HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by failing to ensure rooms were free of ligature points and failed to conduct a Columbia- Suicide Severity Rating Scale on every shift per hospital policy for 6 (#1, 2, 3, 4, 5, 6) of 6 (#1, 2, 3, 4, 5, 6) patient's records reviewed utilizing a hospital bed.

Findings:

A tour of the hospital between 11:50 a.m. and 12:45 p.m. revealed Resident's rooms g, h, i, k, m and s air-conditioner units contained a piece of metal screwed to the top of the units which could be utilized as a ligature pint.

In an interview on 05/10/2021 at 12:00 p.m. S1Adm verified the metal piece could be utilized as a ligature point.

A review of hospital policy titled Safe Use of Hospital Beds and Bedrails effective January 1, 2013 and last revised November 2020 revealed in part:
Suicide Risk Assessment:
Patient will be screened for suicide risk upon admission and on every shift thereafter, using the Columbia- Suicide Severity Rating Scale, to minimize the risk of suicide associated with ligature points on hospital beds.

A review of Patient #1- Patient #6's medical record revealed the Columbia- Suicide Severity Rating Scale was completed only on one shift per day.

In an interview on 05/12/2021 at 11:00 a.m. S2DON verified the above information.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having opened undated medications available for patient use.

Findings:

Observation of the crash cart revealed 1 liter 0.9% Sodium Chloride expired April 2021.

In an interview on 05/10/2021 at 12:25 p.m. S3RN verified the expired Sodium Chloride.

An observation of the medication cart revealed the following opened undated medication:
a) 1 tube Zinc Oxide Ointment 20 oz.,
b) 1 tube Diclofenac Sodium Topical Gel 1% 100 G,
c) 1 tube Clotrimazol 1% 45 G,
d) 2 tubes Santyl Ointment 250 Units 30 G.

In an interview on 05/10/2021 at 12:30 p.m. S2DON verified the open undated medications.

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Based on record reviews and interview, the hospital failed to ensure the methodology of gross testing of Cranial Nerves II-XII, during the neurological examination, was documented in each patient's admission History and Physical. This deficient practice was evidenced by failure to include the methodology used for gross testing of Cranial Nerves II-XII for 8 (#1, 2, 3, 4, 5, 6, 9, 10 ) of 8 (#1, 2, 3, 4, 5, 6, 9, 10 ) sampled patient records reviewed for History and Physicals from a total sample of 10 patients.
Findings:

Review of the hospital's policy HIM-11 titled, "Documentation and Authentication in the Medical Record revealed in part: 2. History and Physical Examination - Minimal requirements include history of present illness, physical exam, complete neurological exam with a detailed description of gross testing for cranial nerves II - XII, and an assessment and plan.

Patient #1's History and Physical revealed a neurological examination with a check mark in a box next to CN (Cranial Nerves) II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #2's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #3's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #4's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #5's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #6's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #9's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Patient #10's History and Physical revealed a neurological examination with a check mark in a box next to CN II-XII grossly intact. The examination failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.

Interview on 05/12/2021 at 10:30 a.m., S2DON reviewed the History and Physical in Patients #1, 2, 3, 4, 5, 6, 9 and #10's medical record and acknowledged the documentation failed to give a methodology or detailed description used for gross testing of Cranial Nerves II-XII.