HospitalInspections.org

Based on record review, observation and interview, the hospital failed to ensure care in a safe setting for psychiatric patients as evidenced by failing to:
1. Mitigate the ligature risk of the hand rails in the seclusion patient bathroom and the bathroom for patient rooms 102/104, which share the bathroom.; and
2. Ensure three pair of patient shorts were free of drawstrings, which pose a ligature risk.

Findings:

1. Mitigate the ligature risk of the hand rails in the seclusion patient bathroom and the bathroom for patient rooms 102/104, which share the bathroom.

On 10/8/18 at 10:40 a.m. a tour of seclusion bathroom and patient rooms 102/104, which shares a bathroom, revealed wooden hand rails noted to have a straight end over hang which are a ligature risk.

On 10/8/18 at 10:45 a.m. S2Adm verified the hand rails were a ligature risk as evidenced by this surveyor looping his belt around the hand rail end and the belt failing to slide off while downward pressure was applied.

2. Ensure three pair of patient shorts were free of drawstrings, which are a ligature risk.

Review of the hospital policy titled, "Body and Belongings Search", Policy Number: NSG-22, effective date 1/11/18, revealed in part: Contraband items include the following: Drawstrings. No clothing with drawstrings will be allowed in the patient use areas. Any articles found to have drawstrings are to be placed with the patient's valuables in a locked area. If the patient gives verbal permission, staff may remove drawstrings from clothing for patient use during hospitalization.

On 10/8/18 at 1:30 p.m. an observation of Patient #6's room revealed three pair of shorts with waistband drawstrings, in the patient's open clothing bin, which were a ligature risk.

On 10/8/18 at 1:35 p.m. S4MHT verified the three pair of shorts contained drawstrings and that patients are not allowed to have any strings or drawstrings in their possession.

Based on record review and interview, the hospital failed to report an allegation of potential neglect to LDH-HSS (Louisiana Department of Health - Health Standards Section) or a local law enforcement agency within 24 hours of receipt of the allegation for 1 (#R4) of 1 sampled patient reviewed for potential neglect.

Findings:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of the hospital policy titled," Assessment and Reporting of Abuse, Neglect, Exploitation, and/or Extortion of Youth and Adults", Policy Number: AS-18, revealed in part: Policy: In order to protect children, adults, and the elderly from harm by evaluating all allegations, observations, and suspected cases of neglect, exploitation, and abuse external to the organization and that which could occur while the patient is receiving care, treatment, and services; provide appropriate advocacy, care; and report abuse, this organization supports and maintains compliance with assessment/reporting standards set by these organizations: * Area police/sheriff's departments. * Department of Health and Hospitals.
Self-Reporting: A facility must self-report internal allegations of abuse/neglect to maintain compliance with: *CMS Regulation 482.13(c)/LA R.S. 40:2009.20. * LA R.S. 40:2009.20. Calls for reporting of knowledge of potential abuse incidents within 24 hours to either law enforcement or DHH (now LDH).

Review of the hospital's incident reports for 1/2018- 10/2018 revealed an incident had occurred on 9/30/18 at 2:25 a.m. involving alleged sexually inappropriate behavior between two patients. Further review revealed the following description of the incident: "Patient #R4 alleged Patient #3 had sat on his bed and touched him inappropriately "by his pants". Both parties dressed with clothes on top and bottom. Patient (#R4) had just screamed when staff answered."

Review of Patient #3's medical record revealed the following MD/LIP progress note, dated 9/30/18: Patient is still very confused here and he has been sexually inappropriate to his roommate; terrified his roommate. He was found naked. He tries to pull his private parts out in front of the female staff. Needing constant support and redirection. Very confused, irrational, disorganized not aware of his symptoms, not aware of his behaviors,. Hard to comprehend, hard to redirect.

Review of the hospital's self-reports of allegations of abuse/neglect submitted to LDH-HSS for the time period of 1/1/2018-10/8/2018 revealed no documented evidence of a self-report regarding Patient #R4's allegation of sexually inappropriate behavior against Patient #3.

In an interview on 10/10/18 at 8:45 a.m. with S3DON, she confirmed the above referenced incident had not been reported to LDH-HSS within 24 hours of discovery. S3DON reported Patient#3 had been moved out of Patient #R4's room after the alleged incident occurred. She indicated Patient#R4 had been examined/interviewed by S10MD and the doctor had felt the patient's delusions, as well as his inconsistent descriptions of the incident, had made the incident unreportable.

In an interview on 10/10/18 at 10:00 a.m. with S1CEO, he confirmed the hospital had looked into Patient#R4's allegation of sexually inappropriate behavior against Patient#3. S1CEO indicated he had not reported the above-referenced allegations to LDH-HSS within 24 hours of discovery because the hospital had looked into the complainants allegations and they had not been able to prove the incident had occurred.

Based on record reviews, interviews, and observations the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure to ensure the condition of patients' skin was accurately assessed, on admit, on every shift, and weekly for 2 (#1, #10) of 3 (#1, #3, #10) sampled patients reviewed for altered skin integrity from a comprehensively reviewed patient sample of 10 (#1-#10) and a total sample of 11. (#1- #11); and
2) failure of the RN to ensure patient weights were obtained and recorded, as ordered, for 5 (#1, #4, #5, #7, #8) of 5 (#1, #4, #5, #7, #8) sampled patients reviewed for weights from a comprehensively reviewed patient sample of 10 (#1-#10) and a total sample of 11.

Findings:

1) Failure to ensure the condition of patients' skin was accurately assessed, on admit, on every shift, and weekly.

Patient #1
Review of Patient #1's medical record revealed an admission date of 10/2/18 with an admission diagnosis of Major Depressive Disorder. Further review revealed the patient was receiving Aspirin (blood thinner) therapy for stroke prevention.

Review of Patient #1's nurses' notes revealed the following entries:
10/3/18 7:00 a.m.: Skin assessment: Bruises;
10/3/18 7:00 p.m.: Skin assessment: Bruises;
10/4/18 7:00 a.m.: Skin assessment: no documentation of Bruises;
10/4/18 7:00 p.m.: Skin assessment: no documentation of Bruises;
10/5/18 7:00 a.m.: Skin assessment: no documentation of Bruises;
10/5/18 7:00 p.m.: Skin assessment: no documentation of Bruises;
10/6/18 7:00 a.m.: Skin assessment: Bruises;
10/6/18 7:00 p.m.: Skin assessment: no documentation of Bruises;
10/7/18 7:00 a.m.: Skin assessment: Bruises;
10/7/18 7:00 p.m.: Skin assessment: no documentation of Bruises;
10/8/18 7:00 a.m.: Skin assessment: Bruises.
Further review of the above referenced nurses' note entries revealed no description of the bruised areas such as location, size, color, number of bruises, and whether the bruised area was flat or raised.

Additional review of Patient #1's medical record revealed the following weekly skin assessment body audit/wound care documentation:
10/3/18 7:50 p.m.: Bruises documented as being located on the forearm and hand of a body diagram.
10/6/18 11:45 a.m.: Bruises documented as being located on the forearm and hand of a body diagram.
Further review of both of the above referenced weekly skin assessments/body audits revealed no description of the bruised areas such as size, color, number of bruises, and whether the bruised area was flat or raised.

Patient #10
Review of Patient #10's medical record revealed an admission date of 9/27/18 with admission diagnoses of
Neurocognitive disorder with behavioral disturbances related to Dementia. Further review revealed the patient was on thrombocytopenia precautions and bleeding precuations.

Review of Patient #10's nurses' notes revealed the following entries:
9/28/18 7:00 a.m.: Skin assessment: Bruises;
10/2/18 7:00 a.m.: Skin assessment: Bruises;
10/3/18 7:00 a.m.: Skin assessment: Bruises;
10/3/18 7:00 p.m.: Skin assessment: Bruises;
10/8/18 7:00 a.m.: Skin assessment: Bruises.
Further review of the above referenced nurses' note entries revealed no description of the bruised areas such as location, size, color, number of bruises, and whether the bruised area was flat or raised.

Additional review of Patient #10's medical record revealed the following weekly skin assessment/wound care documentation:
10/6/18 3:00 p.m.: Bruises to bilateral forearms and hands. Further review revealed no description of the bruised areas such as size, color, number of bruises, and whether the bruised area was flat or raised.

On 10/10/18 at 10:20 a.m. an observation made of the skin on Patient #10's forearms and hands during activity group. The observation revealed the patient had a large bluish/purple bruise on his right arm, near his elbow approximately the size of a silver dollar. Further observation revealed the patient had a large (quarter sized) bluish-red bruise on his left forearm. The patient also had 4 smaller dark red spots (approximately the size of a pencil eraser) on the back of his right arm and 2 small dark red spots approximately the size of a pencil eraser, on his left forearm as well. The findings were verified by S3DON who was present during observation.

In an interview on 10/10/18 at 10:30 a.m. with S3DON, she confirmed patient skin assessments should have been performed on every shift, including night shift, because patients were showered at night and their skin could be visualized at that time. S3DON also reported patient skin assessment body audits were performed on admit and weekly in addition to the assessments performed each shift. S3DON agreed the documentation of bruising should have been more detailed.

2) Failure of the RN to ensure patient weights were obtained and recorded as ordered.

Review of the hospital policy titled, "Vital Signs Monitoring", Policy Number: NSG-34, effective 1/11/16, revealed the purpose is to ensure abnormal readings are reported in a timely manner to establish a guide for nursing staff. Included in the procedure is all trained nursing staff (including MHT's) will obtain all patients' vital signs according to the physician's orders or as needed based on nursing judgement.


Patient #4
Patient #4 was admitted on 10/1/18 with a diagnosis of Bipolar Disorder in addition to a medical diagnosis of DM (Diabetes Mellitus).

Review of the medical record for Patient #4 revealed an admission order for weights every Wednesday and Saturday. Further review revealed a nutritional assessment with a weight of 118 pounds and a BMI of 21. The graphic flowsheet displayed no fluctuation in weight with the same weight documented on all reviewed graphic flowsheets.


Patient #5
Patient #5 was admitted on 10/5/18 with a diagnosis of Major Depressive Disorder without Psychotic Features.

Review of the medical record for Patient #5 revealed an admission order for weights every Wednesday and Saturday. Further review revealed an admission weight of 116 pounds and a BMI of 19.9. The graphic flowsheet displayed no fluctuations in weight with the same weight documented on all reviewed graphic flowsheets. Review of the intake assessment revealed Patient #5 had a 5 pound weight loss in 3 weeks and 40 pound weight loss since February (8 months). Review of admission nursing assessment revealed a 50 pound weight loss over 9 months. Patient #5 had a pattern of weight loss prior to admission to the hospital.

Patient #7
Patient #7 was admitted on 9/26/18 with a diagnosis of Dementia with Behavioral Changes.

Review of the medical record for Patient #7 revealed an admission order for weights every Wednesday and Saturday. Further review revealed an admission weight of 184 pounds. The graphic flowsheet displayed no fluctuation in weight with the same weight documented on all reviewed graphic flowsheets.

Patient #8
Patient #8 was admitted on 10/3/18 with a diagnosis of Major Neurocognitive Disorder related to Alzheimer's Dementia with Behavioral Disturbances.

Review of the medical record for Patient #8 revealed an admission order for weights every Wednesday and Saturday. Further review revealed an admission weight of 234 pounds. The graphic flowsheet displayed no fluctuation in weight with the same weight documented on all reviewed graphic flowsheets.

On 10/10/18 at 10:00 a.m. an observation of the patient weight book, with S3DON, revealed Patient #8's documented weight was 234 pounds which included a wheelchair weight of 45 pounds. S3DON verified there was a discrepancy in the weight of Patient #8 and stated it was not policy to document the weight of the patient with the addition to her wheelchair.

On 10/10/18 at 9:15 a.m. in an interview with S3DON, she verified Patients #4, #5, #7, and #8's medical records had weights ordered every Wednesday and Saturday. Further review of Patients #4, #5, #7, and #8's medical records, with S3DON, revealed no change in the patient weights as of 10/9/18. The need to reweigh the patients to validate the accuracy of the weights was verified with S3DON during the interview.

On 10/10/18 at 11:15 a.m. a re-weigh of Patients #4, #5, #7, and #8 was requested from S3DON to evaluate for weight discrepancies for the above referenced patients.

On 10/10/18 at 11:20 a.m. in an interview with S2Adm and S8QA, they confirmed they were not surprised there was a problem with weights because this was always a problem.

The survey team exited on 10/10/18 at 12:15 p.m. and no new weights had been provided, as requested, for Patients #4, #5, #7, and #8.



39791

Based on record reviews, observations, and interviews, the hospital failed to promote safety in the preparation and administration of drugs and biologicals to hospital patients. This deficient practice was evidenced by failing to follow hospital policy/procedure and acceptable standards of practice during admininstration of insulin for 1 (#2) of 1 patients observed during insulin administration.

Findings:

Review of the hospital policy titled, "Sliding Scale Insulin Administration", last revised 8/1/17, revealed Insulin requires a double check method verifying correct medication and dose by two registered nurses or a RN and a LPN prior to administration. The double check method of correct Insulin dosing is defined as follows: 2 licensed nurses check MAR against order; both licensed nurses will verify that the correct medication is selected by comparing the medication container with the MAR; each licensed nurse will independently calculate the medication dose to be administered by use of the sliding scale order and the CBG measurement; and after the licensed nurse who is to administer the insulin has documented the calculated dose and has initialed the MAR, a second licensed nurse performing the double check method also places his/her initials next to the dose to be administered.

Review of Patient #2's medical record revealed an admission date of 10/4/18 with admission diagnoses including Depression with Suicidal Ideations and Diabetes Mellitus.

An observation was made on 10/9/18 at 12:00 p.m. of S7LPN admininstering Insulin to Patient #2. S7LPN did not follow the hospital's Sliding Scale Insulin Administration policy because she failed to have the Insulin dosage double checked by an RN prior to administration of 15 Units of Insulin to Patient #2.

On 10/10/18 at 9:15 a.m. in an interview with S3DON, she verified S7LPN did not follow the policy regarding Insulin administration. The syringe containing the Insulin was not double checked with the MAR, nor with another nurse before administration of the insulin. S3DON confirmed the proper way to check insulin is to have two nurses, one who is an RN verify the amount of Insulin in the syringe with the bottle of Insulin and compared with the MAR.

Based on observations, record review, and interviews, the infection control officer failed to ensure the infection control plan was implemented to control infections and communicable diseases of patients and personnel as evidenced by:

1) Failing to follow hospital policy by not placing a patient in ordered contact isolation in a private room, per hospital policy, for 1 (#4) of 1 patient records reviewed for isolation from a total comprehensively reviewed patient sample of 10 (#1-#10) and a total patient sample of 11.; and

2) Failing to ensure S7LPN removed her contaminated gloves and performed hand hygiene between patient contacts for 2 (#2, #4) of 2 (#2, #4) observed patient accuchecks performed by S7LPN.

Findings:

1) Failing to follow hospital policy by not placing a patient in ordered contact isolation in a private room.

Review of the hospital policy titled, "Infection Control", Policy Number: IC-02.01, last revised 5/1/16, revealed in part: Contact Precautions - Placement in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection (Cohorting). When a private room is not available and cohorting is not achievable, consider epidemiology of the microorganism and the patient population when determine patient placement. Consult with infection control coordinator or the DON is advised before patient placing.

Review of CDC's "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" revealed contact precautions were intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel caring for patients on Contact Precautions were to wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Hand hygiene was to be performed before having direct contact with patients, after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings, after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient), if hands will be moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after removing gloves.

Patient #4's medical record revealed she was a 69 year old female whom was admitted on 10/1/18 with a diagnosis of Bipolar Disorder in addition to a medical diagnosis of a UTI. Further review revealed on 10/7/18 her urinalysis culture and sensitivity resulted with two bacteria which suggested contact isolation. On 10/7/18 at 4:00 p.m. S9NP ordered to place Patient #4 on Contact Isolation. Further review revealed Patient #4 is incontinent of urine and wears diapers.

On 10/8/18 at 11:35 a.m. in an interview with S8QA revealed she was aware Patient #4 is on Contact Precautions and she has a roommate (Patient #5), who does not have any known infections.

On 10/10/18 at 9:15 a.m. in an interview with S3DON, she verified on 10/7/18, Patient #4 was diagnosed with a UTI that required contact isolation. She is aware as of 10/9/18, there was no change to isolation or added precautions, with the exception to a "Contace Precaution" sign placed next to Patient #4's name outside her room and Patient #4 has a roommate without a known infection. Informed S3DON of an incident documented in Patient #4's Progress Note dated 10/3/18 which stated Patient #4 took off her diaper and threw it across the room.


2) Failing to ensure S7LPN removed her contaminated gloves and performed hand hygiene between patient contacts.

Review of the CDC's "Guidelines for Hand Hygiene in Health-Care Settings" revealed indications for handwashing and hand antisepsis were as follows: decontaminate hands before having direct contact with patients; decontaminate hands after contact with a patient's intact skin (such as when taking a pulse or blood pressure); decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient; decontaminate hands after removing gloves.

On 10/9/18 at 12:00 p.m. an observation was made of S7LPN performing accuchecks on Patients #2 and #4. S7LPN failed to remove her contaminated gloves and failed to perform hand hygiene between patient contacts when obtaining capillary blood glucose sampling for accuchecks. Patient #4 is on contact precautions.

In an interview on 10/10/18 at 9:15 a.m. with S3DON, she verified S7LPN should have removed her contaminated gloves and should have performed hand hygiene when she obtained capillary blood glucose samples for accuchecks on Patient #2 and Patient #4.

Based on record review and staff interview, the Hospital failed to ensure patient History and Physical examination documentation included a descriptive neurological examination indicating what tests had been performed to assess patient neurological functioning for 3 ( #1,#3, #9) of 10 (#1-#10) sampled patients' records comprehensively reviewed for neurological assessments from a total patient sample of 11. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.

Findings:

Review of the Medical Executive Bylaws, Article XIII: Initial Patient Screening, revealed in part:
C. Content of H&P: The minimum content of the medical history and physical examination varies with the patient's level of care, treatment and services, as indicated by the individual patient presentation. A medical history will include at a minimum, the following: (1) Chief complaint; (2) Description of the present illness; (3) Past medical history, as appropriate; (4) Family history, as appropriate; (5) A psychological and social status, as appropriate; (6) Allergies; (7) A physical examination and review of symptoms; (8) A neurological examination, when indicated; (9) A statement of impression; (10) Treatment plan; and (11) Signature of the physician (which authenticates the H&P).

Patient #1
Review of Patient #1's medical record revealed an admission date of 10/2/18 with a diagnosis of Major Depressive Disorder.

Review of Patient #1's History and Physical, dated 10/3/18, revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: marked "No" with no indication of how the patient's ability to smell had been assessed.;
Cranial Nerve II: Vison- Near: Good; Vision - Far: Good with no indication of how the patient's vision had been assessed.;
Cranial Nerve III: Extraocular Movements: marked "Intact" with no indication of how the patient's extraocular movements had been assessed.;
Cranial Nerve IV: Ptosis of eyelids: "No" with no indication of how the patient's eyelids had been assessed.;
Cranial Nerve VI: Mastication of Muscles: marked "Intact" with no indication of how the patient's ability to masticate had been assessed.;
Cranial Nerve VII:. Tactile Loss - Upper Forehead: marked "Present" with no indication of how the patient's tactile loss had been assessed.;
Cranial Nerve VIII: Tactile Loss - Anterior Scalp: marked "Present" with no indication of how the patient's tactile loss had been assessed.;
Cranial Nerve IX: Face Symmetrical at Rest: marked "Yes" with no indication of how the patient's facial symmetry had been assessed.;
Cranial Nerve X: Hearing: Left Ear and Right Ear: both marked "Good" with no indication of how the patient's ability to hear had been assessed.;
Cranial Nerve XI: Palate rises normally: marked "Yes" with no indication of how the patient's palate movement had been assessed;
Cranial Nerve XII: Sternocleidmastoid contracts well: marked "Yes" with no documentation to indicate how the patient's Sternocleidmastoid contraction had been assessed.

Patient #3
Review of Patient #3's medical record revealed an admission date of 9/27/18 with a diagnosis of Vascular Dementia.

Review of Patient #3's History and Physical, dated 9/28/18, revealed the following documented neurological assessment of the patient's cranial nerves:
Cranial Nerve I. Difficulty Distinguishing Various Odors: Left blank (choices were "Yes"/"No").;
Cranial Nerve II: Vison- Near: marked "Good"; Vision - Far: marked "Poor" with no indication of how the patient's vision had been assessed.;
Cranial Nerve III, IV, and VI: All spaces for assessment were left blank (choices were "Yes"/"No").;
Cranial Nerve V: A wave-like mark was noted by the "Yes" choice for intact with no indication of how the patient's mastication muscles had been assessed.; Tactile Loss - Upper Forehead: left blank; Tactile Loss - Anterior Scalp left blank (choices were "Present"/"Absent").;
Cranial Nerve VII: Face Symmetrical at Rest: left blank.;
Cranial Nerve VIII: Hearing- Left Ear and Right Ear: both left blank (choices were "Good"/"Poor" for each ear). Assessment of Cranial Nerves IX through XII was indicated by a vertical line drawn down to a choice labeled "normal" with no documentation to indicate how the patient's cranial nerve function had been assessed for cranial nerves IX-XII.

In an interview on 10/10/18 at 9:08 a.m. with S3DON, she agreed the cranial nerve assessments were not descriptive and lacked a methodology of assessment after review of the above referenced patients' cranial nerve assessments.


Patient #9
A review of the medical record for Patient #9 revealed an admission date of 10/7/18 with a diagnosis of Depression and Suicidal Ideation.

A review of Patient #9's History and Physical, dated 10/8/18, revealed the following documented neurological assessment of the patient's cranial nerves.
Cranial Nerve I. Difficulty Distinguishing Various Odors.
Cranial Nerve II. Vision Near: "Poor" Vision Far: "Poor".
Cranial Nerve III. Extraocular movements are: "Intact".
Cranial Nerve IV. Ptosis of Eyelids: "No".
Cranial Nerve V. Pupils: Pupils Equal and Reactive to Light.
Cranial Nerve VI. Mastication of Muscles Intact: "Yes".
Cranial Nerve VII. Tactile Loss Upper Forehead: "Present".
Cranial Nerve VIII. Tactile Loss of Anterior Scalp: "Present".
Cranial Nerve IX. Face Symmetrical at Rest: "Yes".
Cranial Nerve X. Hearing: Left Ear: "Good" Right Ear: "Good".
Cranial Nerve XI. Palate Rises Normally: "Yes".
Cranial Nerve XII. Sternocleidomastoid contract well: "Yes".
Cranial Nerve XIII. Trapezius muscles contract well: "Yes".
Cranial Nerve XIV Tongue protrudes midline: "Yes".
Cranial Nerve XV. Atrophy: "No".
Cranial Nerve XVI Fibrillary movements present: No Reflexes: Babinski sign: Within normal limits. Meningeal signs: Within normal limits. Abdominal reflexes: Within normal limits. Primitive reflexes: Within normal limits.

In an interview on 10/10/18 at 9:00 a.m. S3DON reviewed Patient #9's History and Physical and verified the cranial nerve assessment was not descriptive and lacked the methodology used for the neurological examination.








38777

Based on record review and interview, the hospital failed to ensure the psychiatric evaluation included supportive information utilized to determine judgment, insight, and memory functioning for 2 (#1,#2) of 6 (#1-#6) sampled patients' records comprehensively reviewed for psychiatric evaluations out of a total patient sample of 11.

Findings:

Review of the hospital policy titled,"Psychiatric Evaluation", Policy Number: AS-03, revealed in part: Purpose: To establish or rule out the presence of active psychiatric pathology, determine acuity when indicated, assess clinical status and to serve as a basis for any psycho/pharmacological regimen. To serve as a format for documentation of a patient's diagnosis ( AXIS I_V), pertinent findings, treatment plan interventions and recommendations.
Procedure: Psychiatrist/Licensed Independent Practitioner: * Documents a complete Psychiatric Evaluation including AXIS I-V, prognosis, recommended treatment interventions, and assessment findings on Psychiatric Evaluation form or dictated in appropriate format within 60 hours. * Performs a systematic mental status examination emphasizing immediate recall, recent and remote memory appropriate to age. * Documents assessment of cognitive functioning, memory, and estimated intelectual functioning sufficiently to establish diagnosis and an objective baseline.


Patient #1
Review of Patient #1's medical record revealed an admission date of 10/2/18 with admission diagnoses including Major Depressive Disorder.

Review of Patient #1's Psychiatric Evaluation, dated 10/3/18, revealed the patient's judgement was documented as fair with no methodology for assessment documented.


Patient #2
Review of Patient #2's medical record revealed an admission date of 10/4/18 with admission diagnoses including Depression with Suicidal Ideations.

Review of Patient #2's Psychiatric Evaluation, dated 10/4/18, revealed the patient's memory was documented as intact with no differential assessment of immediate, recent, remote memory and no methodology for memory assessment documented.

In an interview on 10/10/18 at 8:40 a.m. with S3DON, she agreed the referenced Psychiatric Evaluations lacked supportive information and method used for determining judgement and memory, after review of the documents.

Based on record review, observation, and interview, the hospital failed to ensure each patient had a comprehensive individualized treatment plan which addressed all psychiatric and medical diagnoses for 3 (#1, #4, #10) of 10 (#1- #10) patient records reviewed for treatment plans from a total patient sample of 11.

Findings:

Review of the hospital policy titled,"Treatment Planning; Integrated/Multidisciplinary" Policy Number: CS-02, revealed in part: Policy: The multidisciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated, written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process. The treatment plan shall be initiated as a component of the admission process with continual development and formulation by the attending physician and multidisciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measureable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment andservices, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure: 2. The admitting nurse is responsible for the following: *Revising and developing nursing and medical components of the treatment plan based on additional findings fmro patient assessments, problems, needs, strengths, limitations, and physician's orders. * Revising the plan based on changes in condition and physician's orders received. All physician's orders will be added to the treatment plan.

Patient #1
Review of Patient #1's medical record revealed an admission date of 10/2/18 with admission diagnosis of Major Depressive Disorder.

Review of Patient #1's physician's orders revealed the following order, dated 10/3/18: Cleanse wound left arm with wound cleanser, apply triple antibiotic ointment then cover with bandaid times 5 days.

Review of Patient #1's treatment plan revealed alteration in skin integrity had not been identified as a problem on the patient's plan of care as of 10/8/18 (date of plan review).

Patient #4
Patient #4's medical record revealed she was a 69 year old female whom was admitted on 10/1/18 with a diagnosis of Bipolar Disorder in addition to a medical diagnosis of a UTI. Further review revealed on 10/7/18 her urinalysis culture and sensitivity results revealed two bacteria which suggested contact isolation. On 10/7/18 at 4:00 p.m. S9NP ordered to place Patient #4 on Contact Isolation.

Review of Patient #4's treatment plan revealed a potential risk for UTI infection. Further review revealed no update of actual infection requiring contact isolation on the patient's plan of care as of 10/10/18 (date of plan review).

Patient #10
Review of Patient #10's medical record revealed an admission date of 9/27/18 with admission diagnoses of
Neurocognitive disorder with behavioral disturbances related to Dementia.

Review of Patient #10's nurses' notes revealed the following entries:
9/28/18 7:00 a.m.: Skin assessment: Bruises;
10/2/18 7:00 a.m.: Skin assessment: Bruises;
10/3/18 7:00 a.m.: Skin assessment: Bruises;
10/3/18 7:00 P.M.: Skin assessment: Bruises;
10/8/18 7:00 a.m.: Skin assessment: Bruises.

Further review of Patient #10's medical record revealed the following weekly skin assessment/wound care documentation: 10/6/18 3:00 p.m.: Bruises to bilateral forearms and hands.

Review of Patient #10's treatment plan revealed thrombocytopenia precautions/bleeding precuations were identified as active problems on Patient #10's treatment plan. Further review revealed impaired skin integrity related to bruising had not been identified as a problem to be addressed on the patient's treatment plan.

On 10/10/18 at 10:20 a.m. an observation made of the skin on Patient #10's forearms and hands during activity group. The observation revealed the patient had a large bluish/purple bruise on his right arm, near his elbow approximately the size of a silver dollar. Further observation revealed the patient had a large (quarter size) bluish-red bruise on his left forearm. The patient also had 4 smaller dark red spots (approximately size of a pencil eraser) on the back of his right arm and on 2 small dark red spots approximately the size of a pencil eraser, on his left forearm as well. The findings were verified by S3DON who was present during observation.

In an interview on 10/10/18 at 10:30 a.m. with S3DON, she confirmed the above referenced patients' skin issues (arm wound and bruising) should have been addressed as problems on the patients' treatment plans.








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