HospitalInspections.org

Based on document review, medical record review and interview it was revealed that the facility failed to provide birth control medication to 1 of 1 patients (patient 2) who was taking birth control at the time of admission resulting in increased risk of pregnancy. The facility also failed to complete a Safety/Incident report and investigate an allegation of sexual contact between patients in a timely manner to reduce the risk of exposure to sexually transmitted diseases for all patients. Findings include:

Policies:

1. Medication Reconciliation, # TX-086, states:
"Physician in collaboration with nursing and pharmacy staff, must compare the home medication list with the inpatient medication orders, correct discrepancies, if necessary, and complete admission medication reconciliation."
2. Patient Home Medications/Adjunct Therapies, # 020.1550, states:
"Medications or other preparations that are determined through the medication reconciliation process to be resumed while an inpatient will be provided based on availability through the hospital pharmacy formulary."
3. Patient Safety Reports (PSR), # R1-040, states:
"It is the policy of Bronson Battle Creek to require a PSR to be completed for each event that occurs involving a patient or visitor, which is not consistent with the routine activities of the facility or care of a patient."
III. A. "All Patient Safety Reports will be reviewed by the Risk Management Department to ensure that it is:
2. Completed in a timely manner
3. Signed by the manager/supervisor with follow up measures included, if appropriate

Record Review:

From 4/16/13-4/17/13 review of patient #2's clinical record revealed:
1. Patient #2 was admitted to the facility on 3/21/13.
2. A "Psych Evaluation," dated 3/22/13, by Dr. #3 documented diagnoses of mild mental retardation and mental illness.
3. A Consultation by Nurse Practitioner (NP) #1, dated 3/22/13, listed Aviane, a contraceptive, under "Home Medications" and stated: "We will review and restart appropriate home medications."
4. Aviane was not ordered. There was no documentation to explain why it was not ordered.
5. A "Communication Note," dated 3/28/13 at 12:57 pm by Social Worker #1 states: "During team meeting today patient (#2) stated she had sex with another patient yesterday evening in her bathroom."
6. A Safety/Incident report of the incident was not listed on the Safety log.
7. On 3/28/13 patient #2 was examined in the hospital's Emergency Department and labs for some sexually transmitted diseases and pregnancy were done. A vaginal infection was noted and patient #2 was started on Cephalexin, an antibiotic.
8. Patient #2's Discharge Summary, by Dr. #3 states: "The patient was also advised to continue oral contraceptives."
9. The Discharge Summary contained no documentation of educating patient #2 regarding how long it would take for birth control to become effective again.

On 4/16/13 at approximately 1 pm Recipient Rights Advisor #1 provided notes of a 4/11/13 investigation interview with Nurse #2, in which Nurse #2 states that she observed patient #2 in the her bathroom, through a partially closed door, then witnessed patient #1 exiting patient #2's bedroom.

On 4/17/13 at 11:40 am the Unit Manager verified that there no Incident Report was completed for this incident.

Interviews:

1. On 4/17/13 at 11:15 am Dr. #2, the covering medical professiosnal for Nurse Practitioner #1, (who was unavailable), stated that a patient on contraceptive medication at admission, identified as a "Home Medication," should continue on the medication unless a reason for discontinuing the medication is noted.
2. On 4/17/13 at 11:40 am the Unit Manager stated that a staff Pharmacist verified that Avaine could have been obtained for patient #2 through the hospital's outpatient clinic if it had been ordered.
3. On 4/17/13 at 9:45 am physician #1, responsible for determining patient #1's supervision needs, stated that she was unaware that a staff member witnessed patient #1 exiting patient #2's bedroom on 3/27/13 and did not increase staff supervision of patient #1.
4. On 4/16/13 at approximately 1 pm Recipient Rights Advisor #1 stated that this investigation had not been completed.