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Based on record review and interview, the hospital failed to ensure that 1 of 12 sampled patients' (Patient 8) responsible party was notified of the "Certification Review Hearing" for the 5250 (the initiation of a 14 days detention for intensive treatment after the completion of an assessment and evaluation by the physician and prior to the expiration of the 5150 [an involuntary commitment of a patient for 72 hours for danger to one's self or others] or for a minor [a person under the age of full legal responsibility] to ensure that the patient met the criteria). This contributed in the responsible party not attending the hearing and filing a grievance (an official statement of a complaint over something believed to be wrong or unfair) with the hospital.

Findings:

On September 12, 2012, Patient 8's clinical record was reviewed. It noted that the patient was admitted to the facility on August 2, 2012 and discharged on August 7, 2012. The diagnoses included recurrent depression (a medical illness that causes a persistent feeling of sadness and loss of interest), psychosis (a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning and a distorted or nonexistent sense of objective reality) and suicidal ideation (a medical term for thoughts about suicide).

A review of the face sheet (a form that included patient demographics and contact information) noted that Patient 8 was a minor. His mother was noted as his responsible party.

A review of the form titled, "Consent to Contact/Visitation", noted that it was signed by the patient on August 2, 2012 and included his mother and father to be contacted as needed.

A review of the hospital response to the grievance dated August 8, 2012, noted the following:

"...You expressed concerns regarding not being contacted about the date and time when your son would be having a certification hearing. A review of Policy and procedure was conducted, and the case was discussed with the Hospital patient Advocate. The (hospital) Policy for serving a patient with a 5250 Certification indicates that a patient (including minor patients) should be notified verbally of the date and time of their Certification Review Hearing at the time that they are served with the hold. Patients are informed that they have the right to have family members or other support attend the hearings if they wish. Patients are also given a fact sheet that indicates the day of the week and time that hearings are held...In the case of your son, he reported to the patient advocate that you would attend the hearing and indicated that you already knew about the hearing..." .

An interview was completed on September 12, 2012, at approximately 3:55 PM, with the Hospital Patient Right Advocate. She confirmed that she did not called Patient 8's parents to notify them of the hearing; she relied on the patient, a minor, to contact his parents. The Advocate stated that the patient reported that his mother was going to attend the hearing. On the date of the scheduled hearing, at 1:00 PM, when the mother was not present, the hearing was rescheduled to later that day to allow the patient time to contact his mother. The patient later stated that he was unable to reach his mother the afternoon of the hearing. The hospital policy for notifying parents of minors regarding certification review hearings was requested. The Advocate stated that there was not a specific policy that addressed the hospital responsibility for notifying parents of minors regarding the Certification Review Hearings.

An interview was conducted on 9/13/12, at approximately 7:50 AM, with the Corporate Director of Clinical Services. She stated, "I want you to know that the hospital has a policy in place for the notification of parents of minors for their Certification Review Hearing...The Advocate should have contacted the parents and notified them of the hearing and not relied on the minor to notify his parents."

A review of the hospital policy titled, "Involuntary Detention", initiated on December 1989, and revised on December 2011, included the following:
" 4. Upon receiving the information above, the hospital's patients' rights advocate shall:
a. Notify the patient of the date/time of the hearings;
b. If requested by the patient, notify the patient's next of kin or other family member/friend of the hearing date/time, after obtaining a release of Protected Health Information (PHI) must be completed;
c. Assist in providing information and guidance to the patient with regards to the scheduled hearing".

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Based on interview and record review, the hospital failed to ensure that the Registered Nurse (RN) assessed and monitored the conditions for 2 of 12 sampled patients (Patients 6 and 7) as evidenced by:

1A. The licensed staff failed to assess and document Patient 6's response following the administration of medication and interventions for an episode of aggressive behavior (reactionary and impulsive behavior that often results in the breaking of household rules or the law; violent and unpredictable behavior).

B. The licensed staff failed to assess the effectiveness of medications following the administering of the first dose of these medications per facility policy.

These failures had the potential to result in medical complications for the patient.

2A. The RN failed to accurately complete Patient 7's admission nutritional risk screen (a tool used to identify nutrition risk factors and referral for a dietary nutritional assessment).

B. The RN failed to notify the physician and the dietitian of the patient's weight gain of 11 pounds in one week. The RN failed to monitor the patient's weekly weight per policy.

These failures contributed in an inaccurate admission nutritional risk assessment with no dietary or physician interventions assessing the patient's nutritional status or fluctuating weight; which had the potential for serious medical complications for the patient.

Findings:

1A. On September 13, 2012, Patient 6's clinical record was reviewed. It noted that the patient was admitted to the facility on September 11, 2012. The diagnoses included psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), danger to self and exhibiting aggressive behavior (reactionary and impulsive behavior that often results in breaking household rules or the law; violent and unpredictable behavior).
A review of the "Extreme Emergency Use of Medications assessment Flowsheet", dated September 12, 2012 at 12:35 PM, noted that the patient approached the nursing station and stated, "They are following me. I can't identify them but they won't leave me alone". The patient was extremely angry with clenching teeth. A review of the section on the flowsheet titled, "Less Restrictive means used prior to the administration of Extreme Emergency Medications": (check all those that apply. Use at least two) noted the following that were checked:

"1:1 intervention"
"Clear, firm, limit setting"
"Quiet time"
"Team support"
"Physician notified on 9/12/12 at 12:35 PM. Zyprexa (antipsychotic medication use to treat some forms of mental illness) 10 milligrams (mg) by mouth now".

A review of the assessment flowsheet noted the following sections that were not completed:

"Patient's behavior and/or condition at the time of discontinuation of monitoring:" - was not completed.

"1 HR (hour) Re-check results: Tolerated well -blank; S /S (signs and symptoms); Time of re-checked" - was not completed.

Under the section "Patient/Family Education":

"Explained to the patient and/or parent/guardian the behaviors that resulted in emergency use of medication and will be incorporated into the patient's plan of care" - was not completed.

"Reviewed with the patient and/or parent/guardian the emergency use of medication as a component of care" - was not completed.

"Reviewed with the patient and/or parent/guardian the alternatives used prior to emergency use of medication" - was not completed.

"Identification of alternatives were addressed with the patient and/or parent/guardian that could limit the use of emergency medications" - was not completed.

"...At a minimum, must complete 2 sets of vitals; first, immediately after medications; second, one hour after - if refused, must complete set as soon as patient is compliant".

A review of the vital sign section, noted vital signs at 12:40 PM and at 12:55 PM. There was no documented evidence that the vital sighs were taken one hour after the administration of the emergency medication (1:35 PM).

An interview was conducted on September 13, 2012, at approximately 11:45 AM, with the Director of Nursing (DON) and Patient 6's clinical records form "Extreme Emergency Use of Medications Assessment Flowsheet" and the "Daily Plan Update/RN Assessment" were reviewed. The DON confirmed that the Extreme Emergency Use of Medications Assessment Flowsheet was missing an assessment of the patient's condition when the behavior was resolved or when the monitoring was discontinued. The patient education and the vitals signs one hour after the administration of the emergency medication was missing.

B. A review of the Medication Administration Record (MAR) noted that Patient 6 was administered the following first doses of medications on September 12, 2012 at 9:00 PM:

a. Haldol (a tranquilizer, used to treat some psychotic disorders) 5 mg by mouth at bedtime for psychosis.

b. Cogentin (an anticholinergic and antihistaminic agent that may be prescribed as adjunctive therapy in the treatment of drug-induced extrapyramidal symptoms [EPS - movement disorders that may be a result of the prolonged use of haldol] and use all forms of Parkinson's Disease [disease of the central nervous system affecting motor movement]) 2 mg by mouth at bedtime for depression.

A review of the MAR titled, "PRN (as needed) Effectiveness Documentation Sheet", "Use for all first dose medications, new orders for pain, sleepers, medical, agitation, ESP,and use for Now and Stat (at once) orders", noted that there was no documented evidence describing the assessment of the effectiveness of Haldol or Cogentin one hour after the administering of the medications to the patient.

An interview was conducted on September 13, 2012 at approximately 11:55 AM, with the DON and Licensed Vocational Nurse (LVN) 1. The MAR "PRN Effectiveness Documentation Sheet" was reviewed. LVN 1 confirmed that there was no documentation regarding the effectiveness of the first doses for Haldol or Cogentin on the patient. The DON confirmed that the licensed staff did not follow the hospital policy regarding assessing and documenting the effectiveness of the first doses of medications, one hour after the administration of the medications to the patient.

A review of the facility policy titled, "Medication Documentation", revised August 2012, included the following:

"14...For patients on first time medications, staff are to document date/time/indication / 1 hour re-check reaction on the PRN Effectiveness Documentation record. Re-check results include documentation of effectiveness/action taken/pain/anxiety/symptoms decreased or resolved/vital signs and date/time/initials of nurse".

2A. On September 12, 2012, Patient 7's clinical record was reviewed. It noted that the patient was admitted to the facility on July 20, 2012 and discharged on August 6, 2012. The diagnoses included psychosis (impaired reality testing; unable to distinguish personal subjective experience from the reality of the external world) and schizophrenia (a psychotic disorder [or a group of disorders] marked by severely impaired thinking, emotions, and behaviors).

A review of the form titled, "Initial Referral and Admitting Information", dated July 20, 2012, at 1:45 PM, noted under the section, "Presenting Problems: 5150, not eating or drinking".

A review of the form titled, "Section 1 - Point of contact - Assessment", dated July 20, 2012 at 6:10 PM, noted the following under the section titled, "Symptoms (Appetite, ... .....):

"Appetite poor; patient believes his food is contaminated and refusing to eat or drink; 20 pounds weight loss in the past month".

A review of the form titled, "Nursing Assessment", completed on July 21, 2012 at 5:45 AM, noted the following under the "Nutritional Risk Screen":

"Height - 5 feet, 5 inches"
Weight - 164 pounds"
Body Mass Index (BMI - this estimates the ideal weight of a person based on the person's size and weight) of 27 (A BMI of 25 to 29 indicated that the adult was overweight).

There was no documentation of the risk factors: patient was not eating or drinking prior to admission with an unintentional weight loss of 20 pounds, of greater than 10% of body weight in the past 90 days on the Nutritional Risk Screen. Additional documentation noted, "Patient denies nutrition related problems or special dietary requirements".

A review of the form titled, "History and Physical Evaluation", completed on July 21, 2012 by the physician noted: "Nutritional Assessment: Based on findings of the History and Physical (H & P) and a review of the Nursing Assessment, the patient does not require a full dietary consult".

An interview was conducted on September 13, 2012 at approximately 9:38 AM, with the DON while Patient 7's clinical record was reviewed. The DON confirmed that the admission Nutritional Risk Assessment completed by the registered Nurse, was not accurate and did not reflect the patient presenting problem of not eating or drinking or the weight loss of 20 pounds in the past month. The DON confirmed that the physician H & P did not address the patient's eating habit or weight loss. The DON stated that nurses were re-trained on the revised Nutritional Risk Screen as part of the Nursing assessment on July 13, 2012. The DON confirmed that no dietary consultation was requested or completed on Patient 7 during his hospitalization.

B. A review of Patient 7's Vital Signs Flow Sheet, noted the following:

"Admission 7/20/12, weight = 164 pounds"
"7/28/12, weight = 175 pounds"

There was no further weight from July 28, 2012 through discharge on August 6, 2012. There was no documented evidence that the physician or the dietitian were notified of the weight gain.

A review of the policy titled, "Weight of Patients", effective September 1992, and revised on August 2012, noted the following:

"1. All patients shall have their weights measured and recorded on the Vital Sign Flow Sheet during admission by the nursing staff and every week thereafter throughout hospitalization, unless otherwise ordered by the attending physician".

"2. Nursing personnel and or the dietician will consult with the attending physician in order to increase the frequency of the weight schedule due to the physical condition of the patient such as, but not limited to:

B. Signs of nutritional problems (i.e....sudden weight gain or loss);
D. Increase or decrease of 3 lbs. (pounds) from one weighing to another".

"4. Recording of weights shall be placed in the patient's medical record on the vital sign data sheet at the time the weight is obtained".

An interview was conducted on September 13, 2012 at approximately 9:30 AM, with the DON while Patient 7's clinical record was reviewed. The DON confirmed that there was no documented evidence that the physician or the dietician was notified of the patient's weight gain of 11 pounds on July 28, 2012, and that no further weight was obtained during the hospitalization.


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Based on interview and record review, the hospital failed to ensure that Zoloft (an antidepressant medication used in treating depression [severe despondency and dejection, accompanied by feelings of hopelessness and inadequacy], anxiety [a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome] and other mental health disorders) was administered for 1 of 12 sampled patients (Patient 8) as ordered. This contributed in the patient not receiving the ordered increased dose of Zoloft on August 5, 2012 and August 6, 2012. This had the potential for the patient to exhibit increased behavioral symptoms.

Findings:

On September 12, 2012, Patient 8's clinical record was reviewed. It noted that the patient was admitted to the facility on August 2, 2012 and discharged on August 7, 2012. The diagnoses included recurrent depression, psychosis (a symptom or a feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality) and suicidal ideation (a medical term for thoughts about suicide).

A review of the physician order noted the following:

a. "8/3/12, Zoloft 25 mg by mouth (po) every (Q) AM (morning)".
b. "8/5/12, Increase Zoloft to 50 mg Q AM".
c. "8/6/12, Increase Zoloft to 75 mg Q AM".

A review of the Medication Administration Record (MAR) noted that Zoloft 25 mg was administered on August 5, 2012 and August 6, 2012. The Zoloft order was clarified on August 6, 2012. Zoloft 75 mg was administered on August 7, 2012 at 9:00 AM, prior to patient discharge at 9:20 AM.

A review of the clinical progress notes dated August 7, 2012 at 9:20 AM, noted, "At approximately 9:10 AM, it was brought to my attention by the medication nurse that the patient's medication order from 8/5/12 had not been transcribed in the patients medication administration records...Therefore, patient had not been receiving the increased dosage amount...notified the doctor and he was okay to go ahead with the latest dosage amount and to discharge the patient home on the latest dosage amount as well".

An interview was conducted on September 13, 2012 at approximately 9:47 AM, with the DON while Patient 7's medical record was reviewed. The DON confirmed that the license staff did not follow the physician orders and administered the Zoloft as ordered.



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