HospitalInspections.org

Based on review of open medical records for 3 of 10 sampled patients (#1, #2 and #6) in a total sample of 21, policies and procedures for DNR (Do Not Resuscitate) and interviews, the hospital failed to ensure physicians documented evidence that the DNR status was discussed with the patient and/or family to indicate their response or degree of understanding of a "No Code" (withholding life sustaining measures) in relation to the patient. The hospital also failed to ensure the No Code Authorization form was complete for patients #1 and #2. Findings:

1. Review of the open medical record on 4/04/2011 at 2:00 PM revealed patient #2 was an 87 year-old admitted on 3/15/2011 for treatment of dementia with confusion. Continued review revealed a DNR form signed on 4/02/2011 by Dr. S4 attending psychiatrist and a note on the outer chart for the attending medical doctor (S5) to write the order for the DNR and to co-sign the DNR form. Review of the same DNR form on 4/05/2011 at 11:00 AM revealed the attending medical doctor wrote the DNR order for the patient and signed the DNR form. Review of physician progress notes failed to reveal documentation by Dr. S4 or Dr. S5 regarding the facts of their consideration relevant to the DNR decision including whom they discussed it with.

2. Review of the medical record revealed patient #6 was a 89 year-old admitted on 3/30/2011 with a psychiatric diagnosis of Dementia. Review of the 3/30/2011 admission orders revealed an order for a DNR. Review of the progress notes failed to reveal the physician documented any information to make the patient a DNR. In an interview on 4/04/2011 at 11:30 AM the DON (assistant director of nursing services) confirmed that the physician did not address his decision to withhold cardiopulmonary resuscitation for patient #6.

3. Review of the medical record for sample patient #1 revealed an admission date of 3/15/2011 with diagnoses that included dementia with behavioral disturbances, anemia, hypertension, gastroesophageal reflux disease, and glaucoma. Review of the March 2011 physician orders revealed an order for DNR status. Review of the No Code Authorization form revealed 2 physician signatures concurring the need for a DNR directive and a witness signature. Further review of the form revealed no patient/family signature agreeing with the DNR status. Review of physician progress notes failed to reveal documented evidence the DNR status was discussed with the patient and/or family indicating their response or degree of understanding of a No Code in relation to the patient.

Interview with S1 RN ADON on 4/05/2011 at 1:00 PM confirmed the No Code Authorization form was not complete by the lack of the patient and/or family signature to indicate they were in agreement with the DNR directive. S1 also confirmed that the physician did not address the DNR status in patient #1's physician progress notes.

Review of policy, "No Code Withholding or Withdrawing Life-Sustaining Procedures (reference #3.126, approved 5/2006) revealed, "Upon determination by the attending physician that the "patient condition is terminal and irreversible", the attending physician and a second physician will examine the patient and certify this terminal and irreversible condition by completing the No Code Authorization form, and documenting in the Physician's Progress Notes. This documentation should explain the family's or leal guardian's response and degree of understanding of a No Code in relation to the patient. Also, the level of the No Code should be documented in the form of an order and preferably reiterated in the progress notes".

Review of hospital policy, "No Code Authorization" revealed the "DNR directive shall be written as a formal order by the attending physicians and the facts and considerations relevant to this decision shall be recorded by the attending physician in the progress notes".

Based on observation, record review, and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by: 1) having electric bed with accessible cords throughout the facility; 2) having trash cans lined with plastic liners in areas that were accessible to patients and 3) having wet floors in patient bathrooms which posed as a fall hazard. Findings:

1. On 4/04/2011 at 9:10 AM, observation revealed that the facility had 14 electrical beds with cords that were accessible to patients. Further observation revealed 3 of the 14 beds had extension cords approximately 5 feet in length plugged into electrical outlets in patient rooms. On 4/06/2011 at 9:15 AM, interview with S6 CEO (chief executive officer) confirmed that electric beds are not to be used in a psychiatric hospital.

2. On 4/04/2011 at 9:05 AM, observation of Group Room #1 revealed the door was open and the room was unattended and that the trash can contained a plastic liner. Further observation revealed Group Room #2 and the kitchen area had trash cans lined with plastic liners. On 4/06/2011 at 9:15 AM, interview with the S6 CEO confirmed that the trash cans should not be lined with plastic liners.

3. On 4/04/2011 at 9:35 AM, observation of patient bathroom A revealed that the shower spigot was leaking directly onto the floor with a large puddle of water collected on the floor. Observation on 4/04/2011 at 1:10 PM revealed patient #8 was in bathroom A unattended. Further observation at that time revealed the floor remained wet and was a potential fall hazard for the patient and staff.

Based on observation, review of policy and procedures, review of 5 of 10 open medical records in a total sample of 21 and interviews, the hospital failed to ensure that a RN supervised and evaluated the nursing care for patients who were assessed at high risk for falls and were not on the correct observation status as per policy and procedure. (patients #1, #2, #3, #8, #10) Findings:

On 4/04/2011 at 9:45 AM, an interview with S1 RN ADON revealed that the census for the hospital was 14. On 4/04/2011 at 9:50 AM, an interview with S2 RN charge nurse confirmed that the census was 14 and that all patients were on observation Level III (routine monitoring-every 15 minutes). Further interview with S2 RN confirmed that staff was to note the location of each patient every 15 minutes and document the patients' location and behavior on an observation form. Further interview at that time confirmed that no patients were on constant monitoring observation.

Review of the medical record for patient #8 revealed admission to the facility on 3/28/2011 with an Axis I diagnosis of Psychosis NOS (not otherwise specified), an Axis III diagnoses of hypertension, history of a cerebrovascular accident, and the admitting nurse noted the patient was high risk for falls. Further review of the record revealed patient #8 was admitted on antipsychotic medication, Abilify and antianxiety medication, Ativan.

Review of the medical records for patient #1, #2, #3, #8 and #10 revealed they were assessed as high risk for falls by the admitting RN. Further review revealed the patients were placed on Observation Level III monitoring which indicated a routine, every 15 minutes observation.

Review of the policy for patient falls revealed that the RN must evaluate each patient that may be at risk of falls with a fall assessment tool. Further review revealed that the results from this assessment would be communicated to the treatment team so that appropriate treatment planning could occur. The policy indicated that the responsibility for identification and implementation of patients at risk for falls included all staff. Further review of the policy revealed that when a patient was identified at high risk for falls, constant supervision at all times would be required to prevent a fall and that the patient should be placed as near to the nurses station as possible.

On 4/04/2011 at 1:30 PM, an interview with S2 RN charge nurse confirmed that patients assessed as having an unsteady gait and/or on medications for a psychiatric condition are automatically placed on fall precautions and should be in constant visual observation at all times. S2 RN confirmed that patients #1, #2, #3, #8 and #10 were identified as high risk for falls and should have been on constant visual observation instead of every 15 minutes.

Based on review of 5 of 10 open medical records in a total sample of 21 and interview, the hospital failed to ensure medications were administered as ordered by the licensed practitioner for patients #1, #2, #3, #6, and #9. Findings:

1. Review of the open medical record for sample patient #1 revealed an admission date of 3/15/2011 with diagnoses that included dementia with behavioral disturbances, anemia, hypertension, gastroesophageal reflux disease, and glaucoma. Review of the March 2011 physician orders revealed an order for Lasix (diuretic) 40 mg every morning, Norvasc (antihypertensive) 10 mg every day and Nexium (decreases gastric acid secretion and acidity in the stomach) 20 mg every day. Review of the March 2011 Medication Administration Record (MAR) revealed the time indicated for administration on 3/16/2011 was circled and had a "G" beside the time which indicated the medications were not given because the were not available.

Interview with S2 RN staff nurse on 4/6/2011 at 10:30 AM confirmed after reviewing the MAR for patient #1 that the Lasix 40 mg, Norvasc 10 mg, and Nexium 20 mg were not administered as ordered on 3/16/2011. S2 confirmed they were not administered because they drugs were not available for administration.

2. Review of the open medical record revealed patient #6 was an 89 year-old who was admitted on 3/30/2011 with diagnoses of dementia and depression. Review of the 3/30/2011 physician orders revealed an order for Lotrel (antihypertensive medication) 2.5 milligrams to be administered every AM (morning) and PM (every evening). Review of the MAR revealed the nurse did not administer the PM dose of Lotrel on 3/30/2011 and the AM dose on 3/31/2011. An interview was conducted on 4/05/2011 at 1:15 PM with LPN S3 who confirmed that all of patient #6's medications were administered except for the PM dose of Lotrel on 3/30/2011 and the AM dose on 3/31/2011. She said the pharmacist does not deliver medications until 7:00 PM and the reason patient #6 received his other medications was because they came from the stock supply that the hospital maintains.

3. Review of the medical record for patient #9 revealed an admission date of 3/25/2011 with diagnoses that included dementia with delusions, loss of appetite, Burkitt's tumors, seizures, hypertension, hypothyroidism, hypercholesterolemia, and arthritis. Review of the March 2011 physician orders revealed Megace suspension 10 ml was to be administered twice a day. Review of the March 2011 MAR revealed Megace suspension 10ml was not administered 3/26/2011, 3/27/2011, and 3/28/2011.

Interview with S2 RN on 4/6/2011 at 10:30 AM confirmed after reviewing the MAR for patient #9 that the Megace suspension 10 ml dosages were not administered as ordered on 3/26, 3/27, and 3/18/2011. S2 confirmed they were not administered because the drugs were not available for administration.

4. Review of the open medical record revealed patient #3 was a 93 year-old admitted on 3/23/2011 at 3:00 PM for treatment of depression. Review of the 3/23/2011 physician orders revealed Razadyne ER 24mg (for mild to moderate Alzheimer's) was ordered at hour of sleep and Metformin HCL (controls blood sugars in Type 2 diabetes) 1000 mg twice daily on 3/23/2011. Further review of physician orders revealed on 3/25/2011 the attending medical doctor ordered Amlodipine 5mg (antihypertensive) at hour of sleep.

Review of the MAR for patient #3 revealed documentation that Razadyne was not given on 3/23/2011 because it was not available. Continued review revealed on 3/28/2011 at 8:00 AM the morning dose of Metformin was not administered because it was not available. Further review of the MAR revealed the 3/25/2011 dose of Amlodipine was not given because it was not available. Review of the vital sign graphics revealed the patient #3's blood pressure was 181/75 on 3/29/2011. An interview with S2 RN on 4/04/2011 revealed when the nurses do not have a medicine in stock, they can get it from a local pharmacy until the contract pharmacy delivers the medicine. S2 stated she could not determine why this was not done.

5. Review of the open medical record revealed patient #2 was an 87 year-old admitted on 3/15/2011 at 7:00 PM for treatment of dementia. Review of the 3/15/2011 MAR revealed the patient did not receive Vesicare 5mg (treatment of overactive bladder) by mouth on 3/15/2011 at 8:00 PM and Famotidine (inhibits gastric acid) 20mg at 5:00 AM on 3/16/2011 as ordered by the physician because the medications were not available.

Based on record review and interview the hospital failed to ensure a psychiatric evaluation was completed within 60 hours of admission for 3 of 3 sampled patients in a total sample of 21 (#1, #4 and #10). Findings:

1. Review of the open medical record revealed patient #4 was a 68 year-old female who was admitted on 3/15/2011 for treatment of dementia with confusion and delusions. Review of the psychiatric evaluation revealed it was dictated by an advanced practice nurse on 3/20/2011, 5 days after admit.

2. Review of the open medical record revealed patient #10 was a 62 year-old female who was admitted on 3/18/2011 for treatment of dementia with behavioral disturbances. Review of the psychiatric evaluation revealed it was completed on 3/29/2011 which was 11 days after admit.

3. Review of the open medical record for patient #1 revealed an admission date of 3/15/2011 for treatment of dementia with behavioral disturbances. Review of the Psychiatric Evaluation/Mental Status Exam (to be completed within 60 hrs of Admission by Psychiatrist) revealed it was incomplete as evidenced by the lack of documented answers for Right/Judgement, Mood/Affect, Thought Processing/ Associations, Patient's Memory assessed/Stated Method of Assessing, or Patient's current IQ Level Estimated (Below Average, Average, or Above Average). Further review indicated S7 APRN (advanced practice registered nurse) dictated the examination on 3/16/2011. Review of the typed Psychiatric Evaluation revealed it was dictated on 3/20/2011 and transcribed 3/22/2011 indicating it was not completed within the required 60 hour time period. Interview with S1 RN ADON on 4/05/2011 at 1:00 PM confirmed the psychiatric examinations were not completed timely for patients # 1,#4, and #10.

I. Based on record review and interviews the hospital failed to ensure each patient had a comprehensive care plan as evidenced by the failure to include Axis III diagnoses (general medical condition/s) in the care plan for 5 of 21 sampled patients (#1, #5, #7 #9 and #10). Findings:

Patient #1
Review of the medical record for patient #1 revealed an admission date of 3/15/2011 for treatment of dementia with behavioral disturbances. Review of the Axis III diagnoses revealed anemia, hypertension, gastroesophageal reflux disease (GERD) , and glaucoma. Review of the comprehensive care plan failed to reveal approaches to address the Axis III diagnoses of anemia hypertension, GERD, or glaucoma. Further review of lab results in the medical record revealed patient #1 had a hemoglobin of 5.5 which required admission to an acute care hospital on 3/17/2011 where patient #1 received a blood transfusion. Patient #1 returned to Allegiance Health Center on 3/18/11 for continued psychiatric care.

Interview with S1 RN ADON on 4/05/2011 at 10:30 AM confirmed the care plan for patient #1 was not comprehensive because care plan approaches were not developed to address Axis III (medical conditions).

Patient #5
Review of the medical record revealed patient #5 was an 89 year-old who was admitted with Axis III diagnoses of Osteoporosis, Hypotension and Benign Prostatic Hypertrophy. Review of care plans revealed the nurse failed to document approaches for the Axis III diagnoses.

Patient #7
Review of the medical record for patient #7 revealed an admission date of 3/16/2011 at 6:30 PM and Axis III diagnoses of hypertension, and the presence of a pacemaker. Further review of the medical record failed to reveal documented evidence that the nurse developed care plan approaches for the Axis III diagnoses.

Patient #9
Review of the medical record for sampled patient #9 revealed an admission on 3/25/2011 for treatment of dementia with delusions. Review of the Axis III diagnoses revealed loss of appetite, Burkitt's tumors, seizures, and hypertension. Review of the patient's care plan failed to reveal approaches to address loss of appetite, Burkitt's tumors (a form of malignant lymphoma), or hypertension.

Patient #10
Review of the open medical record revealed this was a 62 year-old female who was admitted on 3/18/2011 for treatment of dementia with behavioral disturbances. Continued review revealed the patient had a PEG (percutaneous endoscopic gastrostomy) tube and received a liquid dietary supplement through the tube. Review of the patient's Axis III diagnoses revealed the patient had chronic obstructive pulmonary disease, hypertension, gastric reflux disease and Type 2 diabetes with sliding scale coverage for capillary blood glucose readings. Review of the patient's care plan revealed approaches for impaired social interaction, risk for falls and self-care deficit, but there failed to be approaches for the Axis III diagnoses.

Interview with S1 RN ADON on 4/5/2011 at 10:30 AM confirmed the care plan for patients #1, #5, #7, #9 and #10 were not comprehensive because care plan approaches were not developed to address Axis III diagnoses.



II. Based on record review and interview, the hospital failed to: 1) ensure the Master Treatment Plan was complete for each patient as evidenced by the lack of the psychiatrist's signature for 2 of 2 sampled patients (#1 and #4) and 2) ensure the weekly team conference was signed by the psychiatrist for 1 of 1 sampled patients (#4) in a total sample of 21. Findings:

Patient #1
Review of the medical record for patient #1 revealed an admission date of 3/15/2011 for treatment of dementia with behavioral disturbances. Review of the Master Treatment Plan dated 3/15/2011 revealed there was not a psychiatrist's signature to complete the plan and to verify participation of the psychiatrist in the development of the Master Treatment Plan.

Interview with S1 RN ADON on 4/5/2011 at 10:30 AM confirmed the psychiatrist should have signed the Master Treatment Plan which would have completed the record and verified his participation in the development of the Master Treatment Plan.

Patient #4
Review of the open medical record revealed patient #4 was a 68 year-old female who was admitted on 3/15/2011 for treatment of dementia with confusion and delusions. Review of the Master Treatment Plan for the patient failed to reveal the attending psychiatrist signed the plan to indicate he participated in the formulation of the care plan and that he approved the approaches to the problems that were identified. Review of the 3/18/2011 Weekly Team Conference form failed to reveal a signature by the psychiatrist to indicate that he attended the meeting and approved the revisions to the care plan.

Based on record review, Daily Activity Schedule and interview with S6 CEO, the hospital failed to follow their policy for a therapeutic activities program by failing to provide activities and process groups on weekends. This was evident for 10 of 10 patients (patients #1-#10) in a total sample of 21. Findings:

Review of the open medical records for 10 sampled patients (#1-10) failed to reveal the hospital provided activities or process groups on weekends. Review of the Daily Activity Schedule revealed patients should receive recreational and psychotherapy twice each day. S6 CEO stated in an interview on 4/05/2011 at 2:00 PM that the hospital did not provide process groups on weekends. S6 reported the hospital only had 2 therapist who worked with in-patients and they were scheduled Monday through Friday from 8:00 AM to 4:30 PM.