HospitalInspections.org

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to ensure a patient's right to have hospital staff and practitioners comply with formulated advance directives for 2 of 2 patients admitted to the SBHU (Pts # 9 and 11).

Findings include:

Review of hospital policy/procedure titled Advanced Directives revealed: "...Admissions and Necessary Documentation: Medical record: a. If the patient has an advance directive in his/her prior...medical record, up-to-date information (including a copy of the document) is placed under the 'advance directive' tab on inpatient records. The directive is placed so it is readily visible to health care providers during the patient's treatment...Medical Record Documentation and Process/Inpatient Hospitalization; Upon arrival of the patient to the nursing unit, nursing personnel admitting the patient to the unit shall review the advance directive status documented on the patient's COA (Conditions of Admission) and the information entered in the EMR (electronic medical record)...a. If the COA indicates the patient has an advance directive, the nurse shall verify a copy of the directive has been placed on the patient's current medical record...."

Review of Pt # 9's medical record revealed:

Pt # 9 is an elderly female and was admitted to the SBHU on 1/19/15.

Pt # 9's medical record contained a form titled Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment with a section Advance Directive Acknowledgement. A check mark was placed in the box next to the statement: "I have executed an advance directive and have supplied a copy to the Facility."

On 1/27/15, Pt # 9's medical record did not contain a copy of her advance directive.

The CNO confirmed during interview conducted on 1/27/15, that Pt # 9's advance directive was not in the current medical record as required by policy/procedure. She obtained the advance directive from the Medical Records Department.

Review of Pt # 11's medical record revealed:

Pt # 11 is an elderly female, and was admitted to the SBHU on 1/12/15.

Pt # 11's medical record contained a form titled Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment with a section Advance Directive Acknowledgement. A check mark was placed in the box next to the statement: "I have executed an advance directive and have supplied a copy to the Facility."

On 1/22/15, Pt # 11's medical record did not contain a copy of her advance directive.

The Director of Behavioral Health confirmed, during interview conducted on 1/22/15, that Pt # 11's advance directive was not in the current medical record as required by policy/procedure. She stated that it was located in Medical Records.

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that the physician complete and document the one hour face-to-face evaluation of 1 of 1 patient who was restrained for the management of violent or self-destructive behavior (Pt # 1).

Findings include:

Review of hospital policy/procedure titled Restraint and Seclusion revealed: "...The LIP (Licensed Independent Practitioner) responsible for the patient in person (sic) within one (1) hour of the initiation of restraint or seclusion used for violent or self-destructive behavior...The in-person evaluation must include: a. An evaluation of the patient's immediate situation...b. the patient's reaction to the intervention...c. The patient's mental (sic) and behavioral condition...d. The need to continue or terminate the restraint or seclusion...Documentation: Each episode of restraint is documented in the patient's electronic medical record, consistent with policies and procedures...Any in-person medical and behavioral evaluation of the patient in restraint or seclusion for violent or self-destructive behavior...."

Review of Pt # 1's medical record revealed:

Pt # 1 was restrained with bilateral restraints to his upper and lower extremities, for the management of violent behavior, while he was in the ED. Restraints were initiated on 1/14/15, at 1250 and removed at 1640. A physician documented a physical examination at 1245 and documented that the patient was combative with severely slurred speech due to alcohol intoxication. At 1255, the MD documented "...face-to-face evaluation with this patient. He is currently requiring her strength (sic) (restraint) due to his altered mental status and belligerent behavior. Restrain orders have been written for the nursing staff...."

The CNO confirmed, during interview conducted on 1/23/15, that the medical record did not contain documentation of the elements of the one hour face-to-face evaluation required by hospital policy/procedure.

Based on review of hospital policies/procedures, hospital document, medical records and interviews, it was determined that the hospital failed to have a well-organized nursing service with delineation of responsibilities for patient care as evidenced by failing to have a policy/procedure related to the Suicide Risk Assessment currently in use by nursing in the SBHU.

Findings include:

Review of the hospital policies/procedures revealed that the hospital does not have a specific procedure for RN's to use for the completion of the Suicide Risk Assessment which is to be completed within 4 hours of admission and again at specific time intervals depending on a patient's Level of Observation.

Cross reference Tag 0395 for information regarding the incomplete Suicide Risk Assessments for Pts # 9 and 10. Documentation of the presence of risk factors by RN's varies between nurses and depending on patients' responses to questions, even when the risk factors such as history of abuse, relationship problems and recent severe stressful life events are unchanging during a patient's hospitalization.

Review of hospital document titled Initial BH Suicide Risk Assessment Form (BH-1308CERMS) Clarification, revealed that it did not contain procedural instructions regarding reassessment of patients. The facility was unable to provide written instructions or procedural guidance for RNs completing a patient's Suicide Risk Assessment when information gathered by other professionals and documented in the medical record is discrepant from the patient's responses at the time of completion of the Risk Assessment. Such information may relate to history and circumstances which are unchanging during the course of a patient's hospitalization and are listed as risk factors of suicide to be used in assessment.

The Director of Behavioral Health and the CNO confirmed, during interviews conducted on 1/27/15, that documentation of a patient's risk factors for suicide vary between nurses and depending on a patient's responses to questions, even for risk factors that are documented elsewhere in the medical record and are unchanging during the patient's hospitalization. They confirmed that the hospital does not have a policy/procedure that addresses documentation of Suicide Risk Assessment.

Based on review of hospital document, medical records and interview, it was determined that the hospital failed to ensure that an RN complete a Suicide Risk Assessment for 2 of 3 patients.

Findings include:

Review of the SBHU document titled BH (Behavioral Health) Suicide Risk Assessment revealed columns titled Observed Risk Factors and Reported Risk Factors. Each column contained lists of several factors with boxes for the RN to mark, indicating which factors were relevant to the patient. "Trauma or abuse history" was included as an Observed Risk Factor". "Chronic unremitting pain", "Financial, social accommodation, or relationship problems" and "Recent severe stressful life events" were included as Reported Risk Factors. A column titled Standard Interventions & Safety Plan contained a list of interventions. Patients placed on Observation Level III require a reassessment by the assigned staff at least every 8 hours and by the RN, at least every 24 hours.

Review of Pt # 10's medical record revealed:

Pt # 10 was admitted to the Senior Behavioral Health Unit (SBHU) on 1/8/15. On 1/8/15, at 1426, a MD documented in the Psychiatric Evaluation: "...Her trauma abuse history is terrible...as a child, was interned in the concentration camps...was tortured...submitted to horrible abuse while in the camp...."

Pt # 10 was placed on Observation Level III.

Review of the Suicide Risk Assessment forms completed by nursing for Pt # 10 on 1/8/15 through 1/22/15, revealed that the space for the RN to place a check mark to indicate the presence of trauma or abuse history was blank on dates 1/8/15 through 1/15/15, and on 1/18/15, 1/20/15 and 1/21/15.

The Director of Behavioral Health confirmed, during interview conducted on 1/22/15, that nursing had failed to record Pt # 10's suicide risk factor of a history of trauma or abuse on the Suicide Risk Assessment.

Review of Pt # 9's medical record revealed:

Pt # 9 was admitted to SBHU on 1/19/15. On 1/19/15, at 2030, a MD documented in the Psychiatric Evaluation: "...pt states over the past 2 weeks, her husband has been more verbally abusive, and recently has gone off on her. Through tears, 'what's the point of going, there's no point, I can't do this anymore.'...she stayed in her first marriage for 6-1/2 years and it was abusive...she may be developing pTSD (sic) (Post Traumatic Stress Disorder) because of the abuse...."

Pt # 9 was placed on Observation Level III.

Review of the 11 (eleven) Suicide Risk Assessment forms completed by nursing for Pt # 9, from 1/19/15 at 1905 through 1/27/15 at 0600, revealed:

The space for the RN to indicate the risk factor of "Recent severe stressful life events" was marked at the time of admission and was blank for 8 forms; it was marked as N/A (not applicable) for 2 forms. The space for risk factor of "Financial, social, accommodation, or relationship problems was blank for 8 forms, including the initial assessment, and was marked as N/A for 2 forms. The space for risk factor of "Trauma or abuse history" was marked at the time of admission and was blank for 6 forms and marked as N/A for 2 forms.

The Director of Behavioral Health confirmed, during interview conducted on 1/27/15, that she instructed RN's to ask the patients questions regarding all of the risk factors during each assessment/reassessment. She stated that if the patient states "no" to risk factors, the RN may leave the space blank by that risk factor, even if the patient's known situation has not changed. She confirmed that the risk factors of "Recent severe stressful life events", "relationship problems" and "Trauma or abuse history" were relevant risk factors for Pt # 9 and would not change during her 8 days of hospitalization. She confirmed that the Suicide Risk Assessments/Reassessments were not complete for Pt # 9.

Based on direct observation and interview, it was determined that the physical plant was not maintained in a manner in which the safety and well-being of patients was assured, when the nursing station in the Telemetry unit revealed an unsanitary environment.

Findings include:

Tour of the Telemetry unit was conducted on 01-27-15 at 10:30 A.M. Direct observation revealed two computer keyboards that contained dust particles and had the appearance of not having been wiped down. An automatic pencil sharpener contained a layer of dust on the top. A blue mouse pad contained evidence of liquid spills and had a brown substance on the surface, which gave the mouse pad the appearance of being "dirty." A sink in the nursing station had dried liquid stains, and contained dried liquid soap on the edge of the sink. The sink and surrounding area had the appearance of not being "clean."

The Chief Quality Officer acknowledged, during interview conducted on 01-27-15 at 10:30 A.M., that the nurses station needed to be cleaned.

Based on direct observation and interview, it was determined that the infection control officer failed to identify and control infections when the nursing station on the Telemetry unit revealed surfaces that nursing staff touch that were unsanitary.

Findings include:

Refer to Tag A 0701 regarding an unsanitary environment in the Telemetry Unit nurses station.