HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure patients received care in a safe setting on 2 (#2, #5) of 5 (#1-#5) patient's records sampled when the hospital staff failed to show evidence of consistent implementation of procedure related to the admission to and discharge from patients to the hospital.
Findings:


Review of the policy and procedure titled, "Contraband" effective 03/01/2018 read, in part, the purpose of this policy is to ensure a safe environment and specify which items will be controlled in locked areas or disallowed on the unit and to outline appropriate nursing interventions to be carried out if contraband is found on the unit. It is the policy to maximize the safety of patients and staff on the unit by controlling access to certain objects known as contraband. Items considered to be contraband will be locked in a secure area with controlled access to patients. If the patient brings in items considered illegal, those items will be destroyed with two staff members as witnesses. Procedure 1. The following items will be restricted from the unit and placed in the contraband valuables storage. These items do not go into the patient room. This list is not all inclusive: b. Patient's own prescriptions - They are to be stored in secure patient storage area. Narcotics must be stored in safe behind double locks. 7. Patients personal belongings are searched for contraband upon arrival in admissions. Any contraband is removed by admission personnel and/or designee and stored appropriately. Personal belongings are stored in the safe closed in the admission area and are never taken to the nursing units.

Patient #2

Review of Patient #2's medical record revealed the patient was admitted via a Physician's Emergency Certificate on 08/02/2022 with a primary diagnosis of Major Depressive Disorder, Recurrent, Severe without Psychotic Features.

Review of Patient #2's admission forms revealed the hospital failed to document whether all elements of the New Admission Safety Check were completed, failed to document the completion of the Mental Health Tech (MHT) patient orientation checklist, and failed to document the location of personal belongings.

Review of Patient #2's MHT Discharge Checklist revealed the staff failed to document any entries, signatures or date on the form.

Patient #5
Review of Patient #5's medical record revealed the patient was admitted via a formal voluntary on 08/01/2022 with a primary diagnosis of Opioid Use Disorder, Severe.

Review of Patient #5's admission forms revealed the hospital failed to document whether the patient was scanned by staff using a wand or asked to empty his pockets, failed to obtain a 2nd witness to verify the new admission safety check, failed to obtain a 2nd witness related to entering personal belonging in the safe, and failed to obtain a 2nd witness related to taking an inventory of belongings placed in storage or documenting where the items were stored.

Review of Patient #5's Mental Health Tech (MHT) Discharge Checklist revealed the staff failed to document any entries, signatures or date on the form.

In interview on 9/8/22 at 12:30 p.m., S6MHT assigned to the admission of Patient #5 verified that he failed to show evidence that the admission procedure related to the patient search and belongings inventory was completed as per procedure.

Review of Patient #5's Urine Drug Screens (UDS) revealed upon admit on 08/01/2022 Patient #5 was positive for Cocaine, Fentanyl and Methamphetamine. Further review revealed on 08/02/2022 a repeat UDS revealed Patient #5 was positive for Amphetamine, Benzodiazepine, Buprenorphine, Marijuana and Methamphetamine.
In interview on 9/8/22 at 12:05 p.m., S7RN who assisted with admitting Patient #5 verified that the patient initially tested positive for Cocaine, Fentanyl and Methamphetamine. S7RN indicated on 08/02/22 at 6:00 p.m., Patient #5 received an in-house UDS using the same specimen collection method as in the admissions procedure and tested positive for Amphetamines, Benzodiazepine, Buprenorphine, Marijuana and Methamphetamine. Upon review of the medical record, S7RN indicated Patient #5 refused his first dose of medication since "it may have put him in a rapid detox" if he consumed drugs within a certain time and that Patient #5's first dose of Subutex was not until 8/4/22.

In interview on 09/07/2022 at 2:35 p.m., S4MHTS verified that staff failed to complete the admission and discharge forms on Patient #2 and Patient #5 as per procedure.