HospitalInspections.org

Based on record review, the Governing Body failed to be accountable for the medical care provided to all patients, specifically Patient #1.

Findings include:

See Tag # 0347, Tag # 0395

Based on record review and interview, the onsite physician failed to be accountable for the the quality of care, specifically in assessing the need for hospitalization and individual care needs of Patient #1.

Findings include:

Review of policy ADM 11.05 " Voluntary Request for Admission " last revised 1/19/05 revealed a physician assessment is completed by a psychiatrist or general practitioner to confirm the patient ' s need for hospitalization and suitability for voluntary status. Upon determining the appropriateness for care, the physician signature, date and time is written in Part B for an adult.

Review of policy NSG " Continuity of Care " effective 7/05 revealed the patient is seen by a physician to further assess appropriateness for admission. If appropriate for admission, the patient is signed in by the physician. A medical physician is on site daily to address the medical needs of patients.

Review of the Intake Assessment dated 4/4/10 for Patient #1 revealed the assessment is signed off by the admissions nurse but the physician signature is blank.

Review of the Voluntary Request for Hospitalization Form dated 4/4/10 at 1940 revealed Staff #1 signed off as to examining Patient #1 prior to admission and confirms the need for psychiatric hospitalization and is appropriate for voluntary status.

Interview on 5/26/10 at 1425 with Staff #3 revealed the on call physician " generally looks at my assessment, the medication list, usually talks with the patient and signs the legal papers. Now they have to talk to the patients. " She stated that she believes the physician does a lethality assessment. She was not sure if Staff #1 spoke or assessed Patient #1 because she was "leaving as he was coming down." She stated that she leaves at 1900 and was running late. The nursing supervisor took over as the admission nurse.

There is no evidence Staff #1 performed an admission assessment of Patient #1.
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Based on record review and document review, the psychiatrist failed to be accountable for the care provided to Patient #1.

Findings include:

Review of the Initial Order Sheet dated 4/4/10 at 2150 revealed telephone orders were received from Staff #2, placing Patient #1 on close observation and suicide precautions. Vital signs as routine. Chemical dependency admission laboratories and a MICA consult were ordered.

Review of the Late Entry by Staff #2 dated 4/12/10 revealed she received a call from the RN at approximately 2115 on 4/4/10 for admission orders. Patient #1 was admitted for increased feelings of depression and had relapsed into drug use in recent weeks. The last ETOH use was several months ago. The RN reported vital signs were stable; Patient #1 was cognitively intact with no physical complaints reported nor agitation or aggression. Medical conditions were reviewed. According to staff, Patient #1 admitted to taking drugs earlier in the day and he obtained the drugs on the street, suspected benzodiazepines and possibly opiates. Lab studies, detox protocol, close observation and suicide precautions were ordered. The RN was advised to monitor Patient #1 and contact the in-house physician and myself with any changes in status.

There is no evidence the physician ordered a detox protocol or recognized the need to have the patient evaluated by the in-house physician.

Based on record review and document review, nursing staff failed to supervise and evaluate the care for Patient #1.

Findings include:

Review of policy ADM 11.16 "Admission Process" last revised 10/09 revealed the admission staff contacts an in-house physician who evaluates the patient to determine if the patient is appropriate for admission. An on call physician must sign in all patients.

Review of policy ADM "Pain Assessment and Management" last revised 4/05 revealed the admissions RN assesses and documents the patient's pain level on the pain assessment area of the intake. The Admissions RN reports all pertinent information to the RN team leader documenting this on the initial treatment plan. Upon admission, the RN team leader incorporates the need for continued pain monitoring into the treatment plan. The patient's status is assessed every shift and documented in the progress notes and pain flow sheet.

Interview on 5/26/10 at 1425 with Staff #3 revealed she was not sure if Staff #1 spoke or assessed Patient #1 because she was "leaving as he was coming down." "Patient #1's vital signs were fine and he had been there before. There was nothing to tell Staff #1." Staff #3 stated that she leaves at 1900 and was running late. The nursing supervisor took over as the admission nurse.

Review of the Intake Assessment dated 4/4/10 revealed a blood pressure of 122/56, pulse 106, respirations of 16 and temperature of 98. Patient #1 sought treatment because he felt suicidal for the past week or two and today is the 2nd anniversary of his mother's death. He has a history of opiate/Heroin addiction and has been getting Methadone and Xanax off the streets. The substance abuse assessment lists an opiate addiction and withdrawal symptoms of diarrhea and feeling bugs crawling on his skin. Medical history lists a complaint of nausea, heartburn and pain in back/hips/knees. Patient #1 rates current leg pain as "bad." He has not slept in 3 days. The lethality assessment section documents Patient #1 is thinking of cutting his wrist or overdosing. The summary of findings lists Patient #1 as depressed and feeling suicidal with a plan to cut wrists and/or overdose. The Initial Treatment plan "places" Patient #1 on close observation and suicide precautions via 15 minute visual checks for depression. For the problem of "opiate addiction" signs and symptoms are listed as "none at present" and to obtain MICA consult.

There is no evidence indicating the date of the last illicit drug use by Patient #1 in the intake assessment. There is no evidence nursing's initial treatment plan addressed Patient #1's physical symptoms. There is no evidence Staff #3 communicated the intake findings to Staff #1 or Staff #2. There is no evidence in the record to indicate Patient #1's pain was reassessed after admission.

Review of policy NSG "Documentation of Progress Notes" last revised 1/05 revealed the progress note reflects the patient's affect, behavior and communication.

Review of the Psychiatric Unit Intake assessment dated 4/4/10 revealed Staff #4 documented the same vital signs as listed on the assessment form. Nursing Biophysical review revealed pupils were reactive.

Review of Nursing Note by Staff #4 dated 4/4/10 at 2130 revealed Patient #1 was admitted to the 3rd floor adult unit on suicide precautions, close observation, MICA consult and 15 minute visual checks. The initial nursing assessment and mini-mental exam were completed. Staff #2 was called for orders. Patient #1 presents under heavy substance abuse, assuming opiates and benzo, in which he admitted to today.

Review of the Special Receive Committee Meeting Minutes dated 4/9/10 revealed Staff #4 admitted Patient #1 to the unit. He appeared "high," vital signs stable at admission, pupils were dilated and breathing normal. There were times when Patient #1 was lucid and coherent answering questions appropriately. He admitted to using Methadone and Xanax obtained from the streets. Staff #4 felt he needed to be medically cleared due to increased lethargy. She placed a call to the Staff #2, reported findings and was instructed to call the in house physician if Patient #1's condition worsened.

There is no evidence Staff #4 performed a full assessment of Patient #1 despite presentation and/or documented an accurate description of Patient #1's clinical presentation.

Review of policy NSG "Close Observation" last reviewed 10/09 revealed the physician will be notified of any significant change in the patient's status while on close observations.

Review of the Graphic Sheet dated 4/4/10 revealed it is blank. Review of the Respiration checks dated 4/5/10 revealed Patient #1's respirations were checked from 2400 to 0600 every hour while he was sleeping. Respirations were 16 per minute every check.

Review of the 24 hour Observation Flow sheet dated 4/5/10 revealed at 2400 Patient #1 was observed awake in the bedroom and at 1215 he was asleep. This assessment contradicts the Respiration check performed at 1200 by Staff #5 as noted on the Graphic Sheet.

Review of Nursing Note by Staff #5 dated 4/5/10 at 0300 revealed Patient #1 is maintained on close observation, suicide precautions and seizure precautions with 15 minute visual checks. He appears to be sleeping, respirations are 16 per minute. Patient #1 seems to inhale fully producing a snorting type sound on inhalation, occasionally accompanied by a cough. Will monitor Patient #1 through the night and offer support.

There is no evidence seizure precautions were ordered by the physician.

Review of the Special Receive Committee Meeting Minutes dated 4/9/10 revealed Staff #5 received report that Patient #1 had a substance abuse history and it appeared on admission that he had taken some drugs prior to arriving to the hospital. It was reported that he was found hanging out of bed during the 3-11 shift requiring assistance from staff. Patient #1 was making a "weird type of snorting sound and was loudly snoring." Staff #5 placed Patient #1 on hourly respiration checks.

There is no evidence Staff #5 conducted a full assessment of Patient #1, despite his abnormal breathing pattern and clinical presentation. There is no evidence nursing staff documented an accurate description of patient events and/or clinical presentation. There is no evidence nursing notified a physician of Patient #1's change in condition.

Review of the Special Receive Committee Meeting Minutes dated 4/9/10 revealed Staff #6 received report from Staff #4 indicating Patient #1 was drowsy and admitted to snorting illicit drugs prior to admission to the unit nurse.

There is no evidence Staff #6 assessed Patient #1 or reviewed the medical record, orders and precautions.

Review of the Special Receive Committee Meeting Minutes dated 4/9/10 revealed Staff #8 had completed 2 full hours of unit rounds and at each 15 minute interval Patient #1 was snoring loudly. During the 0500 to 0545 rounds, Patient #1 had changed position in bed and the snoring was no longer loud. Staff #8 was unable to determine whether Patient #1' s chest was rising as the room was dark he didn't want to wake him. He also knew Staff #5 was performing regular respiratory checks.

There is no evidence staff conducted adequate visual checks of Patient #1.

Based on record review, document review and interview, nursing staff failed to verify telephone orders per facility policy.

Findings include:

Review of policy NSG "Receiving and Transcribing Physician Orders" last revised 4/05 revealed the RN who is accepting a verbal or telephone order is required to confirm the order by reading it back to the physician and documenting "verbal/telephone order read back to physician beneath the order."

Review of the Initial Order Sheet dated 4/4/10 at 2150 revealed telephone orders were received from Staff #2 placing Patient #1 on close observation and suicide precautions. Vital signs as routine. Chemical dependency admission laboratories and a MICA consult were ordered.

There is no evidence the nurse read the orders back to the physician to verify telephone orders.

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Based on record review, document review and interview, medical staff failed to authenticate telephone orders per facility policy.

Findings include:

Review of policy NSG "Receiving and Transcribing Physician Orders" last revised 4/05 revealed all verbal and telephone orders are co-signed by the physician within 24 hours of the given order.

Review of the Admission Medication Reconciliation Order Sheet dated 4/4/10 at 2125 and the Physician Initial Order Sheet dated 4/4/10 at 2150 revealed telephone orders from Staff #2.

There is no evidence the order was signed off by Staff #2 until 4/12/10 at 1210.

Interview on 5/26/10 at 1410 with Staff #7 revealed the timeframe for physicians to sign off on verbal orders is 24 hours.

There is no evidence the physician signed off on verbal orders per facility policy.