HospitalInspections.org

Based on observation, review of facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure a safe setting for patients.
Findings include:
1) Review of facility document "Disposable Supplies," dated July 2008, revealed " ... Procedure: ... 2. Disposable items intended for single use should be properly discarded after one use. ... "
Observation on June 16, 2014, of the Geriatric Psychiatric Unit's medication room revealed an opened used single dose vial of sterile water, that was stored in the medication cart.
Interview on June 16, 2014, at 11:05 AM, with EMP2 confirmed there was an opened used single dose vial of sterile water.
Observation on June 16, 2014, of the Geriatric Psychiatric Unit's medication room revealed the following expired items: a True test Glucose Level two control marked expired November 30, 2013 and a 15 ml Hemocult Developer marked expired May 2014.
Interview on June 16, 2014, at 11:10 AM, with EMP2 confirmed the above mentioned supplies were marked expired.
2) Review of facility document "Eagleville Hospital Patient Handbook," dated May 16, 2014, revealed " ... Contraband List ... The following items are not permitted at Eagleville Hospital: ... Shoelaces ... Acute Co-Occurring and Gero Psych Unit only ... "
Observation on June 18, 2014, of the Geriatric Psychiatric Unit's Day Room revealed PT9, PT10, and PT11 were wearing shoelaces.
Interview on June 18, 2014, at 10: 30 AM, with EMP2 confirmed that PT9, PT10, and PT11 were wearing shoelaces and that shoelaces were not allowed on the Geriatric Psychiatric Unit.

Based on review of facility policy, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to provide adequate justification for the continued use of a physical restraint- Geri Chairs with tray tables, for four of eight medical records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

Review of facility policy "Subject: Seclusion and Restraint," dated April 14, 2014, revealed " ... Definitions: ... Restraint - is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head. ... Documentation: ... B. Each episode of use: ... 1) Circumstances that led to seclusion or restraint 2) Consideration or failure of alternatives 3) Rationale for type of physical intervention selected 4) Notification of family as appropriate 5) Written order for use 6) Behavior criteria for discontinuing seclusion or restraint 7) Informing the patient of behavior criteria for discontinuing seclusion or restraint 8) Verbal orders received from the attending physician, LIP 9) All in-person evaluations and reevaluations of the patient 10) 15 min assessments of the patient's status 11) Assistance provided to the patient to assist him/her meet the behavior criteria for discontinuation of seclusion or restraint 12) Continous monitoring 13) Debriefing with the staff 14) Any injuries or deaths ... "

1) Review on June 18, 2014, of MR1 nursing documentation, dated June 12, 2014 revealed " ... Pt dressed in gloves with sailor cap and strolling halls pleasant, then grabs chest states ... going to die and closes ... eyes and acts ... as unresponsive but then responds. Within seconds attempts to kick staff then becomes combative; kicking / hitting staff. Pt with dramatic behavior. Placed in geri chair with constant monitoring for safety. Pt unsafe walking ... "

Review of MR1 revealed no documented evidence that alternative measures were implemented prior to the initiation of the Geri Chair, nor was there adequate documentation and justification for the continued use of the Geri Chair, that restricted this patient's movement and prevented rising.

Interview on June 18, 2014, at 9:45 AM, with EMP1 confirmed that MR1 was placed in a Geri chair to prevent the patient from rising. EMP1 confirmed that MR1 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

2) Observation on June 18, 2014, of the Geriatric Psychiatric unit's Day Hall, revealed MR2 was sitting in a Geri chair, with the tray table in place, as a method to prevent the patient from rising/ambulating. MR2 was observed trying to get up from the Geri chair. However was unsuccessful because the patient was unable to remove the tray table, therefore preventing the patient from rising.

Review on June 18, 2014, of MR2 nursing documentation, dated June 13, 2014, revealed " ... arrived via ambulance and appeared to be severely confused, unsteady gait, follows prompting but with continuous frequent redirection. ... "

Interview on June 18, 2014, at 10:00 AM, with EMP2 confirmed that MR2 was placed in a Geri chair to prevent the patient from rising. EMP2 confirmed that the patient was unable to remove the tray table, resulting in the patient's inability to rise from the Geri Chair. EMP2 did not know that the use of a Geri chair to prevent the patient from rising was considered a restraint.

Interview on June 18, 2014, at approximately 1:30 PM, with EMP1 confirmed that MR2 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

3) Observation on June 18, 2014, of the Geriatric Psychiatric unit's Day Hall, revealed MR3 was sitting in a Geri chair, with the tray table in place, as a method to prevent the patient from rising/ambulating.

Review on June 18, 2014, of MR3 nursing documentation, dated June 2, 2014, revealed " ... sitting in chair in hallway. Patient frequently attempts to get out of chair unassisted. gait unsteady. Attempted to redirect patient. Patient alert to person only. ... "

Interview on June 18, 2014, at 10:05 AM, with EMP2 confirmed that MR3 was placed in a Geri chair to prevent the patient from rising. EMP2 confirmed that the patient was unable to remove the tray table, resulting in the patient's inability to rise from the Geri Chair.

Interview on June 18, 2014, at 1:35 PM, with EMP1 confirmed that MR3 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

4) Observation on June 18, 2014, of the Geriatric Psychiatric unit's Day Hall revealed MR4 was sitting in a Geri chair, with the tray table in place, as a method to prevent the patient from rising/ambulating.

Review on June 18, 2014, of MR4 nursing documentation, dated June 11, 2014, revealed " ... Patient had great difficulty with sitting for lunch; Patient required significant prompting and direction ... "

Interview on June 18, 2014, at approximately 10:10 AM, with EMP2 confirmed that MR4 was placed in a Geri chair to prevent the patient from rising. EMP2 confirmed that the patient was unable to remove the tray table, resulting in the patient's inability to rise from the Geri Chair.

Interview on June 18, 2014, at approximately 1:40 PM, with EMP1 confirmed that MR4 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

Based on review of facility policies, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to revise and develop patient care plans for the use of a physical restraint- Geri Chairs with tray tables, for four of eight medical records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

Review of facility document "Eagleville Hospital Nursing Services Documentation," dated April 2014, revealed " ... Plan of Care ... Description ... Identification and documentation of nursing problems, goals, interventions and outcomes. Required for patients in Hospital levels of Care. ... Timeframe ... At admission and as new issues are identified. Plans of Care should be reviewed at least weekly or as indicated by time frames for goals and update recorded in a progress note. ... Completed For ... Plans of Care should be reviewed each shift for Hospital level & will be reflected in the patient's progress note (refer to patient goals & objectives). ... Completed By ... Unit Nurse ... "

Review of facility policy "Subject: Seclusion and Restraint," dated April 14, 2014, revealed " ... Definitions: ... Restraint - is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head. ... Documentation: ... B. Each episode of use: ... 1) Circumstances that led to seclusion or restraint 2) Consideration or failure of alternatives 3) Rationale for type of physical intervention selected 4) Notification of family as appropriate 5) Written order for use 6) Behavior criteria for discontinuing seclusion or restraint 7) Informing the patient of behavior criteria for discontinuing seclusion or restraint 8) Verbal orders received from the attending physician, LIP 9) All in-person evaluations and reevaluations of the patient 10) 15 min assessments of the patient's status 11) Assistance provided to the patient to assist him/her meet the behavior criteria for discontinuation of seclusion or restraint 12) Continous monitoring 13) Debriefing with the staff 14) Any injuries or deaths ... "

1) Review on June 18, 2014, of MR1 nursing documentation, dated June 12, 2014 revealed " ... Pt dressed in gloves with sailor cap and strolling halls pleasant, then grabs chest states ... going to die and closes ... eyes and acts ... as unresponsive but then responds. Within seconds attempts to kick staff then becomes combative; kicking / hitting staff. Pt with dramatic behavior. Placed in geri chair with constant monitoring for safety. Pt unsafe walking ... "

Review of MR1 revealed no documented evidence that the patient's plan of care was revised or developed to include the continued use of a Geri Chair, that restricted this patient's movement and prevented rising.

Interview on June 18, 2014, at 9:45 AM, with EMP1 confirmed that MR1 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

2) Observation on June 18, 2014, of the Geriatric Psychiatric unit's Day Hall, revealed MR2 was sitting in a Geri chair, with the tray table in place, as a method to prevent the patient from rising/ambulating. MR2 was observed trying to get up from the Geri chair. However was unsuccessful because the patient was unable to remove the tray table, therefore preventing the patient from rising.

Review on June 18, 2014, of MR2 nursing documentation, dated June 13, 2014, revealed " ... arrived via ambulance and appeared to be severely confused, unsteady gait, follows prompting but with continuous frequent redirection. ... "

Review of MR2 revealed no documented evidence that the patient's plan of care was revised or developed to include the continued use of a Geri Chair, that restricted this patient's movement and prevented rising.

Interview on June 18, 2014, at 10:00 AM, with EMP2 confirmed that MR2 was placed in a Geri chair to prevent the patient from rising. EMP2 confirmed that the patient was unable to remove the tray table, resulting in the patient's inability to rise from the Geri Chair. EMP2 did not know that the use of a Geri chair to prevent the patient from rising was considered a restraint.

Interview on June 18, 2014, at approximately 1:30 PM, with EMP1 confirmed that MR2 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

3) Observation on June 18, 2014, of the Geriatric Psychiatric unit's Day Hall, revealed MR3 was sitting in a Geri chair, with the tray table in place, as a method to prevent the patient from rising/ambulating.

Review on June 18, 2014, of MR3 nursing documentation, dated June 2, 2014, revealed " ... sitting in chair in hallway. Patient frequently attempts to get out of chair unassisted. gait unsteady. Attempted to redirect patient. Patient alert to person only. ... "

Review of MR3 revealed no documented evidence that the patient's plan of care was revised or developed to include the continued use of a Geri Chair, that restricted this patient's movement and prevented rising.

Interview on June 18, 2014, at 10:05 AM, with EMP2 confirmed that MR3 was placed in a Geri chair to prevent the patient from rising. EMP2 confirmed that the patient was unable to remove the tray table, resulting in the patient's inability to rise from the Geri Chair.

Interview on June 18, 2014, at 1:35 PM, with EMP1 confirmed that MR3 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

4) Observation on June 18, 2014, of the Geriatric Psychiatric unit's Day Hall revealed MR4 was sitting in a Geri chair, with the tray table in place, as a method to prevent the patient from rising/ambulating.

Review on June 18, 2014, of MR4 nursing documentation, dated June 11, 2014, revealed " ... Patient had great difficulty with sitting for lunch; Patient required significant prompting and direction ... "

Review of MR4 revealed no documented evidence that the patient's plan of care was revised or developed to include the continued use of a Geri Chair, that restricted this patient's movement and prevented rising.

Interview on June 18, 2014, at approximately 10:10 AM, with EMP2 confirmed that MR4 was placed in a Geri chair to prevent the patient from rising. EMP2 confirmed that the patient was unable to remove the tray table, resulting in the patient's inability to rise from the Geri Chair.

Interview on June 18, 2014, at approximately 1:40 PM, with EMP1 confirmed that MR4 did not contain the required documentation, as outlined in the facility's policy "Subject: Seclusion and Restraint," for the use of a Geri chair as a restraint.

Based on observation, review of facility policies and procedures, review of medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to adequately assess and develop an appropriate plan of care related to identified patient care issues and failed to develop appropriate fall risk interventions for four of eight medical records reviewed (MR1, MR5, MR6, and MR7).

Findings include:

1) Review of facility document "Eagleville Hospital Nursing Services Documentation," dated April 2014, revealed " ... Plan of Care ... Description ... Identification and documentation of nursing problems, goals, interventions and outcomes. Required for patients in Hospital levels of Care. ... Timeframe ... At admission and as new issues are identified. Plans of Care should be reviewed at least weekly or as indicated by time frames for goals and update recorded in a progress note. ... Completed For ... Plans of Care should be reviewed each shift for Hospital level & will be reflected in the patient's progress note (refer to patient goals & objectives). ... Completed By ... Unit Nurse ... "

Review of MR1 physician documentation, dated June 12, 2014, revealed " ... [MR1] has been having poor ADLs and is not able to care of [MR1]self ... ". Further review of MR1 revealed no documented evidence that a nursing plan of care was developed to address the patient's self care deficit.

Review of MR5 nursing documentation, dated June 9, 2014, revealed " ... [MR5] admitted to this unit with the c/o refusing medications, refusing AM care, not eating ... ". Further review of MR5 revealed no documented evidence that a nursing plan of care was developed to address the patient's noncompliance issues.

Interview on June 17, 2014, at 1:30 PM, with EMP1 confirmed that no plan of care had been developed or implemented to address the identified issues in MR1 and MR5.

2) Review of facility policy "Falls Policy," dated April 2013, revealed " ... Policy: All patients will be assessed for their potential for falls at time of admission ... after a fall or change in physical or mental status. The patient will be placed on an appropriate prevention program. ... Procedure: Nursing staff, using the following forms, will assess and determine risk of all patients with regard to falls. The following measures will be instituted when a patient is determined to be at risk for falls: 1) Low Risk 2) Medium Risk 3) High Risk ... A treatment plan for fall prevention will be developed for the patient based on the identified level of risk..."

Review of facility document "Eagleville Hospital Nursing Services Documentation," dated April 2014, revealed " ... Plan of Care ... Description ... Identification and documentation of nursing problems, goals, interventions and outcomes. Required for patients in Hospital levels of Care. ... Timeframe ... At admission and as new issues are identified. Plans of Care should be reviewed at least weekly or as indicated by time frames for goals and update recorded in a progress note. ... Completed For ... Plans of Care should be reviewed each shift for Hospital level & will be reflected in the patient's progress note (refer to patient goals & objectives). ... Completed By ... Unit Nurse ... "

Review of MR1 revealed that a "Morse Fall Risk" assessment was completed on June 9, 2014; and that the patient was identified as a high fall risk. Further review of MR1 revealed no documented evidence that an adequate nursing plan of care was developed to address the patient's risk for falls.

Review of MR5 revealed that a "Morse Fall Risk" assessment was completed on June 10, 2014; and that the patient was identified as a high fall risk. Further review of MR5 revealed no documented evidence that an adequate nursing plan of care was developed to address the patient's risk for falls.

Review of MR6 revealed that a "Morse Fall Risk" assessment was completed on June 13, 2014; and that the patient was identified as a high fall risk. Further review of MR6 revealed no documented evidence that an adequate nursing plan of care was developed to address the patient's risk for falls.

Review of MR7 revealed that a "Morse Fall Risk" assessment was completed on June 15, 2014; and that the patient was identified as a high fall risk. Further review of MR7 revealed no documented evidence that an adequate nursing plan of care was developed to address the patient's risk for falls.

Interview on June 17, 2014, at 1:45 PM, with EMP1 confirmed that MR1, MR5, MR6, and MR7, revealed no nursing care plan to include problems, goals, interventions and outcomes for the identified high fall risk.

Based on review of facility documents, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that all deaths were reported to the OPO for one of one medical record reviewed (MR10).

Findings include:

Review of facility policy, "Organ Donation," dated February 2013, revealed " ... Procedure: 1. On or before the occurrence of each patient death, the nursing supervisor shall contact the Gift of Life Donor Program ... to determine a patient's suitability for anatomical donation ... "

Request was made to EMP1 for a listing of medical records of patients who died at the facility from June 2012, to June 2014. EMP1 provided one medical record, MR10.

Review of MR10 revealed that the patient died at the facility on February 7, 2014. Further review of MR10 revealed no documented evidence that the Gift of Life Donor Program was notified of MR10's death.

Interview on June 18, 2014, at 1:00 PM, with EMP1 confirmed MR10 had died at the facility and that the Gift of Life Donor Program was not notified.