HospitalInspections.org

.
Based on record review and interview the facility failed to ensure 1 patient (#5) out of 10 sampled patients received care in a safe setting. Specifically, the facility failed to identify the risk of harm to others and ensure relief staff received appropriate information about the patient's behavioral status. This failed practice caused the patient to assault the nursing staff and led to the patient's subsequent arrest by the Anchorage Police Department. Findings:

Record review on 11/1-2/18 revealed Resident #5 was admitted to the facility for treatment of necrotizing fasciitis (flesh eating bacteria). The Patient also had diagnoses that included Fetal alcohol syndrome with cognitive impairment, and Paranoid Schizophrenia (symptoms may include hallucinations and delusions, agentive behavior, violent tendencies, and emotional disconnectedness).

Review of a BURT (Behavioral Urgent Response Team) consultation, dated 10/8/17, revealed "It is noted [his/her] cognitive functioning is similar to a 3 year old."

Risk of Harm to Self and/or Others

Review of a "Nursing Note-Inpatient", 10/25/18, a late entry for 10/24/18, by RN #1 revealed " ...During AM shift report, Night RN noted that patient had become more agitated and had taken her PIV IV [peripheral intravenous-catheter inserted into the vein] out. Throughout shift, patient was becoming increasing more agitated when primary RN attempted to place PIV. Primary RN notified MD regarding refusal of PIV placement as well as the increased agitation. Patient voiced suicidal ideation and became more verbally abusive to the primary RN. Approximately 1300 [1:00 pm] this charge RN was notified of the suicidal ideation and escalation and primary RN placed BURT consult in. BURT deemed they had seen patient last week for the same thing and this was a part of [his/her] psychiatric diagnosis and the patient did not require suicidal precautions, Primary RN requested a 1:1 observer, regardless to ensure patient's safety."

Review of a "Nursing Note-Inpatient", dated 10/24/18, by RN #3 revealed "BURT consult placed at [2:03 pm]. Paged BURT to notify then of [his/her] suicidal ideation and a plan. BURT team member stated to this RN that the Patient had been seen last week for similar comments. The BURT provider stated that these remarks were a part of [his/her] mental illness and it is just avoidance behavior, The BURT provider stated this Patient did not need suicidal precautions and [he/she] will not be assessed at this time ...This RN requested from the Charge RN to keep the sitter because of the patient's impulsiveness and pulling out IV's. Patient also was inappropriate to her roommate in 408-2 ...Patient dumped out roommates drinks yesterday ..."

Review of a BURT note, dated 10/19/18, revealed "The referral came to the BURT ...as a risk for suicidal ideation. However, the ask was that the house supervisor was needing a patient observer somewhere else and [he/she] was asking BURT if this Patient still required a patient observer to support the Patient...This BURT clinical supervisor informed [Physician #1] that the Patient was not currently at-risk to complete suicide or her [him/her]."

During an interview on 11/2/18 at 11:15 am, when asked if the Patient had been seen before and why the Patient was not seen on 10/24/18 after increasing agitation and suicidal ideation, Social Worker (SW) #1 stated the Patient was not suicidal when previously evaluated on 10/19/18.

During an interview 11/2/18 at 12:00 pm, SW #2 stated, he/she initially attempted to see the Patient on the 10/18/18, but the Patient refused to engage with him/her. The Patient was subsequently evaluated on 10/19/18 by SW #1.

When asked why the Patient was not reevaluated after the referral on 10/24/18, SW #2 stated Patient #5 was "going to be psychotic" and the Patient was not inclined for suicidality as that was a variability of his/her coping mechanism. SW #2 stated the Patient had no history of violence and he/she was surprised when he/she had heard of it. The SW was unaware of the Patient's trauma history.

During the interview, Physiatrist #1, who had just came into town yesterday, and had not examined the Patient, stated increasing behavior could be considered the Patient's baseline.

Review of the Patient's medication administration record, for the week of 10/18-24/18, revealed the Patient had refused his/her antipsychotic medications on 10/24/18.

Review of the facility's "Suicide Prevention Policy #512", approved 2/21/18, revealed "Staff will determine the need for further mental health evaluation for suicide potential, including the level and type of monitoring needed ...This assessment will be done by appropriately qualified staff, including RNs. Licensed Social Workers, Mental Health Professionals, physicians, or psychiatrists, as outlined by the hospital's procedures."

Failure to Educate Staff of Safety Measures

Further review of the "Nursing Note-Inpatient", dated 10/24/18, by RN #3, revealed " ...Charge RN notified this RN that the Patient punched CNA [Certified Nursing Assistant #1] multiple times and caused the CNA to bleed ...RN stated that the Patient had been slamming and opening the bathroom door multiple times. The CNA [#1] was [his/her] sitter and was looking in the bathroom door to ensure the Patient was not harming [himslef/herself]. Then the Patient proceeded to attack the CNA..."

"At [3:54 PM] a code gray [used for a violent patient] was called overhead by ...Charge RN ...The CNA [#1] was standing by the sink holding [his/her face] with paper towels. The Patient was yelling and standing by [his/her] bed...Patient was yelling, 'I'm going to punch you in the face! I'm going to punch you in the face."

Review of a "Nurse Note-Inpatient, dated 10/25/18 for 10/24/18 by RN #1 revealed "Primary RN requested 1:1 observer [one staff observing one patient] regardless to ensure Patient's safety, this Charge RN notified house supervisor and an observer was placed outside of room by door in order to observe but not increase patients agitation. The Patient remained somewhat less agitated for approximately one to two hours. Patient observer was relieved for a break and a new patient observer was given a brief report by primary CNA observer not to get to close (this was relayed to this Charger RN by CNA observer post-assault)."

During an interview on 11/2/18 at 3:55 pm, the Associate Nurse Executive (ANE) stated he/she was on call the night of the event. The ANE stated CNA #1, who relieved the other CNA for a break, was unaware of the Patient's psychiatric history, thought the patient was suicidal and followed the Patient into the Bathroom. When CNA opened the bathroom door, Patient #5, rushed out of the bathroom at him/her. In addition, the ANE, stated the Patient was not at baseline because he/she had been refusing his/her antipsychotic medications.
.

Based on record review, observation and interview the facility failed to ensure medications were administered and/or effects were monitored per physician's orders for 2 (#s 6 and 7) of 10 sampled patients. This failed practice place the patients at risk for receiving less than optimal medication therapy and medication errors. Findings:

Patient #6

Record review of Patient #6's medical record on 11/1/18 revealed Patient #6 had diagnoses that included traumatic brain injury, grand mal seizures and pneumonia. Further review revealed he/she was to receive Diprivan (propofol - an anesthetic that can cause relaxation and sleepiness during medical procedures) intravenously to maintain a Riker Score (an evaluation tool to evaluate sedation and/or agitation) of 3. In addition, the medical record noted the Patient was given a dose of Versed (a sedative that can cause relaxation and sleepiness during medical procedures) prior to propofol.

Record review of Patient #6's medical record for care provided on 11/1/18 of the revealed:

- Propofol was increased from 0 mL/hr to 17.71 mL/hr at 2:50 pm, with a subsequent Riker Score of 5 noted at 3:00 pm (10 minutes after medication was increased);

- Propofol was increased from 17.71 mL/hr to 23.62 mL/hr at 3:07 pm with no associated Riker Score to validate increase; and

- Propofol - a new 100 mL bag was started at a rate of 23.62 mL/hr at 3:36 pm.

An observation on 11/1/18 at 4:00 pm revealed Patient #6 was intubated (a tube placed into the airway to assist with breathing) and not arousable to tactile or verbal stimulus. During the observation RN #2 was asked about the order for sedation. In response the RN stated Patient #6 was sedated with Propofol due to agitation and because he/she was intubated. When RN #2 was asked what level of sedation the Patient was to be maintained at, the RN reviewed the Patient's record and stated a Riker Score of 3. The RN was unable to verbalize what a Riker Score of 3 indicated. At that time, the Critical Care Unit Manager (CCUM) intervened and instructed the RN to review the reference note in the medical record. RN #2 then lowered the propofol to a rate of 20.66 mL/hr.

During a second observation on 11/1/18 at 4:13 pm, the Patient was still not arousable. When asked what Patient #6's current level of sedation was, the RN replied a Riker Score of 2 and indicated the Patient was too sedated per the physician's order. At that time, RN #2 stated he/she should have decreased the propofol even more.

During an observation on 11/1/18 at 4:22 pm, the patient was still not arousable. RN #2 proceeded to decrease the propofol to 14.76 mL/hr and stated the Patient was still sedated at a Riker Score of 2.

During the observation on 11/1/18 from 4:00 pm to 4:30 pm the CCUM was present. During that time the CCUM stated Patient #6 was over sedated per the physician's order and should have been monitored with medication adjustments. In addition, the CCUM stated the Patient received an earlier dose of Versed which may have caused the lower Riker Score and may not have been considered in titration of the propofol. The CCUM concluded the facility needed to provide further education on the titration of anesthetics and sedatives in conjunction with the use of the Riker Score.

During an interview on 11/1/18 the CCUM stated a Riker Scale consisted of the following parameters:

5 - Agitated Anxious or physically agitated, calms to verbal instructions;

4 - Calm and Cooperative Calm, easily arousable, follows commands;

3 - Sedated Difficult to arouse but awakens to verbal stimuli or gentle shaking, follows simple commands but drifts off again;

2 - Very Sedated Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously; and

1 - Unarousable Minimal or no response to noxious stimuli, does not communicate or follow commands.

Patient #7

Record review of Patient #7's medical record on 11/2/18 revealed the Patient had diagnoses that included respiratory failure and seizures.

Record review of physician's orders, dated 10/31/18, revealed an order the Patient was to receive Propofol at a rate of 5 mcg/kg/min then to titrate 5 mcg/kg/min every 5 minutes to achieve sedation goal of less than 20 on the BIS scale (a monitor that follows brain electrical activity that assist in determinate of sedation level).

Record review of the medical record from 10/31/18 to 11/2/18 revealed the following data while Patient #7 was being administered propofol:

- 10/31/18 from 6:00 am to 12:00 am: the Patient's BIS reading ranged from 28 to 40;

- 11/1/18 from 6:00 pm to 12:00 am: the Patient's BIS reading ranged from 42 to 45; and

- 11/2/18 from 12:00 am to 8:00 am: the Patient's BIS reading ranged from 39 to 53.

During an interview on 11/2/18 at 9:13 am, RN #4 stated the BIS monitoring device was new to the unit and no formal training had been provided. The RN further stated the Patient's BIS reading has been steadily in the 40s. When asked what rate of propofol was being administered the RN stated he/she started it at 10 mcg/kg/min on 11/1/18 at 17:47.

During the same interview, when asked to provide the physician's order for the propofol, RN #4 stated he/she would refer to the physician's orders on the electronic medical record (EMR). Review of the order with the RN revealed an order for Propofol at a rate of 5 mcg/kg/min then to titrate 5 mcg/kg/min every 5 minutes to achieve sedation goal of less than 20 on the BIS scale. When asked about the discrepancy, RN #4 stated on 11/1/18 Physician #1 walked by the RN and verbally informed him/her to restart the propofol at 10 mcg/kg/min.

During an interview on 11/2/18 at 9:22 am Physician #1 stated that he/she provided a verbal order to RN #4 to restart the propofol at 10 mcg/kg/min. When the current order in the EMR was presented the Physician, he/she stated there was no need for the BIS monitoring any longer. In addition, Physician stated the RN must had restarted the order for propofol from the previous administration order on 11/1/18.

During an interview on 11/2/18 at 9:36 am the CCUM stated the propofol order was placed incorrectly into the EMR and should have been discontinued with a new order following the change in medication dosage. The CCUM further stated the Critical Care Unit was not to use verbal orders and the order should have been written. During the interview the CCUM stated the nursing staff had not been following the physician's order to maintain the BIS under 20 for Patient #7. When asked about the education provided to the nursing staff regarding the BIS monitor, the CCUM stated the nursing staff had not been provided formal training.

During a second interview on 11/2/18 at 9:54 am the CCUM confirmed there was no order to reflect the verbal order given by Physician #1.

During a second interview with RN #4 on 11/2/18 at 10:54 am stated the physicians were responsible for putting orders into the Patient's EMR. The RN stated that the unit was very busy when the verbal order was given to him/her as Physician #1 was passing by the Patient's room.

During an interview on 11/2/18 at 2:12 pm the Critical Care Nurse Educator stated the nursing staff has not had any formal training on the BIS monitoring system.
.

.
Based on record review and interview the facility failed to ensure an order for a medication was documented in the medical record and signed by a physician in accordance with hospital policy for 1 patient (#7) out of 10 sampled patients. This failed practice place the patient at risk for receiving less than optimal medication therapy and increased rise for the occurrence of medication errors. Findings:

Patient #7

Record review of Patient #7's medical record on 11/2/18 revealed the Patient had diagnoses that included respiratory failure and seizures.

Record review of physician's orders, dated 10/31/18, revealed an order the Patient was to receive Propofol at a rate of 5 mcg/kg/min then to titrate 5 mcg/kg/min every 5 minutes to achieve sedation goal of less than 20 on the BIS scale (a monitor that follows brain electrical activity that assist in determinate of sedation level).

During an interview on 11/2/18 at 9:13 am, RN #4 stated he/she started it at 10 mcg/kg/min on 11/1/18 at 17:47.

During the same interview, when asked to provide the physician's order for the propofol, RN #4 stated he/she would refer to the physician's orders on the electronic medical record (EMR). Review of the order with the RN revealed an order for Propofol at a rate of 5 mcg/kg/min then to titrate 5 mcg/kg/min every 5 minutes to achieve sedation goal of less than 20 on the BIS scale. When asked about the discrepancy, RN #4 stated on 11/1/18 Physician #1 walked by the RN and verbally informed him/her to restart the propofol at 10 mcg/kg/min.

During an interview on 11/2/18 at 9:22 am Physician #1 stated that he/she provided a verbal order to RN #4 to restart the propofol at 10 mcg/kg/min on 11/1/18. When the current order in the EMR was presented the Physician, he/she stated the RN must had restarted the order for propofol from the previous administration dosage of 5 mcg/kg/min from 11/1/18.

During an interview on 11/2/18 at 9:36 am the CCUM stated the propofol order was placed incorrectly into the EMR and should have been discontinued with a new order following the change in medication dosage. The CCUM further stated the Critical Care Unit was not to use verbal orders and the order should have been written.

During a second interview on 11/2/18 at 9:54 am the CCUM confirmed there was no order to reflect the verbal order given by Physician #1.

During a second interview with RN #4 on 11/2/18 at 10:54 am stated the physicians were responsible for putting orders into the Patient's EMR. The RN stated that the verbal order was given to him/her as Physician #1 was passing by the Patient's room.

Review of the facility's policy "Nursing Services Administrative Procedures Physician Orders," revised date 9/2011, revealed "A RN ...may accept verbal and telephone orders. Verbal orders should be limited to those absolutely necessary for patient safety and comfort ...The RN receiving the verbal order will enter it directly in the [electronic medical record]. Once entered, it will be read back to the Physician to make certain it has been correctly received and written. The physician will then receive the order in their message center and sign it ...Verbal and telephone orders must be signed by the Physician according to Medical Staff Bylaws ...All orders are reviewed in the [electronic health record] by the RN each shift."

.Review of Alaska Board of Nursing Advisory Opinion for Registered Nurse Administration of Sedating and Anesthetic Agents, undated, revealed "Scope Statement ...One level of sedation can quickly change to a deeper level of sedation due to the unique characteristics of the drugs used, as well as the physical status and drug sensitivities of the individual patient. The administration of sedating agents requires ongoing assessment and monitoring of the patient and the ability to respond immediately to deviations from the norm. Sedation should only be provided by a Registered Nurse who is competent in comprehensive patient assessment, is able to administer drugs through a variety of routes, is able to identify responses that are a deviation from the norm, is able to intervene as necessary, and whose duties are solely the monitoring of that patient."

Further review of the Advisory Opinion revealed "Registered Nurse Responsibility and Requirements Relating to the Intubated/Ventilated Patient Given that the following criteria are met, it is within the scope of practice for the Registered Nurse to administer sedation/anesthesia agents in the acute care setting to the intubated/ventilated patient in continuous and bolus dosing, for ongoing sedation ...It is the expectation that the following knowledge and skills are gained prior to administration of sedation/anesthesia agents. Education, training, experience and ongoing competency appropriate to responsibilities, treatment provided and the patient/population ...The Registered Nurse must possess knowledge of and be able to apply in practice...Pharmacology for sedating/anesthesia agents, including drug actions, side effects, contraindications, reversal agents and untoward effects ...Appropriate physiologic measurements for evaluation ... and the patient's level of consciousness ...Patient Monitoring ...Patient monitoring will be established by facility policy and specified by patient need."

.

Based on record review and interview the facility failed to notify 1 patient's (#5) guardian, out of 10 patients' reviewed, of the changed implementation of the discharge plan. This failed practice denied the patient's representative the right to participate in the revisions to the patient's discharge and denied the patient the right to representation. Findings:

Record review on 11/1-2/18 revealed Resident #5 was admitted to the facility for treatment of necrotizing fasciitis (flesh eating bacteria). The Patient also had diagnoses that included fetal alcohol syndrome with cognitive impairment, and Paranoid Schizophrenia (symptoms may include hallucinations and delusions, agentive behavior, violent tendencies, and emotional disconnectedness).

Review of a BURT (Behavioral Urgent Response Team) consultation, dated 10/8/17, revealed "It is noted [his/her] cognitive functioning is similar to a 3 year old."

Review of a "Nursing Discharge Summary", dated 10/24/18, revealed "Report given to ALF [assisted living facility] caregiver and supervisor ...They were notified the Patient assaulted a staff member ...Charges against the patient were made. Anchorage Police Department made an arrest. House Supervisor was notified and Administration was contacted ..."

Review of the "Transfer Requirements", dated 10/24/18 at 4:59 pm revealed "Patient has received medical screening, receiving facility had agreed to accept transfer and provide appropriate medical treatments, receiving facility has available space and qualified personnel for the treatment of the patient. Risk and Benefits explained to legal representative."

Review of a Nursing Note, dated 10/24/18, revealed "Anchorage Police Department arrested the Patient at 18:57 [6:57 pm]."

There was no information the legal representative was notified that Patient #5 was arrested and taken to jail instead of being discharged to the ALF.

During an interview on 11/2/18 at 3:55 pm, when asked about Patient #5 being discharged earlier, the Associate Nurse Executive (ANE), stated he/she was the Administrator on call that evening. The ANE stated after speaking with infection control staff, the decision was made to discharge the patient back to an environment that was "less scary." When asked what the process was for discharging to the police, the ANE stated any information would be in the changed discharge plan. In addition, the ANE stated the police had come to the floor to arrest the Patient.

During an interview on 11/2/18 at 4:20 pm, when asked about the guardian being notified of the deviation from discharge plan, the Risk Manager, and Accreditation Manager, stated the Patient had already been discharged from the facility at the time of the arrest.

Review of the facility's policy "Patient Admission and Discharge Procedure #500-07c" revealed 5.1.1.2 the official date and time of the discharge is when the nurse completes the discharge process and documents in the medical record that the patient was fully prepared and physically leaves the nursing unit."

.

Based on record review and interview the facility failed to reassess 1 patient (#5's) discharge plan, out of 10 sampled patients, for factors that may have negatively effected continuing care. Specifically, after the patient assaulted a staff member, the decision was made to discharge the patient a day early. After subsequent arrest by local law enforcement, the patients discharge location was changed. This failed practice placed the patient at risk for not receiving the necessary care post discharge. Findings:

Record review on 11/1-2/18 revealed Resident #5 was admitted to the facility for treatment of necrotizing fasciitis (flesh eating bacteria). The Patient also had diagnoses that included Fetal alcohol syndrome with cognitive impairment, and Paranoid Schizophrenia (symptoms may include hallucinations and delusions, agentive behavior, violent tendencies, and emotional disconnectedness).

Review of a BURT (Behavioral Health) consultation, dated 10/8/17, revealed "It is noted [his/her] cognitive functioning is similar to a 3 year old."

Review of the "Social Services Progress Note", dated 10/23/18, revealed "This Pt will be discharging back to Kenai Frontier Community Services"

Review of the "Nursing Note-Inpatient", dated 10/24/18, revealed "MD...determined the Patient was medically okay without IV antibiotic and placed discharge orders. This RN was preparing the Patient for a discharge back to [his/her] ALF...Anchorage Police Department arrived to the floor...Anchorage Police Department [APD] arrested the Patient at 18:57 [6:57 pm]."

During an interview on 11.2.18 at 3:30 pm, when asked about Patient #5' discharge, SW #1 stated he/she was not aware of the circumstances until he/she read about the Patient's arrest and subsequent death in the paper. The SW stated the discharge was generally done by the nurse.

Review of a "Nursing Discharge Summary", dated 10/24/18, revealed "Report given to ALF [assisted living facility] caregiver and supervisor ...They were notified the Patient assaulted a staff member ...Charges against the patient were made. Anchorage Police Department made an arrest. House Supervisor was notified and Administration was contacted ..." "Discharge paperwork placed in bag with Patient belongings and given to APD."

During an interview on 11/2/18 at 3:55 pm, when asked about Patient #5 being discharged earlier, the Associate Nurse Executive (ANE), stated he/she was the Administrator on call that evening. The ANE stated after speaking with infection control staff, the decision was made to discharge the patient back to an environment that was "less scary." When asked what the process was for discharging to the police, the ANE stated any information would be in the changed discharge plan. The ANE stated the police had come to the floor to arrest the Patient.

During an interview on 11/2/18 at 4:20 pm, the Risk Manager and the Accreditation Manager stated after the Patient assaulted staff the facility made the decision to discharge the patient a day early. During the interview, both staff stated the Patient had been discharged from the facility at the time of the arrest.

Review of the "Patient Discharge Instructions", dated 10/24/18 at 7:06 pm, after the Patient had discharged with APD, revealed the Patient needed to follow up with the ENT (ear nose and throat clinic) next week for a wound check and follow-up with the primary care provider in 2 days. There was no information how the Patient would follow up with a provider while incarcerated.

Further review revealed the Patient was to "Take your antibiotic medication as told by your health care provider, Do Not stop taking the antibiotic even if your start to feel better or your condition improves." Review of the discharge medications list revealed the Patient was not discharged on any antibiotics.

Review of the facility's policy "Patient Admission and Discharge Procedure #500-07c" revealed 5.1.1.2 the official date and time of the discharge is when the nurse completes the discharge process and documents in the medical record that the patient was fully prepared and physically leaves the nursing unit."

.