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Based on observations, staff interviews and record review conducted throughout the days of survey the Governing Body failed to assure an effective quality assessment and performance improvement program. The Governing Body failed to assure that hospital staff communicated relevant information and conducted a thorough quality review and analysis of an adverse event that resulted in a patient requiring emergency treatment.

Refer to tags: A-263, A-267, A-276, A-287

Based on survey findings the Condition of Participation for Quality Assessment and Performance Improvement was not met related to a failure to communicate relevant information in accordance with the facility's event reporting policy, and a failure to obtain pertinent medical information during a quality review of the medical record for one patient. These failures led to a delay in the completion of a comprehensive analysis of the cause of an adverse event and failure to identify a potential quality deficient practice.


Refer to: A-0267, A-0276 and A-0287

Based on staff interview and record review, after being involved in an adverse patient event, hospital staff failed to complete an incident report, as per hospital policy, to ensure such events are investigated, measured, analyzed and monitored for patient safety and quality of care for 1 applicable patient. (Patient #3) Findings include:

Per record review, on 5/20/12 at approximately 9:30 AM Patient #3 was transferred to the ED (Emergency Department) of an acute care hospital with symptoms of excessive drowsiness, decreased responsiveness, with a oxygen saturation of 84% (normal oxygen level is > 95%) and a drop in blood pressure. At 11:30 AM the hospital ED notified Nurse #1 that Patient #3 became awake and responsive after the administration of intravenous Narcan (an opioid antagonist used to reverse the effects of opioids including respiratory depression, sedation and low blood pressure). Although the hospital has a process for reporting substance ingestion/overdose per Sentinel Event and Critical Incident Management and Communication (last revised 02/2012), by completing an Incident/Occurrence report, Nurse #1 failed to follow policy by not submitting an Incident Report. Nurse #1 also failed to follow hospital procedure on 5/20/12 by not reporting immediately the incident of a possible patient ingestion of opioids to the House Nursing Supervisor.

Per review, Patient #3 was a voluntary admission to the hospital on 5/16/12 for treatment of his/her alcohol dependence. Past medical history includes previous dependence of opioids, however upon admission no opioids were detected via laboratory results. During the course of treatment, Patient #3 received Librium (sedative/ hypnotic/benzodiazepine) as per the Alcohol Withdrawal Assessment Guidelines. On 5/18/12 the treatment team assessed Patient #3 to be safe for increased activities on Tyler 1 and within the hospital. On the evening of 5/18/12 Patient #3 attended a public wide Alcohol Anonymous (AA) meeting held in the hospital cafeteria.

After being appraised of the incident on 5/20/12 involving Patient #3, the Tyler I unit nurse manager, the medical director for Tyler I and the social worker met on 5/21/12 and made a decision to stop patients from that unit from attending the community public AA meetings. This decision was made on the premise Patient #3 may have obtained an opioid substance from a member of the public on 5/18/12 while attending the AA meeting. Although other units within the hospital allow patients to attend the AA community meetings, staff from Tyler I failed to alert the other units of the potential access of drug contraband from public attendees at the AA meeting. Per interview on 6/6/12 at 9:45 AM, the Tyler I unit manager confirmed " I should have passed it on " .

As a result of not completing an Incident/Occurrence report by Nurse #1 and failure of the Nurse Manager to notify senior management, to include the Medical Director, the interim Director of Nursing and the Chief of Operations of the decision to prohibit patients from Tyler 1 from attending the public AA meetings, the full spectrum of Patient #3's critical incident was not sufficiently investigated to assess the situation and determine what immediate interventions were required.

Per interview on 6/5/12 at 3:55 PM, the Senior Director of Quality and Regulatory Services, confirmed s/he was unaware of the suspicion of drug contraband at the AA meeting on 5/18/12 and Tyler #1 ' s decision to close access to AA meetings for patients. The Director further confirmed on 6/7/12 at 4:45 PM the events surrounding Patient #3 ' s emergent transfer to the ED and immediate response to Narcan should have been identified as a Critical Incident requiring a report and a complete review for patient safety concerns and quality improvement.

Based on staff interview and record review, the hospital failed to identify a significant quality deficient practice and implement changes that would lead to improvement following an incident involving a patient's potential access to illicit drugs . (Patient #3) Findings include:

Per interview on 6/7/12 at 4:45 the Senior Director of Quality and Regulatory Services confirmed the circumstances and events surrounding Patient #3 ' s emergent transfer to the ED of an acute care hospital on 5/20/12 should have been identified as a Critical Incident requiring a report and a complete review for patient safety concerns and quality improvement. The symptoms of excessive drowsiness, decreased responsiveness, with a oxygen saturation of 84% (normal oxygen level is > 95%) and a drop in blood pressure treated successfully in the ED with Narcan, created the suspicion Patient #3, while hospitalized and medicated for Alcohol detoxification., had possibly obtained access to opioids while attending a public AA meeting.

Per interview on 6/5/11 at 10:15 AM, the Director of Quality confirmed all Code Blue documentation is audited to ensure documentation is complete and procedures were followed. When Patient #3 was experiencing changes in their vital signs and level of consciousness, a Code Blue was called, staff from other units responded to the medical emergency and the patient was transferred to the ED of an acute care hospital for further evaluation and treatment. Patient #3's medical record was initially reviewed by the Director of Quality due to the Code Blue event. However, the Director further confirmed, that at the time of Patient #3 ' s record review pertinent medical information was missing from the record. Although an attempt had been made, by the Quality Department, to obtain the medical record from the ED where treatment had occurred, as of the date of survey that information had still not been obtained, delaying the process for thorough analysis of the event by the facility. At the surveyor's request the ED record was obtained and revealed the ED provider's " Clinical Impression " which stated on 5/20/12: " Reversal of lethargy and hypoxia secondary to narcotic use " . A progress note states " Pt. (patient) placed - opioid titration reversal with 0.1 mg. per min. At 0.3 mg, s/he was able to breath > 10 and awakened .... " .)

As a result of staff not submitting a Critical Incident Report and the lack of communication from Tyler I staff, the Senior Director of Quality and Regulatory Services was not aware of the termination of AA meetings for patients on Tyler I. Per Discharge Summary finalized on 5/29/12 the attending physician states regarding prognosis for Patient #3 " ...it is likely that s/he found some opiate at the AA meeting that s/he attended and used that while s/he was here. " Even though the attending physician and the Medical Director for Tyler 1 had an awareness of Patient #3's clinical case, there was a failure to inform the hospital's Medical Director. It was not until 6/5/12, at the time of survey, the Medical Director was appraised of the circumstances. An opportunity to conduct a Peer review of the case based on the impressions of Patient #3 ' s clinical condition and outcomes also did not occur.

Per Patient Safety Plan (last revised on 04/2009) "The Department Directors and clinical managers are responsible for the prevention, monitoring , identification, investigation, correction and reporting of incidents and adverse events within their area of responsibility"
The nurse manager stated on the morning of 6/6/12 that s/he had not reviewed Patient #3's clinical record to ensure all documentation was complete and policies followed especially as it relates to the potential opiate ingestion/overdose of Patient #3 while under the care of staff on Tyler I. The nurse manager did not obtain written statements from staff who had attended the AA meeting on 5/18/12 with Patient #3 or were present at the time of the Code Blue incident on 5/20/12 as required per Sentinel Event and Critical Incident Management and Communication (last revised 02/2012).

It was further confirmed by the Senior Director of Quality and Regulatory Services there was a failure by staff to identify how the events surrounding Patient #3 impacted patient safety on all the patient treatment units. As a result, patients from other units continued to attend the AA public meetings on and after 5/18/12. Due to the lack of prompt reporting of events related to Patient #3, and the incomplete Quality Assessment review of all pertinent information delayed the hospital's opportunity to initiate changes that would lead to improvement.

Based on staff interview and record review, the hospital's Quality Assessment and Performance Improvement failed to track and analyze an adverse patient event thereby creating a delay in appropriate response to assure patient safety. Findings include:

The Quality Assessment/Performance Improvement program failed to track and analyze the causes surrounding a patient adverse event related to the possible substance ingestion/overdose. Per record review, on 5/20/12 at approximately 9:30 AM Patient #3 was transferred to the hospital with symptoms of excessive drowsiness, decreased responsiveness, with a oxygen saturation of 84% (normal oxygen level is > 95%) and a drop in blood pressure. At 11:30 AM the hospital Emergency Department (ED) notified Nurse #1 that Patient #3 became awake and responsive after the administration of intravenous Narcan (an opioid antagonist used to reverse the effects of opioids including respiratory depression, sedation and low blood pressure).

Per interview on 6/5/11 at 10:15 AM Senior Director of Quality and Regulatory Services confirmed all Code Blue documentation is audited to ensure documentation is complete and procedures were followed. When Patient #3 was experiencing changes in their vital signs and level of consciousness, a Code Blue was called and staff from other units responded to the medical emergency. This record was initially reviewed by the Director of Quality due to the Code Blue event. However, the Director further confirmed, that at the time of Patient #3 ' s record review pertinent medical information was missing from the record. Although an attempt had been made, by the Quality Department, to obtain the medical record from the ED where treatment had occurred, as of the date of survey that information had still not been obtained. This delay prevented the the Director from tracking and conducting a thorough analysis of the event. At the surveyor's request the ED record was obtained on 6/6/12 and revealed the ED provider's " Clinical Impression " which stated on 5/20/12: " Reversal of lethargy and hypoxia secondary to narcotic use " . A progress note states " Pt. (patient) placed - opioid titration reversal with 0.1 mg. per min. At 0.3 mg, s/he was able to breath > 10 and awakened .... " .)

As a result of not having obtained all necessary information for analysis, the hospital's Medical Director had not been informed of the potential circumstances surrounding Patient #3's adverse event. On 6/7/12, at the time of survey, the Medical Director was first appraised of the circumstances related to the Code Blue, the possible ingestion of opiates and the patient's response to Narcan while receiving treatment in the Emergency Department. A peer review analysis of causes and responses of the events surrounding Patient #3's medical treatment on Tyler I had not been conducted as of 6/7/12.

Based on interview and record review nursing staff failed to conduct a timely and ongoing assessment of a patient medicated for the symptoms of alcohol withdrawal. (Patient #3) Findings include:

Per record review, Patient #3 was admitted to the hospital for the treatment of alcohol withdrawal on 5/16/2012. The physician ordered nursing staff to medicate Patient #3 by assessing the patient utilizing a scoring process for alcohol withdrawal. Librium, an anxiolytic commonly used for symptoms of alcohol withdrawal and prescribed as a PRN (as needed), was administered to Patient #3 over a 4 day period. An assessment would include vital signs, and scoring the severity of withdrawal symptoms. This information was then provided to the nurse assigned to administer medications for the entire unit. Per review of the Medication Administration Record (MAR) Patient #3 was medicated several times with Librium, without evidence of an assessment for the effectiveness of the drug. On 5/19/12, Patient #3 demonstrated increased symptoms of alcohol withdrawal including tremors, agitation and anxiety. Although, from 12:05 AM through 8:30 PM on that date the patient received a total of 275 mg Librium, there was no evidence nurses had reassessed him/her, following each dose administration, for symptom relief..

Per interview on 6/7/12 at 10:45 AM, the Tyler I charge nurse confirmed nursing staff who are administering the PRN Librium are not consistently reassessing each patient for the effectiveness of the medication. In addition, although Patient #3 had a physician's order for Vistaril 50 mg orally every 2 hours PRN agitation, nursing staff failed to administer Vistaril although the patient was continuing to display symptoms of ongoing agitation. In addition, the patient's physician was not consulted regarding the ongoing symptoms the patient was experiencing and whether the use of Vistaril would be advisable.

Per interview on 6/7/12 at 12:25 PM when discussing how s/he assesses for the effectiveness of medications administered, the medication nurse stated there was no where on the MAR to document the effectiveness of PRN medications administered. At the top of each MAR page is printed "symptom relief, yes, no, or partial" and corresponding code "sx ref " is to be documented by staff after the administration of PRN medications. When shown evidence on the MAR where nursing is to document effectiveness of PRN medication, the medication nurse stated "That is a good point...not aware of that".

Based on staff interview and record review, the hospital failed to assure that nursing staff developed and kept current a nursing care plan to address each patient's needs for 1 of 10 patients in the applicable sample. (Patients #3) Findings include:

Per record review on 6/6/12, nursing staff failed to revise the care plan for Patient #3 who was experiencing significant pain from an infected wisdom tooth. Per review of the care plan for Patient #3's "Master Problem List" from which problems are identified and interventions, monitoring and goals are developed, both the patient's wisdom tooth infection and persistent pain were not identified to be care planned. This was confirmed by the Tyler I nurse manager on the morning of 6/6/12.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified physician and nursing interventions that were individualized and specific to the treatment needs for 8 of 8 active sample patients (A7, A14, B7, C7, D2, D13, E3 and E6). Instead, the MTPs included interventions which were routine, generic discipline functions that lacked focus for treatment. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

The sample patients' MTPs included the notation: "Who are the members of your team and how will we help you achieve your goals..." The following generic interventions were listed:

1. Patient A7 (MTP dated 3/17/12)

"[Physician] will talk with you about appropriate medications, educate you on the long-term physiological effects of substance abuse/dependence, assess other psychiatric symptoms that may be impacting your recovery and will monitor your medical safety..." "[Nursing] will monitor your detox symptoms and any acute medical issues you may have, support you in participating in groups and activities."

2. Patient A14 (MTP dated 3/16/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

3. Patient B7 (MTP dated 3/14/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

4. Patient C7 (MTP dated 3/3/12)

"Psychiatrist] will continue to evaluate for possible adjustments or changes in medications." "[Nursing] will administer medications, assess for effectiveness, observe for side effects, review safety assignments for clinical effectiveness and assist the patient with remaining safe and provide assignments to do so as necessary."

5. Patient D2 (MTP dated 1/20/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

6. Patient D13 (MTP dated 3/5/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

7. Patient E3 (MTP dated 2/23/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

8. Patient E6 (MTP dated 3/11/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

B. Staff Interview

During an interview on 3/20/12 at 1:30p.m., the Medical Director confirmed that the treatment plans were "boilerplate" and non-specific.

Based on record review and interview, the Medical Director failed to ensure that the Master Treatment Plans for 8 of 8 active sample patients (A7, A14, B7, C7, D2, D13, E3 and E6) included individualized interventions. The interventions were non-specific and similar on all treatment plans regardless of the patients' problems. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

Review of the sample patients' MTPs included the notation: "Who are the members of your team and how will we help you achieve your goals..." The following generic interventions were listed:

1. Patient A7 (MTP dated 3/17/12)

"[Physician] will talk with you about appropriate medications, educate you on the long-term physiological effects of substance abuse/dependence, assess other psychiatric symptoms that may be impacting your recovery and will monitor your medical safety..." "[Nursing] will monitor your detox symptoms and any acute medical issues you may have, support you in participating in groups and activities."

2. Patient A14 (MTP dated 3/16/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

3. Patient B7 (MTP dated 3/14/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

4. Patient C7 (MTP dated 3/3/12)

"Psychiatrist] will continue to evaluate for possible adjustments or changes in medications." "[Nursing] will administer medications, assess for effectiveness, observe for side effects, review safety assignments for clinical effectiveness and assist the patient with remaining safe and provide assignments to do so as necessary."

5. Patient D2 (MTP dated 1/20/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

6. Patient D13 (MTP dated 3/5/12)

"[Physician] will complete a psychiatric assessment, discuss medication interventions with you, monitor your symptoms and discharge you from treatment." "[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

7. Patient E3 (MTP dated 2/23/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

8. Patient E6 (MTP dated 3/11/12)

"[Psychiatrist] will continue to evaluate for possible adjustments or changes to medications."
"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

B. Staff Interview

During an interview on 3/20/12 at 1:30p.m., the Medical Director confirmed that the treatment plans were "boilerplate" and non-specific.

Based on interview and record review, the Interim Director of Nursing failed to ensure that the Master Treatment Plans for 8 of 8 active sample patients (A7, A14, B7, C7, D2, D13, E3 and E6) included specific nursing interventions. The listed nursing interventions were generic nursing activities. This deficiency can result in the lack of an integrated focus for patient treatment and fragmented nursing care for patients.

Findings include:

A. Record Review

1. Patient A7: The Master Treatment Plan of 3/17/12 included the following generic nursing interventions: "nursing staff will complete a Medical Nursing Care Plan if indicated and monitor symptoms as appropriate"; "nursing staff will encourage your participation in group and unit activities" and "nursing staff will monitor detox symptoms and any acute medical issues you may have, support you in participating in groups and activities."

2. Patient A14: The Master Treatment Plan of 3/16/12 included the following generic nursing interventions: "nursing staff will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medication."

3. Patient B7: The Master Treatment Plan of 3/14/12 included the following generic nursing interventions: "nursing staff will monitor your detox symptoms and any acute medical issues you may have, support you in participating in groups and activities" and "nursing staff will complete a Medical Nursing Care Plan if indicated and monitor your symptoms as appropriate."

4. Patient C7: The Master Treatment Plan of 3/3/12 included the following generic nursing interventions: "nursing will administer medications, assess for side effects, review safety assignments for clinical effectiveness, and assist the patient with remaining safe and provide assignments to do so as necessary" and "nursing will encourage appropriate social interactions in the milieu. During 1:1 time will help pt. identify resources and coping skills."

5. Patient D2 (MTP dated 1/20/12)


"[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

6. Patient D13 (MTP dated 3/5/12)

"[Nursing] will monitor your symptoms and safety, encourage you to participate in unit activities and administer your medications."

7. Patient E3 (MTP dated 2/23/12)

"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

8. Patient E6 (MTP dated 3/11/12)

"[Nursing] will administer medications, assess for effectiveness, and observe for side effects."

B. Staff Interviews

During an interview on 3/20/12 at 2:30p.m., the Interim Director of Nursing and Clinical Manager agreed that nursing interventions were written similarly on all Master Treatment Plans.