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Based on interview, document review, and observation, the hospital failed to inform admitted patients whom to contact to file a grievance. Findings include:

<1> Hospital recipient rights advisors, interviewed 1-20-2010, were asked whether the CMS 800 complaint hot line or information regarding filing a complaint/grievance with the designated CMS Agency is included in the patient rights booklet or the hospital's complaint and appeal policy/procedure. Recipient rights advisors confirmed that no information is provided to an admitted patient about the availability of filing a patient rights complaint through the CMS complaint system nor does the hospital complaint and appeal policy/procedure reference this requirement.

<2> Observations on the hospital's psychiatric units on 1-20-2010 and 1-21-2010 revealed that signage was posted for filing a grievance with the hospital's recipient rights advisor, but no signage was posted informing patients of the CMS 800 complaint hot line or information regarding filing a complaint/grievance with CMS.

<3> On 1-20-2010 the admission coordinator was interviewed and a sample admission packet was examined. While the admission packet included information regarding Michigan Mental Health Code patient rights information, there was no information in the admission packet informing an admitted patient of his/her right to file a grievance with CMS or noting the CMS 800 complaint hot line.

Based on document review and interview, the hospital failed to ensure that the grievance process included a mechanism for timely referral of Medicare beneficiaries concerns regarding quality of care to the appropriate Utilization and Quality Control Quality Improvement Organization. Findings include:

<1> Hospital recipient rights advisors (#1 and #2) were interviewed 1-20-2010 and were asked whether the Recipient rights Office advises a Medicare beneficiary of his/her right to have his/her complaint/grievance regarding a quality of care concern referred to the local Quality Improvement Organization. The rights advisor #1 responded, stating that no such notice is provided to a Medicare beneficiary when a complaint/grievance is received or when notice of the hospital's investigative findings or interventions are sent to patient.

<2> The hospital's Complaint and Appeal Process policy/procedure was reviewed. The document does not include any information as to how a Medicare patient's grievance regarding quality of care is referred to the local Quality Improvement Organization.

Based on interview and document review, the hospital failed to ensure at the time of admission an admitted patient was provided written information regarding his/her right to formulate advance directives. Findings include:

<1> On 1-20-2010 the hospital ' s Director of Admissions (DA) was interviewed and an admission packet was reviewed. Review of the admission packet provided to an admitted patient revealed that the admission packet did not include any written information regarding a patient's right to form an advance directive. When queried, the DA confirmed that at the time of admission, an admitted patient is not provided any written information regarding his/her right to formulate an advance directive.

The DA further stated that: on admission a patient is asked whether he/she has completed a Durable Power of Attorney for Health Care (DPOA-HC) for medical and/or psychiatric treatment decisions. If the patient states that s/he has completed a DPOA-HC, information is solicited from patient as to how a copy of the advance directive may be secured. Social work staff are responsible in making the necessary follow-up to secure a copy of the patient's DPOA-HC when one has been executed.

The DA also stated that if a patient requests information regarding advance directives/DPOA-HC, the patient's inquiry is referred to social services for follow up.

<2> The assistant director of social services was interviewed 1-20-2010 and confirmed that her staff are responsible for securing a copy of a patient's advance directive/DPOA-HC when one has been executed. The assistant director of social services showed the surveyor written information regarding advance directives/DPOA-HC that can be provided to a patient if a patient should express an interest in receiving further information on this topic.

<3> Review of the hospital ' s Advance Medical/Psychiatric Directive Policy and Procedures (Statement number 224) revealed that the policy/procedure does not reference the requirement to provide to an admitted patient at the time of admission written information regarding his/her rights to formulating an advance directive.

Based on document review and interview, the hospital failed to ensure that hospital policy/procedure specified the maxim time frames that restraint could be initially ordered and then re-ordered when restraint was used to ensure the physical safety of the non-violent or non-self-destructive patient. Findings include:

<1> On 1-20-2010 the hospital Seclusion and Restraint Policy/Procedures was reviewed. Review revealed that the policy/procedures defined medical restraint, restraint, and seclusion. The policy/procedure specifies time frames for ordering restraint and seclusion but not for ordering medical restraint.

<2> The lack of specificity for time frames for ordering medical restraint was reviewed with the hospital ' s compliance officer on 1-21-2010. The surveyor was advised that the time frames for ordering and re-ordering medical restraint are the same as the ones for ordering seclusion and restraint (i.e. every 4 hours).

<3> During the 1-21-2010 review of open medical records on psychiatric unit R2 which treats medically fragile patients, staff were unable to identify any current patients that had been restrained as a " medical restraint " . The hospital wide log of restraint use that was provided to the survey team did not identify any " medical restraints " . Thus, the review of restrained patients did not include a sample of " medically restrained " patients.

Based on document review, the hospital failed to ensure that its seclusion and restraint policy procedure specified that CMS is notified by telephone of the death any patient within 1 business day when the death occurs within 24 hours after the patient has been removed from restraint or seclusion and that the notification to CMS is documented in the patient's medical record. Findings include:

<1> Hospital Seclusion and Restraint Policy/Procedures was reviewed 1-20-2010. The review revealed that section AA of the Standards section is limited to the following language: " The hospital Director/designee shall report any death that occurs while a patient is in seclusion/restraint, or where it is reasonable to assume that a patient's death is a result of seclusion/restraint to CMS and Michigan Protection and Advocacy Services.

<2> The reviewed policy/procedure does not include the following required provisions:

a. CMS notification of the death any patient whose death occurs within 24 hours after the patient has been removed from restraint or seclusion.

b. The death notification to CMS is to be made by phone.

c. The death notification to CMS is to occur within 1 business day of the patient's death.

d. The date and time of the death notification to CMS should be documented in the deceased patient's medical record.

The facility failed to provide appropriate nursing monitoring and response to the presentation of medical conditions. See tag A 395 and A 404.

Based on review of records and policies, and interview, the facility failed to monitor and appropriately report the medical presentation of patients (including pain management) and to appropriately document the response of medications administered to patients #5 and #6. Findings include:

The facility policy entitled "Acute Change in Medical Condition & Medical Emergency" states: "Any employee receiving reports or observing a change in medical condition shall immediately report this to the unit RN (Registered Nurse) and/or physician."

The facility policy entitled Pain Management, A. states, "All patients shall be assessed for pain...as required by condition. If pain is identified, a more thorough evaluation is to be done to determine possible causes or underlying conditions and to determine treatment." E. "Response to pain treatment shall be monitored. If treatment is ineffective, treatment plan shall be modified." A #9 level on the facility's pain scale means " hurts a whole lot-hurts worst." Per the same policy, the RN "assesses pain and notifies the attending Physician if acute or chronic pain is identified.

Review of facility Progress Notes (PNs) and the Medication Administration Record (MAR) for patient #5 for 10/1 and 10/2/09 revealed the following:

1) 8 am, MAR- Vicodin (Hydrocodone 5 mg/APAP 500mg) was given for back pain at 8:35 am. An effectiveness of 10 was documented. The MAR space for rating pain before and 1 hour after each dose was left blank.
2) 1 pm, PN- "Patient complained of back pain. Patient asked pain level- #9. Vicodin 5/500 given at 8:35 am.. Denies any further discomfort at this time." It was unclear how the patient's pain rating of 9 out of 10 related to the statement "denied any further discomfort at this time." There was no documentation of any follow-up.
3) 8:20 pm MAR- 30 ml (milliliters) Mylanta given. The nurse did not initial (identify herself) or complete the back of the form, explaining the reason and effectiveness of the medication.
4) 8:30 pm (? illegible time) PN by On-call Physician states "Patient complains of pain in chest like hot feeling which started in his epigastric (unreadable word) and spread to upper chest. He walked to Nurses station and felt dizzy and like throwing up ...He also felt (unreadable word) left upper arm. Patient was given Mylanta 30 ml and pain (unreadable word) soon after taking it."... "responded to Mylanta. If has chest pain again will send to ER."
5) 9:00 pm PN- by Nursing labeled "late entry." (unclear what time this note covers). "Patient complaint of chest pain radiating to left arm and heartburn and feeling dizzy. Patient complaint of feeling light headed upon rising with heartburn sensation in chest and pain to left arm." Nurse states " will monitor patient condition and notify on-coming nurse/staff of patient status." There is no explanation regarding why patient was not being sent to the ER (per prior PN plan by Physician.)
6) 9 pm MAR- Prevacid 30 mg and Vicodin 5/500 mg. given. The MAR pre and post pain ratings were left blank as well as the section reason and effectiveness.
7) 9:45 pm PN by Nursing labeled "delayed charting" (no indication of what time period the note covers). "Complaint of heartburn sensation." States "monitored" but does not specify where the heartburn is located, vital signs, or asking the patient about pain.
8) 10/2/09 12:45 am- PN by the On-Call Physician states "Patient is having chest pain again. Pain is radiating to his left shoulder and arm ... Will send to ER for evaluations...Give sublingual Nitroglycerin". Nursing PN (same time) - patient stated "My chest was hurting this afternoon."
9) 12:25 am MAR- no documentation of Nitroglycerin given (as ordered by MD.)

On 1/21/10 at approximately 10:30 am, a Recipient Rights Complaint Form (Allegation # 1-2826330, dated 11/23/09) was reviewed. It states that patient #5 "reported that he was feeling chest pain on 10/1/09. He said he reported it to staff at the R-3 Nursing Station and was told to return to his room and lie down. He didn't feel that his concern was taken seriously. He did go back to the Nurse's Station and at after his vitals were taken, he eventually was sent to Annapolis Hospital where he was diagnosed as having a heart attack and was hospitalized which was confirmed by further record review. On 1/20/10 at 11 am record review revealed that patient #5 was admitted to Oakwood Annapolis Hospital on 10/2/10 for treatment of a myocardial infarction and underwent a cardiac catheterization and stenting procedure. In the Oakwood Annapolis Hospital History and Physical dated 10/2/10 at 5:15 pm (which was available at Walter Reuther Psychiatric Hospital), the MD stated: "He (patient #5) told me that a Walter Reuther employee told him that he did not look well and sent him to his room. "

On 1/21/10 at approximately 9 am the Performance Improvement/Utilization Review Coordinator verified that she does not review individual patient complaints. At approximately 10:50 am the Director of Nursing (DON) confirmed that she had not reviewed patient #5's complaint related to nursing care. At approximately 10:15 am, this incident was reviewed with the Compliance Officer/Risk Manager (CO/RM), responsible for reviewing this incident and identifying concerns related to patient incidents. The CO/RM provided a document entitled "10/1/09 Incident" written by the Director of Medical Services (DMS) that consisted of a brief chart review, contained no evidence of a patient interview and concluded that the patient received appropriate and timely care. Based on this evaluation, the CO/RM stated that he did not conduct further evaluation of patient #5's complaints.

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A) On 1/20/10 at 12:15 pm, review of patient #6's record revealed that she returned from a hospital ER on 1/10/10 with discharge instructions to get a mammogram for evaluation of left breast pain.

B) On 1/11/10 the patient's MD wrote an order for a bilateral mammogram. Patient #6 received Motrin for chest or breast pain on 7 of 10 days since 1/10/10. Nursing notes did not contain any notes indicating that the patient's on-going pain was reported to the MD. Nurse #4 verified the patient's use of Motrin for pain and that there was no documentation that the MD had been informed of the patient's pain.
C) On 1/20/10 at approximately 3:00 pm, patient #6's MD was asked whether he had reviewed the 1/10/10 ER report and if the mammogram had been scheduled. The MD stated that the facility's Clinic was responsible for both tasks. On 1/20/10 at approximately 3:10 pm the Clinic LPN (Licensed Practical Nurse) was asked whether the mammogram appointment had been made. She stated that it had not been made yet because it is their practice to wait to see if other patients need the same service before making appointments for individual residents.



28267

Based on record review the facility failed to ensure that a registered nurse supervises and evaluate the nursing care for each patient. Findings include:

On 1/21/10 at approximately 11:00 a.m. during an open medical record review on patient #21 it revealed that the patient received Ativan 2 mg IM on 1/16/10, 1/17/10, and 1/19/10 for agitation and had subsequent falls within 36 hours after each dose of Ativan. On 1/20/10 the patient was transferred to the Emergency Department for a fall that resulted in a head injury. Upon review of the Hypersensitivity Report form that documents allergies to medications dated 12/22/09 it was noted that Ativan was reported as an allergy. The Medication Administration Record also had listed under allergies Lorazepam (Ativan).

On 1/21/10 at approximately 1:30 p.m., during policy and procedure review, the procedure titled " Medication: Administrative Procedure " under V. D. states " Allergy status must be checked before administering any medication. If a prescribed medication is listed as an allergy on the Medication Administration Record or Hypersensitivity Sheet, notify physician immediately for instructions. DO NOT GIVE THE MEDICATION UNTIL CLARIFICATION IS GIVEN."

Based on observation, interview and record review the facility failed to prepare and administer medications according to accepted standards of practice and facility policy. Findings include:

On 1/20/10 at approximately 10:50 am two medication carts on R-5 unit were examined. Drawers contained unlabeled, pre-poured medications identified only by room number for patient #s 11, 13, 14, 16, 17, 18, and 19. The Unit Manager stated that it is not facility practice to pre-pour patient medications. She was unable to identify a clear liquid stored with no identifying information.

Two vials of Tubersol Purified Protein Derivative that were labeled as opened more that one month (one on 6R dated 12/14/09 and one on 3R dated 11/29/09) were observed. The 4R Nurse Manager verified that these vials should have been discarded after 30 days. He also verified that patient #20's Lantus insulin (dated as opened on 12/2/09) had expired per facility policy.

On 1/20/10 at approximately 12 noon record review revealed that patient #6 had a one time order for Tylenol gr X (10 grains) written at 9:55 am. A unit nurse wrote a second order for Tylonol gr X in the MAR that day and administered it at 6 pm There was no MD's order for that dose.

On 1/21/10 at 11:30 am review of patient #5's record revealed that a Physician's order for Nitroglycerin written at 12:45 am on 10/2/10 was not documented in the MAR (Medication Administration Record).




28267

Based on observation, interview, and record review the facility failed to administer drugs in accordance with accepted standards of practice and hospital policy. Findings include:

On 1/20/10 at approximately 12:10 p.m. during medication administration to 6 of 6 patients (#22, #23, #24, #25, #26, #27) it was observed that the LPN for R-1 #1 did not watch the medication intake by the patients or assure that the patient swallowed the medication (the medications that were being administered were Clozapine, Lorazepam, Neurontin Wellbutrin SR, Invega, Trilafon, Klonopin, Glulcophage, and Seroquel). The patients were observed walking away from the medication room while swallowing their medication, which was confirmed by Nurse Manager R-4.

On 1/20/10 at approximately 3:00 p.m., during policy and procedure review, the procedure titled "Medication: Administrative Procedure " under 5. H. states "the nurse administering medication must assure that the patient swallows the medication."

On 1/20/10 at approximately 10:30 a.m. while touring R-5 medication room, the narcotic count was incorrect with the following counts when checked against the form DCH-D727:
Klonopin 2mg minus 1
Klonopin 1mg minus 7
Ativan 0.5mg minus 1

Upon interview with RN #1 on R-5 stated that she hadn't documented them yet and needed to start a new sheet (form DCH-D727). RN #1 proceeded to fill out the form and add patient names without confirming patient names and dosages with the Medication Administration Record. In addition, she documented controlled substances given by RN #2 to patients and stated that she would have to go get the RN #2 to come in and sign those lines that showed what medications were given to patients. This occurrence was confirmed by Nurse Manager R-4.

On 1/20/10 at approximately 3:00 p.m., during policy and procedure review, the procedure titled " Medication: Administrative Procedure " under VI. Controlled Substance: 8. states " as medication is administered, enter the following on the DCH-D727 Form in the appropriate area: a. Patient Name, b. Date, c., Time of Administration, d. Sign your complete signature and classification " .