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Based on a review of facility documentation and staff interview, the facility failed to ensure that all direct patient care licensed personnel, including personnel routinely involved in psychiatric hospital restraint and seclusion events, maintained current certification in CPR.


Findings:


A review of the personnel record for Staff #6, RN, revealed an online course completion certificate provided by ProCPR. The certificate was issued on 8/7/13.


In an interview with Staff #19, Human Resources Assistant Coordinator, on the morning of 1/21/15 in the facility meeting room, she acknowledged that the CPR certificate provided by the online training course was the only documentation of CPR completion in the record of Staff #6. In addition, she acknowledged there was no practical component involved in the online course.


The above findings were confirmed in an interview with the facility CEO, Chief Nursing Officer and Director of Risk Management on the morning of 1/22/15 in the facility meeting room.

Based on a review of facility documentation and staff interviews, the facility failed to monitor patients at the level most recently specified in the patient's medical record for 3 of 10 patients [Patients #1, #4, #5].


Findings:


A review of patient records revealed inconsistently documented precaution levels on nursing assessments from shift to shift, as well as on mental health technician observation sheets from shift to shift. Also, the precautions checked for the patients on the nursing assessment did not consistently match the precautions checked on the mental health observation sheets.


For example, The 24-Hour Nursing Assessment and Patient Education forms included the following entries for Patient #1:


10/26/14 at 10:00 a.m. (7a.m. - 7p.m. shift)
Suicide, Fall and Assault/Homicide Precautions were checked.


10/26/14 at 2:27 a.m. (7p.m. - 7a.m. - note: evening shift - actual date of note 10/27/14 in early a.m.)

Fall Risk entered as "NO Risk." Patient #1 sustained a fall during this shift which required her to be transported to a nearby acute care hospital ER for a CT scan.
Suicide and Assault/Homicide Precautions were checked.


10/27/14 at 6:15 p.m. (7:00 a.m. - 7:00 p.m. shift)
Suicide and Assault/Homicide Precautions were checked.


10/27/14 at 3:15 a.m. (7p.m. - 7a.m. - note: evening shift - actual date of note 10/28/14 in early a.m.)

Fall Risk entered as "NO Risk "
Suicide Precautions were checked.


10/28/14 at 11:00 a.m. (7a.m. - 7p.m. shift)
Suicide Precautions were checked. Patient #1 was discharged on this date.


Mental Health Tech Daily Notes included, for example, on 10/26/14, the first shift checked suicide, assault/homicide and fall precautions. No precautions were noted on the second shift. Inconsistencies such as this were found throughout the MHT Daily Notes forms.


Similar nursing documentation issues were found in the clinical records for Patients #4 and #5.


Facility policy #PC-150, entitled Levels of Precautions, last reviewed 6/23/14, stated in part:


"3. The Charge Nurse/RN implements individualized Precautions as follows:...

b. Initiates Precautions Checklist, checks patient every fifteen (15) minutes and places checklist in patient's chart at end of each twenty-four (24) hours. (MHTs checks pts every 15 minutes)

c. Continues to evaluate and observe for associated risk behaviors and documents in the Medical Record...

6. The physician must re-assess a pt on suicide precautions:

a. Prior to lowering level of observation or discontinuing suicide precautions

b. At individual therapy sessions with pt Immediately prior to discharge

7. Documentation by nursing staff shall include a daily assessment as to whether the patient continues to require suicide precautions.

D. a. 24 Hour Nursing Assessment and Patient Education progress note by R.N. will include a nursing assessment with the rationale for initiation and continuation of precautions.

b. Mental Health Tech Daily Notes form completed by staff member assigned to patient...

d. Progress note by R.N. with rationale when precautions are discontinued..."


In an interview with Staff #2, Chief Nursing Officer, on the afternoon of 1/21/15, in the facility meeting room, she reviewed the issues noted and agreed that there were many inconsistencies regarding the nursing documentation of patients' precaution levels.


The above findings were confirmed in an interview with the facility Chief Executive Officer, Chief Nursing Officer and Director of Risk Management on the morning of 1/22/15, in the facility meeting room.

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient's care was adequately supervised and evaluated by a registered nurse as nursing staff failed to follow facility policies related to patient falls when Patient #1 sustained 2 falls. Additionally, nursing staff failed to meet the fluid/nutritional/metabolic needs of 2 patients [Patients #1 and #7] who had a medical diagnosis of diabetes mellitus, as the patients were not consistently monitored or provided interventions for their dietary and fluid intake, blood sugar/accuchecks, and insulin was not administered as ordered. Both Patients #1 and #7 were transferred to a local hospital ER either during their stay at or upon discharge from the facility with acute renal failure. Dietary and fluid intake assessments were inaccurate or left blank for 6 of 10 patients [Patients #1, #3, #6-8, and #10].


Findings were:


Patient #1 sustained falls on two occasions during her inpatient stay which required her to be transferred to a nearby acute care hospital for assessment. The falls occurred on 10/23/14 and 10/26/14.


A 24-Hour Nursing Assessment form signed at 6:00 p.m. on 10/23/14 included the following "Comments" in their entirety: "At 1330 pt is seen lowering herself to floor intentionally and hits her head near nurses station. c/o...pain "10" on a 0-10 pain scale. 119, 99/66, 16, 98.7, 98%. MD orders to transfer pt to ER for CT of head and neck. Small » 2x2" round area on back of head noted to be swollen. 0 bleeding. Thought process is very disoriented. Returns to ALH (Austin Lakes Hospital) » 1700."


The facility was unable to provide documented evidence of a neuro evaluation conducted on the patient per facility policy. The facility was unable to provide documented evidence of a completed Austin Lakes Hospital Fall Report form as required by facility policy. The results of the ER visit were not included in the medical record and were unavailable for surveyor review.


A 24-Hour Nursing Assessment form for the 7:00 p.m. to 7:00 a.m. shift on 10/26/14 which was signed at 12:27 a.m. on 10/27/14 included the following "Comments" in their entirety: "[Patient #1] has been visible on the unit in wheelchair near to nurse station. Agitated @ times. Scooted herself out of wheelchair & fell down & hit her head in occipital area. [Physician] notified @ 2020. Stat CT head [with] contrast ordered. VS stable. 97.4, 103, 118/86, 20, 96%. No skin breakdown noted. Pt went to [a nearby hospital] @ 2120. Ambulance and [illegible] to unit @ 2345. Still agitated. [Physician] called back confirmed that there is not blood on CT scan, confused agitated. [Increased] risk of self induced harm by falling; pressured speech & flight of ideas by [illegible] tangential."


The facility was unable to provide documented evidence of a neuro evaluation conducted on the patient after this fall per facility policy. The facility was unable to provide documented evidence of a completed Austin Lakes Hospital Fall Report form as required by facility policy. The results of the ER visit were not included in the medical record and were unavailable for surveyor review.


In an interview with Staff #4, Lead Mental Health Technician, on the morning of 1/21/15, in the facility meeting room, regarding Patient #1 she stated, "That fall she had - I was right there. It was bad...I was about to sit down and she was trying to pull my chair out from under me. When she did that she fell back and hit her head on the floor. I actually heard her hit her head on the floor - it was loud. I heard her head hit twice - like it bounced. You could hear it even in the nurse's station ..."


In an interview with Staff #5, RN, Adult Acute Unit, on the morning of 1/21/15, in the facility meeting room, he was asked what he remembered about Patient #1. He stated, "I remember that she would kind of throw herself on the ground repeatedly on the unit...She would purposely lower herself to the ground. She would purposely bang her forehead on the ground. It sounded like when you bowl. It was a horrific sound. "


Further review of the clinical record of Patient #1 revealed the following:


The Vital Signs Flow Sheet included the following "Abnormal Vital Sign Parameters...Blood Pressure: < 90 / 50 or > 140 / 90...Pulse: < 60 bpm or > 100 bpm...Pulse Oximeter/PO%: < 95%...MHT please notify Nurse of any abnormal findings documented on the flow sheet. Nurses please sign that abnormal vital signs was reviewed. After reviewing please notify physician and document follow up in 24 hour Daily Nursing Assessment..."


The Vital Signs Flow Sheets for Patient #1 included the following entries:

o 10/21/14 Diet Intake: 50% breakfast, 50% lunch, 20% dinner

o 10/22/14 This date did not exist on the flow sheet

o 10/23/14 Vital signs taken at 7:00 a.m. included the following: Pulse 107, Pulse Oximeter % 93. Diet Intake: 50% breakfast, 0% lunch, 5% dinner

o 10/24/14 Vital signs taken at 12:00 noon included the following: Pulse 103, Pulse Oximeter % [blank], Blood Pressure 70/43. Diet Intake: 75% breakfast, Æ lunch, [blank] dinner

o 10/25/14 Diet Intake: R (refused) breakfast, 50% lunch, [blank] dinner

o 10/26/14 This date did not exist on the flow sheet

o 10/27/14 Vital signs taken at 7:00 a.m. included the following: Pulse 113. Diet Intake: 0% breakfast, 0% lunch, 35% dinner.

o 10/28/14 This date did not exist on the flow sheet. Patient discharged at 1:45 p.m.


The Medication Administration Record - Novolin-Reg Sliding Scale form included the following printed guide:

"If blood sugar < 79, give orange juice or milk.
80-150 = 0 units SQ
151-200 = 2 units SQ... "


Entries for accucheck results included:

o 10/25/14: refused accucheck at 8:00 a.m.; at 12:00 noon, BS (blood sugar) 78 - no insulin given; at 5:00 p.m. BS 83 - no insulin given; at 9:00 p.m. BS 163 with the note "refused" possibly referring to insulin. There is no documented mention of the 9:00 p.m. BS result on the 24-Hour Nursing Assessment and Patient Education form.

o 10/26/14: refused accucheck at 8:00 a.m.; at 12:00 noon, BS 180, Æ entered as
insulin given; no accucheck amounts were recorded for 5:00 p.m. or 9:00 p.m. The only other entry on that date is a note in parenthesis "(didn't eat)."


The 24-Hour Nursing Assessment and Patient Education forms included the following entries:


10/23/14 at 6:00 p.m. (7a.m. - 7p.m. shift)
"% of Meal Eaten - Breakfast: 50, Lunch 50, Dinner 50..."(contradicting the Vital Sign Flow Sheet entries).


10/24/14 at 6:15 p.m. (7a.m. - 7p.m. shift)
"% of Meal Eaten - Breakfast: 75%, Lunch Ref, Dinner 10%..."(contradicting the Vital Sign Flow Sheet entries)


10/25/14 at 2:02 a.m. (7p.m. - 7a.m. shift - note: evening shift - actual date of note 10/26/14 in early a.m.)
No meal entries for evening shift.


10/26/14 at 10:00 a.m. (7a.m. - 7p.m. shift)
"% of Meal Eaten" - no entries made; each meal blank.


10/26/14 at 2:27 a.m. (7p.m. - 7a.m. - note: evening shift - actual date of note 10/27/14 in early a.m.)
No meal entries for evening shift.


10/27/14 at 6:15 p.m. (7:00 a.m. - 7:00 p.m. shift)
"% of Meal Eaten - Breakfast: (Ensure only), Lunch Æ, Dinner 35%... "
Nursing Comments did not address the patient's lack of dietary intake.


10/27/14 at 3:15 a.m. (7p.m. - 7a.m. - note: evening shift - actual date of note 10/28/14 in early a.m.)
No meal entries for evening shift.
Nursing Comments included no mention of patient's lack of dietary intake and continued to note the "nonsensical" speech of the patient.


10/28/14 at 11:00 a.m. (7a.m. - 7p.m. shift)
"% of Meal Eaten - Breakfast: Refused", Lunch and Dinner blank.
Nursing Comments were, in entirety: "Pt DC'ed to group home. See RN DC note. "


Mental Health Tech Daily Notes included an area for percentages eaten at each meal. The entries on these forms were not consistent with the daily nursing notes and were sometimes left completely blank. For example, on 10/26/14 and 10/28/14 there were no entries at all for percentages of breakfast, lunch and dinner consumed by the patient. Patient #1 was discharged on 10/28/14, but not until 1:45 p.m.


The facility was unable to provide documented evidence of fluid intake for Patient #1 while at the facility in October 2014.


Patient #1 was discharged from Austin Lakes Hospital on 10/28/14, at 1:45 p.m.


A review of the patient record for Patient #1 from a nearby hospital revealed she was admitted to that hospital on 10/28/14, at 5:18 p.m. The history and physical dated 10/28/14 at 5:19 p.m. stated, in part:


"History of Present Illness...Patient presented to the ED after being discharged from Austin Lakes hospital as it was deemed appropriate for discharge. Patient was brought to the ED as she had fallen and had not been eating or drinking. Patient was found to be in acute renal failure ...

Diagnosis, Assessment & Plan:...

--Acute renal failure...Pt appears very dry...

--AMS (Altered Mental Status), Likely metabolic in nature exacerbating schizoaffective personality, pt takes Haldol normally...

--Hyperkalemia...

--H/O falls per EMR - Unclear etiology...

--Schizoaffective Disorder...

Patient will need more than 2 midnight hospitalization... "


Patient #7 was admitted to Austin Lakes Hospital on 12/4/14. It was noted on admission she was taking metformin for diabetes mellitus, type II and had ordered an insulin injection sliding scale in addition.


Recorded intake amounts were especially reviewed for the dates 12/25/14 through 1/3/15. On the 24-Hour Nursing Assessments and the Mental Health Tech Daily Notes, intake amounts were often left blank and/or did not concur.


Nursing Assessment amounts recorded of Patient #7 intake for the dates mentioned were as follows:

o 12/25/14 - breakfast 0%, lunch 25%, dinner [blank]

o 12/26/14 - breakfast 15%, lunch 15%, dinner [blank]

o 12/27/14 - breakfast 5%, lunch 5%, dinner 80%

o 12/28/14 - breakfast [blank], lunch [blank], dinner [blank]

o 12/29/14 - breakfast 0%, lunch 15%, dinner 10%

o 12/30/14 - breakfast 90%, lunch 25%, dinner 50%

o 12/31/14 - breakfast [blank], lunch [blank], dinner [blank]

o 1/1/15 - breakfast [blank], lunch [blank], dinner [blank]

o 1/2/15 - breakfast [blank], lunch [blank], dinner [blank]

o 1/3/15 - breakfast 90%, lunch 50%, dinner "ER "


Mental Health Tech Daily Notes were almost consistently blank regarding dietary intake of Patient #7.


No documentation of fluid intake was noted in the patient's chart. During this time period, Patient #7's accucheck results were varying from 265 on 12/29 with very little recorded intake, to 34 on 1/3/15 when she was transferred to a local hospital due to being found unresponsive. A Nursing note on the 24-Hour Nursing Assessment on 1/3/15 at 9:00 p.m. was as follows: "Received a call from St. David's ER, pt. is admitted to ER due to renal failure... "


Inconsistency in the documentation of dietary intake was similar to that noted above in the clinical records of Patients #3, #6, #8 and #10.


Facility policy #PC-139, entitled Vital Signs, last reviewed 6/23/14, stated in part:

"3. Any vital sign findings outside of normal range, taken by a MHT (Mental Health Technician) should be reported to the nurse responsible for the care of the patient immediately.

4. Vital signs are to be charted daily on the graphic record.

5. Standard values for vital signs may vary for each patient. Values should always be interpreted in the light of past readings and the patient's present clinical state. The physician is to be notified by the nurse of abnormal vital signs or per the physician's order. If no specific order is present, the physician will be notified when the values fall outside the standard range..."


Facility policy #PC-136, entitled Patient Daily Nursing Assessment and Reassessment, last reviewed 6/23/14, stated in part:

"3. The Registered Nurse, LVN, or MHT may complete dietary intake, patient activities as listed and any vital signs that have been performed that shift. The Registered Nurse shall be informed of any vital signs that are abnormal and shall review the documentation of the unlicensed staff each shift...

6. The Registered Nurse shall perform a complete or modified assessment when the patient's condition warrants..."


Facility policy #PC-150b, entitled Fall Risk Program, last reviewed 6/23/14, stated in part:
"Documentation of a fall on the appropriate forms will include:...

b. Notification of the physician and family

c. Assessment of the patient

d. Vital Signs (if necessary)

e. Neuro assessment (if necessary)..."

An Austin Lakes Hospital Fall Report was included with the Fall Risk Program policy.


Facility policy #DT-122, entitled Recording Meal Intake in Medical Records, last revised 11/30/12, stated in part:

"Staff will document the percentage of meal consumed for each resident on a meal by meal basis...

1. MHTs or nursing staff covering the dining room will record the percentage eaten for each meal by each patient on the graphics page for that meal...

2. Fluids will be tallied for each meal/shift and recorded on the graphics form for each patient. MHT will record fluid intake as ml (cc) as ordered by physician..."


In an interview with Staff #2, Chief Nursing Officer, on the afternoon of 1/21/15, in the facility meeting room, she reviewed the issues noted and agreed that to be in accord with the facility policy regarding patient falls, neuro checks should have been completed on Patient #1 after the falls she sustained on 10/23/14 and 10/26/14. She also acknowledged and agreed that dietary intakes and accucheck results were incomplete in the patient charts noted above.


The above findings were confirmed in an interview with the facility Chief Executive Officer, Chief Nursing Officer and Director of Risk Management on the morning of 1/22/15 in the facility meeting room.