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Based on interview and document review, the facility failed to obtain consents or initiate denial of rights when implementing behavior modification treatment (Patient #9) and when administering psychotropic medications (Patient #11).
Findings include:
Patient #9
Patient #9 was admitted to the facility on 7/20/10, with diagnoses including depressive disorder, polysubstance abuse, chronic pain, seizures and possible borderline personality disorder. She was on a Legal 2000 (State of Nevada's involuntary civil commitment process).
Record review revealed the patient was alert, coherent and oriented to person, place and time. A psychology consult dated 9/3/10, revealed the patient to be alert, fully oriented with memory for immediate, recent and remote events unimpaired.
Record review revealed Patient #9 repeatedly reported she had suicidal thoughts and intended to kill herself once she was discharged to the community. She was placed on various forms of special observation during her hospital stay including one to one observation, close observation and full view observation.
On 9/8/10, Employee #15 entered a progress note revealing Patient #9 refused to meet with her. The employee requested that Employee #14 assess the patient for discharge. On 9/9/10, the patient was seen by the treatment team, including Employee #14. The patient was reported to become angry and threatening about the change in her pain medication and of the discovery of social security benefits from another state. The progress note report revealed she was placed on full view observation and her room was locked due to her anger and threats of self harm. The room was locked "so she can be fully observed in milieu." The patient went to her room at 5:00 PM and refused to leave. An order for 1:1 observation was given to monitor the patient in her room.
Review of physician orders revealed that on 9/9/10 at 12:35 PM, Employee #15 wrote an order that read, "full view - lock pt ' s room and quiet room during daytime. No off unit activities." Later that same day Employee #14 wrote the following order: "Full view for safety and self harm - block room and lock during daytime hours for self injurious behavior." In addition, the physician wrote the patient could have no Schedule III drugs and no off-unit privileges.
On 9/10/10, Patient #9 's 1:1 status was discontinued and she remained on full view observation. The patient's room remained locked during daytime hours from 9/9/10 until 9/14/10 (five days).
During a conversation with a non-employee, #21, on 9/20/10, she reported observing the patient on 9/10/10, with her blanket trying to sleep in the day room.
On 9/17/10, Employee #14 reported that Patient #9's room was locked during the day to change her sleeping hours (behavior modification) and to protect her from injuring herself in the room. The employee further indicated the patient was sleeping during the day and was awake all night. He reported the patient was awake most of the night and would disturb other patients and staff. The employee communicated that the patient was drug seeking and would request pain medication on most nights.
Employee #14 explained there was no policy and procedure addressing the locking of a patient's room and locking the quiet room to change sleeping patterns. He reported that a policy needed to be developed regarding the rights of patients and treatment procedures. He reported he intended to meet with the Rights Committee to discuss the issue further. He confirmed that a Denial of Rights report was not completed for Patient #9.
The facility's "Notification of Client Rights" form, given to each patient upon admission to the facility, listed the following protocol: "Before instituting a plan of care, treatment, or training, or carrying out any procedure, expressed and informed consent must be obtained in writing from you, if you are 18 years of age or over, or legally emancipated and competent to give that consent; your parent or guardian if you are under 18 years of age and not legally emancipated; or your legal guardian if you have been adjudicated. An informed consent requires that, with your consent, you are adequately informed as to the nature and consequences of the procedure, the reasonable risks, benefits, and purposes of the procedure, and alternative procedures available."
Review of the facility's "Clients Rights and Responsibilities" policy, effective 2/09, revealed that a denial of clients rights report shall be initiated when rights described in NRS 433.534 are denied. (According to NRS 433.534, "The rights of a client enumerated in this chapter must not be denied except to protect the client's health and safety or to protect the health and safety of others, or both. Any denial of those rights in any facility must be entered in the client's record of treatment, and notice of the denial must be forwarded to the administrative officer of the facility...")
Review of Policy #2.002 - "Reporting of Denial of Rights" - revealed it was the policy of Mental Health Services to review all denial of rights of consumers within the division and to forward Denial of Rights forms to the Mental Health and Developmental Services Commission for its approval.


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Patient #11

Patient #11 was admitted to the facility on 9/10/10, with diagnoses including psychotic disorder. According to the Psychiatric evaluation conducted on 9/13/10, the patient had average intellectual function and was alert and oriented x 2 (oriented to person and place).

Review of the patient's record revealed a Treatment/Medication Consent Form was initiated on 9/10/10, for the antipsychotic medication Seroquel. According to the documentation on the form, the patient refused to sign the consent for the following reason: "states he is not ill."

The Treatment/Medication Consent Form also indicated that on 9/12/10, a physician discussed with Patient #11 the risks and benefits of the psychotropic medications Ativan and Benadryl. A note on the form read, "Pt (patient) refused to sign, 9/13 - 9/14."

Review of Patient #11's record revealed a order for Ativan 2 mg (milligrams) every six hours as needed for agitation, Benadryl 50 mg every six hours as needed for agitation, and Seroquel 200 mg every night for psychosis.

The patient's Medication Administration Record (MAR) indicated that the patient was given Seroquel on 9/10/10; Ativan once on 9/11/10; Ativan once on 9/12/10; Ativan three times on 9/14/10; Benadryl twice on 9/14/10; Ativan twice on 9/15/10; and Benadryl once on 9/15/10.

Patient #11 was interviewed on 9/16/10. When asked about the psychotropic medications, the patient stated, "They are not my meds. They say, 'We will have to give you a shot if you don't take them. I don't want a shot.'"

There was no evidence in the record that a Denial of Rights was initiated for Patient #11, and this was confirmed by Employee #22.

According to the facility's "Medications: Informed Consent for Administration and Protocol for Involuntary Administration" policy, dated 4/2009, "The only times medication will be administered over the patient's objection shall be in emergency situations, as determined by a Physician, or when the Denial Process for involuntary administration of medications is implemented...Denial of Rights to give psychotropic medications without patient's informed consent: An order for Involuntary Administration can only be prescribed on a standing basis for patients who are admitted to the hospital under an Involuntary Court Commitment and who are additionally court ordered to receive Involuntary Administration of Medications."


Complaint #NV00026485

Based on record review and staff interview, the facility failed to obtain written consent for the administration of psychotropic drugs for 1 of 33 patients (Patient #20).

Findings include:

Patient #20 was admitted to the facility on 8/20/10, with diagnoses including schizophrenia and epilepsy.

Record review revealed the patient consented to the administration of Zyprexa, Ativan, Ambien and Depakote on 8/21/10. Records also revealed the patient agreed to the use of Benadryl and Cogentin on 8/28/10.

Review of Patient #20's Treatment/Medication Consent form revealed that the patient's written consent was not obtained for the administration of Prolixin, Klonopin and Zoloft. The Treatment/Medication Consent Form did not identify the names or dosages of the drugs. Records revealed that Prolixin, Klonopin and Zoloft were ordered on 9/7/10. Although there were physician orders for the medications, no physician initials were on the consent form.

During an interview with Employee #20, she reported that the night shift adds the medications to the consent forms, and the physician and patient then sign the consent form. The employee reported that the night shift must have forgotten to add the medications to the consent form and obtain the required signatures.

Review of the policy and procedure entitled, " Medications: Informed Consent for Administration and Protocol for Involuntary Administration," revealed that psychopharmacological medications, including antipsychotics, antidepressants, anxiolytics/hypnotics, antimanics, and antidyskinetics, were not to be given on a routine or PRN (as needed) basis unless certain exceptions existed. The policy and procedure revealed the medications could be given for 24 hours upon verbal order of a physician with verbal consent of the patient or legal guardian. The medications could be given with written consent of the patient or guardian on the Treatment/Medication Consent Form or for emergency treatment. No exceptions were reported when Patient #20 received Prolixin, Klonopin and Zoloft.

Record review did not reveal a reason Patient #20 did not sign the consent for the drugs.

Note: Patient #20 did sign the consents for the drugs voluntarily following the discovery of the omission.

Based on document review, interview, and observation, the facility failed to ensure a current list of services provided by the laboratory was available to medical staff.

Findings include:

A complete list of laboratory services was not available on four of five nursing pods inspected. The laboratory supervisor confirmed on 9/14/10, that the list found and reviewed on one of the five pods was not a current list.

Based on interview, policy review and document review, the facility failed to ensure specimen examination requirements were determined and defined.

Findings include:

A review of the laboratory policy regarding specimen collection, a review of the services provided by the contracted laboratory service, and interviews with the laboratory supervisor on 9/14/10 and 9/15/10, revealed that a list of specimens requiring macroscopic examination and those requiring both macroscopic and microscopic examination, as determined by the medical staff and a pathologist, was not present in the laboratory.

Based on observation, interview, and document review, the facility failed to ensure that the hot water temperatures were maintain at safe levels.

Findings include:

On 09/20/10, the hot water temperature was measured throughout the Rawson Neal Complex's housing Sections (C, D, E, G and H). Housing Section E and G were found to have hot water greater than 120 degrees Fahrenheit (F) at the bathroom hand sinks.

The arrangement of the bathrooms are common dormitory-style, where all the fixtures are within four bathrooms per housing Units D, E, G and H, and less rooms for Unit C

The E unit hand sinks were measured at the following:
126 degrees F for both the men and women's south bathroom hand sinks;
136 degrees F for the women's north bathroom hand sinks; and
130 degrees F for the men's north bathroom hand sinks.

The G Unit hand sinks were measured at the following:
132 degrees F for the men's and women's north bathroom hand sinks;
132 degrees F for the women's south bathroom hand sinks; and
130 degrees F for the men's south bathroom hand sink.

Interviews with the facility's Maintenance Supervisor indicated that the hot was measured quarterly, while a Maintenance Staff Member indicated that the hot water was measured monthly. No documentation was provided for review to establish the frequency for measuring the hot water and what the hot water temperatures had measured.

Note: The facility eventually got the hot water temperature to a safer temperature (below 120 degrees F) on 09/20/10.

Based on observation and staff interview, the facility failed to follow the infection control standards identified by the Center for Disease Control and Prevention (CDC) and The Association for Professional in Infection Control and Epidemiology, Inc. (APIC).

Findings include:

On 9/14/10, Employee #18 was observed performing a blood glucose fingerstick on a patient. The employee conducted the finger stick and neglected to disinfect the glucometer after it was used on the patient. The employee was interviewed as to when the glucometer was cleaned. She reported it was cleaned by the night shift when the accuracy of the glucometer was tested.

On 9/16/10, Employee #19, was interviewed as to when the glucometer was disinfected. She reported that the glucometer was disinfected by the 11:00 PM to 7:00 AM shift. Additional employees were questioned throughout the facility and agreed the glucometer was only disinfected daily.

On 9/16/10, Employee #16 and Employee #17 were interviewed. They reported that the facility followed Center for Disease Control standards and APIC standards. The employees reported their policy required that the glucometer be cleaned when visibly soiled and when uploaded.

Review of the facility policy entitled "ACCU-CHECK Inform Blood Glucose Monitoring System," effective 5/2009, revealed the ACCU-CHECK Advantage meter (glucometer) was to be cleaned if contaminated with blood.

CDC and APIC standards require that the exterior surfaces of the glucometer be disinfected after each use, even if there is no visible blood or soil, following the manufacturer 's directions. An EPA-registered disinfectant effective against HBV, HCV and HIV must be used.