HospitalInspections.org

Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting patient's rights as evidenced by:

Cross reference A-0144: The hospital failed to ensure staff followed policy and physician orders concerning: administering medication within set time frame, notifying the physician of late medication administration, rounding, and notifying the physician of a patient change in condition that led to a patient's death.

The egregious nature of this deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on the review of documents and interviews, it was determined that the hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following references to standard-level deficiencies:

Cross reference A-0395: The Nurse Executive failed to ensure appropriate supervision of non licensed staff providing services related to patient care.

Cross reference A-0405: The Nurse Executive failed to ensure: 1. Medications were administered in compliance with an order and per policy; 2. A patient's medication administration record contained accurate documentation.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Nursing Services.

Based on policies and procedures, hospital documentation review, medical record review, medical examiner case review and interview, it was determined the hospital failed to ensure Patient #1 received care in a safe setting. An immediate jeopardy was called in regards to Patient #1 receiving contradictory medications too closely together, staff falsifying medical record documentation, and staff not notifying a physician of a patient's change in condition that ultimately lead to patient death.

Findings include:

Policy titled "Patient Bill of Rights, Policy #15835613, last reviewed 05/2024," revealed, "...Procedures...B. An Administrator shall ensure that:...2. A patient is not subjected to...b. Neglect...."

Policy titled "Nursing Care Standards, Policy #16957141, effective 10/2024," revealed, "...Procedures...Assessment:...Standard of Care: The patient is assessed by the RN in a timely, comprehensive, accurate, and systemic manner...Standards of Nursing Practice: The RN continuously and systematically collects, records, and analyzes data that is comprehensive and accurate...."

Policy titled "Shift Nursing Assessment/Reassessment, Policy #16019044, last reviewed 07/2024," revealed, "...I. Anytime that there is a change in the patient ' s behavior or variance from the normal, it must be documented...."

Policy titled "Change in Patient Condition Chain of Command Notification, Policy #15769455, last reviewed 06/2024," revealed, "...as necessary, notify the charge nurse, assistant nurse manager, nurse manager, nursing supervisor and/or administrator on call for administrative and/or clinical consultation and/or assistance...The nurse notifies the on-call or attending (depending on the time of day) Physician utilizing appropriate channels and chain of command...Decrease in Baseline Level of Functioning...Notify Provider if the patient exhibits any acute changes in status including but not limited to:...Change in level of independence, increased need for assistance...Change in ability to perform self-care...Change in gait/coordination...."

Policy titled "Rounds for Patient Observations, Policy #162352784, last reviewed 07/2024," revealed, "...Procedures...E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient, noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation...F. Close observation Sheets must be with a staff member who is with the particular patient...."

Policy titled "MM 05-001 Medication Administration, Policy #15904885, last reviewed 09/2024," revealed, "...Medications prescribed for daily, weekly, or monthly administration are administered within 2 hours before or after the scheduled dosing time...Missed or Delayed Administration of Scheduled Medications...When medications eligible for a scheduled dosing time are not administered within the defined time period...Document the reason the dose was missed or delayed...Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for medication errors that are the result of missed or late dose administration must be reported to the attending physician and in accordance with hospital policy...Medication Administration Procedure...Verifies there is no contraindication with respect to allergy, sensitivity, or diagnosis...Verifies the medication is administered by the correct route and the route is appropriate for the medication and patient...Verifies the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration...Document the exact time the medication is administered...Report medication administration errors, adverse drug events, and incompatibilities immediately to the attending physician...."

Policy titled "MM 06-004 Adverse Drug Reactions (ADRs) Reporting, Policy #15968803, last reviewed 09/2024," revealed, "...DEFINITIONS...Medication Administration Error...is an error in medication administration that actually reaches the patient...(i.e., a medication administered to a patient when it should not be, or medication is administered as the wrong dose, wrong route, or wrong time)...Sentinel Event is a patient safety event (not primarily related to the natural course of the patient ' s illness or underlying condition), that reaches a patient and results in death, permanent harm, or severe temporary harm...Responding to an Adverse Drug Event...Immediately upon identification or suspicion of an adverse drug reaction, medication administration error or incompatibility...Assess the patient ' s current condition...Immediately notify the attending physician and implement treatment as ordered...Document the factual description of the event; medication given; notification of the physician; subsequent monitoring and patient response, in the patient's medical record...All medication administered are documented including those given in error...The pharmacist ' s input is included in the documentation...Report events using the organization-wide event reporting process/system...."

Hospital document titled "Position Title: Registered Nurse," revealed, "...Will oversee and supervise the shift...delegating taste such as groups, close observation, meal supervision, etc...Will also oversee staff to ensure nursing policies and procedures are followed and exemplary patient care is consistently delivered by self and all members of the team...Will monitor patient for change of condition and respond accordingly up to and including notification of the physician...."

Hospital document titled "Position Title: LVN/LPN," revealed, "...Ensures that individual patient observation/checks are conducted...Medications are administered safely and accurately with demonstrated knowledge of indications and side effect...Will monitor patient for change of condition and respond accordingly up to and including notification of the physician...Will follow hospital policy for medication administration...."

Review of Patient #1 ' s medical record revealed the following:
Hospital document titled, "Ancillary (non-medication) Orders," revealed, "...Observations...Level of Observation: Every 15 minutes...Start Time: 1/9/25 17:00...."

Hospital document titled, "Ancillary (non-medication) Orders," revealed, "...Nursing Orders - General...CIWA ArScale (CIWA) Q 4H...Start Time: 1/10/25 0:00...Comments...Contact physician for...unarousable patient...."

Hospital document titled, "Medication Orders," revealed, "...PRN...hydrOXYzine pamoate Oral 50 mg CAP...50 mg...PO...Q4HPRN...Start: 01/09/25 17:00...."

Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...gabapentin Oral 300 mg CAP...300 mg...PO...TID...Start: 01/10/25 15:00...."

Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...QUEtiapine Oral 100 mg TAB...100 mg...PO...HS...Start: 01/10/25 21:00...."

Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...methadone Oral 10 mg TAB 1 ea...40 mg...PO...QDAY...Start: 01/11/25 06:00...."

Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...LORazepam Oral 0.5 mg TAB...1.5 mg...PO...TID...Start: 01/11/25 10:00...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...hydrOXYzine pamoate (Vistaril) 50 mg...Administered 09:59 1/10/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...QUEtiapine (SEROquel) 100 mg...Administered 21:16 1/10/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...gabapentin (Neurontin) 300 mg...Administered 09:12 1/11/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...methadone (Methadose) 40 mg...Administered 09:14 1/11/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...LORazepam (Ativan) 1.5 mg...Administered 10:44 1/11/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...CIWA ArScale...Not Administered 13:07 1/11/25...Pt too sedated, unable to obtain...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...LORazepam (Ativan) 1.5 mg...Not Administered 15:06 1/11/25...Pt sedated, unable to wake up...."

Hospital document titled, "Nursing Shift Progress Note" dated 1/11/2025 15:00, revealed, "...RN went to check on pt(sic) c(sic) med(sic) nurse...Pt ' s(sic) left shoulder was off the bed...RN attempted to wake up pt(sic), pt(sic) snoring...Chest rising & falling...Pt(sic) took a deep breath....appeared to be sleeping...."

Hospital document titled, "7:00AM-7:00PM Shift Nursing Assessment" dated 1/11/2025 15:03, revealed incomplete assessment with "unable to assess" written with a line across the page. Section titled "Progress Note," revealed, "...Pt(sic) sedated, unable to assess...Respirations even & unlabored...Difficulty waking up, snoring...Pt(sic) on back...Pt(sic) awake this morning, went to breakfast & went to bed...Obs(sic) done Q 15"...Pt(sic) repositioned in bed after laying with L(sic) shoulder off bed...." Section "Progress Note" further revealed, "...Has patient experienced any medical problems or change in overall condition during the shift?...No...Was physician notified?...No...."

Hospital document titled, "Code Blue Record" dated 1/11/2025 16:55, revealed, "...Code Called at: 16:55...911 called at: 16:56...AED applied at: 16:57...CPR begun at: 16:56...911 arrived at: 16:59...Reason for calling code: Pt(sic) unresponsive, not breathing, no pulse...PATIENT CONDITION ST ONSET OF CODE: unable to obtain, no pulse/not breathing...17:02...Narcan given, EMS arrived, CPR continued...17:04...intubated by EMS...17:06...Epinephrine given by EMS...17:12...Pt(sic) transferred by EMS...Attending Physician...Time Notified: 17:03...."

Office of the Medical Examiner Case Status revealed Patient #1 ' s Manner of Death: "...Accident..." with the Primary Cause of Death: "...Combined toxic effects of gabapentin, hydroxyzine, lorazepam, methadone and olanzapine..."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that video review of the incident revealed that Patient #1 was not administered Ativan 1.5 mg at 10:44 as documented, but was administered Ativan 1.5 mg at 09:33. Nineteen (19) minutes after Methadone 40 mg was administered at 09:14. Employee #1 confirmed this medication administration was falsified by Employee #30. Employee # 1 confirmed that Employee #23 ' s nursing assessment was incomplete and failed to notify the provider of a change in patient condition. Employee #1 also confirmed that close observations were falsified at times: 08:45, 10:30, 12:15, 12:30, 12:45, 13:00, 14:00, 15:00, 15:15, 15:45, 16:15 and 16:45 by Employee #37 on the patient observation sheet.

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #1's medical record contained inaccurate documentation after video review. Employee #1 confirmed that staff failed to follow policy and provider orders by not administering medication within set time frame, failing to notify the provider of late medication administration, failing to perform close observation, and failing to notify physician of a patient change in condition.

Based on review of policy and procedure, personnel records, and interview, it was determined The Nurse Executive failed to document that clinical oversight was provided to Behavioral Health Technicians (BHT) at least once each two-week period if the BHT provides services related to patient care at the health care institution during the two-week period. This deficient practice resulted in Behavioral Health Professionals (BHP) not accurately rounding on patients resulting in an adverse event.

Findings include:

Policy titled "Clinical Oversight, Policy #17383375, last reviewed 01/2025," revealed, "...Procedures...3. Clinical oversight will be provided by the BHP every two (2) weeks, 14 calendar days...a. Unlicensed clinical care staff that provide patient care must participate in at least one scheduled oversight, during each two week period, if the staff member provides services related to patient care during the two weeks; employee or supervisor of an employee may request additional clinical oversight...b. Clinical oversight may include monitoring the behavioral health services provided by a behavioral health staff member to ensure services are provided according to the health care institution's policies and procedures, review skills and knowledge related to the provision of behavioral health services, guidance to improve skills and knowledge related to the provision of behavioral health services, training recommendation, or oversight in response to an incident, or an emergency safety response...5. Documentation of clinical oversight will include:...a. The date of the clinical oversight...b. The name of the staff member receiving clinical oversight...c. The signature and professional credential or job title of the individual providing clinical oversight and the date signed...d. Identification of topic(s) covered...6. Documentation of clinical oversight shall be maintained by the staff member ' s director...."

Clinical oversight was requested for the following Employees for the month of December 2024 through January 13, 2025 and none were provided at the time of survey:

Employee #33
Employee #34
Employee #35
Employee #36
Employee #37
Employee #38
Employee #39
Employee #40
Employee #41

Employee #6 confirmed in an interview on April 16, 2025 through April 21, 2025 that Employees #33, 34, 35, 36, 37, 38, 39, 40, and 41 had no clinical oversight documentation for review at the time of survey for the month of December 2024 through January 13, 2025, despite providing services related to patient care at the facility during that time frame.

Based on policies and procedures, medical records and interview, it was determined that the The Nurse Executive failed to ensure that:
1. Medications were administered to Patients #1, 2, 3, and 4 in compliance with an order and per policy.
2. Patient #1's Medication Administration Record (MAR) contained factual documentation.
These deficient practices contributed to Patient #1's adverse outcome as contradictory medications were administered too closely together despite physician order and policy and Patient's #1 MAR did not accurately reflect when medications were administered. This could result in additional adverse patient outcomes if not corrected.

Findings include:

1. Medications were administered to Patients #1, 2, 3, and 4 in compliance with an order and per policy as evidenced by:

Policy titled "MM 05-001 Medication Administration, Policy #15904885, last reviewed 09/2024," revealed, "...Medications prescribed for daily, weekly, or monthly administration are administered within 2 hours before or after the scheduled dosing time...Missed or Delayed Administration of Scheduled Medications...When medications eligible for a scheduled dosing time are not administered within the defined time period...Document the reason the dose was missed or delayed...Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for medication errors that are the result of missed or late dose administration must be reported to the attending physician and in accordance with hospital policy...Medication Administration Procedure...Verifies there is no contraindication with respect to allergy, sensitivity, or diagnosis...Verifies the medication is administered by the correct route and the route is appropriate for the medication and patient...Verifies the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration...Document the exact time the medication is administered...Report medication administration errors, adverse drug events, and incompatibilities immediately to the attending physician...."

Policy titled "MM 06-004 Adverse Drug Reactions (ADRs) Reporting, Policy #15968803, last reviewed 09/2024," revealed, "...DEFINITIONS...Medication Administration Error...is an error in medication administration that actually reaches the patient...(i.e., a medication administered to a patient when it should not be, or medication is administered as the wrong dose, wrong route, or wrong time)...Sentinel Event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition), that reaches a patient and results in death, permanent harm, or severe temporary harm...Responding to an Adverse Drug Event...Immediately upon identification or suspicion of an adverse drug reaction, medication administration error or incompatibility...Assess the patient's current condition...Immediately notify the attending physician and implement treatment as ordered...Document the factual description of the event; medication given; notification of the physician; subsequent monitoring and patient response, in the patient's medical record...All medication administered are documented including those given in error...The pharmacist's input is included in the documentation...Report events using the organization-wide event reporting process/system...."

Office of the Medical Examiner Case Status revealed Patient #1 ' s Manner of Death: "...Accident..." with the Primary Cause of Death: "...Combined toxic effects of gabapentin, hydroxyzine, lorazepam, methadone and olanzapine..."

Review of Patient #1's medical record revealed the following:
Hospital document titled, "Ancillary (non-medication) Orders," revealed, "...Nursing Orders - General...CIWA ArScale (CIWA) Q 4H...Start Time: 1/10/25 0:00...Comments...Contact physician for...unarousable patient...."

Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...methadone Oral 10 mg TAB 1 ea...40 mg...PO...QDAY...Start: 01/11/25 06:00...."

Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...LORazepam Oral 0.5 mg TAB...1.5 mg...PO...TID...Start: 01/11/25 10:00...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...methadone (Methadose) 40 mg...Administered 09:14 1/11/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...LORazepam (Ativan) 1.5 mg...Administered 10:44 1/11/25...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...CIWA ArScale...Not Administered 13:07 1/11/25...Pt too sedated, unable to obtain...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...LORazepam (Ativan) 1.5 mg...Not Administered 15:06 1/11/25...Pt sedated, unable to wake up...."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Employee #30 administered Methadone 40 mg over three (3) hours after the time it was ordered for, Ativan was administered at 09:33 and not at 10:44 as documented, did not notify the physician of the late medication administration per policy and did not notify the physician for a change in patient condition despite provider order.

Review of Patient #2's medical record revealed the following:
Hospital document titled, "Medication Administration Record (MAR)," revealed, "...buprenorphine (*Subutex) 2 mg...for TAPER...May Crush and give Sublingual...DO NOT GIVE WITHIN 2 HOURS OF A BENZO...Administered...20:07 7/22/24...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...clonazePAM (*KlonoPIN) 1 mg...Oral AT BEDTIME...To give 1 mg use 2 of 0.5 mg...for Insomnia...Administered 20:07 7/22/24...."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #2 was not administered medication in compliance with the provider's order.

Review of Patient #3's medical record revealed the following:
Hospital document titled, "Medication Administration Record (MAR)," revealed, "...buprenorphine (Subutex) 4 mg...Sublingual GIVE EVERY 6 HOURS AS NEEDED PRN...for FOR COWS SCORE MORE THAN 11...DO NOT GIVE WITHIN 2 HOURS OF A BENZO...Administered...15:04 8/30/24...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...LORazepam (Ativan) 2 mg...Oral THREE TIMES DAILY (3 Doses)...for INPATIENT DETOX...Administered 14:54 8/30/24...."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #3 was not administered medication in compliance with the provider's order.

Review of Patient #4's medical record revealed the following:
Hospital document titled, "Medication Administration Record (MAR)," revealed, "...paliperidone (*Invega Sustenna) 234 mg...Intramuscular ONCE ONLY...for Psychosis...GIVE IN GLUTEAL INJ SITE...Administered...11:29 12/10/24...."

Hospital document titled, "Incident Abstract Report," revealed, "...Incident Description...Nurse gave medication in right deltoid despite provider order to be given in gluteal...."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that Patient #4 was not administered medication in compliance with the provider's order.

2. Patient #1's Medication Administration Record (MAR) contained factual documentation as evidenced by:

Policy titled "MM 05-001 Medication Administration, Policy #15904885, last reviewed 09/2024," revealed, "...Medication Administration Procedure...Document the exact time the medication is administered...."

Hospital document titled "Position Title: LVN/LPN," revealed, "...Medications are administered safely and accurately with demonstrated knowledge of indications and side effect...Will follow hospital policy for medication administration...."

Review of Patient #1's medical record revealed the following:
Hospital document titled, "Medication Orders," revealed, "...SCHEDULED...LORazepam Oral 0.5 mg TAB...1.5 mg...PO...TID...Start: 01/11/25 10:00...."

Hospital document titled, "Medication Administration Record (MAR)," revealed, "...LORazepam (Ativan) 1.5 mg...Administered 10:44 1/11/25...."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that video review of the incident revealed that Patient #1 was not administered Ativan 1.5 mg at 10:44 as documented, but was administered Ativan 1.5 mg at 09:33. Nineteen (19) minutes after Methadone 40 mg was administered at 09:14. Employee #1 confirmed this medication administration was falsified by Employee #30.

Based on policies and procedures, hospital documentation review, medical record review, and interview, it was determined The Nurse Executive failed to ensure Patient #1's medical record contained factual rounding documentation. This deficient practice contributed to Patient #1's adverse outcome as staff were not completing close observations on Patient #1 every fifteen (15) minutes as ordered and per policy.

Findings include:

Policy titled "Rounds for Patient Observations, Policy #162352784, last reviewed 07/2024," revealed, "...Procedures...E. Staff members must complete the Close Observation Sheet at least every 15 minutes by making visual contact with the patient, noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation...F. Close observation Sheets must be with a staff member who is with the particular patient...."

Hospital document titled "Position Title: Patient Care Assistant (PCA)," revealed, "...Responsible for observation and maintenance of safe milieu through patient checks, safety monitoring, etc.: completes 15 minute checks, monitors for contraband, evaluates for change in condition, and provides line of sight or one on one care as directed...."

Hospital document titled "Position Title: LVN/LPN," revealed, "...Ensures that individual patient observation/checks are conducted...."

Hospital document titled "Position Title: Registered Nurse," revealed, "...Will oversee and supervise the shift...delegating taste such as groups, close observation, meal supervision, etc...Will also oversee staff to ensure nursing policies and procedures are followed and exemplary patient care is consistently delivered by self and all members of the team...."

Review of Patient #1 ' s medical record revealed the following:
Hospital document titled, "Ancillary (non-medication) Orders," revealed, "...Observations...Level of Observation: Every 15 minutes...Start Time: 1/9/25 17:00...."

Employee #1 confirmed in an interview on April 16, 2025 through April 21, 2025 that video review of the incident revealed that rounding was falsified at times: 08:45, 10:30, 12:15, 12:30, 12:45, 13:00, 14:00, 15:00, 15:15, 15:45, 16:15 and 16:45 by Employee #37 on the Patient #1 ' s observation sheet on January 11, 2025.