HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing staff followed facility policy related to body searches of all patients upon admission to the inpatient unit to remove potentially dangerous items for 1 of 10 patient medical records reviewed. (Patient #5)

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure nursing staff followed facility policy related to body searches of all patients upon admission to the inpatient unit to remove potentially dangerous items for 1 of 10 patient medical records (MR) reviewed. (Patient #5)

Findings include:

1. Facility policy titled "Admission Assessment", policy number #11.2.005R, with a revision date of 4/5/24 indicated the following: I. ADMISSION ASSESSMENT GUIDELINES: d. BODY CHECKS: i. Upon admission to the ACU, all clients will have a body search completed to remove potentially dangerous items and establish a baseline physical assessment of distinguishing body marks. 1. The body search will be done in a private setting by a same sex staff member. If a same sex member is not available, the body search will be completed by two staff members. a. A client can request a search be completed by two staff members, regardless of sex of the staff members involved. 2. Body checks may also be completed should a question of safety arise during admission, and all above procedures will be followed. ii. All findings will be documented in the admission nursing assessment, or a progress note should the check occur after admission. e. PERSONAL POSSESSIONS: 2. Restricted items, i.e., any item that could present a safety risk, are to be sent home with a family member/guardian. If no alternative is available items will be locked in a secure area until discharge.

2. Review of Patient #5's medical record indicated the following:
The patient was admitted on EDO (Emergency Detention Order) due to SI (Suicidal Ideation)/HI (Homicidal Ideation) toward (family members) with a plan/intention and means on 6/18/24 at 7:13 p.m. and was discharged on 6/20/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent, severe with psychotic symptoms and posttraumatic stress disorder.

(a.) A review of a nursing assessment for Patient #5 dated 6/18/24 at 7:13 p.m. indicated the following: Searches completed, and findings indicated: (Patient #5) has not had body search yet as (he/she) refuses to have body search done and is refusing to come onto the unit. (Patient #5) states, "I will stay here until Dr. (Doctor) comes in". (Patient #5) refusing to get up off of the couch. LIP (Licensed Independent Practitioner) notified and stated to monitor (patient).

(b.) A review of a psychiatric note dated 6/19/24 at 9:00 a.m. indicated the following: (Patient #5) was agreeable to voluntary admission but refused admission when (he/she) arrived to (Facility #1) (Patient #5) refused to sign paperwork, allow search, vitals. EDO was obtained from (Facility #1) psychiatrist. (Patient #5) continued to refuse admission process, attempted to leave intake room, urinated on the floor, yelled and made verbal threats to staff. When (patient) was given clear direction by this writer to enter unit on (his/her) own or staff would need to assist (patient), (he/she) was angry, yelling, but stood and walked onto unit with no physical intervention or need for PRN (as needed) medication. (Patient #5) was allowed to enter the unit with (his/her) clothing on and phone.

3. Review of an incident report for Patient #5 dated 6/20/24 indicated the following: Incident Location and Time of Day: (Facility #1 parking lot) at 3:02 p.m. Incident Description: At admission, 6/18/24, pt was severely agitated, refused to change clothes, consent to vital or body search, and refused to relinquish (his/her) phone. Due to pt's agitated state and extent of time (he/she) had been in the intake room, (he/she) was allowed to enter unit with (his/her) belongings. On 6/20/24, pt was discharged and escorted out of the building by facility staff (N6, Client Care Specialist). Outside pt showed (N6), (his/her) gun permit and then took a small firearm out of (his/her) pocket, that (he/she) had concealed during admission.

4. During an interview with A6 (Assistant Director of Quality & Compliance) on 10/25/24 at approximately 2:00 p.m., A6 verified the medical record information for Patient #5.

5. During a phone interview with N6 on 10/28/24 at 10:43 a.m., N6 indicated that they had not worked when Patient #5 was first admitted to the facility but when (he/she) had come back to work Patient #5 was on the inpatient unit and was getting discharged. N6 indicated that (he/she) had escorted the patient downstairs at approximately 11:00 a.m. via the elevator from the inpatient unit and the patient showed (him/her) a very small handgun that (he/she) had in (his/her) pant pocket. N6 indicated that they were off the inpatient unit when Patient #5 showed the handgun to (him/her). N6 indicated that (he/she) told Patient #5 to put the handgun away, when the Mobile Crisis Team arrived to transport Patient #5 back to (City #3), (N6) had Patient #5 put the handgun on their front seat until they could call the cops and get it safe. N6 indicated that the handgun was about the size of Patient #5's palm. N6 indicated that Patient #5 also had (his/her) personal cell phone on the inpatient unit and that (he/she) had all of (his/her) belongings on (him/her), because Patient #5 would not change into scrubs.

Based on document review and interview, the facility failed to ensure nursing staff followed physician orders related to medication administration and failed to follow facility policy to ensure nursing staff notified a patient related to a medication error for 1 of 10 patient medical records (MR) reviewed. (Patient #1)

Findings include:

1. Facility policy titled "CLIENT RIGHTS", policy number: 26.2.030N, last revised on 6/12/24 indicated the following: "PROCEDURE: Client have the right: 17. To be informed of unanticipated outcomes of treatment and/or medical errors."

2. Review of patient #1's medical record indicated the following:
(a.) The patient was admitted on 8/5/24 and discharged on 8/23/24 at 11:27 a.m. The patient had a diagnosis that included, but was not limited to, schizoaffective disorder, bipolar type.

(b.) A review of a psychiatric note dated 8/21/24 at 11:00 a.m. indicated the following orders: Medications: Clozapine: mood stability/psychosis:
Titration schedule:
Day 1 (8/9/24): 12.5 mg (milligrams) QD (every day).
Day 2 (8/10/24): 25 mg QD
Day 3 (8/11/24): 25 mg BID (twice a day)
Day 4 (8/12/24): 25 mg QD and 50 mg HS (hour of sleep)
Day 5 (8/13/24): 50 mg BID
Day 6 (8/14/24): 50 mg QD and 75 mg HS
Day 7 (8/15/24): 50 mg QD and 100 mg HS
Day 8 (8/16/24): 175 mg HS
Day 9 (8/17/24): 200 mg HS
Day 10 (8/18/24): 225 mg HS
Day 11 (8/19/24): 250 mg HS
Day 12 (8/20/24): 275 mg HS
Day 13 (8/21/24): 300 mg HS
Day 14 (8/22/24): 300 mg HS

(c.) A review of a psychiatric note dated 8/22/24 at 12:00 p.m. indicated the following: Behavior/PRNs: None: Nursing staff reported (Patient #1) did not have clozapine in (his/her) medication tray for last night's dose. (Patient #1) will resume at current dose today.

(d.) The medical record for Patient #1 did indicate that the patient was not administered Clozapine medication on 8/21/24 at HS as ordered due to the medication not being available/out of stock/not filled by pharmacy. The medical record for Patient #1 also lacked documentation that the patient was notified of the medication error related to Clozapine/Clozaril and/or the reason why the patient was not notified of the medication error.

3. An incident report for Patient #1 dated 8/22/24 related to an incident on 8/20/24, the report indicated pharmacy sent Clozaril 50 mg tablets with a set amount for each date in the medication card to give at night. Sometime during 8/16/24 through 8/19/24, (Patient #1) received double the dose (he/she) should have due to the label not matching the order. The incident report also indicated that on 8/20/24, it was noted in the patient's EMAR that 10 pills were given versus 11 tablets and per the 50 mg label 5.5 tablets should have been given. It was also noted that on 8/21/24 there were not any tablets left to give or for 8/22/24. Clozaril 300 mg was picked up on 8/22/24 to give the HS dose.

4. During an interview with A3 (Director of Nursing) on 10/24/24 at 1:00 p.m., A3 indicated that the pharmacy had changed the dose of the Clozaril tablets that they provided for Patient #1 without letting the staff know, we should have still completed the 5 rights with each medication pass. A3 indicated the 5 rights of medication administration are 1.) Right drug. 2.) Right patient. 3.) Right dose. 4.) Right route. 5.) Right time. A3 indicated that the facility was still investigating the medication error when Patient #1 was discharged, and that Patient #1 was not notified of the medication error. A3 indicated that an incident report was completed.

5. During an interview with A6 (Assistant Director of Quality & Compliance) on 10/25/24 at approximately 2:00 p.m., A6 verified the medical record information for Patient #1.