HospitalInspections.org

Based on review of hospital policy/procedure, medical records, and interviews, it was determined that the hospital did not inform the patients or patient's representative of the patient's rights, in a language they could understand for 2 of 4 non-English speaking patients (Pt #'s 13 & 16).

Findings include:

Review of the hospital's policy titled Patients Rights and Responsibilities, reviewed 8/2007, required: "...At the time of admission/entry to the hospital, patients are provided a copy...of the Patient Rights and Responsibilities...Your Rights as a Hospital patient...You have a right to communication without language, visual, hearing or learning barriers...."

Patient #13 presented to the Emergency Department on 5/4/10 at 2302, and was subsequently admitted to the hospital.

Review of the patient's medical record revealed:

On 5/5/10 at 0145, a nurse wrote:"... (Interpreter used?)...no...(Language Spoken)...Spanish." An "Intent of Advance Medical Directive" form, printed in English, contained the patient's signature, designating a "Health Care Agent." The medical record did not contain Conditions of Admission signed by the patient or patient's representative.

On 5/5/10, on interview, patient #13, confirmed that he/she could not understand English. Patient's representative (Health Care Agent) also confirmed that he/she (the representative) did not speak English. The representative provided the surveyor with a copy of the Conditions of Admission (printed in English) signed by the representative. The representative also provided the surveyor with the copy of the document "Your Rights as a Hospital Patient" also printed in English. The representative confirmed that neither he/she nor the patient could understand written or spoken English, and that an interpreter had not explained the Patient Rights and Responsibilities.

On 5/5/10, at 1000, employee #21 confirmed that neither patient #13 nor his/her representative received a copy of the Patient Rights and Responsibilities in a language that he/she could understand per policy.

Patient #16 was admitted to the hospital on 5/4/10 at 1620.

Review of the patient's medical record revealed that it did not contain a copy of a signed Condition of Admission or Intent of Advance Medical Directive.

On 5/5/10, at 1440, employee #40 confirmed that patient #16 only understands Spanish. Employee #40 interviewed patient #16, in Spanish, and confirmed that the patient did not receive a copy of the Patient Rights and Responsibilities, the Conditions of Admission, or Intent of Advance Medical Directives.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the hospital failed to require informed consents were obtained and documented according to policy, as demonstrated by:

1. One of 1 obstetric patients signed a consent for Cesarean Section, prior to the physician's order for the procedure (Patient #25);

2. One of 1 newborn's medical record included the mother's signed consent for Recombivax administration, prior to the birth (Patient #26);

3. One of 1 informed obstetric patients signed a consent that did not accurately reflect the physicians orders (Patient #24); and

4. Three of 3 obstetric patients signed informed consents that did not demonstrate the patients' understanding of the procedure (Patients #25, 34 and 35).

Findings include:

The hospital policy titled Informed Consent (last revised 06/08) requires: "...The physician who will administer or supervise the treatment or procedure...is responsible for obtaining the patient's informed consent. This responsibility cannot be delegated to anyone else...The physician must take reasonable steps to ensure that the patient has comprehended the information provided...and has had all questions answered before consenting. The physician's signature on the informed consent form or note in the record that informed consent was given certifies that this information was provided...."

1. Patient #25: Gravida 2 para 1, previous cesarean section, was admitted in active labor on 05/05/10. The Informed Consent indicated: "...Clinical term for procedure:...Delivery - Episiotomy - poss. (possible) Cesarean Section - forceps or vacuum assist...Reason for this procedure: Intrauterine pregnancy...." The patient signed the consent at 0835. The physician's Cesarean Section Admission Orders (verbal) on 05/05/10, at 0828, required, "Consent: Cesarean Section."

The patient signed the consent prior to the physician's order for the procedure.

2. Patient #26: The neonate's medical record included the mother's consent for Recombivax (Hepatitis B vaccine) on 05/05/10, at 0835. The neonate however was delivered by cesarean section on 05/05/10 at 0915.

The consent was signed 40 minutes before the birth (before there was a patient to consent for).

The Director of Women/Infant Services stated during an interview conducted on 05/06/10 at 1500, that Recombivax is administered per policy "which acts as the physician's order".

3. Patient #24 (as described above): The physician's order for consent did not include, "episiotomy, forcep or vacuum assist" for which the patient signed.

The Director of Women/Infant Services stated during an interview conducted on 05/06/10 at 1500, that "all patients admitted in labor sign the same consent (for Delivery - Episiotomy - poss. (possible) Cesarean Section - forceps or vacuum)," and that only scheduled repeat cesarean section patients sign consents for the specific surgical procedure.

Obstetric patients are signing Informed Consents for procedures not specifically ordered by the physician.

4. Patient #25 (as described above): The reason for the procedure was documented as "intrauterine pregnancy," which does not describe the reason(s) substantiating the procedure.

Patient #34: The Informed Consent indicated, "...Cesarean Section...Reason for procedure: IUP (intrauterine pregnancy)...." The patient signed the consent on 04/22/10. "IUP" was not written out, and does not describe the reason(s) substantiating the surgical procedure.

Patient #35: The Informed Consent indicated, "...Repeat C/Section (sic)...Reason for procedure: term intrauterine pregnancy...." The patient signed the consent on 04/24/10. "C/Section" was not written out. In addition, a term intrauterine pregnancy does not describe the reason(s) substantiating the surgical procedure.

Based on review of policy and procedure, medical records, and interview, it was determined that the hospital failed to require that policies and procedures covering restraints were implemented for 3 of 3 violent and/or self-destructive patients (Pts # 29, 30, and 31), as evidenced by:

1. failure to require that restraint or seclusion is guided by the reason for need, according to the hospital's policy for 2 of 3 violent and/or self-destructive patients (Pt's # 29, & 31); and

2. failure to require an order for a manual restraint for 1 of 1 violent and/or self-destructive patient, per policy (Pt #30).

Findings include:

The hospital's policy and procedure titled Restraints and Seclusion in the Acute Care Setting required: "...Restraint or seclusion is guided by the reason/rationale for the need whether...Restraint or seclusion is intended to manage Violent or Self-Destructive Behavior that jeopardizes the immediate physical safety of the patient, a staff member or others; or the restraint is used to ensure the physical safety of the non-violent or non-self-destructive patient...Medical Restraint Management (i.e., Non-violent, Non-Self-Destructive Patient)...Behavioral Restraint Management (i.e.,Violent or Self-Destructive Behavior)...."

1. Pt. #29 presented to the ED via ambulance on 4/15/10, and was seen by a physician at 2310. The ED record contains information that the patient had been driving while intoxicated and "ran into iron fence...airbag and windshield broken...pt kept driving...violent...brought in handcuffed by police...had 15mg Versed to sedate...wild violent behavior in ambo (ambulance)...stated to police was trying to kill self...also pt hallucinating...threatened everyone at scene...Clinical Impression...ETOH (Alcohol ) intoxication, violent behavior, homicidal, suicidal...." At 2315 a nurse documented: "...combative, uncooperative...PD (Police Department) on scene @ bedside...." The patient received intravenous (IV) fluid and medication. At 2320, a physician wrote an order: "...4 Pt (point) hand restraint medical restraint...protect lines, pt, & staff...."

At 2325, the physician completed the Medical Restraint Order Form (for the non-violent, non-self-destructive pt). The order indicates that restraints would be applied to the patient's wrists and ankles.

Pt. #31 presented to the ED via ambulance on 4/7/10 at 1120. The ED record contains information that Emergency Medical Services (EMS) personnel found the patient in her house, after a "forced entry," and found "pills about the house...EMS reports SI (suicidal ideation) in past...no other hx (history) available...."

At 1215, a physician wrote orders: "...2/4 pt (point) restraints as needed--form to chart...Haldol 5mg IM (intramuscular)...Valium 5 mg IM...attempt IV x2 (twice)...2-4 pt restraints needed until cooperative and staff safe...."

At 1200, a nurse initiated the Medical Restraint Order Form (for the non-violent, non-self-destructive pt) and recorded the physician's name at 1240.

During interview on 5/6/10, at 1530, the Director of Emergency Services and the Clinical Manager ED stated that they believed the medical restraint order (for non-violent patient, non-self-destructive patient) was appropriate for patients #29 and #31 to prevent these patients from pulling out their IV lines.

2. The hospital's policy and procedure titled Restraints and Seclusion in the Acute Care Setting revealed: "...Restraint: ...Any manual method...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Holding a patient in a manner that restricts the patient's movement against his or her will, including a therapeutic hold, is a restraint...a restraint order is required for each episode of restraint or seclusion...."

Pt. #30 presented to the Emergency Department (ED) via ambulance on 4/4/10, at 1945. The ED record contains information that the patient sustained a head injury "a couple days ago" and that he had been drinking alcohol on the day of his ED visit.

At 1945, nurse wrote: "...per pt, hears voices...." At 2055, a nurse wrote: "...gave pt risperdone mixed in drink. pt took sip and threw drink, per tech, pt shoved him and ran, tech was able to hold pt down with help of security guard...2100...."

The medical record does not contain a physician order for manual restraint.

Based on review of policy and procedure, and medical records, it was determined the hospital failed to require that staff monitored violent and/or self-destructive patients per facility policy for 3 of 3 violent and/or self-destructive patients (Pts # 29, 30, & 31).

Findings include:

Review of the hospital's policy and procedure titled Restraints and Seclusion in the Acute Care Setting revealed: "...Chemical Restraint:...a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement, and is not a standard treatment or dosage for the patient's condition...Simultaneous Use of Seclusion and Restraint (either physical or chemical):...Simultaneous use of restraint and seclusion is only permitted if the patient is continually (on going without interruption) monitored and use is justified...Trained staff is assigned to be present face-to-face...or using both video and audio equipment that is in close proximity to the patient...patient monitoring (is documented) every 15 minutes...Behavioral Restraint Management (Violent or Self-Destructive Behavior)...Patient monitoring by staff is performed every 15 minutes during the episode of restraint...."

Pt #29's medical record contains the physician's clinical impression of the patient: "...ETOH intoxication, violent behavior, homicidal, suicidal...." The patient was placed in restraints at 2324. Restraints were discontinued at 0108. The medical record contains no staff documentation of patient monitoring every 15 minutes per procedure for the violent, self-destructive patient.

Pt # 30's medical record contains documentation that he received Haldol 5mg IM and Ativan 2 mg IM and was placed in seclusion after "assaulting" an ED employee and trying to "escape."

On 4/4/10 2100, a nurse wrote: "Patient to seclusion...elopement attempt...Security at door...2135...Patient sleeping. Seclusion ended...."

On 4/5/10 at 0600, a physician wrote: "...sleeping NAD (No Acute Distress)...chemical/phy (physical) restraints...assaultive behavior...."

Pt #30 was chemically restrained and placed in seclusion. The medical record contains no documentation that the patient was continually monitored. The record contains no staff documentation of patient monitoring every 15 minutes per procedure for the patient requiring simultaneous use of seclusion and chemical restraint.

Pt #31's medical record contains documentation that the patient was "combative" and required 4 pt restraints "until cooperative and staff safe." The record also contains information that the EMS personnel reported that the patient had suicidal ideation in the past and no other history was available. The medical record contains no staff documentation of patient monitoring every 15 minutes per procedure for the self-destructive patient.

Based on review of policy/procedure and medical records, it was determined that the hospital failed to require documentation of a face-to-face evaluation of violent and/or self-destructive patients within 1 hour of a restraint or seclusion, per hospital policy, for 3 of 3 violent and/or self-destructive patients (Pts #29, 30, and 31).

Findings include:

Review of the hospital's policy and procedure titled Restraints and Seclusion in the Acute Care Setting required: "...Behavioral Restraint Management (Violent or Self-Destructive Behavior)...A physician or NP (Nurse Practitioner) must perform a face-to-face evaluation within one hour of the initiation of the restraint or seclusion to evaluate the patient's: immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint...Simultaneous Use of Seclusion and Restraint (either physical or chemical)...A physician must perform a face-to-face evaluation within one (1) hour with a description of the patient's behavior and intervention used...Document...Evaluation of the Violent or Self-Destructive Patient...within one hour face-to-face evaluation...."

For specific information regarding patients #29, 30 &31,

Cross reference A175 Patient rights: Restraint or Seclusion.

The medical records of Pt's #29 #30 and #31 do not contain documentation of the required face-to-face evaluation.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the hospital failed to require 1 of 1 medical record included documentation to verify pain relief (Pt #2), and 1 of 1 medical record included documentation of pain description and interventions (Pt #1), according to policy, as demonstrated by:

1. Pt #2's pain was recorded at a level of "1" (on a scale of 0 - 10, 10 being the worst) when the description substantiated a higher level; and

2. pain assessment codes (descriptions) were inconsistent with the pre-printed Nursing Documentation form's legend for Patient #1.

Findings include:

The hospital policy titled Pain Management (revised 08/08) required: "...The patient' pain goal (comfort goal) and functional status should be used as a guide in determining the effectiveness of pain management, usually a score of 5 or higher requires a pain intervention...."

1. Pt #2: The physician ordered Morphine 2 mg for moderate pain. Nursing documented the patient's pain as "1," "05/02/10 - 05/03/10" at 0330, as well as, "...Description: St/B/R (stabbing, burning, rigid/tense body)...." No interventions were documented based on the patient's description of the pain.

2. The pre-printed Nursing Documentation form requires the nurse to document the time, assessment, rating, location, description (non-verbal indicators), and interventions, to address the patient's pain.

Pt #1: Nursing Documentation dated 05/04/10 - 05/05/10, indicated:

2100: pain 8/10 for HA (headache). Description: C/TH. No intervention.
2200: pain 5 for HA. Description: C/TH. No intervention.
0315: pain 8 for HA. Description: C/TH. No intervention.
0435: pain 7 for HA. Description: C/TH. Intervention "IV med".

C= constant, according to the form. There is no code listed on the legend, referencing "TH".

RN #32 confirmed the inconsistencies during an interview and record review conducted on 05/06/10.

Based on review of hospital policies/procedures, Medical Staff Rules and Regulations, medical records, and staff interviews, it was determined that the hospital failed to require that physicians wrote clear and complete orders for 4 of 4 patients (Patients #1, 2, 9, and 26), or that nursing clarified the orders.

Findings include:

The hospital's Medical Staff Rules and Regulations require: "...The practitioner's orders must be written clearly, legibly, and completely...."

The hospital policy titled Ordering and Administration of Medications (last revised 07/09) requires: "...All pharmaceutical preparations shall be ordered by credentialed practitioners...Medication orders must contain:...exact dosage...dosage form, route of administration, frequency of administration...If not specified, the order is clarified with the physician...."

Patient #1: The physician ordered, "...morphine 1 mg IV Q (every) 6 (hours) PRN (as needed) pain/fever...." on 05/04/10.

The Pharmacist confirmed during an interview and record review conducted on 05/05/10, that Morphine is not indicated for fever.

There was no documentation to conclude that the order was clarified for the administration of Morphine to relieve fever.

Patient #2: The Emergency Department (ED) physician ordered: "...Zofran 4 mg SL (sublingual)..." and "...NPO...." (nothing by mouth). The nurse administered Zofran 4 mg "IVP" (intravenous push).

There was no documentation to conclude that the order was clarified for the medication route.

Patient #9: The physician ordered, "...Levophed IV (intravenous) gtt (drip) titrate to keep MAP (mean arterial pressure) (greater than) 60..." on 05/02/10. The medical record included a copy of the hospital's approved protocol for titrating Levophed, however the physician's order did not include initiating the protocol.

The physician's order for Levophed did not define a starting dose, increments, medication parameters, or maximum titration rate.

RN #21 stated during an interview and record review conducted on 05/06/10, that Levophed is administered per protocol, however acknowledged that the physician's order did not include initiating the protocol.

Patient #26: The pre-printed Physician's Orders included: "...Obtain permit for Hepatitis B vaccine...Vitamin K 1 mg IM (intramuscular)...Erythromycin ophthalmic ointment...Recombivax HB 5 mcg/0.5 ml IM...." The orders did not include the physician's signature, or documentation to confirm the orders were telephone/verbal. The nurse noted and carried out the orders on 05/05/10.

The Director of Women/Infant Services confirmed during an interview and record review conducted on 05/06/10, that the pre-printed Physician's Orders were not standing physician's orders.

Based on review of hospital policy and procedure, documents, and interview, it was determined that the hospital failed to require that the Director of Dietary implemented the established policy for food safety.

Findings include:

Review of the hospital policy titled Food Safety required: "...Food Temperatures for Service...All hot and cold food temperatures will be taken prior to the start of service and recorded on the temperature record form...If food is not at the appropriate temperature, the item will be immediately removed from the line and returned to the cook/chef to be brought up/down to appropriate service temperature...At the end of tray line, again temperatures will be taken and recorded...Temperature Logs: All records and/or logs are kept in the Manager's office...Cafe line...Tray line...."

During tour on 5/6/10, employee #7 provided the Food Temperature Logs for the Cafe line and the Tray line. Review of the May, 2010 Food Temperature Log for the Cafe line revealed that no food temperatures were recorded for Lunch or Dinner. Review of the April and May 2010 Food Temperature Logs for the Tray line revealed that no food temperatures were recorded for "PM" (the third meal) for 28 dates in April and 2 dates in May. Food temperature logs for the Tray line for dates 5/1/2010 and 5/2/2010 were blank (no recording of temperature for all three meals).

Employee #7 confirmed on interview that the employees had not recorded the food temperatures as required by policy and that this had been an ongoing problem.