HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients.

Findings:

On 06/07/17 at 8:55 a.m., an observation of the inpatient psychiatric hospital at the off-site campus was made with S3DON and S4ADON. There were 2 windows observed on each side of the hallway past patient rooms 104 and 105. All 4 windows were observed to have horizontal blinds. The window on the right side of the hall located over an air condition unit was observed to have a string extending from the bottom of the blinds that was over 3 feet in length. The adjacent window was observed to have a loose string extending from the blinds approximately 1-2 feet. S3DON and S4ADON confirmed the string was present and could pose a safety hazard for suicidal/homicidal patients.

Based on record review and interview, the hospital failed to ensure the use of restraints and seclusion was in accordance with a written modification to the patient's plan of care for 2 of 2 (#9, #R4) sampled and random patients reviewed for the use of restraints out of a total sample of 13 patients.

Findings:

Review of the hospital's policy titled, Seclusion and Restraints, Policy number CS-26, effective date of 01/11/16 revealed the Treatment Team will review the occurrence and use of seclusion and restraints and modify the patient's plan of care as needed. There was no documented evidence of a provision to update the patient's treatment plan after the use of restraints and seclusion.

Patient #9
Review of the medical record for Patient #9 revealed the patient was a 61 year old admitted to the hospital on 05/16/17 with diagnoses of Bipolar Disorder and Mental Retardation. Further review revealed the patient had been admitted under a PEC dated 05/16/17 to this facility from a group home due to the patient threatening to kill the caregivers and himself.

Further review revealed Patient #9 was placed in a therapeutic hold on 05/17/17 at 4:10 a.m. and at 4:15 a.m. for being aggressive toward staff and requiring law enforcement to assist in restraining the patient. The record also revealed the patient was placed in seclusion on 05/17/17 at 7:35 a.m. for 3 hours and 15 minutes.

Review of Patient #9's plan of care revealed there had been no modification for the use of restraints or seclusion on 05/17/17.

In an interview on 06/07/17 at 11:25 a.m., S3DON and S4ADON reviewed the medical record for Patient #9 and confirmed the plan of care had not been updated to include the use of restraints and seclusion. S3DON confirmed the care plan should have been modified to reflect the use of restraints.

Based on record review and interview, the Medical Staff failed to enforce the hospital's Medical Staff Bylaws. This deficient practice was evidenced by failure of the Medical Staff to ensure Physicians/Licensed Independent Practitioners were authenticating medical records entries in accordance with Medical Staff Bylaws for 6 (#5, #7, #8, #11, #12, #13) of 13 (#1-#13) sampled patient medical records.

Findings:

Review of the Medical Staff By-laws provided by S1RegDir as current revealed in part, all clinical entries and summaries in the patient's medical record shall be accurately dated, timed and authenticated.

Patient #3
Review of the medical record for current Patient #3 revealed an admission date of 05/22/17 and a diagnosis of Dementia with Behavioral Disturbances. Review of the psychiatric evaluation dated 05/23/17 documented by S10MedDir revealed the physician had signed the document, but did not date or time his signature.
Review of the physician's orders dated 05/23/17 revealed an order to decrease Celexa. The order was documented by S10MedDir but there was no documented evidence of the time of the order.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #3 and confirmed S10MedDir did not date or time his signature on the psychiatric evaluation dated 05/23/17. S3DON confirmed the physician's order dated 05/23/17 did not have documentation of the time the order was written.

Patient #5
Review of the medical record for current Patient #5 revealed an admission date of 05/22/17 and a diagnosis of Dementia with Behavioral Disturbances. Review of the psychiatric evaluation dated 05/23/17 documented by S10MedDir revealed the physician had signed and dated the document, but did not time his signature. Review of the date documented by the physician's signature revealed the date was not legible

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #5 and confirmed S10MedDir did not time his signature on the psychiatric evaluation dated 05/23/17, and confirmed the date documented was not legible.


Patient #7
Review of the medical record for current Patient #7 revealed an admission date of 05/23/17 and a diagnosis of Dementia with Behavioral Disturbances. Review of the psychiatric evaluation dated 05/24/17 co-signed by S10MedDir revealed the physician had signed and dated the document, but did not time his signature.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #7 and confirmed S10MedDir did not time his signature on the psychiatric evaluation dated 05/24/17.


Patient #8
Review of the medical record for current Patient #8 revealed an admission date of 05/30/17 and a diagnosis of Schizophrenia. Review of the H&P dated 05/31/17 revealed S16MD had signed the H&P but failed to document the time of his signature.

In an interview on 06/07/17 at 9:45 a.m., S4ADON reviewed the medical record for Patient #8 and confirmed S16MD did not document the time the H&P was signed and dated.


Patient #11
Review of the medical record for Patient #11 revealed the patient was admitted to the hospital on 03/21/17 with a diagnosis of Bipolar Disorder. The patient was discharged on 03/28/17. Review of the discharge summary revealed the discharge summary was done by S15LPN. Further review of the discharge summary revealed S15LPN had signed the discharge summary but did not document the date or time of her signature. The discharge summary was co-signed by S10MedDir and included the date of his signature but there was no documentation of the time the discharge summary was co-signed.
Review of the physician orders dated 03/21/17 revealed S10MedDir documented orders for multiple medication changes, but there was no documented evidence of the time of the order.


Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 03/03/17 with a diagnosis of Major Depressive Disorder. The patient was discharged on 03/16/17. Review of the discharge summary revealed the discharge summary was done by S15LPN. Further review of the discharge summary revealed S15LPN had signed the discharge summary but did not document the date or time of her signature. The discharge summary was co-signed by S10MedDir but there was no documentation of the date or time the discharge summary was co-signed.

Patient #13
Review of the medical record for Patient #13 revealed the patient was admitted to the hospital on 03/06/17 with a diagnosis of Paranoid Schizophrenia. The patient was discharged on 04/13/17. Review of the discharge summary revealed the discharge summary was done by S13APRN. Further review of the discharge summary revealed S13APRN had not signed the discharge summary. The discharge summary was co-signed by S10MedDir and included the date of his signature but there was no documentation of the time the discharge summary was co-signed.
Review of the physician orders dated 03/14/17 revealed S10MedDir documented orders for multiple medication changes, but there was no documented evidence of the time of the order.

In an interview on 06/07/17 at 2:30 p.m. with S5HIM, she confirmed that she only monitored the discharge summaries for medical record completeness and did not monitor all patient medical record entries for authentication, dates, and times.

In an interview on 06/07/17 at 5:20 p.m., S1RegDir confirmed the above findings. S1RegDir confirmed S13APRN had not signed the discharge summary she dictated for Patient #13 and stated it was not considered delinquent because the physician had co-signed the discharge summary. S1RegDir confirmed the physician had not documented a time on the above orders.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by the RN failing to evaluate/score an initial suicide risk level, upon admission, for a patient (#1) who had been admitted for having suicidal ideations and death wishes for 1 (#1) of 9 (#1-#8, #10) current sampled patients reviewed for suicide risk assessments from a total of 13 sampled patients.

Findings:

Review of the hospital policy titled, "Suicide/Homicide Risk Assessment", policy number: AS-19, revealed in part: Purpose: To establish guidelines for the identification of individuals who are actively suicidal/homicidal and intervene in a manner to protect the individuals/others safety. It is the policy to assess/identify safety risks inherent in the facility's client population in identifying those clients of high risk potential for suicide/homicide. Factors and features that may increase/decrease risk will be identified and assessed to provide for the individual's safety needs and appropriate placement. Procedure: Staff responsible: Nurse/Therapist: Assess risks/protective factors as indicated in the Five Step Evaluation and Triage. Determine suicide/homicide risk level and choose appropriate intervention to address and reduce/mitigate risk. Action: Suicidality: Follow the "Suicide Assessment Five-Step Evaluation and Triage" Process: 1. Identify risk factors, 2. Identify protective factors, 3. Conduct suicide inquiry, 4. Determine risk level/intervention, and 5. Document.

Review of Patient #1's medical record revealed an admission date of 05/23/17 with an admission diagnosis of Major Depressive Disorder, recurrent, severe with psychosis. Further review revealed the patient's legal status was Formal Voluntary. Additional review revealed the reason for the patient's admission was due to symptoms of severe depression and patient having stated, "I want to die."; "I'm ready to go right now."; "I'm miserable, and ready for it to end."

Review of Patient #1's Admit orders, dated 05/23/17 at 9:30 a.m., revealed the patient was placed on close observation supervision level with every 15 minute checks on admission. Further review revealed the patient had remained on close observation with every 15 minute checks from admission to present (06/06/17).

Review of Patient #1's Psychiatric Evaluation, dated 05/25/17, revealed in part: Chief Complaint: Depression, status post admission to inpatient Geriatric Psychiatric Hospital Unit due to depression, crying, talking about wanting to die, not sleeping/eating with a marked decline in energy and difficulty in caring for self. Reason for admission: Presents as danger to self; socially withdrawn and isolated, when questioned about suicidal ideations indicated she felt hopeless, not worth living. Denies hallucinations and paranoia. Patient admits death wishes.

Review of Patient #1's Admit Nursing Assessment, dated 05/23/17 at 9:00 a.m. revealed the section of the assessment utilized to score the patient's suicide risk level as High, Moderate, or Low (scores were based on risk factors, protective factors, and suicidality) was left blank. The scores on this section of the Admit Nursing Assessment are utilized to identify patient risk factors, to determine patient suicide risk level and to establish appropriate interventions based upon identified risk level.

In an interview on 06/06/17 at 11:00 a.m. with S1RegDir (Regional Director), she confirmed the portion of Patient #1's Admit Nursing Assessment utilized to score the patient's suicide risk level as High, Moderate, or Low was left blank. S1RegDir confirmed Patient #1's Suicide Risk Level had not been scored. S1RegDir also confirmed Patient #1 had been placed on close observation level, every 15 minute checks, on admission. S1RegDir indicated Patient #1 was currently on close observation level with every 15 minute checks and had not been placed on any type of increased observation level or special precautions, except for fall precautions, since admission.

25119

Based on record review and interview, the hospital failed to ensure an accurate system was in place for identifying delinquent patient medical records. This deficient practice was evidenced by failure of the hospital to maintain an accurate list of delinquent patient medical records which included monitoring for authentication, dating, and timing of all medical record entries, to ensure completeness within 30 days of patient discharge for 3 of 3 (#11, #12, #13) sampled patient records and 1 of 1 (#R4) random discharged patient medical records reviewed out of a total sample of 13.

Findings:

Review of the hospital policy titled Medical Records, Policy number HIM-01.01, dated 01/11/16 revealed in part: Procedure for Quantitative Analysis, A chart is considered complete when the discharge summary is completed and signed, psychiatric evaluation is completed and signed by the attending physician and the physician signs all physician orders, and progress notes.

Review of the hospital policy titled Authentication, Policy number HIM-01.04, revised 02/01/17 revealed in part: 4. All entries in the patient medical record are authenticated, dated and timed by the author by either hand written or electronic signature. This includes information introduced into the medical record through transcription or dictation.

Review of the hospital policy titled Patients' Discharge Summary revealed in part: Whether delegated or non-delegated, it is expected that the person who writes the discharge summary will authenticate, date and time their entry and additionally for the delegated discharge summaries it is expected that the MD/DO responsible for the patient during his/her hospital stay to co-authenticate and date/time the discharge summary to verify its content.

Review of the hospital Medical Staff Rules and Regulations "Medical Records and Orders" revealed in part: 7. All clinical entries and summaries in the patient's medical record shall be accurately dated, timed, and authenticated.


Patient #11
Review of the medical record for Patient #11 revealed the patient was admitted to the hospital on 03/21/17 with a diagnosis of Bipolar Disorder. The patient was discharged on 03/28/17. Review of the discharge summary revealed the discharge summary was done by S15LPN with a dictation date of 04/10/17. Further review of the discharge summary revealed S15LPN had signed the discharge summary but did not document the date or time of her signature. The discharge summary was co-signed by S10MedDir and included the date of his signature but there was no documentation of the time the discharge summary was co-signed.
Review of the physician orders revealed the following:
The Admit Orders/Initial Plan of Care form dated 03/21/17 revealed a verbal order was received on 03/21/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.
The Physician Order/Admission Medication Reconciliation form dated 03/21/17 revealed a verbal order was received on 03/21/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.
The physician order dated 03/21/17 revealed S10MedDir documented orders for multiple medication changes, but there was no documented evidence of the time of the order.


Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 03/03/17 with a diagnosis of Major Depressive Disorder. The patient was discharged on 03/16/17. Review of the discharge summary revealed the discharge summary was done by S15LPN with a dictation date of 04/03/17. Further review of the discharge summary revealed S15LPN had signed the discharge summary but did not document the date or time of her signature. The discharge summary was co-signed by S10MedDir but there was no documentation of the date or time the discharge summary was co-signed.


Patient #13
Review of the medical record for Patient #13 revealed the patient was admitted to the hospital on 03/06/17 with a diagnosis of Paranoid Schizophrenia. The patient was discharged on 04/13/17. Review of the discharge summary revealed the discharge summary was done by S13APRN with a dictation date of 05/12/17. Further review of the discharge summary revealed S13APRN had not signed the discharge summary. The discharge summary was co-signed by S10MedDir and included the date of his signature but there was no documentation of the time the discharge summary was co-signed.
Review of the physician orders revealed the following:
The Admit Orders/Initial Plan of Care form dated 03/06/17 revealed a verbal order was received on 03/06/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.
The Physician Order/Admission Medication Reconciliation form dated 03/06/17 revealed a verbal order was received on 03/06/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.
The physician order dated 03/14/17 revealed S10MedDir documented orders for multiple medication changes, but there was no documented evidence of the time of the order.

In an interview on 06/07/17 at 5:20 p.m., S1RegDir confirmed the above findings. S1RegDir confirmed S13APRN had not signed the discharge summary she dictated for Patient #13 and stated it was not considered delinquent because the physician had co-signed the discharge summary. S1RegDir confirmed the physician had not documented a time on the above orders. S1RegDir confirmed the above records had not been identified as delinquent because the medical records staff was not reviewing records for timing of signatures.


Patient #R4
Review of Patient #R4's medical record revealed an admission date of 01/05/17 with an admission diagnosis of Major Depressive Disorder, recurrent, unspecified. Patient #R4 was discharged on 01/26/17.

Further review of Patient #R4's medical record revealed the following incomplete medical record entries:
Psychiatric Evaluation, dictated 01/08/17 by S17MD, authenticated by S17MD, but not dated or timed as of 06/06/17(date of chart review).
Verbal order for Seroquel taken by the nurse on 01/23/17, authenticated by S17MD, but not dated or timed as of 06/06/17(date of chart review).
Verbal order for restraints/seclusion taken by the nurse on 01/26/17 not authenticated, dated, or timed by the ordering MD (S10MedDir) as of 06/06/17(date of chart review).

In an interview on 06/06/17 at 10:30 a.m. with S1RegDir, she confirmed all orders/medical record entries should have been authenticated, dated, and signed by the Physician/Licensed Independent Practitioner.

In an interview on 06/07/17 at 9:45 a.m., S15LPN indicated she was a chart auditor at off-site campus. S15LPN indicated there were delinquent records, over 30 days incomplete at the off-site campus. S15LPN was unable to provide the number of delinquent records at the off-site campus.

Interview on 06/07/17 at 2:30 p.m. with S5HIM confirmed that she did not have a list of incomplete records. S5HIM stated that the hospital had no delinquent records past 30 days. S5HIM confirmed that she only monitored the discharge summaries for medical record completeness and did not monitor all patient medical record entries for authentication, dates and times.












30984

Based on record reviews and interviews, the hospital failed to ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing the service as evidenced by physicians not authenticating medical records entries in accordance with Medical Staff Bylaws for 7 (#3, #5, #7, #8, #11, #12, #13) of 13 (#1-#13) sampled patient medical records.

Findings:

Review of the Medical Staff By-laws provided by S1RegDir as current revealed in part, all clinical entries and summaries in the patient's medical record shall be accurately dated, timed, and authenticated.

Patient #3
Review of the medical record for current Patient #3 revealed an admission date of 05/22/17 and a diagnosis of Dementia with Behavioral Disturbances. Review of the psychiatric evaluation dated 05/23/17 documented by S10MedDir revealed the physician had signed the document, but did not date or time his signature.
Review of the physician's orders dated 05/23/17 revealed an order to decrease Celexa. The order was documented by S10MedDir but there was no documented evidence of the time of the order.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #3 and confirmed S10MedDir did not date or time his signature on the psychiatric evaluation dated 05/23/17. S3DON confirmed the physician's order dated 05/23/17 did not have documentation of the time the order was written.


Patient #5
Review of the medical record for current Patient #5 revealed an admission date of 05/22/17 and a diagnosis of Dementia with Behavioral Disturbances. Review of the psychiatric evaluation dated 05/23/17 documented by S10MedDir revealed the physician had signed and dated the document, but did not time his signature. Review of the date documented by the physician's signature revealed the date was not legible

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #5 and confirmed S10MedDir did not time his signature on the psychiatric evaluation dated 05/23/17, and confirmed the date documented was not legible.


Patient #7
Review of the medical record for current Patient #7 revealed an admission date of 05/23/17 and a diagnosis of Dementia with Behavioral Disturbances. Review of the psychiatric evaluation dated 05/24/17 co-signed by S10MedDir revealed the physician had signed and dated the document, but did not time his signature.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #7 and confirmed S10MedDir did not time his signature on the psychiatric evaluation dated 05/24/17.


Patient #8
Review of the medical record for current Patient #8 revealed an admission date of 05/30/17 and a diagnosis of Schizophrenia. Review of the H&P dated 05/31/17 revealed S16MD had signed the H&P but failed to document the time of his signature.

In an interview on 06/07/17 at 9:45 a.m., S4ADON reviewed the medical record for Patient #8 and confirmed S16MD did not document the time the H&P was signed and dated.


Patient #11
Review of the medical record for Patient #11 revealed the patient was admitted to the hospital on 03/21/17 with a diagnosis of Bipolar Disorder. The patient was discharged on 03/28/17. Review of the discharge summary revealed the discharge summary was done by S15LPN. Further review of the discharge summary revealed S15LPN had signed the discharge summary but did not document the date or time of her signature. The discharge summary was co-signed by S10MedDir and included the date of his signature but there was no documentation of the time the discharge summary was co-signed.
Review of the physician orders dated 03/21/17 revealed S10MedDir documented orders for multiple medication changes, but there was no documented evidence of the time of the order.


Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 03/03/17 with a diagnosis of Major Depressive Disorder. The patient was discharged on 03/16/17. Review of the discharge summary revealed the discharge summary was done by S15LPN. Further review of the discharge summary revealed S15LPN had signed the discharge summary but did not document the date or time of her signature. The discharge summary was co-signed by S10MedDir but there was no documentation of the date or time the discharge summary was co-signed.

Patient #13
Review of the medical record for Patient #13 revealed the patient was admitted to the hospital on 03/06/17 with a diagnosis of Paranoid Schizophrenia. The patient was discharged on 04/13/17. Review of the discharge summary revealed the discharge summary was done by S13APRN. Further review of the discharge summary revealed S13APRN had not signed the discharge summary. The discharge summary was co-signed by S10MedDir and included the date of his signature but there was no documentation of the time the discharge summary was co-signed.
Review of the physician orders dated 03/14/17 revealed S10MedDir documented orders for multiple medication changes, but there was no documented evidence of the time of the order.

In an interview on 06/07/17 at 5:20 p.m., S1RegDir confirmed the above findings. S1RegDir confirmed S13APRN had not signed the discharge summary she dictated for Patient #13 and stated it was not considered delinquent because the physician had co-signed the discharge summary. S1RegDir confirmed the physician had not documented a time on the above orders.

Based on record review and staff interview, the Hospital failed to ensure verbal orders were dated, timed, and authenticated promptly by the ordering physician in accordance medical staff bylaws, rules, and regulations for 5 of 5 (#3, #5, #7, #11, #13) sampled records reviewed for authentication of verbal orders out of a total sample of 13.

Findings:

Review of the Medical Staff Rules & Regulations revealed in part the following:
All clinical entries and summaries in the patient's medical record shall be accurately dated, timed and authenticated.
Orders dictated by telephone shall be signed by the person to who dictated with the name of the ordering medical staff member and then signed by the person to who dictated. Within 10 days the ordering medical staff member shall date and sign the orders (in accordance with LA state law R.S. 40:2144H3).

Patient #3
Review of the medical record for current Patient #3 revealed an admission date of 05/22/17 and a diagnosis of Dementia with Behavioral Disturbances.
Review of the physician orders revealed the following:
The Physician Order/Admission Medication Reconciliation form dated 05/22/17 revealed a verbal order was received on 05/22/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order. Further review of this order revealed the date documented by the physician's signature was not legible.
The Discharge Medication Reconciliation Order form revealed the physician had signed and dated the verbal order authentication but failed to document the time of authentication.
The Physician's Discharge Orders dated 06/06/17 revealed S10MedDir had signed and dated the verbal orders but failed to document the time of the authentication.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #3 and confirmed the above verbal orders had not been timed when the physician authenticated the orders. S3DON confirmed the date on the verbal order dated 05/22/17 was not legible.


Patient #5
Review of the medical record for current Patient #5 revealed an admission date of 05/22/17 and a diagnosis of Dementia with Behavioral Disturbances.
Review of the physician orders revealed the following:
The Admit Orders/Initial Plan of Care form dated 05/22/17 revealed a verbal order was received on 05/22/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order. Further review of this order revealed the date documented by the physician's signature was not legible.
The Physician Order/Admission Medication Reconciliation form dated 05/22/17 revealed a verbal order was received on 05/22/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order. Further review of the this order revealed the date documented by the physician's signature was not legible.
The Discharge Medication Reconciliation Order form revealed the physician had signed and dated the verbal order authentication but failed to document the time of authentication.
The Physician's Discharge Orders dated 06/06/17 revealed S10MedDir had signed and dated the verbal orders but failed to document the time of the authentication.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #5 and confirmed S10MedDir did not time his signature on the admission orders dated 05/22/17, and confirmed the dates documented on the authentication of the orders were not legible.


Patient #7
Review of the medical record for current Patient #7 revealed an admission date of 05/23/17 and a diagnosis of Dementia with Behavioral Disturbances.
Review of the physician orders revealed the following:
The Admit Orders/Initial Plan of Care form dated 05/23/17 revealed a verbal order was received on 05/23/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order. Further review of this order revealed the date documented by the physician's signature was not legible.
The Physician Order/Admission Medication Reconciliation form dated 05/23/17 revealed a verbal order was received on 05/23/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.

In an interview on 06/06/17 at 3:30 p.m., S3DON reviewed the medical record for Patient #7 and confirmed S10MedDir did not time his signature on the admission orders dated 05/23/17, and confirmed the date documented on the authentication of the admit order was not legible.


Patient #11
Review of the medical record for Patient #11 revealed the patient was admitted to the hospital on 03/21/17 with a diagnosis of Bipolar Disorder. The patient was discharged on 03/28/17.
Review of the physician orders revealed the following:
The Admit Orders/Initial Plan of Care form dated 03/21/17 revealed a verbal order was received on 03/21/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.
The Physician Order/Admission Medication Reconciliation form dated 03/21/17 revealed a verbal order was received on 03/21/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.

Patient #13
Review of the medical record for Patient #13 revealed the patient was admitted to the hospital on 03/06/17 with a diagnosis of Paranoid Schizophrenia. The patient was discharged on 04/13/17.
Review of the physician orders revealed the following:
The Admit Orders/Initial Plan of Care form dated 03/06/17 revealed a verbal order was received on 03/06/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.
The Physician Order/Admission Medication Reconciliation form dated 03/06/17 revealed a verbal order was received on 03/06/17. Review of the order revealed the physician had signed and dated his signature but failed to time the authentication of the verbal order.

In an interview on 06/07/17 at 5:20 p.m., S1RegDir confirmed the above findings on the medical records for Patients #11 and #13. S1RegDir confirmed the above orders were not timed when the physician authenticated the verbal orders.

Based on record review and staff interview, the hospital failed to ensure pharmaceutical services were provided that met the needs of the patient as evidenced by medications not available to be administered as ordered by the physician due to the medications were not available at the off-site campus for 8 of 8 (#R7-#R14) random sampled patients during the months of April and May 2017.

Findings:

Review of the medication variances for the months of April and May 2017 at the off-site campus revealed the following:

Patient #R7
05/20/17 at 8:06 a.m. - Patient has order for Cymbalta 20 mg daily, Med Dispense does not contain any and none was sent for patient.
05/21/17 at 8:00 a.m. - Patient has order for Cymbalta 20 mg daily, when attempting to dispense, assigned drawer does not contain Cymbalta so patient missed scheduled dose.

Patient #R8
05/20/17 at 8:13 a.m. - Patient has order for Etodalac twice a day, medication not available in Med Dispense and unavailable per pharmacy, so patient missed scheduled morning dose.

Patient #R9
05/15/17 at 2:11 p.m. - Patient has Hydrocortisone Cream ordered three times a day. At time dose was due, Hydrocortisone was out of stock in Med Dispense and not sent patient specific. Patient missed scheduled 2:00 p.m. dose.

Patient #R10
05/10/17 at 7:15 a.m. - Patient has Maxide-25 scheduled daily, medication presently unavailable in Med Dispense and has not been sent patient specific per pharmacy so patient missed today's dose.

Patient #R11
04/26/17 at 8:00 a.m., Patient has Alora Patch 0.1 mg ordered weekly every Wednesday. Patch unavailable in Med Dispense and hasn't been delivered by pharmacy.

Patient #R12
04/26/17 at 7:34 a.m. - Patient has Topamax 100 mg ordered four times a day, not stocked in Med Dispense and bag with patient specific medication is empty, so patient missed scheduled dose.

Patient #R13
04/08/17 at 12:17 p.m. - Patient has 1 gram Sodium Chloride ordered four times a day. Medication unavailable in Med Dispense and has not been delivered from Pharmacy at this time. Pharmacy notified earlier and awaiting delivery.

Patient #R14
04/05/17 at 9:00 a.m. - Lotrisone cream not available at this time.

In an interview on 06/07/17 at 12:50 p.m., S4ADON confirmed the above medication variances due to medications not available when the medication was scheduled to be administered. S4ADON stated all medications come from the contracted pharmacy. S4ADON stated they had discussed this with the pharmacist but he did not know what action was being taken to address the issue. S4ADON stated he would contact the pharmacist regarding what actions were being taken to address this issue.

In an interview on 06/07/17 at 1:15 p.m., S3DON stated she was unaware the off-site campus was having problems getting medications from the pharmacy. S3DON was requested to provide any documentation of corrective actions or plans to address the identified medication variances related to medications not available.

On 06/08/17 at 12:20 p.m., at the time of the exit conference, there was no documentation related to the medication variances and medication delivery/availability provided.

Based on record reviews, observations and interviews, the hospital failed to ensure the infection control officer developed a system for investigating and monitoring infection control practices and breaches as evidenced by:
1) Failing to ensure that staff adhered to the hospital policy when cleaning/disinfecting patient multiple-use equipment as evidenced by failing to clean a glucometer with an EPA approved disinfectant after patient use;
2) Failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures as evidenced by staff failing to perform hand hygeine after glove removal, and;
3) Failing to store cleaned patient care equipment according acceptable standards of practice as evidenced by failing to store cleaned equipment separate from soiled patient care equipment.

Findings:

1) Failing to ensure that staff adhered to the hospital policy when cleaning/disinfecting patient multiple-use equipment as evidenced by failing to clean a glucometer with an EPA approved disinfectant after patient use:

Review of the hospital's policy titled, Glucometer Method for Obtaining CBGs, Policy number NSG-26 revealed in part the following: Clean the meter between patients and per manufacturer's instructions.

Review of the manufacturer's instructions for cleaning of the hospital's glucometer revealed the glucometer should be cleaned and disinfected between each patient and the instructions listed 4 EPA registered disinfectants that were approved for cleaning and disinfecting the glucometer, including Micro-Kill.

On 06/07/17 at 11:30 a.m., an observation of a finger stick blood sugar procedure was made with S7LPN at the off-site campus. S7LPN was observed to perform a finger stick blood sugar test on Patient #R15 using a glucometer. After using the glucometer on Patient #R15, S7LPN was observed to wipe the glucometer with an alcohol pad. After wiping the glucometer with an alcohol pad, S7LPN placed the glucometer back in the case and returned to the medication room. S7LPN confirmed she had cleaned the glucometer with an alcohol pad. S7LPN stated she usually used a "micro kill" wipe but they were out of micro kill wipes at present.

In an interview on 06/08/17 at 8:05 a.m., S6PI/IC confirmed an EPA registered disinfectant should be used to clean the glucometers after each patient use. S1RegDir was present for the interview and stated the order of Micro-Kill wipes came in yesterday and indicated the staff at the off-site campus could have obtained the disinfectant wipes from the main campus until their order was delivered.



2) Failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures as evidenced by staff failing to perform hand hygiene after glove removal:

On 06/07/17 at 11:30 a.m., an observation of a finger stick blood sugar procedure was made with S7LPN at the off-site campus. S7LPN was observed to perform a finger stick blood sugar test on Patient #R15 using a glucometer with disposable gloves on. After completing the procedure, S7LPN was observed to remove the gloves and dispose of the gloves. S7LPN was observed to return to the medication room, document on the MAR, and then remove a bottle of insulin from the refrigerator. S7LPN then prepared an insulin injection. S7LPN was observed to not perform hand hygiene after removal of her gloves. S7LPN confirmed she had not washed her hands or used hand sanitizer after removal of her gloves.

In an interview on 06/08/17 at 8:05 a.m., S6PI/IC confirmed hand hygeine was required after removal of disposable gloves and confirmed S7LPN should have washed her hands after the removal of the disposable gloves and before she began another task or procedure.


3) Failing to store cleaned patient care equipment according to acceptable standards of practice as evidenced by failing to store cleaned equipment separate from soiled patient care equipment:

On 06/07/17 at 11:30 a.m., an observation of the storage room for patient care equipment revealed multiple walkers, bed side commode chairs, oxygen concentrators, and a geri chair were covered and dated. Also stored in the room were 2 wheel chairs, not covered. S4ADON was present for the observation and confirmed the above findings. S4ADON stated all clean equipment was bagged and dated when cleaned. S4ADON confirmed the wheelchairs were not bagged and he was unable to confirm if the wheel chairs had been cleaned.

25119

Based on record review and staff interview, the Hospital failed to ensure patient History and Physical examination documentation included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 5 of 5 (#1, #2, #3, #4, #5) sampled patients and 2 of 2 (#R2, #R3) random patients reviewed for neurological assessments out of a total sample of 13. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.

Findings:

Review of hospital policy titled Assessment Process, Policy number AS-02, dated 01/11/2016 revealed in part: The Physician or Assistant conducts a physical examination within 24 hours of admission which includes a review of systems and a neurological evaluation of cranial nerves I-XII.


Patient #1
A review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 05/23/17 with a diagnosis of Major Depressive Disorder. The History and Physical dated 05/23/17 revealed the neurological assessment of cranial nerves was indicated by a vertical line drawn through "normal" adjacent to cranial nerves II through XII. Further review revealed no documentation to indicate how Patient #1's cranial nerve function had been assessed for cranial nerves II-XII.

Patient #2
A review of the medical record for Patient #2 revealed the patient was admitted to the hospital on 05/25/17 with diagnoses of Depression, and Aggressive Behavior. The History and Physical dated 05/26/17 performed by S12MD did not have any documentation to support Neurological cranial nerves I-XII were assessed for Patient #2.

Patient #3
Review of the medical record for current Patient #3 revealed the patient was admitted to the hospital on 05/22/17 with a diagnosis of Dementia with Behavioral Disturbances. Review of the H&P dated 05/23/17, documented by S11MD, revealed the neurological assessment of cranial nerves indicated a vertical line drawn through "normal" adjacent to cranial nerves II through XII. "No formal test done" was documented beside the cranial nerves. There was no documented evidence of how the cranial nerve function was assessed.

In an interview on 06/06/17 at 3:20 p.m., S1RegDir and S2ClinDir confirmed there was no documented evidence of how the patients' cranial nerve function had been assessed.

Patient #4
A review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 05/31/17 with diagnoses of Depression, Dementia, and Alzheimer's. The History and Physical dated 06/01/17 performed by S12MD did not have any documentation to support the Neurological cranial nerves were assessed for Patient #4.

Patient #5
Review of the medical record for current Patient #5 revealed the patient was admitted to the hospital on 05/22/17 with a diagnosis of Dementia with Behavioral Disturbances. Review of the H&P dated 05/23/17, documented by S11MD, revealed the neurological assessment of cranial nerves indicated a vertical line drawn through "normal" adjacent to cranial nerves II through XII. "No formal test done" was documented beside the cranial nerves. There was no documented evidence of how the cranial nerve function was assessed.

In an interview on 06/06/17 at 3:20 p.m., S1RegDir and S2ClinDir confirmed there was no documented evidence of how the patient's cranial nerve function was assessed. Both confirmed there should be documentation of how the cranial nerve function was assessed.

Patient #R2
A review of the medical record for Patient #R2 revealed the patient was admitted to the hospital on 05/19/17 with a diagnosis of Major Depression with psychosis. The History and Physical dated 05/20/17 revealed the neurological assessment of cranial nerves was indicated by a vertical line drawn through "normal" adjacent to cranial nerves II through XII. Further review revealed no documentation to indicate how Patient #R2's cranial nerve function had been assessed for cranial nerves II-XII.

Patient #R3
A review of the medical record for Patient #R3 revealed the patient was admitted to the hospital on 04/28/17 with diagnoses of Schizophrenia, and Psychosis. Patient #R3 was admitted to the hospital from a long term care facility for increased confusion and agitation and confrontational with staff. The History and Physical dated 04/28/17 performed by S12MD did not have any documentation to support the Neurological cranial nerves were assessed for Patient #R3.

Interview on 06/07/17 at 11:40 a.m. with S2ClinDir confirmed the neurological part of the History and Physical should be completed and filled out on all admissions.






30984

25119

Based on record review and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's strengths/assets in a descriptive manner and not in an interpretive fashion for 5 (#1, #2, #3, #4, #5) of 5 sampled patient records and 2 of 2 (#R2, #R3) random patient records reviewed for strengths/assets in the psychiatric evaluation out of a total of 13 (#1-#13) sampled patient medical records.

Findings:

Review of the hospital's policy titled, Psychiatric Evaluation, Policy number AS-03 revealed the Psychiatrist/LIP would identify specific patient strengths and assets to enable the multidisciplinary treatment team to choose treatment modalities that best utilize these strengths and assets in patient's treatment.

Patient #1
A review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 05/23/17 with a diagnosis of Major Depressive Disorder.

A review of the psychiatric evaluation dated 05/25/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #1 were, "verbal and motivated". There was no documented evidence of any individualized personal strengths that could be utilized in the development of Patient #1's treatment plan.

Patient #2
A review of the medical record for Patient #2 revealed the patient was admitted to the hospital on 05/25/17 with diagnoses of Depression and Aggressive Behavior.

A review of the psychiatric evaluation dated 05/26/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #2 were, "verbal, independent, and good family support". There was no documented evidence of any individualized personal strengths that could be utilized in the development of Patient #2's treatment plan.

Patient #3
A review of the medical record for current Patient #3 revealed the patient was admitted to the hospital on 05/22/17 with a diagnosis of Dementia with Behavioral Disturbances.

A review of the psychiatric evaluation dated 05/23/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #3 were, "Verbal, Motivated, and Consented family". There was no documented evidence of any individualized personal strengths that could be utilized in the development of Patient #3's treatment plan.

In an interview on 06/06/17 at 3:20 p.m., S1RegDir and S2ClinDir reviewed the medical record for Patient #3 and confirmed the identified patient strengths in the psychiatric evaluation were not individualized and confirmed patient strengths/assets should be individualized and be useful personal factors to base the treatment plan on.


Patient #4
A review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 05/31/17 with diagnoses of Depression, Dementia, and Alzheimer's.

A review of the psychiatric evaluation dated 05/26/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #4 were, "verbal, motivated, concerning family". There was no documented evidence of any individualized personal strengths that could be utilized in the development of patient #4's treatment plan.


Patient #5
A review of the medical record for current Patient #5 revealed the patient was admitted to the hospital on 05/22/17 with a diagnosis of Dementia with Behavioral Disturbances.

A review of the psychiatric evaluation dated 05/23/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #5 were, "Verbal, Motivated, Lives in nursing home". There was no documented evidence of any individualized personal strengths that could be utilized in the development of Patient #5's treatment plan.

In an interview on 06/06/17 at 3:20 p.m., S1RegDir and S2ClinDir reviewed the medical record for Patient #5 and confirmed the identified patient strengths in the psychiatric evaluation were not individualized and confirmed patient strengths/assets should be individualized and be useful personal factors to base the treatment plan on.


Patient #R2
A review of the medical record for Patient #R2 revealed the patient was admitted to the hospital on 05/19/17 with a diagnosis of Major Depression with psychosis.

A review of the psychiatric evaluation dated 05/21/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #R2 were, "verbal, motivated, and good family support". There was no documented evidence of any individualized personal strengths that could be utilized in the development of Patient #R2's treatment plan.

Patient #R3
A review of the medical record for Patient #R3 revealed the patient was admitted to the hospital on 04/28/17 with diagnoses of Schizophrenia and Psychosis.

A review of the psychiatric evaluation dated 05/26/17 by S10MedDir revealed the only strengths and assets identified and documented for Patient #R3 were, "verbal, accepting of treatment, nursing home resident". There was no documented evidence of any individualized personal strengths that could be utilized in the development of Patient #R3's treatment plan.

Interview on 06/07/17 at 2:30 p.m. with S1RegDir confirmed that she was aware of the documentation issues with the psychiatric evaluations of the patient's strengths/assets not being individualized.






30984

Based on record review and staff interview, the facility failed to ensure that patient discharge summaries contained an individualized recapitulation of the patient's hospitalization indicating the individual treatment plan goals that were met for 3 of 3 (#11, #12, #13) sampled discharged patients reviewed for discharge summaries out of a total sample of 13. Failure to complete discharge summaries for patients being discharged compromises communication with future clinicians, and can result in inadequate provision of follow-up care for patients.

Findings:

Review of the hospital policy titled, Patients' Discharge Summary, Policy number HIM-01.12, revealed in part the following: The discharge summary will contain the following information: 4. Course and progress in the hospital - include mental status at admission, target symptoms, address treatment modalities utilized, response to treatment, adverse or unexpected results of treatment, special treatment procedures used, and patient's role in the treatment process....

Patient #11
Review of the medical record for Patient #11 revealed the patient was admitted to the hospital on 03/21/17 with a diagnosis of Bipolar Disorder. The patient was discharged on 03/28/17. Review of the discharge summary revealed the following: "The patient tolerated the medication changes, no adverse effects. She began to have some positive responses to the medication changes, as well as to the treatment program. Throughout the hospital course, the patient was educated regarding the biological aspects of her disorder. Individual and group therapy did focus on disease process, symptoms management, positive coping skills, and leisure skills while the nursing groups did focus on medication education, importance of medication compliance. Staff provided much positive redirection, and emotional support. As the treatment course progressed, patient slowly began to display an improved mood and affect as well as improved thought processes. It was noted by staff that her interaction and participation did increase on a daily basis. She remained compliant with the medication and her ADLs. Her sleep and appetite pattern, as well as energy level, motivation all continued to improve. The patient did achieve maximum benefits of inpatient hospitalization at this level of functioning and she was discharged...."

Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 03/03/17 with a diagnosis of Major Depressive Disorder. The patient was discharged on 03/16/17. Review of the discharge summary revealed the following: "Now the patient continued to tolerate the medication changes with no adverse effects and she began to have some positive responses to the medication changes as well as to the treatment program. Throughout the hospital course, the patient was educated regarding the biological aspects of her disorder. Individual and group therapy did focus on disease process, symptoms management, positive coping skills, and leisure skills while the nursing groups did focus on medication education, and importance of medication compliance. Staff provided much positive redirection, and emotional support. As the treatment course progressed, patient slowly began to display an improved mood and affect as well as improved thought processes. It was noted by staff that her interactions and participations did increase on a daily basis. She remained compliant with her medications and her ADLs. Her sleep and appetite pattern, as well as energy level and motivation all continued to improve. The patient did achieve maximum benefits of inpatient hospitalization at this level of functioning and she was discharged...."

Patient #13
Review of the medical record for Patient #13 revealed the patient was admitted to the hospital on 03/06/17 with a diagnosis of Paranoid Schizophrenia. The patient was discharged on 04/13/17. Review of the discharge summary revealed the following: "The patient tolerated all of these medication changes with no adverse effects and slowly began to show a positive response to the medications and to the treatment program. During hospitalization, the patient was educated regarding the dynamic aspects of his disorder. Individual and group psychotherapy sessions focused on disease process, symptoms management, effective coping skills, healthy living skills, and leisure skills. A family meeting was ordered to educate his support system on these things as well. Nursing groups focused on medications and the importance of both medication and treatment compliance. As the treatment course progressed, the patient slowly began to display an improved affect and mood and improved thought processes. It was noted by staff that the patient's interactions and participation increased on a daily basis. He was compliant with his ADLs. Sleep and appetite patterns, energy levels and motivation all continued to improve. The patient achieved maximum benefits of inpatient hospitalization. At this level of functioning, the patient was discharged...."

Review of the above recapitulation of the patients' hospitalization revealed the same verbiage for all 3 patients. There was no documented evidence of an individualized recapitulation of the patient's individual treatment goals that were met. There was no documented evidence of the patient's individual responses to the treatment provided.

In an interview on 06/08/17 at 12:15 p.m., S1RegDir confirmed the above findings. S1RegDir confirmed the discharge summary should include the patient's individual response to treatment and treatment planning goals that were met.