HospitalInspections.org

Based on review of documentation and interviews, it was determined that Hospital Nursing staff failed to:
1.) consistently document specific self-injurious behaviors (SIBs) exhibited by Patient #1 during his/her 7/22-8/7/10 hospitalization.
2.) consistently document interventions taken to address Patient #1's specific SIBs during his/her 7/22-8/7/10 hospitalization.
3.) document indicated full skin assessments on Patient #1 during his/her 7/22-8/7/10 hospitalization.
4.) document the exact time of medication administration for 6 of 6 applicable patients sampled.

Findings include:

Multidisciplinary Progress Notes dated 7/22-8/7/10 indicated that Patient #1 had a severe developmental disability and a very severe obsessive-compulsive disorder (a disorder characterized by recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress) and akathisia (an inability to sit down because the thought of doing so causes severe anxiety) with SIBs that were resistant to treatment. Patient #1 was on constant one-to-one (1:1) observation. Efforts were made to treat his/her obsessive-compulsive disorder (OCD) and akathisia and to redirect or distract him/her from OCD and SIBs, but they were only minimally effective. SIBs included forceful forehead rubbing, forehead slapping, head-banging, hand biting, wrist biting, rectal digging, scratching, pica (an eating disorder characterized by a craving to ingest material not fit for food) and dropping to and rolling around on the floor.

1.) The frequency of each of Patient #1's SIBs could not be determined because recorded SIB events throughout Patient #1's 7/22-8/7/10 medical record (Multidisciplinary Progress Notes, 1:1 Constant Observation Records and/or Treatment Plans) did not consistently describe the SIB(s). Documentation frequently read: SIBX1, SIBX2, SIBX3, etc.

2.) The interventions taken to address Patient #1's specific SIBs during his/her 7/22-8/7/10 hospitalization were not consistently documented.

3.) Admission Assessment documentation dated 7/22/10 indicated that Patient #1 was admitted with red marks on his/her forehead from rubbing. Admission Assessment documentation did not include a full skin assessment.

Mental Health Specialist (MHS) #6 was interviewed in person on 12/13/11 at 3:40 P.M. MHS #6 said that Patient #1 was admitted to the Hospital with bruises.

Multidisciplinary Progress Notes and 1:1 Constant Observation Records dated 7/23-8/7/10 indicated that Patient #1 was often restless and often had OCD and SIBs. OCD behaviors included stripping/re-dressing. Patient #1 often refused to re-dress and would lie on the floor naked. Periodic full skin assessments were not documented.

A Nursing Progress Noted dated and timed 7/25/10, 9:30 P.M. indicated that Patient #1 was very skinny and had sores on his/her body. The sores were not described.

A Nursing Progress Note dated and timed 7/26/10, 5:25 A.M. indicated that Patient #1 was noted to have numerous red areas on his/her back, buttocks and legs that had not been there the morning before. The nurse indicated the red marks looked like friction burns and were probably due to Patient #1 constantly lying on the floor and rubbing his/her skin. The red areas were not open.

A Physician Progress Note completed by the Attending Psychiatrist on 7/26/10 at 12:05 P.M. indicated that Patient #1 had several areas of redness on pressure points (bony prominences).

A Nursing Progress Note dated and timed 7/29/10, 3:40 P.M. indicated that Patient #1 was noted to have abrasions on his/her forehead apparently from rubbing against the padding in the Quiet Room.

MHS #1 was interviewed in person on 12/13/11 at 2:45 P.M. MHS #1 said that Patient #1 had bruises and/or friction marks secondary to rolling around on the floor and a reddened forehead from rubbing. He could not recall the locations of the bruises/friction marks.

MHS #2 was interviewed in person on 12/13/11 at 3:00 P.M. MHS #2 said that Patient #1 had bruises from rolling around on the floor. He could not recall the locations of the bruises/friction marks.

MHS #3 was interviewed in person on 12/13/11 at 3:15 P.M. MHS #3 said that Patient #1 had bruising secondary to throwing himself/herself to the floor, rubbing his/her forehead and scratching. She also said that Patient #1 had pressure marks from lying on the floor. MHS #3 could not recall the locations of the all bruises/pressure marks, but said Patient #1 had 1 rather large bruise on his/her buttocks.

A Nursing Progress Note dated 8/3/10 indicated that a red area was noted on Patient #1's right buttock.

A Physician Progress Note completed by the Attending Psychiatrist on 8/6/10 at 9:30 A.M. indicated that Patient #1 had several ecchymotic (black & blue bruises) areas all over his/her body.

Physician Orders dated 8/6/10 and Medication Administration Records (MARs) dated 8/7/10 indicated that Patient #1 was started on an antibiotic and Motrin for a right hand cellulitis (a skin/subcutaneous tissue infection).

A Nursing Progress Note dated and timed 8/7/10, 5:00 P.M. indicated that Patient #1 was directed to the Quiet Room because he/she kept attempting to put the mattress on the bed and kept falling down on his/her buttocks and hitting the heater.

MHS #9 was interviewed in person on 12/14/11 at 10:50 A.M. MHS #9 said that Patient #1 had multiple bruises secondary to dropping to the floor and biting himself/herself.

Registered Nurse (RN) #2 was interviewed by telephone on 12/19/11 at 4:30 P.M. RN #2 said that Patient #1 had some bruising on his/her extremities and back secondary to rolling around on the floor.

Documentation obtained from Hospital #2 indicated that Patient #1 arrived in the Hospital #2 Emergency Department at 7:04 P.M. on 8/7/10. A Skin Assessment performed at Hospital #2 on 8/7/10 indicated Patient #1 had the following: 1.) an abrasion and bruise on the forehead, 2.) an ecchymotic area on the right inner groin, 3.) an ecchymotic area on the right upper thigh, 4.) an ecchymotic area on the right upper knee, 5.) an ecchymotic area on the right lower knee, 6.) an ecchymotic area on the left knee, 7.) a ecchymotic area on the left shin and 8.) a bruise on the right inner buttock.

4.) A review of Patient #1's MARs for the time period of 7/22-8/7/10 indicated that the exact times of the administration of scheduled medications were not documented.

The Hospital's Medication Administration Policy/Procedure did not indicate that the time of administration of scheduled medications needed to be documented.

According to the United States Department of Health and Human Services the 5 rights, as an important goal for safe medication practices include: 1.) the right patient, 2.) the right drug, 3.) the right dose, 4.) the right route and 5.) the right time. The 5 Right's form the foundation for safe medication administration and error reduction.

The Hospital's Interim Chief Executive Officer (CEO) was interviewed in person on 12/14/11 at 8:00 A.M. The Interim CEO said the exact time of the administration of scheduled medication did not need to be documented as long as the medication was administered within 1/2 hour of the scheduled time.

A Medical Transfer Progress Note dated 8/1/10 indicated that Patient #1 was administered medications scheduled for 9:00 P.M. and/or bedtime around 7:35 P.M. The medications included 4 medications with sedating effects (Trazodone, Trileptal, Klonopin and Neurontin). Patient #1's 8/1/10 MAR did not indicate the 9:00 P.M. and/or bedtime medications were administered at 7:35 P.M.

A review of Patient #2's 10/14-11/4/11 MARs indicated that the exact times of the administration of scheduled medications were not documented. There was no way to determine if the medications were administered within 1/2 hour of the scheduled times.

A review of Patient #3's 11/14-12/1/11 MARs indicated that the exact times of the administration of scheduled medications were not documented. There was no way to determine if the medications were administered within 1/2 hour of the scheduled times.

A review of Patient #4's 10/8-12/7/11 MARs indicated that the exact times of the administration of scheduled medications were not documented. There was no way to determine if the medications were administered within 1/2 hour of the scheduled times.

A review of Patient #5's 10/31-12/8/11 MARs indicated that the exact times of the administration of scheduled medications were not documented. There was no way to determine if the medications were administered within 1/2 hour of the scheduled times.

A review of Patient #6's 11/14-12/12/11 MARs indicated that the exact times of the administration of scheduled medications were not documented. There was no way to determine if the medications were administered within 1/2 hour of the scheduled times.