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Based on observation, interview, and record review, the facility failed to ensure all patients were housed in a state licensed bed.

As a result, 1 of 111 patients was housed in a seclusion room that was not a state licensed bed.

Findings:

During the Adult Unit ICU tour conducted on 6/3/15 at 8:50 A.M., the seclusion room was observed. The bed was unmade and there were patient clothes lying around the room.

During an interview on 6/3/15 at 9:35 A.M., RN 11 stated Patient 11 occupied the seclusion room. RN 11 said Patient 11 had been in the seclusion room for days because he tried to hit a peer, but that Patient 11 could come and go into the seclusion room as he pleased. RN 11 said Patient 11's licensed bed was room 227.

When room 227 was approached, there was a small sign outside the door with a female name on it. RN 11 stated there was a female patient in the room. RN 11 said there was no male bed available for Patient 11 but they blocked off 227-A for him. RN 11 said Patient 11 could not go into 227 if he wanted to leave the seclusion room. RN11 further stated that Patient 11 would have to remain in the seclusion room until a bed was available.

On 6/3/15 at 12:50 P.M. the CNO was interviewed. The CNO stated, "It is a comfort room." The CNO also stated, "It's a room more quiet for him." The CNO further said she did not know how long he had been assigned in the seclusion room and that the seclusion room was not a licensed bed.

On 6/3/15 at 1:05 P.M. RN 12 stated, "Patient 11 is in the seclusion room." RN 12 stated, "It is the seclusion and restraint room but we rarely use it for that." RN 12 also stated that it is "not infrequent" that a patient is housed in the seclusion room.

The census sheet for the Adult ICU was reviewed. The licensed bed capacity for the unit was 27 patients. Patients listed on the unit were 27. Patient 11 a male patient was listed on the census sheet as the occupant of the seclusion room. The room listed as being blocked off, was occupied by a female patient in 1 of 2 beds.

A computer generated transfer sheet was reviewed. Patient 11 was admitted to room 224-A on 5/27/15. On 5/30/15 Patient 11 was transferred to room XYZ (a Seclusion/Restraint Room), which is not a licensed patient bed.

Based on interview and record review, the facility failed to ensure 1 of 32 sampled patient's (12) received the correct name and telephone number regarding the patient rights notice from Medicare.

As a result, a form titled, "Important Message from Medicare About Your Rights" had the wrong Quality Improvement Organization name and telephone number, thus, there was a potential for a patient to be unable to exercise his/her rights for the appeal process.

Findings:

Patient 12 was admitted to the facility on 2/21/15. On 2/22/15 at 10:18 A.M., Patient 12 signed a form CMS-R-193 titled, An Important Message From Medicare About Your Rights.

On 6/4/15 at 1:55 P.M. RN 13 called the phone number that was listed on the form to direct a patient in the appeal process. RN 13 stated there was a recording stating the phone had not been set up. RN 13 stated the phone number on the form was incorrect.

On 6/4/15 at 1:56 P.M. RN 14 called the phone number that was listed on the form. RN 14 stated there was a recording stating the phone had not been set up. RN 14 stated the phone number on the form was incorrect.

RN 13 and RN 14 stated the form is provided to the patient by the admissions department/business office.

On 6/4/15 at 4:15 P.M. the Utilization Review Manager (URM) was interviewed. The URM stated the form was given to the patient by the business office and the form signed by Patient 12 was an old form. The URM acknowledged the importance of ensuring patients received the correct information in order to exercise their appeal rights if they choose.

Based on interview and record review, the facility failed to ensure that staff conducted patient observation rounds for 1 of 32 sampled patients (Patient 1) and three non-sampled patients (Patients 33,34, 35), per their policy and procedure. As a result, there was a potential for the patients' immediate safety to be jeopardized.

Findings:

During a document review of the patient Day Shift Rounds ("CLOSE WATCH") form dated 5/20/15, the boxes next to Patient 1, 33, 34, and 35's names under the "1300"
(1 P.M.) column were blank and had no location code entered in the boxes. According to the "Code" key on the rounds document, the code indicated the location of each patient during 15-minute interval checks. In addition, printed at the bottom of the rounds document was, "NOTE: ROUTINE OBSERVATION INCLUDES VISUALIZATION OF PATIENT."

When interviewed on 6/3/15 at 4 P.M., Registered Nurse 1 (RN) said staff conducted patient rounds every 15 minutes. She said staff were required to visualize each patient and enter a location code in each box on the Shift Rounds document, next to the patient's name, and under each designated 15-minute time slot. RN 1 said she had conducted patient rounds beginning at 11:30 A.M. on 5/20/15 and ended at 1 P.M., however, she did not know why there were no documented location codes to indicate she visualized Patients 1, 33, 34, and 35 at 1 P.M. RN 1 stated she could not remember if she communicated to the next staff member assigned to conduct rounds, whether or not she visualized the 4 patients.

When interviewed on 6/4/15 at 1:22 P.M, RN 2 stated he was assigned to conduct day shift patient rounds after RN 1 on 5/20/15 at 1:15 P.M. RN 2 said he could not remember if RN 1 communicated any information to him indicating she had not visualized Patients 1, 33, 34, and 35 during the 1 P.M. patient rounds. RN 2 stated he had not noticed the blank boxes next to the 4 patients' names under the 1 P.M. column when he began the patient rounds.

During an interview at 1:35 P.M. on 6/4/15, Administrative Nurse 1 (AN) stated staff was expected to conduct patient rounds every 15 minutes, visualize each patient, and document under each 15-minute interval the location of each patient using the appropriate location code, as listed on the Day Shift Rounds form. AN 1 stated she expected "all blanks to be filled in," and that the assigned rounding staff carried the Shift Rounds form when conducting the patient rounds. AN 1 said she also expected assigned rounding staff to communicate to each other immediately if they were unable to complete the rounding of all patients, or if a patient could not be found.

According to the facility's policy and procedure entitled Levels of Patient Observation
(#32084.99), reviewed on 5/13, Section II-C directed the assigned staff member to "...visualize the patient on Close Watch (CW) every fifteen minutes, including during group sessions and unit activities. The patient's location is documented at 15-minute intervals." Additionally, Section II-H also directed the responsible staff member to "...include visualization of the patient ...validating the patient's immediate safety."

Based on observation, interview, and record review, the facility failed to safe guard patient confidential information on 2 of 6 unit white boards.

As a result, patient confidential information was viewable by unauthorized persons.

Findings:

On 6/2/15 at 11:25 A.M. upon exiting the elevator to enter the CAP 3 unit, the nurses station was in front of the elevator. The nurses station's back wall had a large white board that was lined for patient room, patient name. Also on the white board by each patient name were the following: program, physician, and voluntary or legal hold status. Anyone getting off the elevator could easily read patient information.

On 6/3/15 Intensive Care Unit (ICU) was entered. Inside of the nurses station was a large white board. On the white board were patients names, physician, program, and admission status. The white board was easily read from outside of the nurses station.

RN12 stated during an interview on 6/3/15 at 1:55 P.M., the patient's physician, program, and admission status could never be given out without the permission of the patient. RN 12 further stated, "That is confidential information and you can get into trouble if you disclose it without their permission."

The Director of Regulatory Affairs stated on 6/4/15 at 1:05 P.M., she thought the only information posted were patient names and further said she was unaware confidential information was also posted.

According to the facility's policy and procedure, dated 9/14, Confidentiality of Information, "Viewing or obtaining sensitive information not needed for an assigned or professionally appropriate task constitutes a violation of confidentiality. Individuals may not: Display patient specific or diagnosis, specific information in public view (i.e. white boards...)"

Based on observation, interview, and record review, the facility failed to replace 9 of 83 bathroom faucets that were identified in 2014 as a ligature safety hazard.

As a result, patients admitted with suicidal tendencies were potentially at risk for a serious suicide attempt.

Findings:

On 6/3/15 at 12:15 P.M., the CAP 3 unit was toured. Nine patient bathrooms had faucet knobs that were not ligature safe. The faucet knobs had enough clearance for something to be tied around them and held in place without slippage.

On 6/4/15 at 9:55 A.M. the Director of Regulatory Affairs was interviewed. The Director of Regulatory Affairs stated the faucets were identified as a safety risk a long time ago and that 74 had been replaced.

On 6/4/15 at 10:05 The environmental program was reviewed jointly with the Director of Regulatory Affairs. The ligature risk faucets were identified in 2013 and 2014. The date listed for completion of replacing the faucets was 12/2015.

Based on interview and record review, the facility failed to ensure nursing staff conducted and documented skin reassessments, and communicated information related to patient behavior to other members of the health care team, for 1 of 32 sampled patients (Patient 1.) In addition, the facility failed to ensure social work staff documented and communicated information related to patient behavior, for 1 of 32 sampled patients (Patient 1). As a result, relevant information required to provide a current and coordinated interdisciplinary plan of care was not available to the patient's health care team.

Findings:

The Department entered the facility on 5/29/15 to initiate a Complaint Validation Survey related to a facility reported incident. On 5/26/15, the facility reported that Patient 1 was found hanging in his bathroom on 5/20/15. According to the ICU physician's Discharge Summary dated 5/27/15, the patient was in cardiac arrest when found, resuscitated, and transferred to the Intensive Care Unit (ICU) of the general acute care facility. Patient 1 had severe anoxic brain injury (injury to the brain caused by lack of oxygen), which progressed to brain death. The patient expired on 5/24/15.

a. The facility initially admitted Patient 1 from a group home (an intensive two week residential treatment program that focused on treatment of issues to include, anxiety, depression, self harm, and suicidal ideation) on 4/30/15, due to chief complaints of increased depression, anxiety, ongoing self-injurious behavior over his arms and thighs, and suicidal ideation, per the History and Physical (H&P) dated 4/30/15. On 5/7/15, the patient returned to the group home for continued treatment, per the Discharge Summary dated 5/7/15.

According to the H&P dated 5/17/15, Patient 1 had a history of self-injurious behavior, and expressed to the staff at the group home that he had suicidal thoughts such as using a knife to harm himself or walk into traffic. The patient was brought to the Emergency Department for evaluation, then, was sent to the facility.

The facility re-admitted Patient 1 on 5/17/15 for diagnoses that included major depressive disorder, rule out mood disorder, and rule out eating disorder. On admission, the patient had superficial healing cuts over his arm and burns to his skin from a pencil eraser.

During review of the medical record on 6/1/15, the physician documented that "as of yesterday (5/18/15)...," Patient 1, "...claimed he felt bad and he made some scratches over his left arm...," per the Progress Note dated 5/19/15. According to the Medication Orders dated 5/19/15 at 9:29 A.M., the physician entered an order for "neomycin-bacitracin-polymyxin B topical ...1 appl, topical, BID (twice a day), supplied as oint" to start at 5:00 P.M. on the same day.

Per the nursing day shift Summary Note dated 5/18/15, Registered Nurse 3 (RN) documented that Patient 1 rated his depression level a 7/10 and that he had "fleeting thoughts of SI without a current plan." There was no documentation on 5/18/15 to indicate that nursing staff conducted any reassessments of Patient 1's left arm or other areas of the patient's body.

During an interview with RN 3 on 6/1/15 at 2:37 P.M., RN 3 stated that she "could see if a patient inflicted harm because most wear short sleeves." She stated she did not perform any other physical exam unless she felt the patient had done something that was "not visible." RN 3 said if she noticed any changes with a patient, there were many variables she considered prior to notifying the physician. RN 3 said, "It is subjective and based on judgement." RN 3 stated she did not communicate any information to the physician on 5/18/15 related to Patient 1.

According to the Progress Note dated 5/20/15, the physician documented that "As of yesterday (5/19/15)...", the patient was "engaged in scratching himself, cutting on himself."

Per the nursing day shift Summary Note dated 5/19/15, Licensed Vocational Nurse 1(LVN) and RN 4 documented that the patient reported "fleeting passive suicidal ideation ..., "...urges to scratch wrists with a pencil," and "Admitted to purging after dinner last night and after breakfast this morning." According to the evening shift Summary Note also dated 5/19/15, RN 5 documented that Patient 1 had "...urges to cut and purge..." and "Notes fleeting thoughts of scratching self ..." There was no documentation on 5/19/15 to indicate nursing staff conducted any reassessments of Patient 1's left arm or other areas of the patient's body after the patient expressed urges to injure himself.

When interviewed on 6/2/15 at 3:40 P.M., RN 5 said she remembered looking at Patient 1's arms after he expressed urges to cut himself, but she did not document a reassessment of the patient's skin. RN 5 stated that if there was a change identified related to the patient's skin assessment or the patient's behavior, she would notify the physician by the end of her shift. There was no documentation on 5/19/15 to indicate nursing staff communicated to the physician any information related to the patient.

When interviewed on 6/2/15 at 10 A.M., the medical doctor (MD 1) said that on 5/19/15, he met with Patient 1, examined the patient, and asked the patient, "What are you doing to your arm?" MD 1 stated that Patient 1 explained he used his fingernail to "re-scratch" a previously healing area on his arm. The MD stated that the nurses had not communicated to him on 5/19/15, nor on 5/20/15, that the patient began scratching himself, but that he identified the patient's scratching and cutting behavior during his own exam of the patient.

Per the facility's policy entitled Assessment & Reassessment - Nursing & Interdisciplinary Services (# 30070), revised/reviewed on 5/15, Section III-B directed the RN to "...perform a nursing assessment and reassessment to collect information relevant to the patient's care, treatment, and services. " Section III-D directed the "RN and other appropriate interdisciplinary staff member ..." to reassess the patient when there was an "...Intervention in response to an event or patient complaint."
According to the facility's Guidelines of Care 2011, caregivers were to communicate using the "...standardized hand off communication format Situation, Background, Assessment, Recommendation (SBAR) between caregivers and providers."

b. The facility initially admitted Patient 1 from a group home (an intensive two week residential treatment program that focused on treatment of issues to include, anxiety, depression, self harm, and suicidal ideation) on 4/30/15, due to chief complaints of increased depression, anxiety, ongoing self-injurious behavior over his arms and thighs, and suicidal ideation, per the H&P dated 4/30/15. On 5/7/15, the patient returned to the group home for continued treatment, per the Discharge Summary dated 5/7/15.

According to the H&P dated 5/17/15, Patient 1 had a history of self-injurious behavior, and expressed to the staff at the group home that he had suicidal thoughts such as using a knife to harm himself or walk into traffic. The patient was brought to the Emergency Department for evaluation, then, was sent to the facility.

The facility re-admitted Patient 1 on 5/17/15 for diagnoses that included major depressive disorder, rule out mood disorder, and rule out eating disorder. On admission, the patient had superficial healing cuts over his arm and burns to his skin from a pencil eraser.

During review of the medical record on 6/2/15, the social worker (SW 1) documented she met with Patient 1 and his parents on 5/20/15 to "discuss aftercare plan, safety, and expectations post-discharge." SW 1 documented that Patient 1 could not compromise with his parents regarding safety limitations they tried to implement and became "irritable and tense" during the meeting. SW 1 also documented the patient refused to allow his parents to do body checks, refused to spend time out of his room, refused to spend time with his parents when at home, and became irritated and asked to leave the meeting. In addition, the SW documented that the patient became agitated when discussing safety and refused to share with his parents where he hid sharps at home. The SW also documented, "As of now pt will remain on the unit until he is stable." There was no documentation to indicate that the SW communicated the patient's behavior to nursing staff or other members of the paitent health care team. There was no documentation to indicate there was any follow-up with the patient after the family meeting.

When interviewed on 6/3/15 at 2:30 P.M., SW 1 stated that during the patient and family morning meeting on 5/20/15, Patient 1 had difficulty compromising with his parents regarding the safety checks they wanted to do, especially related to skin checks and checking for sharp objects hidden by the patient in their house. SW 1 stated the patient struggled with the idea of his parents being "hypervigilant." SW 1 said the patient became irritable and wanted to stop the meeting and leave.

The SW said that Patient 1's behavior was not a "red flag," or concerning at the time because she felt she acknowledged with the patient that "things weren't going well" in the meeting and that there was no "explosive end." SW 1 also said the patient had agreed with the plan for his parents to return later that day to discuss developing a behavior contract surrounding self-injurious behavior. The SW said she thought she had documented this information, however, there was no documentation found.

SW 1 stated she did not communicate the events of the patient and family meeting to nursing staff because this was the same behavior the patient had exhibited at a previous patient and familiy meeting during the patient's first admission on 4/30/15.

When interviewed on 6/3/15 at 1:50 P.M., RN 2 stated he was the nurse assigned to care for Patient 1 during the day shift on 5/20/15. RN 2 stated he did not recieve any communication from the SW after the patient and family meeting regarding the patient's behavior during the meeting.

According to the facility's Guidelines of Care 2011, caregivers were to communicate using the "...standardized hand off communication format Situation, Background, Assessment, Recommendation (SBAR) between caregivers and providers."

Based on observation, interview, and record review, the facility failed to ensure an opened medication vial was dated correctly in 1 of 6 medication rooms.

As a result, an opened and undated vial of insulin was available for patient use.

Findings:

The ICU medication room was entered on 6/3/15 at 9:15 A.M. In a patient medication drawer was 1 opened multi-dose vial of 70/30 Novolin insulin. The vial had a label that read, "expires on 7/30/15." A date of when the insulin was opened could not be found on the vial or label.

On 6/13/15 at 9:20 A.M. RN 15 stated, "It expires in 30 days from when it was opened." RN 15 acknowledged there was no open date marked on the insulin vial.

On 6/4/15 at 1:35 P.M., RN 16 stated, multidose insulin "expires 28 days from the day it is opened."

According to the facility's policy and procedure, dated 5/15, Expiration Dating-Medications, "Unless otherwise recommended by the manufacturer or listed on the manufacturer's label, the expiration date for MDV (multi-dose vial) will be 28 days from the time of opening." "Opened MDVs will be assigned a 28 day expiration date from the date of first use of the vial. Write the correct expiration date on the vial label if there is room or on an ancillary label that is affixed to the vial."