 occurred on 06/05/13, and identified the suicide risk level and number of suicidal patients residing on L500. A nurse (#22) from L500 identified six patients at low risk for suicide and two patients at intermediate risk for suicide on the form as of the morning of 06/03/13. During an interview on 06/05/13 at 11:45 a.m., the nurse (#22) stated she considered Patient #6 as one of the six patients at low risk for suicide. As of 06/05/13, the nurse (#22) identified six patients on L500 at continued risk for suicide.

During an interview on 06/05/13 at 10:00 a.m., a nurse (#22) stated after a LIP placed Patient #6's privileges on hold, the patient should not have left the secured ward unless accompanied by staff. Prior to having her privileges placed on hold, Patient #6 could move about the Hospital (inside and outside on Hospital grounds) independently during her free time. The nurse (#22) stated the patient reported she arranged a man from the community to pick her up after she eloped from the facility and told the nurse (#22) she escaped through an unlocked door of the dining room (shared with a less secure unit - L600) and exited through another unlocked door on L600. The nurse (#22) stated Patient #6's male friend picked her up and drove her to [name of retail center] to purchase a bottle of Benadryl and some alcohol, which the patient consumed at her friend's apartment causing her friend to take her to the ER after ingesting 100, 25 mg tabs of Benadryl and six beers.

During an interview on 06/05/13 at 3:30 p.m., an administrative staff member (#20) stated a "tech (direct care assistant) on L500 thought Patient #6 was at the treatment mall and a tech at the treatment mall thought the patient was still on L500." The staff member (#20) stated the techs failed to complete consistent, face-to-face patient safety checks. The administrative staff member (#20) identified a LIP went to L500 on the afternoon of 06/05/13 to check on Patient #6 due to her concern from their visit that morning. Once the LIP arrived on L500 to reassess the patient, staff could not locate Patient #6. The nurse (#22) working on L500 called the treatment mall after realizing the patient's absence and discovered her absence from the treatment mall as well. The nurse (#22) then implemented the facility's AWOL procedure. The administrative staff member (#20) stated she and a security officer witnessed Patient #6 outside on facility grounds, however, both thought she still possessed full privileges and authorization to be outside alone. The administrative staff member (#20) stated Patient #6's LIP placed her privileges on hold for safety reasons as the patient expressed a great deal of shame after staff caught her smoking and kissing another male patient and identified the LIP worried Patient #6 might become suicidal due to the amount of shame she voiced.

The Hospital failed to ensure Patient #6 ate in a secure dining room, staff completed timely and/or accurate safety checks on the patient, and staff communicated with all key staff members as Patient #6's licensed independent practitioner placed her off-unit privileges on hold.

2. Based on observation, record review, and staff interview, the Hospital failed to ensure patients received liquids at a safe temperature on 3 of 4 nursing unit kitchens (L100, L400, L500/600). This failure resulted in burns to 4 inactive patients (Patient #26, #28, #34, and #35) and has the potential to result in injuries to other patients.

Findings include:

Review of an incident report summary for the past six months occurred on all days of survey. The summary included the following incidents:
*Patient #28, 02/05/13 at 2:40 p.m., second degree burn - "Hot coffee spilled on right upper thigh. Cool/wet compress applied. Wound inspected-area injected at +2 and +4, blistered area present within red injected area. Silvadene applied."
*Patient #26, 02/08/13 at 2:15 p.m., no injury - "[Patient #26] spilled hot chocolate on the last 3 fingers of his right hand. Staff ran cool water over the affected area."
*Patient #34, 03/17/13 at 5:10 p.m., reddened abdomen - "[Patient #34] spilled his coffee onto his clothes, he quickly pulled his wet clothes away from his skin and went and changed his clothes. Upon assessment staff noted 2 small reddened areas, no blisters noted. Will continue to monitor."
*Patient #35, 05/24/13 at 5:30 p.m., reddened hand - "[Patient #35] spilled a small amount of hot coffee on his right hand on 05/24/13."

Reviewed on 06/05/13, the facility's action plan in response to the above incidents identified the following:
*Patient #28 on 02/05/13 - "Patient's burns were treated. Re-educated/reminded to check coffee temp [temperature] prior to serving or cool coffee prior to serviing [sic]."
*Patient #26 on 02/08/13 - "Patient assessed, cold water was run over hand/fingers; no further treatment needed."
*Patient #34 on 03/17/13 - "Patient was assessed, required no treatment, cold water will be added to coffee to decrease the temp prior to serving."
*Patient #35 on 05/24/13 - "Patient assessed - area was slightly reddened, no blisters noted; cold water was run over his hand. Nursing Supervisor and LIP [licensed independent practitioner] notified. Will continue to monitor and document. Staff was informed to carry coffee for him and to add a little cold water to make sure it's not too hot."

Observation on L100 on 06/04/13 at 7:40 a.m. showed a direct care assistant (DCA) (#28) pouring patients' coffee and serving it through the window of the kitchenette. The staff member failed to take the temperature of the coffee and did not attempt to lower the temperature of the coffee using cold water or ice cubes. Observation showed the temperature of the coffee measured 160 degrees Fahrenheit (F).

Observation on 06/04/13 at 8:50 a.m. in the kitchen shared by L500 and L600 showed coffee brewing in a large heated unit. The temperature of the coffee measured 162 degrees F.

Observation on L400 on 06/04/13 at 11:40 a.m. showed an unidentified DCA serving patients coffee from the window of the kitchen without taking the temperature of the coffee or cooling it prior to serving it to the patient. The temperature of the coffee measured 174 degrees F.

During an interview on 06/05/13 at 8:00 a.m., a DCA (#27) working on L600 stated if a patient wants hot chocolate, staff obtain water from the faucet in the kitchen on each unit and heat it in the microwave. The staff member (#27) stated staff do not take the temperature or add cold water/ice cubes to any of the hot liquids served to patients.

During an interview on the morning of 06/05/13, an administrative dietary staff member (#26) and an administrative nurse (#1) both confirmed neither department monitored the temperatures of hot liquids served to patients on the nursing units. The staff member (#1) confirmed the Hospital lacked a policy on serving hot liquids to patients and stated the Hospital failed to educate all staff members on methods to ensure patient safety when serving hot liquids.


15707


3. Based on observation, record review, review of professional reference, and staff interview, the Hospital failed to ensure patients received care in a safe setting for 2 of 4 sampled patients (Patient #9 and #10) observed during provision of care. Failure to utilize a gait belt during transfers and/or ambulation placed the patients at risk for a fall or injury.

Findings include:

Kozier and Erb's Fundamentals of Nursing Concepts, Process, and Practice, 9th Edition, Pearson, Boston, Massachusetts, Page 1158, stated, "Transferring Clients: Many clients require some assistance in transferring . . . Before transferring any client, however, the nurse must determine the client's physical and mental capabilities to participate in the transfer technique. . . . A gait belt provides the greatest safety. A gait belt is a safety device used for moving or transferring a client. . . . It can also be used when assisting a client to ambulate. . . ."

- On 06/03/13 at 1:15 p.m. observation showed Patient #9 seated in the Core (a common area in unit L300) in a recliner. Observation showed a cast on the patient's left arm. A licensed nurse (#2) stated the patient fell "about a week ago" and fractured her left elbow.

Patient #9's record, reviewed on all days of survey, identified diagnoses including dementia with behavior disturbance, impulse control disorder, schizoaffective disorder, and mild mental retardation. Nursing progress notes identified the following:
* 04/08/13 at 9:30 p.m.: ". . . Has required more assistance due to difficulty with her vision. . . . Pt [patient] has been spending more time in the core area due to needing assistance with mobility and cares. . . ."
* 06/03/13 at 3:00 a.m.:". . . Patient has sustained 3 falls between 5/20/13 - 5/30/13. Is a fall risk, with NCP (Nursing Care Plan) in place. Does have a low bed, mat on floor, and ambulates with walker. . . ."

Patient #9's nursing care plan, dated 05/14/13, identified a problem, "Mobility Impaired related to use of assistive device, poor vision." An undated handwritten intervention stated, "Encourage to use walker @ [at] all times."

A Post Fall Assessment Progress Note, dated 05/21/13 at 11:25 a.m., stated, "Pt walking towards bathroom door - fell backwards, hitting her head on door frame of pt's bathroom . . ." The record showed Patient #9 sustained a laceration to the back of her head and fractured her left elbow during the fall. The record failed to identify if Patient #9 utilized a walker at the time of the fall on 05/21/13.

On 06/03/13 at 2:40 p.m., observation showed Patient #9 lying in bed with a walker beside the bed. A licensed nurse (#5) assisted the patient to stand and ambulate to the Core by holding her right upper arm and right hand and not using a gait belt.

On 06/03/13 at 3:15 p.m., observation showed a licensed nurse (#4) assisted Patient #9 to ambulate from the Core to the Women's Bathroom (a common bathroom on the unit) without a gait belt. When asked if the patient used a walker, the nurse stated, "Sometimes she does and sometimes she doesn't. It's her preference. She doesn't want to put too much pressure on it" (referring to the left elbow fracture). Following toileting, the nurse (#4) assisted Patient #9 to walk from the toilet to the sink (in an adjoining room). Observation showed Patient #9 did not stand upright, but stood and ambulated with her knees slightly bent. The nurse held Patient #9 by her right upper arm as she walked from the toilet to the sink. After handwashing, the nurse (#4) assisted Patient #9 to ambulate back to the Core by holding her left hand and not using a gait belt. The patient again bent her knees as she ambulated. The nurse stated, "Straighten your knees."

On 06/04/13 at 9:43 a.m., observation showed a DCA (#3) ambulated Patient #9 in the hall. The DCA held Patient #9 by her right upper arm and did not use a gait belt. Observation showed the patient's shoes caught on the carpet as she walked. The DCA stated, "You're dragging your feet. Lift them up a little bit."

Record review identified Patient #9 sustained another fall on 06/04/13 at 12:30 p.m. The record showed the patient fell while ambulating to church with a staff member. The record stated when the staff member was locking the door, Patient #9 "turned, tried to lean on wall & [and] fell forward landing on knee & stated she landed on both arms & [and] hands also." The record failed to identify if staff utilized a gait belt or walker at the time of the fall.

- Patient #10's record, reviewed on all days of survey, identified diagnoses including dementia with behavior disturbance. The record showed, on 05/15/13, staff implemented a wheelchair with seat belt due to "unsteady gait." The patient's nursing care plan, dated 05/01/13, identified a problem, "Potential for injury r/t [related to] impaired judgement AEB [as evidenced by] pushing staff, recent fall due to tripping, overestimates self."

Observation, on 06/03/13 at 3:35 p.m., showed two DCAs (#6 and #7) assisted Patient #10 to the Women's Bathroom. The DCAs transferred the patient from a geriatric chair to the toilet by holding under her arms and not using a gait belt. Patient #10 cried as she sat on the toilet. One DCA (#6) assisted Patient #10 to stand by lifting under her right arm and without using a gait belt. The DCAs then transferred the patient back to the chair and repositioned her by holding her under the arms and not using a gait belt.

During an interview on 06/05/13 at 10:25 a.m. an administrative nurse (#1) stated the Hospital had no policy regarding gait belt use.


12763

THIS IS A REPEAT CITATION FROM THE COMPLAINT SURVEY CONDUCTED ON 04/11/13.

Based on observation, record review, policy and procedure review, and staff interview, the Hospital failed to ensure patients remained free of physical restraints for 3 of 3 sampled patients (Patients #9, #10, and #11) observed seated in a geriatric chair (geri chair) with a seat belt or tray attached and for 1 of 1 sampled patient (Patient #9) for whom staff used a one piece undergarment (onesie). Failure to recognize and assess the devices as restraints has the potential to violate the patients' right to be free of restraints.

Findings include:

Review of the Hospital's "Consumer Handbook" occurred on 06/04/13. The handbook, dated May 2011, stated, "Individual Right and Responsibilities. I have the right to . . . 5. least restrictive conditions necessary to achieve treatment, such as: only clinically justified restrictions and restraint . . ."

Review of the Hospital policy "Restraint" occurred on 06/05/13. The policy, revised May 2013, stated, ". . . Definition: Restraint is the use of physical grip or mechanical device to restrain involuntarily the movement of the whole or portion of the individual's body as a means of controlling his/her physical activities in order to protect him/her or others from injury. (These can be mobile restraints, protective restraints . . .) . . . Procedure: . . . 2) . . . On rare occasions, tray chair use for restraint purposes for less than 2 hours may be used on L300 and L600 if the LIP [licensed independent practitioner] or RN [registered nurse] determines this is the most appropriate intervention. . . ."

Review of the Hospital policy "Medical Protective Supports" occurred on 06/05/13. The policy, revised May 2013, stated, "Rationale: Medical Protective Supports are used to provide medically compromised individuals the least restrictive intervention to allow optimal mobility, independence and safety.
Definition: Medical Protective Supports are devices that can be removed by the individual, used to protect the medically compromised patient from injury and to maintain normative bodily function . . . Examples are: postural supports . . . lap buddy . . . seatbelt that the individual is able to remove . . .
Indications for use: 1. To prevent an individual from falling and consequent self-harm when other less restrictive alternatives have been considered or attempted and deemed not effective. 2. To maintain normal posture and enhance mobility.
. . .
Contraindications: . . . 2. Any device used to control inappropriate behavior or wandering. A device used for these purposes would be considered restraint for behavior and all policies for restraints need to be followed.
Procedure: 1. Alternatives to Medical Protective Supports have been considered or attempted and deemed not effective. 2. The RN will complete the Evaluation for Medical Protective Support form (357) to identify the need for medical protective support . . . 6. The LIP will write an order daily for 3 days, then weekly thereafter. . . ."

On the morning of 06/03/13, the Hospital provided a list of all patients using restraints. Patient #9, #10, and #11's names did not appear on the list.

- Observation on 06/03/13 at 2:05 p.m. and on 06/04/13 at 8:30 a.m. showed Patient #9 seated in the dining room in a small geriatric chair with a tray secured in place.

Patient #9's record, reviewed on all days of survey, identified diagnoses including dementia with behavior disturbance, impulse control disorder, schizoaffective disorder, and mild mental retardation. A nursing progress note, dated 04/08/13 at 9:30 p.m., stated, "Behaviors
. . . Pt [patient] has had several noted behaviors during this past month. She has had episodes of pulling off her colostomy bag and throwing it on the floor. She has removed her colostomy and/or clip at least 3-4 times that is known or witnessed during this past month. She has attempted to spit, kick and strike out at staff members when assisting her to clean up or with other cares. Pt has also done some self-abusive episodes. She put her fingers in stoma site and was hitting herself on another occasion. . . . Restraints or Medical Protective Supports [MPS] (if applicable): Pt had a onsie [sic] put on her when pulling on colostomy site. No MPS ordered at this time. . . ."

The current nursing care plan identified a problem "Poor impulse control." A handwritten intervention, dated 04/08/13, stated, "Place pt. in onsie [sic] if attempting to remove colostomy or to self abuse by putting fingers in stoma." The care plan failed to identify use of the geri chair with tray.

Patient #9's record failed to identify an LIP or RN determined the geri chair with tray as an appropriate device for Patient #9 and lacked evidence the patient could independently remove either restrictive device (onesie or tray). The record indicated staff used the onesie for the behaviors related to her colostomy, which Hospital policy identified as a contraindication for a MPS and considered a restraint for behaviors. The record lacked evidence staff recognized the onesie and tray as restraints, attempted less restrictive interventions, and obtained a licensed practitioner's order prior to implementing and continuing the use of the devices.

- Observations 06/03/13 at 12:40 p.m., 2:05 p.m., and 3:32 p.m. showed Patient #11 seated in a geri chair with the chair reclined and locked in that position with anti-roll back brakes. With the chair in a reclined position, the patient was unable to exit the chair independently.

Observations on 06/04/13 at 8:30 a.m., 9:43 a.m., and 2:25 p.m. showed Patient #11 seated in a geri chair with a seat belt buckled. Observation showed staff in the immediate area each time.

Patient #11's record, reviewed on all days of survey, identified diagnoses including schizoaffective disorder and post neurolyptic malignant syndrome. Patient #11's nursing care plan, dated 04/24/13, identified the problem, "Potential for injury related to impaired mobility AEB [as evidenced by] his inability/unwillingness to stand, rigid posture and resistence [sic] to moving." Interventions for the problem included, "Utilize medical protective supports as ordered for safety from falls due to rigid posture, inability or unwillingness to stand and resistance to ambulation."

An Evaluation For Medical Protective Supports, dated 04/25/13, identified the selected device as "Lap buddy in wheel chair or geri chair as needed to prevent falls." The form stated, "Pt has OCD [obsessive compulsive disorder] et [and] psychomotor agitation. Pt requires two staff to assist in daily cares. Pt is unable to stand et walk without staff assist. Medical Protective Support will keep pt. safe." The record failed to identify use of the seat belt in the wheel chair or geri chair and lacked evidence Patient #11 could release the seat belt.

Failure to recognize and assess the seat belt and the geri chair in a reclined position as restraints placed Patient #11 at risk for a fall or injury if he attempted to exit the chair independently.

- Observation, on 06/03/13 at 12:40 p.m., showed Patient #10 seated in a geri chair in the Core (a common area in unit L300) with the chair reclined and locked in that position with anti-roll back brakes. In the reclined position, the patient was unable to exit the chair independently.

Observations on 06/03/13 at 2:05 p.m. and 5:20 p.m.; on 06/04/13 at 8:27 a.m. and 1:20 p.m.; and on 06/05/13 at 9:15 a.m. showed Patient #10 seated in a geri chair with a seat belt buckled. Observation showed staff in the immediate area each time.

Patient #10's record, reviewed on all days of survey, identified diagnoses including dementia with behavioral disturbances. The patient's nursing care plan, dated 04/30/13, identified a problem, "Potential for injury r/t [related to] uncontrollable behavior AEB [as evidenced by] increased aggression since December, physical aggression towards 3 peers in nursing home, pushed a nursing home employess [sic] to the floor." Interventions for the problem included, "Medical Protective Supports: w/c [wheel chair] [with] seatbelt added 5-15-13 d/t [due to] unsteady gait." The record lacked an assessment for the geri chair in the reclined position.

An Evaluation for Medical Protective Supports, dated May 15, 2013, stated, "Gait unsteady, pt put self down of [sic] floor x [times] 1, [with] several other attempts. Pt tripping on objects as she's walking, pt agitated and resisting staff assistance . . ."

The nursing care plan indicated staff implemented the device as an intervention for Patient #10's "uncontrollable behavior" which Hospital policy identified as a contraindication for a MPS and considered a restraint for behaviors. Failure to recognize and assess the geri chair in the reclined position as a restraint placed the patient at risk for an injury if she attempted to exit the chair.

During an interview on 06/05/13 at 10:25 a.m., an administrative nurse (#1) stated the Hospital does not consider geri chairs, seat belts, and onesies as restraints. She stated the Hospital's Medical Protective Supports policy covered these devices.

THIS IS A REPEAT CITATION FROM THE COMPLAINT SURVEY CONDUCTED ON 04/11/13.

Based on observation, record review, policy review, and staff interview, the Hospital failed to ensure staff utilized restraints only after determining less restrictive interventions ineffective for 1 of 1 sampled patient (Patient #9) observed seated in a geriatric (geri) chair with a tray attached and for whom staff used a one piece undergarment (onesie). Failure to attempt less restrictive measures has the potential to violate the patient's right to be free of restraints.

Findings include:

Review of the Hospital's "Consumer Handbook" occurred on 06/04/13. The handbook, dated May 2011, stated, "Individual Right and Responsibilities. I have the right to . . . 5. least restrictive conditions necessary to achieve treatment, such as: only clinically justified restrictions and restraint . . ."

Review of the Hospital policy "Restraint" occurred on 06/05/13. The policy, revised May 2013, stated, ". . . Definition: Restraint is the use of physical grip or mechanical device to restrain involuntarily the movement of the whole or portion of the individual's body as a means of controlling his/her physical activities in order to protect him/her or others from injury. (These can be mobile restraints, protective restraints . . .) . . . Procedure: . . . 2) . . . On rare occasions, tray chair use for restraint purposes for less than 2 hours may be used on L300 and L600 if the LIP [licensed independent practitioner] or RN [registered nurse] determines this is the most appropriate intervention. . . ."

Review of the Hospital policy "Medical Protective Supports" occurred on 06/05/13. The policy, revised May 2013, stated, "Rationale: Medical Protective Supports are used to provide medically compromised individuals the least restrictive intervention to allow optimal mobility, independence and safety.
Definition: Medical Protective Supports are devices that can be removed by the individual, used to protect the medically compromised patient from injury and to maintain normative bodily function . . . Examples are: postural supports . . . lap buddy . . . seatbelt that the individual is able to remove . . .
Indications for use: 1. To prevent an individual from falling and consequent self-harm when other less restrictive alternatives have been considered or attempted and deemed not effective. . . . Contraindications: . . . 2. Any device used to control inappropriate behavior or wandering. A device used for these purposes would be considered restraint for behavior and all policies for restraints need to be followed.
Procedure: 1. Alternatives to Medical Protective Supports have been considered or attempted and deemed not effective. . . ."

On the morning of 06/03/13, the Hospital provided a list of all patients using restraints. Patient #9's name did not appear on the list.

- Observation on 06/03/13 at 2:05 p.m. and on 06/04/13 at 8:30 a.m. showed Patient #9 seated in the dining room in a small geriatric chair with a tray secured in place.

Patient #9's record, reviewed on all days of survey, identified diagnoses including dementia with behavior disturbance, impulse control disorder, schizoaffective disorder, and mild mental retardation. A nursing progress note, dated 04/08/13 at 9:30 p.m., stated, "Behaviors
. . . Pt [patient] has had several noted behaviors during this past month. She has had episodes of pulling off her colostomy bag and throwing it on the floor. She has removed her colostomy and/or clip at least 3-4 times that is known or witnessed during this past month. She has attempted to spit, kick and strike out at staff members when assisting her to clean up or with other cares. Pt has also done some self-abusive episodes. She put her fingers in stoma site and was hitting herself on another occasion. . . . Restraints or Medical Protective Supports [MPS] (if applicable): Pt had a onsie [sic] put on her when pulling on colostomy site. No MPS ordered at this time. . . ."

The current nursing care plan identified a problem "Poor impulse control." A handwritten intervention, dated 04/08/13, stated, "Place pt. [patient] in onsie [sic] if attempting to remove colostomy or to self abuse by putting fingers in stoma." The care plan failed to identify use of the geri chair with tray.

Patient #9's record failed to identify an LIP or RN determined the tray chair an appropriate device for Patient #9 and lacked evidence the patient could independently remove either device (onesie or tray). The record indicated staff used the onesie for the behaviors related to her colostomy, which Hospital policy identified as a contraindication for an MPS and considered a restraint for behaviors. The record lacked evidence staff attempted less restrictive interventions prior to implementing the devices.

During an interview on 06/05/13 at 10:25 a.m. an administrative nurse (#1) stated the Hospital does not consider geri chairs and onesies as restraints. She stated the Hospital's Medical Protective Supports policy covered these devices.

THIS IS A REPEAT CITATION FROM THE COMPLAINT SURVEY CONDUCTED ON 04/11/13.

Based on observation, record review, review of Hospital policy, and staff interview, the Hospital failed to ensure restraint use in accordance with a written modification to the patient's plan of care for 1 of 1 sampled patient (Patient #9) observed seated in a geriatric (geri) chair with a tray attached. Failure to include the restraint in the plan of care inhibits staff's ability to provide continuity of care.

Findings include:

Review of the Hospital policy "Restraint" occurred on 06/05/13. The policy, revised May 2013, stated, "Rationale: The justification for restraint is for the need to intervene to save life or prevent injury. Definition: Restraint is the use of physical grip or mechanical device to restrain involuntarily the movement of the whole or portion of the individual's body as a means of controlling his/her physical activities in order to protect him/her or others from injury. (These can be mobile restraints, protective restraints . . .) . . ."

Review of the Hospital policy "Medical Protective Supports" occurred on 06/05/13. The policy, revised May 2013, stated, "Rationale: Medical Protective Supports are used to provide medically compromised individuals the least restrictive intervention to allow optimal mobility, independence and safety.
Definition: Medical Protective Supports are devices that can be removed by the individual, used to protect the medically compromised patient from injury and to maintain normative bodily function . . . Examples are: postural supports . . . lap buddy . . . seatbelt that the individual is able to remove . . ."

On the morning of 06/03/13, the Hospital provided a list of all patients using restraints. Patient #9's name did not appear on the list.

- Observation on 06/03/13 at 2:05 p.m. and on 06/04/13 at 8:30 a.m. showed Patient #9 seated in the dining room in a small geriatric chair with a tray secured in place. The chair lacked a foot rest and Patient #9's feet hung unsupported approximately six inches off the floor. Lack of foot support could result in the patient sliding down in the chair and becoming caught in the tray.

Patient #9's record, reviewed on all days of survey, identified diagnoses including dementia with behavior disturbance, impulse control disorder, schizoaffective disorder, and mild mental retardation. A nursing progress note, dated 04/08/13 at 9:30 p.m., stated, ". . . Restraints or Medical Protective Supports [MPS] (if applicable): Pt had a onsie [sic] put on her when pulling on colostomy site. No MPS ordered at this time. . . ."

The current nursing care plan identified a problem "Poor impulse control." A handwritten intervention, dated 04/08/13, stated, "Place pt. [patient] in onsie [sic] if attempting to remove colostomy or to self abuse by putting fingers in stoma." The care plan failed to identify use of the geri chair with tray attached.

During an interview on 06/05/13 at 10:25 a.m., an administrative nurse (#1) stated the Hospital does not consider geri chairs as restraints. She stated the Hospital's Medical Protective Supports policy covered these devices.

THIS IS A REPEAT CITATION FROM THE COMPLAINT SURVEY CONDUCTED ON 04/11/13.

Based on observation, record review, policy review, and staff interview, the Hospital failed to ensure staff used restraints in accordance with a physician's or other licensed independent practitioner's (LIP's) order for 1 of 1 sampled patient (Patient #9) observed seated in a geriatric (geri) chair with a tray attached and for whom staff used a one piece undergarment (onesie). Failure to obtain a physician's or LIP's order has the potential to violate the patient's right to be free of restraints.

Findings include:

Review of the Hospital's "Consumer Handbook" occurred on 06/04/13. The handbook, dated May 2011, stated, "Individual Right and Responsibilities. I have the right to . . . 5. least restrictive conditions necessary to achieve treatment, such as: only clinically justified restrictions and restraint . . ."

Review of the Hospital policy "Restraint" occurred on 06/05/13. The policy, revised May 2013, stated, ". . . Procedure: . . . 2) . . . On rare occasions, tray chair use for restraint purposes for less than 2 hours may be used on L300 and L600 if the LIP [licensed independent practitioner] or RN [registered nurse] determines this is the most appropriate intervention. . . ."

Review of the Hospital policy "Medical Protective Supports" occurred on 06/05/13. The policy, revised May 2013, stated, ". . . Procedure: . . . 6. The LIP will write an order daily for 3 days, then weekly thereafter. . . ."

On the morning of 06/03/13, the Hospital provided a list of all patients using restraints. Patient #9's name did not appear on the list.

- Observation on 06/03/13 at 2:05 p.m. and on 06/04/13 at 8:30 a.m. showed Patient #9 seated in the dining room in a small geriatric chair with a tray secured in place.

Patient #9's record, reviewed on all days of survey, identified diagnoses including dementia with behavior disturbance, impulse control disorder, schizoaffective disorder, and mild mental retardation. A nursing progress note, dated 04/08/13 at 9:30 p.m., stated, "Behaviors . . . Pt [patient] has had several noted behaviors during this past month. She has had episodes of pulling off her colostomy bag and throwing it on the floor. She has removed her colostomy and/or clip at least 3-4 times that is known or witnessed during this past month. She has attempted to spit, kick and strike out at staff members when assisting her to clean up or with other cares. Pt has also done some self-abusive episodes. She put her fingers in stoma site and was hitting herself on another occasion. . . . Restraints or Medical Protective Supports [MPS] (if applicable): Pt had a onsie [sic] put on her when pulling on colostomy site. No MPS ordered at this time. . . ."

Patient #9's record failed to identify an LIP or RN determined the tray table as an appropriate device for Patient #9 and lacked evidence the patient could independently remove either device (onesie or geri chair tray). The record lacked evidence staff obtained an LIP's order prior to implementing the devices.

During an interview on 06/05/13 at 10:25 a.m., an administrative nurse (#1) stated the Hospital does not consider geri chairs and onesies as restraints. She stated the Hospital's Medical Protective Supports policy covered these devices.

Based on policy review, record review, and staff interview, the Hospital failed to file an incident report for 1 of 1 sampled patient (Patient #14) who obtained a cutting laceration while absent from the nursing unit. Failure to report the patient injury through the incident reporting process limited the Hospital's ability to analyze the incident and determine the causative factor and implement corrective action if necessary; and placed the patient at risk of further injury.

Findings include:

Review of the policy titled "NDSH [North Dakota State Hospital] Patient Incident Policy" occurred on 06/04/13. This policy, dated 04/2011, stated,
"Purpose:
To provide accurate identification, reporting and review of incidents involving individuals receiving care at the NDSH. . . .
II. Procedure for General Patient Incidents: . . .
3. The staff member fills out a Risk Management Medical Services Incident Report . . . completing all required information.
4. The incident form . . . will be sent to the appropriate Clinical Coordinator. These incidents are logged, monitored and reviewed by the service and/or department QM [Quality Management] committee. Critical Analysis of general patient incidents using root cause analysis principles is encouraged as identified by trends or patterns at the service or department level. . . ."

Review of Patient #14's medical record occurred on 06/04/13. The Hospital admitted Patient #14 on 09/16/11 with diagnoses including: episodic mood disorder, post traumatic stress disorder, and mild intellectual disabilities. A progress note from 05/16/13 at 1:30 p.m. stated, ". . . Pt [patient] at Treatment Mall [therapy center in an adjacent building]. Brought back from Tx [treatment] mall in w/c [wheelchair] @ [at] approx [approximately] 11:15 A.M. Pt has approx a 4 1/2 " [inch] laceration on L [left] forearm . . . Depth along entire laceration through skin layer to fatty layer . . . pt transported per w/c [with] 2 staff to c. [consult] clinic. Pt did not want to tell how incident happened, as said she didn't want to get some one else mad at her. Soon did admit to this writer that she had told pt #[patient number] to cut her, and that pt #[patient number] did then cut this pt's forearm. . . ."

Upon request on 06/04/13, the Hospital failed to provide evidence of an incident report for Patient #14's injury on 05/16/13.

During interview on 06/04/13 at 11:55 a.m., an administrative staff member (#20) confirmed the Hospital staff had not filed an incident report for Patient #14's injury on 05/16/13.

During interview on 06/05/13 at 10:20 a.m., an administrative quality management staff member (#25) confirmed the Hospital staff had not filed an incident report for Patient #14's injury on 05/16/13, and she would expect staff to file an incident report for this type of injury.

Based on bylaws review, credentialing files review, and staff interview, the Hospital failed to ensure the medical staff conducted appraisals for 1 of 1 active family practice medical staff member (Provider #1) and 2 of 3 consulting medical staff members (Providers #2 and #3) reviewed. Failure to conduct appraisals of the medical staff limits the hospital's ability to ensure the physicians furnished quality and appropriate care to the hospital's patients.

Findings include:

Review of the "North Dakota State Hospital Medical Staff Bylaws" occurred on 06/03/13. These bylaws, dated 06/07/11, stated,
". . . Article II . . .
The purpose of the Medical Staff includes the following: . . .
2. To monitor and evaluate the professional performance by all practitioners authorized to practice in the hospital. . . .
Article V . . .
Section 3 - Reappointment Process
a. . . . Information to be included in the determination of reappointment to the Medical Staff includes . . . peer review data . . ."

Review of the providers' credentialing files occurred on 06/05/13. The files for Providers #1, #2, and #3 indicated the governing board approved their reappointments on 09/17/12. The files lacked evidence the medical staff had conducted appraisals or performed peer review of these providers prior to their reappointments in 2012. Upon request on 06/05/13, the Hospital failed to provide any other evidence the medical staff conducted appraisals or performed peer review for Providers #1, #2, and #3 in 2012.

During interview on 06/05/13 at approximately 3:05 p.m., an administrative staff member (#20) confirmed the medical staff failed to perform peer review for Providers #1, #2, and #3 in 2012.

Based on observation, record review, policy and procedure review, and staff interview, the Hospital failed to develop and keep current the nursing plan of care and/or recovery plan (a type of interdisciplinary care plan) for 4 of 20 active patient records (Patient #5, #9, #16, and #19) reviewed. The failure to assess patient-specific health conditions and behaviors, develop an individualized plan of care, evaluate the plan on a periodic basis, and revise or update the patient's care in response to those assessments resulted in unmet health and behavioral needs of these patients.

Findings include:

Review of the Hospital policy "Section Two Plan of Nursing Care (NCP)" occurred on 06/05/13. The policy, revised November 2012, stated, "Purpose: The plan of nursing care is a professional tool utilized throughout the individual's hospital stay which provides a guide to maximize the individual's level of health. . . . The RN [Registered Nurse] utilizes the nursing process, incorporating assessment, nursing diagnosis, individual oriented goals, nursing interventions (action), and evaluation into the plan of care for each individual. . . . Formal Nursing Care Plans shall be written for: 1. Newly identified medical problems or medical problems that need further nursing interventions than those identified by the goal on the RECOVERY PLAN. . . ."

- The hospital admitted Patient #16 to the adult psychiatric services admission unit (L100) in August 2011 with a diagnosis of schizoaffective disorder. The Hospital provided a brief summary of an incident, which occurred on 03/23/13 and involved Patient #16. Staff initiated a "Code Blue" after they found the patient unresponsive in the women's bathroom on the L100 unit.

Patient #16's Progress Notes stated,
*03/24/13 at 12:20 a.m., - "During 2300 [11 p.m.] rounds on 03/23/13, nursing staff found individual in the tub with water still running. Staff reported that the water was hot and the patient was drooling excessively and face flushed. Patient was not responding to staff despite multiple attempts to arouse her. Code Blue was initiated at 2315 [11:15 p.m.] and vital signs were checked, T [temperature]=101.3, P [pulse]=114, BP [blood pressure]=72/36, O2 [oxygen] sat [saturation] 98% room air, BS [blood sugar]=114. Vital signs were constantly monitored . . . Patient was transferred to her room via wheelchair and was placed on bed with her legs part [sic] elevated. After a few minutes she started responding. Staff checked her pupils and they were at 2 mm [millimeters], equally reactive to light and accommodation. She was responding to pain this time and was able to move her extremities. On call physician came to the unit and ordered to send individual to [name of medical facility] for consult and evaluation due to recent syncopal episode in the bath tub.
. . ."
*03/24/13 at 5:00 a.m. - "Patient came back to the unit at approximately 4:04 a.m. Per nursing staff she was able to go to the van by herself. Able to ambulate without assistance when she came back to the unit. Went to the bathroom right away as she felt that she needed to urinate. She was observed washing her face and then eventually went back to her room. Vitals signs taken . . . Individual on 1:1 observation due to recent syncopal episode. . . ."
*03/24/13 at 7:30 p.m. - "Patient is on randomized 10 to 15 minutes checks. Female bathroom has been locked due to patient going into bathroom excessively and taking multiple, hot baths within a short timeframe . . . She has used the men's bathroom x 2. When redirected she yells and continues to take her time. 'No one cares if I use this bathroom.' . . . She has been yelling randomly in the hallway. . . ."
*03/25/13 at 5:30 a.m. - ". . . has rested only 1 1/2 hours tonight. Bathroom door has been locked. Pt [patient] did ask to wash hands [and] face [and] brush teeth. Staff assisted her in the bathroom. . . ."
*03/25/13 at 10:45 p.m. - "Patient was washing her hands repeatedly and not following redirection. Patient's knuckles are bleeding. Due to this behavior among repeated long hot baths, multiple per day - door to women's bathroom locked. Patient was offered lotion for her hands and feet and refused . . . She has been using the bathroom multiple times with staff supervision. She has been observed to change clothes multiple times. . . ."
*04/03/13, (completed by the physician)- "1. Record symptoms demonstrating need for hospitalization - [patient name] is here for a long term treatment and stabilization. She has severe Schizophrenia and has been somewhat recalcitrant to treatment . . . She has been running the bath water, but was reminded that she was not to bathe during the night . . . 6. Medications prescribed, medication changes, . . . Her Clozapine was reduced a little while back because she had a period of being nonresponsive in the bathroom on 03/24/13. Apparently, she had a syncope episode when taking a bath. . . ."

Patient #16's recovery plan, dated 02/15/13 identified a problem with "frequent bathing/washing." The recovery plan and/or nursing plan of care failed to address Patient #16's history of a syncopal episode due to frequent prolonged bathing with excessively hot water and failed to include interventions to reduce/minimize the behavior and promote patient safety.

- The hospital admitted Patient #19 to the Hospital's adult psychiatric chemical dependency unit (L400) on 05/02/13 with diagnosis of schizoaffective disorder. Patient #19's admission history and physical identified the patient is under constant one to one staff observation secondary to an admission to an adult unit as a minor (under age 18).

Observation during all days of survey identified one staff member constantly present with Patient #19.

Review of Patient #19's Progress Notes identified four separate incidents of verbal and/or physical aggression toward other patients residing on the L400 unit on May 8, 19, 21, and 26, 2013. Patient #19's recovery plan and/or care plan failed to address the verbal and/or physical aggression toward other patients on the unit and interventions implemented to reduce/minimize the behavior and promote patient safety.


15707


- On 06/03/13 at 1:15 p.m,. observation showed Patient #9 seated in the Core (a common area in unit L300) in a recliner. Observation showed a cast on the patient's left arm. A licensed nurse (#2) stated the patient fell "about a week ago" and fractured her left elbow.

Observation on 06/03/13 at 2:05 p.m. and on 06/04/13 at 8:30 a.m. showed Patient #9 seated in the dining room in a small geriatric chair with a tray secured in place. The chair lacked a foot rest and Patient #9's feet hung unsupported approximately six inches off the floor.

Patient #9's record, reviewed on all days of survey, identified diagnoses including impulse control disorder, schizoaffective disorder, and mild mental retardation. A nursing progress note, dated 05/21/13 at 11:25 a.m., identified Patient #9 fell backwards while walking, hit her head on a door frame, and sustained a fracture of her left elbow. The record lacked evidence staff developed a nursing care plan addressing Patient #9's fractured left elbow or use of the geriatric chair with tray.



27645

- Review of Patient #5's medical record occurred on June 04-05, 2013. Diagnoses included borderline personality, moderate mental retardation, adjustment disorder, psychotic disorder, and anxiety. Review of nursing progress notes identified Patient #5 wandered off his unit on 04/18/13, 05/08/13, and 05/13/13. The record lacked evidence staff developed a nursing care plan addressing this concern.

During an interview on 06/05/13 at 10:30 a.m., an administrative nurse (#1) stated she expected staff to identify a patient's history of wandering and risk for elopements on the nursing plan of care.

Based on observation, policy review, and patient interview, the Hospital failed to ensure patients received palatable food for 1 of 1 meal tested (evening meal on 06/04/13). Failure to ensure the Hospital served palatable food has the potential to result in unmet nutritional and caloric needs of the patients.

Findings include:

Review of the facility policy titled "Ordering, Transmitting and Serving Diets" occurred on 06/05/13. This policy, revised April 2013, stated,
". . . Procedure . . . 4. Trays are assembled on the tray line using tray tickets which identify the diet to be portioned . . . 5. Trays are placed on food carts and delivered to wards. Ward staff are responsible for delivering trays and snacks to the correct patient according to the tray ticket. . . ."

Review of the facility policy titled "Nutrition Services Infection Control Policies" occurred on 06/05/13. This policy, reviewed 04/18/12, stated, ". . . 2. Holding temperature - Use tray line documentation sheet to document hot and cold holding temperatures. Cover trays and steam table pans when shortages or errors cause a tray line delay . . . 3. Service temperature - Use customer surveys and periodic test trays to determine if service temperatures are safe and at preferable temperatures as discerned by the customer and customary practice. Re-heat hot foods in dining room microwave ovens if necessary . . . Food . . . Thin soup, broth, gravy
. . . Cooking (minimum degrees F (Fahrenheit)) 170 . . . Holding (minimum degrees F) 150 . . . Service (minimum degrees F) 125."

The evening meal on 06/04/13 consisted of tuna salad on a croissant, vegetable beef soup with dumplings, an apple, and banana cake with cream cheese icing.

A sample tray of the evening meal on 06/04/13, tested at 5:50 p.m., identified the temperature of the vegetable beef soup at 109 degrees F and unpalatable.

On 06/04/13 at 5:40 p.m., Patient #3 stated, "This soup is nasty."

During an interview on 06/04/13 at 6:00 p.m., a direct care assistant (DCA) (#6) stated patients eating in the L300 dining room ate less of the soup than any other food served during the evening meal.

Based on observation, review of policy and procedure, review of professional literature, record review, and staff interview, the Hospital failed to follow professional standards of care relating to infection control practices during observations of patient care, when storing scoops in food/beverage items, and cleaning fans on 3 of 3 days of survey (June 3-5, 2013). Failure to follow established infection control practices may allow transmission of organisms and pathogens from patient to staff, to other patients, or to visitors; and from one environment to another.

Findings include:

Review of the policy "Hand Hygiene Technique" occurred on 06/05/13. This policy, reviewed March 2012, stated, ". . . When to wash hands:
. . . Before and after direct individual care and between patients/residents . . . Before and after contact with dressings, catheters, sputum containers, urinals, bedpans, etc., even though gloves are worn . . . Before and after procedures, such as catheterization, suctioning, etc., even though gloves are worn . . . If hands are not visibly soiled, an alcohol-based hand rub may be used for routine hand hygiene. . . ."

Review of the policy "Precision PCx Plus" occurred on 06/05/13. This policy, reviewed May 2013, stated, ". . . Purpose: The PCx Blood Glucose System is used for the quantitative measurement of glucose in venous, capillary, and arterial or neonatal whole blood . . . Instrument Maintenance: . . . 1. Cleaning the Exterior Surface: . . . After each patient use, clean the meter according to the manufacturers recommendations with approved cleaners . . . Recommended solutions are Sani-Cloth HB, Sani-Cloth Plus, and Super Sani-Cloth. . . ."

Review of the policy "Dressings Application (Sterile, Wet, Dry)" occurred on 06/05/13. This policy, reviewed May 2012, stated, ". . . Remove old bandage . . . Remove gloves, wash hands, and apply new gloves. . . ."

- On 06/03/13 at 3:45 p.m., observation showed two Direct Care Assistants (DCAs) (#8 and #9) donned gloves and toileted Patient #11 in the Men's Bathroom (a common bathroom on the L300 unit). Following toileting, the DCAs stood the patient using a sit to stand lift and a DCA (#8) performed perineal care. The DCAs (#8 and #9) then transferred Patient #11 to a geriatric (geri) chair. The DCA (#8) failed to remove his gloves as he handled the lift controls and propelled the geri chair from the bathroom to the Core (a common area on the unit). After positioning the patient's chair in the Core, DCA #8 removed his gloves and sanitized his hands.

During an interview on 06/04/13 at 8:00 a.m., an infection control nurse (#15) stated she expected staff performing perineal care to remove their gloves and wash/sanitize their hands prior to performing other tasks.

- Observation on 06/04/13 at 9:30 a.m. identified a nurse (#24) donned gloves, removed the dressing to Patient #2's right heel, cleansed the wound with a gauze pad and normal saline, rubbed ammonium lactate lotion on the area, and then dressed the area using a Telfa pad and Kerlix wrap. After completing the dressing change, the nurse (#24) removed his gloves, exited the patient's room, walked down the hall, unlocked the door to the exam room, and washed his hands in the exam room. The nurse (#24) failed to change his gloves and perform hand hygiene after removing the dressing and cleansing the patient's wound, prior to applying the new dressing; and failed to perform hand hygiene prior to exiting Patient #2's room.

During an interview on 06/05/13 at 10:30 a.m., an administrative nurse (#1) stated she expected staff to change gloves and perform hand hygiene between soiled and clean dressings. The staff member (#1) confirmed staff should wash their hands at the nearest sink after completing the dressing change.

- On 06/04/13 at 4:00 p.m., observation showed a nurse (#23) disinfected a glucometer, measured Patient #8's blood glucose level, and measured Patient #7's blood glucose level with same glucometer. The nurse (#23) failed to disinfect the glucometer between use with the two patients.

During an interview on 06/05/13 at 10:30 a.m., an administrative nursing staff member (#1) confirmed staff should disinfect the glucometer between each patient.

- Observation of the kitchen on each nursing unit (L100, L300, L400, and L500/600) occurred on the morning of 06/04/13 and identified the following:
*L100 - one cup measuring cups stored inside each container of caffeinated and decaffeinated coffee
*L300 - scoops stored in a container of Beneprotein and a container of Thick and Easy, a one-third measuring cup stored in a container of decaffeinated coffee
*L500/600 - one tablespoon stored in a container of hot chocolate mix, one-fourth cup measuring cups stored inside each container of caffeinated and decaffeinated coffee

- During a tour of the L300 medication room, on 06/04/13 at 10:45 a.m. with a licensed nurse (#2), observation showed a scoop in a container of Thick and Easy.

- Observation on 06/04/13 at 4:55 p.m. showed a large fan with accumulated dust on the blades sitting on the counter of the L300 kitchen and blowing towards the kitchen service window.

- An environmental tour of the facility occurred at 8:30 a.m. on 06/05/13 with staff members of both the Safety Department and Plant Services (Staff Members #13, #14, #15, #16, and #17). While in the kitchen area on the L300 unit, observation revealed a box fan with accumulated dust on the blades setting on a counter top. The staff members present (#13, #14, #15, #16, and #17) agreed staff should not place the fan on the counter in the kitchen area. A staff member (#13) indicated he expected housekeeping staff on the unit to clean the fan.


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