HospitalInspections.org

Based on document/record review and staff interview it was determined in 7 of 10 patients (Pt #3, 4, 5, 6, 8, 9, and 10) on the Psychiatric Unit, the Hospital failed to ensure those patients were weighed on admission then every Wednesday and Saturday per physician order.
Findings include:
1. The medical record of Pt #3 was reviewed on 3/11/15 at 10:00 AM. Pt #3 was admitted on 2/7/15 with a diagnosis of dementia/behavioral disturbance. Physician order dated 2/7/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 2/18/15 (Wednesday) or 2/21/15 (Saturday).
2. The medical record of Pt #4 was reviewed on 3/11/15 at 10:15 AM. Pt #4 was admitted on 3/6/15 with a diagnosis of depressive disorder. Physician order dated 3/6/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 3/7/15 (Saturday).
3. The medical record of Pt #5 was reviewed on 3/11/15 at 10:20 AM. Pt #5 was admitted on 3/3/15 with a diagnosis of major depressive disorder. Physician order dated 3/3/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 3/7/15 (Saturday).

4. The medical record of Pt #6 was reviewed on 3/11/15 at 10:25 AM. Pt #6 was admitted on 2/23/15 with a diagnosis of major depressive disorder. Physician order dated 2/23/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 2/28/15 (Saturday).

5. The medical record of Pt #8 was reviewed on 3/11/15 at 10:30 AM. Pt #8 was admitted on 2/10/15 with a diagnosis of schizophrenia. Physician order dated 2/10/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 2/11/15, 2/18/15 (Wednesday) and 2/21/15, 2/28/15 (Saturday).

6. The medicall record of Pt #9 was reviewed on 3/11/15 at 10:35 AM. Pt #9 was admitted on 3/3/15 with a diagnosis of depressive disorder. Physician order dated 3/3/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 3/4/15 (Wednesday).

7. The medical record of Pt #10 was reviewed on 3/11/15 at 10:40 AM. Pt #10 was admitted on 2/16/15 with a diagnosis of bipolar disorder. Physician order dated 2/16/15 required the patient to be weighed on admission then every Wednesday and Saturday. There is no documentation to indicate patient was weighed on 2/18/15 (Wednesday) and 2/28/15 (Saturday).

8. On 3/11/15 at 11:00 AM an interview with the Director of Behavioral Health (E #7) was conducted. E #7 verbalized that patients' weights had not been documented in the clinical record and stated "they should have been done on as ordered by the physician (On admission then Wednesdays and Saturdays).

Based on document/record review and staff interview it was determined in 1 of 10 patients (Pt #1) on the Psychiatric Unit, the Hospital failed to update patient's care plan in response to changes in the patient's condition.

Findings include:

1. On 3/9/15, at 11:00 AM the electronic medical record of patient #1 was reviewed with the Director of Behavioral Health (E #7). The medical record revealed the patient was voluntarily admitted to Harrisburg Medical Center Psychiatric Unit (Mulberry Center) on 1/24/15 with a principal diagnosis of schizoaffective disorder and secondary diagnoses of type II diabetes mellitus, lower extremity lymphedema with stasis changes, hypothyroidism, hypertension and obesity, resolving. Documentation on the "Initial Orders Sheet" dated 1/24/15 at 00:42 AM, which was included in the plan of care, required the patient to be weighed on admission then every Wednesday and Saturday. On admission the patient's weight was documented as 177 pounds. The patient summary sheet with encounter dates from 01/24/15 (admission) through 02/17/15 (discharge) showed the patient's weight on discharge to be 310 pounds, a net gain of 133 pounds. There is no documentation to indicate nursing staff notified the physician of the patients change in condition. There is also no documentation to indicate the physician detected the patients change in medical condition or responded with interventions, updated or revised the patient's plan of care. All documentation indicated the staff focused on the patients needs related to the primary diagnosis (psychiatric) and no interventions were initiated for the patients weight gain.

2. On 2/11/15 at 2:00 PM the Hospital policy "Reporting Patient's Change of Condition" effective 1/29/04 was reviewed. Under parapgraph one it reads "The nursing staff will notify the attending physician (or physician on-call for an attending physician) for the following.....(6th bullet statement) "When the patient's needs requires a medication or treatment change."

3. On 3/11/15 at 12:00 PM an interview with the medical doctor (E #5) was conducted. E #5 verbalized that his physician's assistant or nurse practitioner make rounds at least once a day in the psychiatric unit. " I make rounds on the weekends." " I didn't know anything about his weight gain. " E #5 verbalized that "Common sense makes this impossible. Whether its caloric or fluid, to gain this much weight in the allotted time is impossible." "He was a psych patient."

4. On 3/11/15 at 12:00 PM an interview with the Director of Behavioral Health (E #6)was conducted. E #6 verbalized that he agreed the documentation in the medical record did not indicate nursing staff reacted to the patients weight gain or notify the physician. "I was never notified by my staff of the changes in patients condition." He also verbalized the physician or the psychiatrist should have been notified and changes to the care plan should have been made accordingly.