HospitalInspections.org

Based on record review and interview staff failed to ensure all patient's needs are addressed, evaluated and appropriate interventions are provided in 2 of 10 medical records reviewed (Pt 1, 2). This could potentially impact all 15 patients receiving treatment at this facility.

Findings Include:

Review of policy and procedure titled, "Patient Assessment, Multidisciplinary" last reviewed 8/25/2015 states, in the Emergency Department (ED) medical screening upon ED by registered nurse following triage protocols as appropriate to patient condition. On the Medical/Surgical unit a full head to toe assessment is to be done a minimum of every 12 hours. The depth and frequency of the head to toe and functional pattern assessment is individualized according to patient needs, the nursing care plan, nursing judgement and physician orders.

Review of policy and procedure titled, "Interdisciplinary Discharge Planning for Acute Care" last reviewed 7/1/2014 states, staff nurses participate in multidisciplinary approach to discharge planning by developing and implementing a discharge (After Visit Summary) reflective of individual patient needs and abilities of the patient to manage the patient's continuing care needs for patients that will be discharged to home

Review of Pt 1's medical record on 6/1/2016 beginning at 1:00 pm shows on 4/20/16 at 10:19 pm Pt 1 arrived to the emergency department via ambulance complaining of auditory hallucinations. Per ED provider note at 11:50 pm, Pt 1 states that he turned the radio on at about 8:00 pm and the radio station was playing the same song over and over. Pt 1 switched the channel but it continued to play the same song. The lyrics were telling Pt 1 "(pts name) do this, (pts name) do that, (pts name) loves crystal." Pt 1 finds these auditory hallucinations very distressing. Pt 1 recalls an episode about 2 years ago when Pt 1 heard a song trying to convince him "come over to our side your mom needs you".

Per ED physician plan, Pt 1 will be kept overnight for observation and physician will consult with Psychiatrist to evaluate whether these symptoms are related to Pt 1's narcotic therapy.

Per Pt 1's medical record, on 4/21/16 at 12:00 am Pt 1 was admitted to inpatient medical/surgical floor. Suicide Risk assessment done at 12:40 am states "Yes" to depression and hopelessness, "Yes" to Rational thinking loss, "Yes" to organized or serious suicide attempt, "NO" to stated future intent, and "High Risk" is listed for Pt 1.

On 4/22/16 at 4:24 am registered nurse "Care Progression Note" states, "History of depression, pt states he has suicidal thoughts sometimes, denies intent." "Pt trial with Zyprexia, after Zyprexia pt stated voices muffled and not as loud. If condition worsens may need to transfer to St. E's (hospital which offers psychiatric treatment), at this time provider feels pt can stay here."

Review of Pt 1's registered nurse inpatient "Head-to-Toe Assessment" from 4/21/16 to 4/22/16 shows no evidence of an ongoing suicide risk/behavioral risk assessment done to determine if Pt 1 was at risk for injuring self or others. No evidence of the registered nurse developing a plan and providing safety interventions to ensure patient safety after Pt 1 was determined to be "High Risk" on the admission Suicide Assessment and admitting to having thoughts of suicide.

Review of Pt 1's "Discharge Instructions" list the following "Reasons to Call Your Doctor": New onset Pain, Chest pain, shortness of breath, swelling or pain in one or both legs, persistent cough, frequency or burning with urination, elevated temperature, and bowel concern. Review of Pt 1's discharge instructions shows no evidence of an individualized discharge plan addressing Pt 1's continuing care needs related to auditory hallucinations, suicidal thoughts, and depression and how and when to seek treatment or help if these issues were to worsen after discharge home.

Per interview with Director of Nursing (DON) "D" on 6/1/16 at 4:05 pm, "D" stated suicide risk assessment is done on admission, Per "D" patients presenting with psychiatric disorder should have an ongoing psychiatric assessment completed including suicide/behavioral risk assessment. Per "D" no evidence in Pt 1's medical record of an ongoing suicide risk assessment being done. Per "D" Pt 1's discharge instructions should be individualized and address Pt 1's continuing care needs, "D" agreed there is no evidence of staff individualizing Pt 1's continued care needs in the discharge instructions.

Review on 6/1/16 beginning at 2:15 pm of Pt 2's medical record shows Pt 2 arrived in the ED on 1/27/16 at 10:38 am with complaints of increased suicidal ideations. Per ED provider note, "(Pt 2) has very frequent suicidal ideation and has formulated a plan to end his life by slashing his wrist."

Review of Pt 2's ED timeline shows no evidence of a suicide/behavioral risk assessment being completed for Pt 2 on admission to the ED.

Per interview with Quality RN "C" on 6/1/16 beginning at 3:45 pm, "C" stated suicide/behavioral risk assessment should be completed in the ED on all patients presenting with psychiatric symptoms, "C" confirmed Pt 2's ED record shows no evidence of a suicidal/behavioral risk assessment being completed.

Based on record review and interview staff failed to ensure all patient's care plans address individualized patient needs and is kept current based on patient's continuing needs in 1 of 10 medical records reviewed (Pt 1). This could potentially impact all 15 patients receiving treatment at this facility.

Findings Include:

Review of policy and procedure titled, "Documenting/Charting" last reviewed 4/22/2015 states, A care plan must be initiated on every patient within 8 hours of an inpatient/observation admission. The registered nurse is accountable to initiate and update care plans. All members of the interdisciplinary team are accountable to document assessment data, problem per care plan, interventions carried out and the results of those interventions that they perform on the behalf of the patient. Reassessments are to be based on the interdisciplinary team's judgments, based on clinical assessment of the patient needs and the provider's orders.

Review of Pt 1's medical record on 6/1/2016 beginning at 1:00 pm shows on 4/20/16 at 10:19 pm Pt 1 arrived to the emergency department via ambulance complaining of auditory hallucinations. Per ED provider note at 11:50 pm, Pt 1 states that he turned the radio on at about 8:00 pm and the radio station was playing the same song over and over. Pt 1 switched the channel but it continued to play the same song. The lyrics were telling Pt 1 "(pts name) do this, (pts name) do that, (pts name) loves crystal." Pt 1 finds these auditory hallucinations very distressing. Pt 1 recalls an episode about 2 years ago when Pt 1 heard a song trying to convince him "come over to our side your mom needs you".

Per ED physician plan, Pt 1 will be kept overnight for observation and physician will consult to evaluate whether these symptoms are related to Pt 1's narcotic therapy.

Per Pt 1's medical record, on 4/21/16 at 12:00 am Pt 1 was admitted to inpatient medical/surgical floor. Suicide Risk assessment done at 12:40 am states "Yes" to depression and hopelessness, "Yes" to Rational thinking loss, "Yes" to organized or serious suicide attempt, "NO" to stated future intent, and "High Risk" is listed for Pt 1.

Pt 1's "Care Progression Note" dated 4/22/16 at 4:24 am states, "History of depression, pt states he has suicidal thoughts sometimes, denies intent." Pt 1's care plan problem is listed as "Cognitive-Perceptual Pattern-Impaired", goal is listed as, "Demonstration of organized thought processes". No evidence of a care plan addressing Pt 1's suicidal ideations and initiating an ongoing plan assessing, providing interventions, and evaluating for Pt 1's safety.

Review of Pt 1's registered nurse "Head-to-Toe Assessment" from 4/21/16 to 4/22/16 shows no evidence of an ongoing suicide risk/behavioral risk assessment done to determine if Pt 1 was at risk for injuring self or others. No evidence of the registered nurse developing a plan and providing safety interventions to ensure patient safety after Pt 1 was determined to be "High Risk" on the admission Suicide Assessment and admitting to having thoughts of suicide.

Per interview with Director of Nursing (DON) "D" on 6/1/16 at 4:05 pm, "D" stated care plan should be individualized and address patient care needs. "D" agreed that Pt 1's care plan does not recognize and address Pt 1 admitting to having "suicidal thoughts sometimes".