HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to ensure accurate safety precautions and one-to-one observations had been documented for one of one patient (26) who had attempted suicide. Findings include:

1. Review of patient 26's electronic medical record (EMR) revealed:
*On 11/6/22 she had come through the emergency department (ED) after a suicide attempt.
*Poison control had been consulted related to the medication she intentionally ingested.
*She was alert, oriented, and able to answer questions.
*An unidentified registered nurse (RN) had completed a suicide screening which included the following patient responses, she:
-Wished she was dead.
-Had thoughts of killing herself in the past month.
-Had the thoughts and intended on acting on them.
-Had worked out the details of the plan and intended on carrying out the plan.
*Her nursing and physician orders included:
-"Suicide prevention."
-"Assure patient has 1:1 [one to one] supervision and NOTIFY provider to determine next steps."
-"Complete Environmental Risk Assessment with Safety Checklist."
-"All objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medication care need to be removed."
-"All patient belongings, which pose potential risk, need to be removed from patient's possession."
-"Ensure management of diet trays, modify diet order to a 'high risk' diet."
-"Document initiation and discontinuation of suicide precautions."
-"Constant Observation Log to be completed by staff member serving in that role."

Interview on 1/31/23 at 3:00 p.m. with ED/trauma director C revealed:
*ED staff have a paper environmental safety checklist to fill out to ensure all items had been removed from the room and the suicide precautions have been implemented.
*She had:
-Been unable to find a checklist completed for patient 26.
-Agreed a checklist should have been completed and kept with patient 26's medical record.
-Been unable to find documentation that one-to-one observation had been completed for patient 26.
*Patient 26 did not have a physician's order stating suicide precautions could be discontinued or not done.

Interview on 2/1/23 at 3:10 p.m. with executive director A, director of nursing/clinical services B, quality and risk director H, supervisor of inpatient nursing E, accreditation manager I, and accreditation nurse J revealed, they all agreed a checklist should have been completed for patient 26 and one to one observations should have been documented.

Review of the provider's December 2021 Suicide policy revealed:
*"Patients will not be left alone and suicide precautions will be implemented according to the procedure below."
*"Provider will be notified to determine next steps. Additional evidence-based assessment completed, building upon the results of the Columbia Suicide Severity Rating Scale to identify suicide ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors."
*"A safety plan will be completed prior to discharge home."
*"When a patient is taken off of the unit, constant 1: 1 observation will be maintained and documented."
*"During the recovery phase, the patient surrounding will be evaluated for risk items, 1:1 observation and documentation will resume."
*"Suicide precautions may only be discontinued by a provider order."

Review of the provider's undated Patient Rights and Responsibilities documentation revealed:
*"Our goal is to have a safe and comfortable environment for you while you are a patient at [hospital's name]."
*"Have care and services that are within professional standards of practice."
*"Medical and personal health care based on your own individual needs."
*"Be cared for in a safe environment."

Based on interview, record review, and policy review, the provider failed to ensure 13 of 30 sampled patient's care plans (3, 4, 5, 6, 17, 18, 19, 20, 21, 22, 23, 24, and 25) had included treatment needs and goals. Findings include:

1. Review of patient 3's electronic medical record (EMR) revealed:
*She had been admitted on 9/7/22 and discharged on 9/10/22.
-Admitting diagnosis was pneumonia.
--Treatment included intravenous (IV) antibiotics, nebulizer treatments, and oxygen as needed.
*Her care plan problem was impaired gas exchange.
*No care plan had been initiated for her infection and the use of antibiotics.

2. Review of patient 4's EMR revealed:
*She had been admitted on 8/29/22 and discharged on 8/31/22.
-Admitting diagnosis was acute cystitis and a small bowel obstruction.
*Treatment included an IV antibiotic and bowel rest to improve the small bowel obstruction.
*Her care problem was the risk for falls.
*No care plan had been initiated for her problem of acute cystitis infection or bowel obstruction.

3. Review of patient 5's EMR revealed:
*He had been admitted on 9/9/22 and discharged on 9/11/22.
-Admitting diagnosis was atrial fibrillation with a rapid ventricular response, low potassium, and alcohol abuse.
*Treatment included IV medication to control his heart rate, potassium replacement was given IV and orally, and alcohol detoxification.
*He had a care plan for decreased cardiac output and risk for shock.
*No care plan had been initiated for his low potassium or alcohol abuse and detoxification.

4. Review of patient 6's EMR revealed:
*He had been admitted on 9/8/22 and discharged on 9/10/22.
-Admitting diagnosis was pneumonia.
*Treatment included IV antibiotics, nebulizer treatments, and oxygen as needed.
*His care plan included impaired gas exchange and risk for falls.
*No care plan had been initiated for his pneumonia infection.





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5. Review of patient 22's August 2022 EMR revealed:
*He had been admitted to the hospital on 8/4/22.
-He was discharged on 8/8/22.
*His principal problem was alcohol withdrawal syndrome with complications.
*His active problems included chronic kidney disease.
*He had:
-Been a heavy drinker and a "long-term alcohol abuser."
-Recently lost his job.
-Been drinking to forget about his difficulties.
-Recently stopped taking his antidepressants.

Interview on 2/1/23 at 9:14 a.m. with supervisor of inpatient nursing E and review of patient 22's 8/4/22 through 8/8/22 care plan revealed:
*He had one problem on his care plan, "acute confusion."
*His care plan had not addressed any of his psychosocial needs.
*She would have expected his care plan to include other problems as well as to address his psychosocial needs.

6. Review of patient 17's August 2022 EMR revealed:
*He had been admitted to the hospital on 8/13/22.
-He was discharged on 8/16/22.
*His principal problem was an epidural abscess.
*His active problems included:
-Asymptomatic HIV [human immunodeficiency virus] infection.
-Chronic hepatitis B.
-Bipolar disorder.
-Type 1 diabetes with hypoglycemia
-Osteomyelitis.
-Complex seizures.
-Methicillin resistant Staphylococcus aureus (MRSA) infection.
*His initial blood glucose had been noted to be 45 measure of density (Mg/dL) [critically low].
-80-130 Mg/dL would be a normal fasting blood glucose for someone with diabetes.
*He had blood cultures drawn and infectious disease had been involved in his care.

Interview on 2/1/23 at 9:18 a.m. with supervisor of inpatient nursing E and review of patient's 17's 8/13/22 through 8/16/22 care plan revealed:
*His care plan included:
-Physical comfort.
-Ineffective health management.
-Discharge readiness.
*His care plan had not addressed any problems related to his active infection.
*Supervisor of inpatient nursing E would have expected infections to have been included in his care plan problems.

7. Review of patient 25's August 2022 EMR revealed:
*He had been admitted to the hospital on 8/21/22.
-He had been discharged on 8/26/22.
*His principal problem was infectious colitis.
*His active problems included:
-Anxiety disorder.
-Celiac disease.
-Post-traumatic stress disorder (PTSD).
*He was receiving IV antibiotics while hospitalized.

Interview on 2/1/23 at 9:22 a.m. with supervisor of inpatient nursing E and review of patient 25's 8/21/22 through 8/26/22 care plan revealed:
*His care plan included. "Diarrhea."
*She agreed his care plan should have included other items such as:
-Infections.
-Psychosocial needs.

8. Review of patient 18's November 2022 EMR revealed:
*He had been admitted to the hospital on 11/30/22.
-He was discharged on 12/3/22.
*His admitting diagnosis was systemic inflammatory response syndrome (SIRS).
*His active problems included:
-Sweet's syndrome (fever and painful skin rashes).
-Stage 3 chronic kidney disease.
*He also had a significant sacral wound.
*He was receiving intravenous antibiotics for his multiple sacral wounds and SIRS.

Interview on 2/1/23 at 9:26 a.m. with supervisor of inpatient nursing E and review of patient 18's 11/30/22 through 12/3/22 care plan revealed:
*He had one problem listed, "Risk for infection."
-The goal was listed as "Immune Status."
*She would have expected patient 18's care plan to include "physical comfort."
*She agreed there was many other interventions staff could choose.
*Her expectation for nursing staff was to have at least two problems listed on a patient's care plan.

9. Review of patient 24's August 2022 EMR revealed:
*She had been admitted to the hospital on 8/19/22.
-She was discharged on 8/25/22.
*Her admitting principal problem was listed as, "Acute diastolic heart failure."
-She had acute hypoxia related to her heart failure.
*Her active problems included:
-Depression with anxiety.
-Endometrial cancer.
-Severe aortic stenosis.
-Essential hypertension with blood pressure parameters.
-Type II diabetes.
-Atrial fibrillation.
-Iron deficiency.

Interview on 2/1/23 at 9:30 a.m. with supervisor of inpatient nursing E and review of patient 24's 8/19/22 through 8/25/22 care plan revealed:
*The patient a problem of, "impaired gas exchange" on her care plan.
-She also had "discharge readiness.
*Her care plan had not addressed her:
-Heart failure.
-Diabetes.
-Hypertension with physician-ordered blood pressure parameters.
*She would have expected more interventions listed on patient 24's care plan.

10. Review of patient 23's August 2022 EMR revealed:
*He had been admitted to the hospital on 8/8/22.
-He had been discharged on 8/9/22.
*His principal admitting diagnosis was, "diabetic ketoacidosis."
*His other active problems included:
-Type I diabetes.
-Alcohol abuse.
-Tobacco use.
-Hyponatremia.
-Noncompliance with treatment.
-Metabolic acidosis.
-Leukocytosis.
-Acute kidney injury.
-Elevated lactic acid level.

Interview on 2/1/23 at 9:34 a.m. with supervisor of inpatient nursing E and review of patient 23's 8/8/22 through 8/9/22 care plan revealed:
*He
-Was admitted and given IV fluids due to diabetic ketoacidosis and dehydration.
-Had an elevated troponin level [protein released from heart damage/stress].
*His care plan had one problem listed, "ineffective health management."
*Supervisor of inpatient nursing E would have expected other interventions to have been included on his care plan.

11. Review of patient 19's December 2022 EMR revealed:
*He had been admitted on 12/19/22.
-He had been discharged on 12/20/22.
*His principal admitting diagnosis was, "Dental abscess with decreased appetite."
-He received antibiotic treatment and had his sinus cavity drained.

Interview on 2/1/23 at 9:36 a.m. with supervisor of inpatient nursing E and review of patient 19's 12/19/22 through 12/20/22 care plan revealed:
*His care plan had one intervention, "Risk for shock."
*She would have expected physical comfort to have been on his care plan.

12. Review of patient 20's December 2022 EMR revealed:
*He had been admitted on 12/27/22.
-He was discharged on 1/7/23.
*His principal admitting diagnosis was, "post-surgical infected joint."
-His surgical site had become infected and he needed to have the joint removed.

Interview on 2/1/23 at 9:40 a.m. with supervisor of inpatient nursing E and review of patient 20's 12/27/22 through 1/7/23 care plan revealed:
*His care plan had included:
-Risk for falls.
-Risk for shock.
*She would have expected staff to include physical comfort in his care plan:

13. Review of patient 21's January 2023 EMR and revealed:
*She was admitted inpatient due to metastatic pancreatic cancer.
*Her plan was to discharge home on hospice care.

Interview on 2/1/23 at 9:44 a.m. with supervisor of inpatient nursing E and review of patient 21's 8/13/22 through 8/16/22 care plan revealed:
*Her care plan had not addressed any of her psychosocial needs related to her impending death.
*She would have expected the staff to include psychosocial interventions related to dying in her care plan.

Interview on 2/1/23 at 1:30 p.m. with director of nursing (DON)/clinical services B regarding care plans revealed she:
*Stated nursing had been improving on the documentation of patient intervention in the care plans.
*Agreed that a care plan should be initiated for every problem and intervention.
-Patients should have more than one care plan intervention.

Review of provider's September 2020 Plan of Care policy revealed:
*"A plan developed by assessing the patient's nursing care needs and treatment goals. The plan develops appropriate nursing interventions in response to the identified nursing care needs."
*"The nursing plan of care will be representative of the patient's needs and the nursing care to be provided to meet those needs."
*"Consideration given to why the patient is in the hospital and where staff are spending their time with the patient."
*"An exception to utilization of the Care Plan Activity may be made in departments where a formal interdisciplinary plan of care or interdisciplinary treatment plan is developed and includes nursing goals and interventions."

Review of the provider's undated Patient Rights and Responsibility documentation revealed, patients had the right to "Be cared for by staff members who know about you and your plan of care."

Based on record review, interview, and policy review the provider failed to initiate discharge planning for two of two sampled patients (2 and 9) that were discharged on a weekend. Findings include:

1. Review of patient 2's electronic medical record (EMR) revealed she:
*Had been admitted on 9/2/22 which was a Friday and was discharged on 9/4/22 which was a Sunday.
*Had a care plan for impaired gas exchange started but no documentation in the care plan for discharge planning.
*No additional progress notes were found in the EMR pertaining to her discharge planning.

2. Review of patient 9's EMR revealed:
*She had been admitted on 8/26/22 which was a Friday and was discharged on 8/28/22 which was a Sunday.
*She had a care plan started for risk for shock initiated but there was no care plan interventions for discharge planning.
*Discharge destination for home with self-care had been addressed on admission.
*No additional progress notes had been added to the EMR regarding her discharge planning.

Interview on 2/1/23 at 10:30 a.m. with patient care relations G and registered nurse (RN) case manager F regarding discharge planning for patient's 2 and 9 revealed:
*They both agreed discharge planning began on admission and updated as needed.
*Both worked Monday through Friday.
*RN case manager F would initiate a readiness for discharge care plan to document discharge planning.
*Patient care relations G would write a progress note regarding discharge planning.

Interview on 2/1/23 at 1:20 p.m. with quality improvement advisor H regarding discharge planning revealed:
*Both patients 2 and 9 had been discharged over the weekend.
*Stated that usually the discharge summary would have discharge planning in it.

Interview on 2/1/23 at 1:30 p.m. with director of nursing (DON)/clinical services B regarding discharge planning revealed:
*Discharge planning should have been addressed regardless of the day of the week of discharge.
*Agreed the opportunities for documentation on discharge planning had been missed.

Review of the provider's January 2022 Discharge Plan policy revealed:
*Discharge planning for the continuum of care began prior to admission, with the initial nursing assessment at the time of admission, and during the hospital stay based on reassessment.
*All disciplines would have been involved, as appropriate, in the assessment and planning for continued transitional care.