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Based on observations, review of the facility "Patient Rights and Responsibilities" form and interviews with facility staff, it was determined the facility failed to provide the patients or the patient's representative a phone number and address for lodging a complaint or grievance with the State Agency. This had the potential to affect all patients.

Findings include:

A tour of the Emergency Department (ED) was conducted with Employee Identifier, (EI) # 5, the ED Manager, on 8/21/12 at 1:39 PM. There was no sign posted in the ED for lodging a complaint or grievance with the State Agency.

A review of the "Patient Rights and Responsibilities" form revealed that it did not have the State Agency hot line number for patients to call to file grievances and complaints.

During an interview conducted on 8/21/12 at 2:15 PM with EI # 5, confirmed the aforementioned findings.

Based on review of medical records, policies and procedures and interview, it was determined in 2 of 2 Geri-psych Unit records reviewed the treatment plans did not include an update on the therapeutic interventions when the patients' condition did not improve. This affected Patient Identifiers (PI) # 11, and # 12 and had the potential to affect all patients served on the Geri-psych Unit.

Findings include:

Facility Policy: Treatment Planning Process # 05.002

1.0 Purpose:

To ensure plans for care, treatment, and service are individualized to meet the patient's unique needs and circumstances


8.0. Treatment Plan Review Procedure

B. Record progress or lack of progress for each short-term goal. Determine the extent to which the interventions were implemented and the extent to which the goals were accomplished. Discuss any modifications that should be made to the interventions or goals and give a narrative statement describing progress or response to the treatment interventions in the lines provided. Review of major family, social or life events that may complicate treatment occurs and all changes in treatment are documented. When all goals are accomplished a problem is considered resolved.

Facility Policy: Treatment Team Protocol # 05.004

1.0 Purpose

To develop a coordinated consistent and well-focused approach to treating the patient.

4.0 Subsequent Team Reviews

C. Format

4. The Treatment Plan review will identify and a brief descriptive, measurable summary of patients' progress or lack thereof for each short-term goal. The Individual treatment plan will reflect change in target date, interventions and/or short-term goals to enable patient to achieve their treatment goals.

1. PI # 11 was admitted to the facility on 8/10/12 with a diagnosis of Depression.

Review of the PI # 11's Interdisciplinary Treatment Plan on 8/22/12 revealed the following:

Problem # 1 - Psychotic Symptoms: Delusional Thoughts

Short Term Goals included:

A. Will accept medications, food/fluids for 3 consecutive days. Target date 8/16/12

B. Will verbalize understanding of at least 1 difference between reality and non-reality based beliefs. Target date 8/16/12

Problem # 2 - Fall Risk

Short Term Goals included:

B. Will demonstrate adherence to fall prevention plan by call for assistance. Target date 8/13/12

Problem # 3 -Nutritional Deficit

Short Term Goals included:

B. Will state at least 1 purpose of balanced nutritional intake and demonstrate adequate intake by eating at least 30% of meals. Target date 8/16/12

Problem # 4 - Depressive Symptoms - Date Initiated 8/16/12

Short Term Goals included:

A. Will report level of sadness less than 5 for 2 consecutive days. Target date 8/20/12

F. Will consistently consume 50% of each meal. Target date 8/20/12

Review of the Interdisciplinary Treatment Plan Review dated 8/17/12 revealed the following:

Problem # 1: Delusional Thoughts

A. Improved, "Accepting food and medications". There was no documentation the problem was resolved or changed interventions.

B. Improved, "Can identify differences sometimes..." There was no documentation the problem was resolved or changed interventions.

Problem # 2: Fall Risk

B. Improved, "Adhering to plan". There was no documentation the problem was resolved or changed interventions.

Problem # 3: Nutritional Deficit

B. Improved, "Eating at least 30%". There was no documentation the problem was resolved or changed interventions.

Problem # 4: Depressive Symptoms

A. There was no documentation the short term goal was improved, unchanged, revised or resolved.

F. Improved, "Improved eating". There was no documentation the problem was resolved or changed interventions.

Review of the Interdisciplinary Treatment Plan Review dated 8/21/12 revealed the following:

Problem # 1: Delusional Thoughts

A. Improved, "Accepts medications. Has not participated with some meals". There was no documentation the problem was resolved or changed interventions.

B. Improved, "Verbalizes differences with reality checking with others..." There was no documentation the problem was resolved or changed interventions.

Problem # 2: Fall Risk

B. There was no documentation on the short term goal.

Problem # 3: Nutritional Deficit

B. Unchanged, "Not eating all meals,...verbalizes importance of nutrition". There was no documentation of changed interventions.

Problem # 4: Depressive Symptoms

A. Unchanged, "Reports level of sadness at a 5 or above...reports feeling depressed being on an inpatient psychiatric unit and would prefer to go home rather than assisted living".

F. Unchanged, "Not eating 50% of each meal consistently". There was no documentation the problem was resolved or changed interventions.

An interview was conducted with Employee Identifier # 7, Behavioral Registered Nurse on 8/22/12 at 10:45 AM who verified none of the interventions or target dates were changed even when the patient's progress warranted a change.

2. PI # 12 was admitted to the facility on 8/10/12 with a diagnosis of Depression.

Review of the PI # 12's Interdisciplinary Treatment Plan dated 8/14/12 was conducted on 8/22/12 and revealed the following:

Problem # 1 - Suicide Thoughts

Short Term Goals included:

B. Will identify 2 positive reasons for living for 2 consecutive days. Target date 8/17/12

C. Will participate in the development of Suicide Safety Plan to focus on reduction of poor stress tolerance. There was no documentation of a target date.

Problem # 2 - Depressive Symptoms

Short Term Goals included:

A. Will report level of sadness less than 3 for 2 consecutive days. Target date 8/18/12

Review of the Interdisciplinary Treatment Plan Review dated 8/17/12 revealed the following:

Problem # 1: Suicide Thoughts

B. Unchanged, "Difficulty identifying reasons". There was no documentation the problem was resolved or changed interventions.

C. Unchanged, "Developing coping skills, has not added any to Safety Plan yet." There was no documentation the problem was resolved or changed interventions.

Problem # 2: Depressive Symptoms

A. Unchanged, "Stating sadness is higher than a 3". There was no documentation the problem was resolved or changed interventions.

Review of the Interdisciplinary Treatment Plan Review dated 8/21/12 revealed the following:

Problem # 1: Suicide Thoughts

B. Improved, "Has identified relationship with fiancee as important and a positive reason for living". There was no documentation the problem was resolved or changed interventions.

C. Improved, "Has developed skills for distress tolerance and is now seeking solutions for financial problems with planning to start debt consolidation." There was no documentation the problem was resolved or changed interventions.

Problem # 2: Depressive Symptoms

A. Unchanged, "Rates depression at an 8 on a 0-10 scale". There was no documentation the problem was resolved or changed interventions.


An interview was conducted with Employee Identifier # 7, Behavioral Registered Nurse on 8/22/12 at 10:45 AM who verified none of the interventions or target dates were changed even when the patient's progress warranted a change.

Based on interviews, review of the facility's policies and procedures, and observations, it was determined the facility failed to ensure patients were taking only medication prescribed by the physician, verified by a pharmacist and supplied by the hospital. This had the potential to affect all patients being served by the hospital.

Findings include:

Facility Policy: Administration of Medications: Patient's Personal Medications

Effective/Review Date: 3/17/12

Policy:

The use of a patient's personal medication is discouraged. A patient's personal medication shall not be administered to the patient unless specifically authorized by the prescribing practitioner responsible for the patient and the agent can be positively identified.

Retention of Personal Medications in the Facility:

Unless administration of a patient's personal medications is authorized by the responsible prescribing practitioner, these medications shall be sent home with the patient's family...

Identification of Patient's Personal Medications:

Medications brought into the facility by patients shall not be administered unless the medications have been absolutely identified and their quality and integrity is not questionable. There should be a written order from the responsible prescribing practitioner to administer the medications.

Identification of a patient's personal medication must be by the pharmacist, attending physician, or another responsible licensed practitioner.

An observation of medication administration was conducted on 8/22/12 at 9:10 AM. Employee Identifier (EI) # 6, Registered Nurse administered Patient Identifier (PI) # 6's medication. Upon entering PI # 6's room the surveyor observed a bottle labeled Nystatin sitting on the patient's bedside table. The Nystatin had a local pharmacy label. The surveyor asked PI # 6 where the Nystatin came from and the reply was, "My daughter brought it to me last week."

Review of PI # 6's medical record revealed no documentation of a physician's order for the use of Nystatin.

An interview was conducted on 8/22/12 at 9:20 AM with EI # 1, the Manager of Medical/Surgical and Critical Care Unit who verified there was no documentation of a physicians order or verification the pharmacist had identified the medication.

Based on observations and interviews, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner and sanitary measures were used in the cleaning and sanitation of cooking and serving utensils. This had the potential to negatively affect all patients.

Findings include:

Observations on 8/21/12 at 10:40 AM in the food service area revealed the following:

Refrigerator: 2 trays of peaches in cups uncovered, undated and unlabeled; 1 container of onions, sour kraut and parsley covered with clear wrap, undated and unlabeled.

Walk in Cooler: 1 container of blue berries uncovered, undated and unlabeled.

Main Kitchen Area Cart beside Refrigerator: Items stored in a cardboard box without a lid: 1 opened bag Port Roast Gravy Mix, Instant Cream Soup and Quaker Grits.

Dry Storage:
Observed sitting on the floor were: Vanilla Pudding x 1, Sweet and Sour Sauce x 1 box and single wrap spoons x 1 box.
Observed dented cans on the shelves were: Glucerna x 4 cans and Cream of Chicken (large) x 1 can. The dented cans were not in the designated area for removal.

Stove: dirty with grease build up at bottom.

Utility Cart utilized to transfer food items to tray line: dirty with grease build up.

During an interview conducted on 8/21/12 at 10:40 AM with Employee Identifier (EI) # 2, the Dietary Manager, confirmed that items were not covered, dated and labeled and that cleaning had not been performed as scheduled.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to the Life Safety Code survey report.

Based on review of the policies and procedures, observations and interviews, it was determined the facility failed to ensure all equipment was safe for patient use. This had the potential to affect all patients being served by this facility.

Findings include:

Facility Policy: Medical Equipment Management Plan

I. Purpose

The purpose of the Medical Equipment Management Plan (MEMP) shall be to facilitate a safe environment for its occupants during the use of powered medical equipment. Medical equipment shall be defined as any device used for the diagnosis, treatment, monitoring or care of patients.

VI. Equipment Testing

C. Labeling Equipment After Testing

Equipment shall be affixed with a safety inspection label indicating the date of testing and the person who performed the test.

A tour of the Critical Care Unit (CCU) was conducted on 8/21/12 at 1:15 PM. The surveyor observed an electric fan in room 2303. The fan was dented at the top with a piece of paper folded and placed under the handle. The screen covering the blades was cracked and broken in places. The safety sticker on the fan read last dated tested was 12/29/06. The surveyor asked Employee Identifier (EI) # 1, Manager of Medical/Surgical/CCU units if the fan should have a more current safe test and the response was, "Yes".

The surveyor observed 6 tongue blades in the CCU medication room that expired June of 2011 and 66 tongue blades that expired March of 2012.

An interview was conducted with EI # 1 on 8/22/12 at 8:15 AM. EI # 1 stated the fan had been taken out of service and maintenance was going to test the fan.

A tour of the Rehabilitation Unit was conducted on 8/22/12 at 2:30 PM. The surveyor observed a hydraulic lift chair by the pool. The surveyor asked EI # 4, the Physical Therapist, when the last time the lift chair had been tested and labeled as safe. The response was, there was no documentation of the chair being tested.