HospitalInspections.org

17650

Based on review of medical records and facility policy and interview it was determined the facility failed to follow their policy for Treatment Planning Process in 2 of 2 Geriatric Behavioral Health records reviewed. This included Medical Record (MR) # 1 and 2 and had the potential to affect all patient served by Geriatric Behavioral Health.

Findings include:

Facility Policy: 05.001 Treatment Planning Process

1.0 Purpose

To ensure plans for care, treatment and service are individualized to meet the patient's unique needs and circumstances.

4.0 Problem Identification and Interdisciplinary Team Meeting

D. Interdisciplinary Team Meeting

"The initial treatment team meeting is held no later than three (3) days after admission at which time the Interdisciplinary Treatment Plan is reviewed and revised. Each team member is responsible for having completed their assessment and to present a summary in the team meeting. The treatment team meeting are directed by the Attending Psychiatrist. The Social Worker or Case Manager serves as Treatment Plan Coordinator for each patient. This individual is responsible for ensuring that the appropriate documentation is entered on the treatment plan. The Social Worker or Case Manager is also responsible for explaining the plan to the patient, soliciting their input, and obtaining their signature..."


1. MR # 1 was admitted to the facility on 1/16/15 with diagnoses including Dementia and Depression.

Review of the Treatment Team Participant Signature Sheet on 1/20/15 revealed the following participation dates:

Registered Nurse - 1/16/15
Social Worker - 1/19/15
Physician - no documentation of participation

Further review of the Treatment Team Participant Signature Sheet on 1/20/15 revealed the treatment plan had been discussed with the patient on 1/16/15 and the patient's family on 1/19/15.

An interview was conducted with EI # 3, Director of Geriatric Behavioral Health on 1/22/15 at 9:30 AM. EI # 3 submitted the Treatment Team Participant Signature Sheet which now contained the Physician's signature dated 1/21/15. EI # 3 stated Treatment Team Meetings were held on Wednesdays and Fridays. EI # 3 stated MR # 1's Treatment Team Meeting was 5 days after admission instead of 3 days.

2. MR # 2 was admitted to the facility on 1/16/15 with diagnoses including Dementia with Psychotic Features and Behavioral Disturbances.

Review of the Treatment Team Participant Signature Sheet on 1/20/15 revealed the following participation dates:

Registered Nurse - 1/16/15
Social Worker - 1/19/15
Physician - no documentation of participation

Further review of the Treatment Team Participant Signature Sheet on 1/20/15 revealed the treatment plan had been discussed the patient's family on 1/19/15.

An interview was conducted with EI # 3 on 1/22/15 at 9:35 AM. EI # 3 submitted the Treatment Team Participant Signature Sheet which now contained the Physician's signature dated 1/21/15. EI # 3 stated Treatment Team Meetings were held on Wednesdays and Fridays. EI # 3 stated MR # 2's Treatment Team Meeting was 5 days after admission instead of 3 days.

Based on record review and interview, it was determined the facility failed to ensure the nursing staff followed the physician's orders for nutritional supplements in 1 of 1 record reviewed with nutritional supplements ordered. This affected Medial Record (MR) # 1 and had the potential to affect all patients served by this facility with nutritional supplements ordered.

Findings include:

1. MR # 1 was admitted to the facility on 1/16/15 with diagnoses including Dementia and Depression.

Review of the physician's order dated 1/19/15 at 2:15 PM revealed orders for the staff to give MR # 1 Ensure or Boost if the patient consumes less than 75% of a meal.

Review of the MR revealed the patient consumed the following:

1/20/15 - Breakfast = 10%
1/20/15 - Lunch = 15%
1/21/15 - Breakfast = 20%

There was no documentation the staff gave the Ensure or Boost on the above meals.

An interview was conducted with Employee Indentifer # 2, Charge Nurse Geriatric Behavioral Health on 1/20/15 at 10:00 AM who verified the above findings.

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17650

Based on observation, policy review and interview, it was determined the facility failed to ensure the staff followed policy for Intravenous Medication Preparation. This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Intravenous (IV) Admixture System and Sterile Preparations

4) Swab vials and ampules with alcohol prior to penetration.

Observation of IV medication preparation was conducted on 1/21/15 at 8:45 AM with Employee Identifier (EI) # 4, Certified Registered Nurse Anesthetist (CRNA). The surveyor observed EI # 4 open a vial of Fentanyl, Propofol, Versed, Zofran and Decadron. EI # 4 then drew up each medication in separate syringes without swabbing the open vials with alcohol.

An interview was conducted with EI # 1, Director of Professional Standards on 1/21/15 at 11:00 AM, who verified EI # 4 should have swabbed the open vials with alcohol.

Based on the review of medical records, policy and procedure and Medical Staff Bylaws and interview, it was determined the facility failed to ensure a history and physical was in the medial record 24 hours after admission in 3 of 4 records reviewed. This affected Medical Record (MR) # 1, 2 and 3.

Findings include:

Medical Staff Bylaws

14. A complete history and physical examination shall in all cases be documented in the medical record within twenty-four hours after admission of the patient.

Policy:

Inpatient Policies and Procedures

3.0 Procedure:

B. Medical History and Physical Examination. The admitting physician is responsible for completing the Medical History and Physical Assessment... The Medical History and Physical Examination is initiated upon admission and is completed within twenty-four (24) hours of admission.

1. MR # 1 was admitted to the facility on 1/16/15 with diagnoses including Dementia and Depression.

Review of the medical record on 1/20/15 revealed no documentation of a History and Physical.

An interview was conducted with Employee Identifier (EI) # 3, Director of Geriatric Behavioral Health on 1/20/15 at 9:30 AM. EI # 3 verified there was no documentation of a History and Physical in the medical record.

2. MR # 2 was admitted to the facility on 1/16/15 with diagnoses including Dementia with Psychotic Features and Behavioral Disturbances.

Review of the medical record on 1/20/15 revealed no documentation of a History and Physical.

An interview was conducted with EI # 3 on 1/20/15 at 9:35 AM. EI # 3 verified there was no documentation of a History and Physical in the medical record.

3. MR # 3 was admitted to the facility on 12/23/14 with diagnoses including Wound Care of Septic Left Shoulder.

Review of the medical record revealed a History and Physical dated 12/25/14, which was 2 days after admission to the hospital.

An interview was conducted with EI # 1, Director of Professional Standards on 1/22/15 at 9:30 AM. EI # 1 verified the History and Physical was 2 days after admission instead of 24 hours.

The condition under 482.41 Physical Environment remains out of complaince pending a CMS Waiver with a completion date of 6/1/15.


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17650

Based on review of the facility's policy, observation and interview, it was determined the facility failed to ensure the staff performed hand hygiene according to acceptable standards in 1 of 1 observations of a Registered Nurse (RN) starting an Intravenous (IV) line. This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Hand Hygiene

Policy:

A. Objective

The purpose of this policy is to outline indications for and methods of hand hygiene for personnel in a patient care setting at Bryan Whitfield Memorial Hospital. Hand hygiene measures are the single most important prevention strategy for avoiding healthcare-associated infections (HAI). The hands of personnel serve as a critical reservoir of infectious agents. All staff will adhere to this policy to reduce the transmission of microorganisms to patients and other personnel.

Procedure:

A. Hand Hygiene Indications

1. Hand hygiene with either waterless hand sanitizer or soap and water is required:

Before donning and after removing gloves.

An observation of care was conducted on 1/22/15 at 7:35 AM with Employee Indentifer (EI) # 5, RN. EI # 5 was starting an IV line on an unsampled patient. During the procedure EI # 5 changed gloves 4 times without hand hygiene.

An interview was conducted on 1/22/15 at 7:50 AM with EI # 1, Director of Professional Standards. EI # 1 stated hand hygiene should have been performed between each glove change.

T.Blankenship, RN