HospitalInspections.org

Based on an onsite survey on 03/06/18 to 03/07/18, review of hospital policies and procedures, interviews with staff and 10 medical record reviews, it was determined that the hospital was out of compliance with the Condition of Patient Rights due to the following. The hospital 1) had not maintained adequate training for clinical staff on the application and monitoring of violent restraints on non-psychiatric units, 2) failed to obtain the appropriate restraint orders for patient #1's behavior, 3) failed to maintain safe and appropriate restraint techniques as determined by hospital policy, 4) used a medication to manage a patient's behavior that was outside of the standard dosage, route administration and diagnostic criteria, 5) failed to make adjustment to one patient's discharge plans in response to the noted changes in the patient's condition, and 6) failed to follow the appropriate process for declaring a patient's lack of capacity with two physicians and 7) failed to allow one patient the right to refuse medication and medical treatment while in a non-emergent state.

Please see the following deficiencies.

Based on the review of 5 open and 5 closed medical records, it was determined that 1 of 10 patients was denied the right to refuse treatment and be free from restraints.

Patient # 9 was a 30 + year old that was admitted to the hospital on involuntary status, per certification process, related to suicidal ideation, and a decreased level of functioning behaviors. Patient #9 had refused medications, assessments, care, food, and fluids during admission.

On the fifth day of admission, the psychiatrist initiated and documented "Capacity Assessment for Making Decisions Regarding Medical Conditions" note. Per note, the patient was incapable of making informed decisions as "The patient is unable to engage in a rational process of manipulation the relevant information." The document continues indicating that " ... [patient] lacks capacity to refuse routine medical care including blood draws to check hydration status, kidney function, and electrolytes [or] to refuse IVF (intravenous fluids) if necessary and electrolyte repletion."

Based on this documented incapacity statement, the patient was restrained on multiple episodes to have blood drawn. In addition, the patient was held and restrained to administer Intravenous potassium replacements, and one of these restraint administrations lasted for over two hours. Documentation from other practitioners throughout the chart referenced this note and stated that the patient was unable to refuse blood draws.

On the eighteenth day of admission, a physician was consulted from the medicine department to evaluate the patient for anorexia and abnormal lab values. Based on this physician's history and physical documentation, EKG results, lab values, and assessment of the patient's overall health status, the patient was found to be hypokalemic (low potassium level), but non-acute. Patient #9 was noted to be hemodynamically stable, abnormal features were present on the EKG, but no abnormal interval prolongation suggesting impending arrhythmia (irregular heart beat, often seen with hypokalemia) was seen.

On the twenty-first day of this admission, patient #9 received a Clinical Medication Review Panel. This panel's purpose in convening was to determine whether psychiatric medication(s) may be administered to patient despite patient's refusal. The panel reviewed pertinent patient documents and found that the patient required forced psychiatric medication. The Panel's decision documented the specific psychiatric medications allowable under the determination. The results of this decision pertained to psychiatric medications only and did not, and could not, give permission procedures, and treatment related to medical care.

In summary, the hospital failed to allow the patient the right to refuse medication and medical treatment while in a non-emergent state. The physicians failed to demonstrate the clinical emergency, and if an emergency was present failed to follow the appropriate process for declaring a patient's lack of capacity with two physicians. Clinical staff were allowed to forcibly restrain patient #9 to obtain blood work and to administer medications that were not included in the patient's approved medical panel list.

Based on review review of 5 open 5 closed medical records and review of hospital pharmacy formulary standards, it was determined that the hospital used a medication to manage a patient's behavior that was outside of the standard dosage, route administration, and diagnostic criteria.

Findings include:
Medical record review for Patient #6 revealed he/she was 80+ years old with a history of cancer and high blood pressure who presented to the emergency department (ED) after a fall from the previous evening. The patient was alert and oriented with a chief complaint of right arm pain. X-rays were completed and revealed a fracture. By the next morning, Patient #6 had developed a fever and started exhibiting some symptoms of confusion and delirium. Several nursing notes over the next 36 hours revealed that Patient #6 was intermittently confused, agitated and occasionally combative. During this time, verbal orders were given by 3 different Licensed Individual Practitioners (LIPs) for Patient #6 to receive an antipsychotic medication by mouth twice and then intravenously thereafter. An ED nurse requested an order for a speech-language assessment, which was completed, and Patient #6 was diagnosed with aspiration pneumonia.

Over the course of the first 36 hours, Patient #6 received a total of 42 mg of the antipsychotic medication with 25 mg being given within the first 24 hours. During this time, neither nursing or physicians consistently documented that Patient #6 was exhibiting psychotic or violent behaviors prior to receiving these doses of medication.

Patient #6 remained in the ED for two days before being admitted with a diagnosis of delirium. A psychiatric consult dated for the next morning stated "Patient currently somnolent and difficult to arouse, likely due to the high amount of parenteral antipsychotics he/she was given yesterday." This physician also noted EKG changes consistent with high-dose antipsychotics and recommended that all antipsychotics be discontinued but another (non-psychiatrist) LIP later wrote an order to resume both the PRN (as needed) and daily dose of the medication.

According to the drug formulary used by the hospital's pharmacy, the dosage of this medication for geriatric patients should not exceed 20 mg/day and the recommended routes of administration are either by mouth in a pill form or injected into the muscle. The intravenous route is not FDA approved and not recommended except in intensive care settings with continuous cardiac monitoring.

Using an antipsychotic medication in high doses via an unapproved administration route likely contributed to Patient #6's development of aspiration pneumonia and prolonged Patient #6's stay in the hospital.

Based on review of 5 open and 5 closed medical records and hospital policy, it was determined the hospital failed to follow their policy on the appropriate use of restraints.

Per hospital policy, "Use of Seclusion and/or Restraints for Uncontrolled, Violent and/ or Aggressive Behavior" (06/2018), "Patients in 4 point restraints are placed in 1:1 observation, in view of assigned staff at all times with documentation every 15 minutes."

Per hospital policy, "Observation Policy" (02/2017), the definition for "One to One Observation (1:1)" is "Visual monitoring of an individual patient involving one staff member being within arm's length of the patient at all times."

Patient #1 was a 25+ year old with a recent traumatic brain injury who presented to the emergency department (ED) from prison for a surgical procedure. Towards the end of the patient #1's admission an order for non-violent 4 point restraints was placed after the patient hit a nurse. At this time, patient #1 was on remote monitoring (telesitter) and was not subsequently ordered for 1:1 observation. While this episode was ordered as a non-violent restraint, even though the patient exhibited violent behavior requiring 4-point restraints, staff did not follow the hospital's policy for safely monitoring a patient in 4 point restraints.

Based on review of 5 open and 5 closed medical records, it was determined the hospital failed to obtain violent restraint orders for violent behavior on patient #1.

Patient #1 was a 25+ year old with a recent traumatic brain injury who presented to the emergency department (ED) from prison for a surgical procedure. In the ED and on the inpatient unit, patient exhibited multiple episodes of violent behavior outlined in provider and nursing documentation. This included attempting to kick and spit at staff. On one occasion, per provider documentation, "pt punched (the) RN in the face x 2 ...Will initiate 4 point restraint."

Review of the record revealed that while patient #1 required violent restraints for episodes of violent behavior, non-violent orders with less intense nursing oversight were written and conducted. Additionally, for episodes in which non-violent restraint orders were appropriate, orders were found to be missing, indicating that staff failed to conduct both violent and non-violent restraints per regulation.

Based on review of 6 registered nursing personnel files and staff interviews, it was determined that 4 of the 4 non-psychiatric nurses did not have competencies for violent restraints in the past year.

Review of the nursing personal files for 4 non-psychiatric nurses indicated they received non-violent restraint training as part of their annual competencies. Per interview with hospital staff, including human resource staff and learning management system administrator it was reported and confirmed that nurses outside of the behavioral health units (inpatient units and the psychiatric emergency unit) did not receive violent restraint training. See tag 167 and 168 as an example of care of a patient in restraints for violent behavior on a non-psychiatrist inpatient unit.

Based on review of 6 open and 5 closed medical records, it was determined that hospital staff failed to report a "near miss" for 1 of 10 patient records reviewed.

Per hospital policy, "Adverse Event and Incident Reporting," (11/2015) incidents, including "near misses" should be reported "within 24 hours to the appropriate individual or office including the Office of Risk Management (entering incident in the on-line reporting tool)."

Patient #2 was a 30+ year old patient who presented to the hospital with complaints of shortness of breath and swelling in lower extremities. Per pharmacist progress note at 09:25 on the second day of patient #2's hospital stay, allergies were verified with the patient. On the third day of patient' #2's hospital stay, patient #2 was ordered an antibiotic medication at 04:49 that was listed on their allergy list from 2013. On that same day, another pharmacist wrote a consult note at 05:06 for the antibiotic giving the dosing recommendations. Per medication administration record (MAR), patient #2's nurse at 05:86 documented "pt refused" under "Action" and "pt is allergic to vancomycin" in the comment section. Patient #2 brought this up to the provider's attention, per provider progress note, at 06:50 and to a social worker, per their note, at 11:51.

While patient #2 did not end up receiving the antibiotic, a resident ordered it, pharmacy reviewed it, and, per the MAR, the medication made it to the patient's bedside. Multiple staff members were also made aware by the patient about the incident, including the hospital's patient relations department; however, the incident had not been reported per the hospital's policy at time of survey, 9 days into patient # 2 stay.

Based on the review of 5 open and 5 closed medical records, it was determined that the hospital staff failed to respond to changes in the patient's condition prior to discharge.

The 90+ year old patient #8 presented to the emergency department with family due to signs and symptoms of a stroke. The patient #8 was examined, received treatment work up and imaging that confirmed that patient was positive of a stroke. Patient #8 was admitted and followed during visit by a Physician Assistant (PA) along with consults from a neurologist. On the second day of admission, the PA's assessment note indicated that the patient #8 was aphasic and had deficits present, but was able to say Good Morning, was alert, attentive to examiner, and appeared to comprehend some simple phrases. On the same day two of admission, the Neurologist's note indicated that the patient #8 "had significant aphasia with limited communication." The Neurologist's note also stated "the patient is alert, has fair to good intention, able to repeat one short phrase, followed command, but unable to follow verbal two step commands."

On the third day of admission and day of discharge, the patient #8's assessment changed. Per the PA's note on this day of discharge, morning assessment revealed that the patient #8 was not following commands, was lethargic, and unable to void overnight, his verbal utterances were incomprehensible. The Neurologist also noted changes in the patient #8's condition including: patient #8 was globally aphasic and could not communicate, attention was fair, no verbal output, not following verbal only command, asymmetry in the patient upper extremity tone and grasp. Both practitioners' notes showed a deterioration in the patient #8's condition from one day prior; however, the patient #8 was discharged as planned. There was no evidence that any additional evaluation or change in treatment plan occurred prior to the discharge of the patient #8 to rehab to address the changes in patient #8's condition.

The hospital failed to make adjustment to the patient's discharge plans in response to the noted changes in the patient's condition.