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Based on record review and interview, the organizational structure failed to monitor and ensure quality health care was being provided at the facility. The facility staff were using verbal orders as a common practice (see C0297). The facility staff used a restraint without adequate monitoring. The facility staff discharged a patient after a fall who exhibited a change in behavior after waking up (see C0241). This deficient practice could affect all patients who receive medical care at the facility.

Based on record review and interview, the governing board failed to ensure quality health care was provided for one (#1) of twenty sampled record. Findings include:


Provider interview:
In an interview on 2/25/15 at 10:50 a.m., staff member D, medical provider, stated patient #1 was treated in the ER the first time for a broken nose and abrasions to his face and hands. Staff member D stated patient #1 had a syncope episode and the first CT scan did not reflect a stroke. Staff member D stated he was not concerned with patient #1's cognition and when he woke up with a change in mood and wanting to go home he was discharged on 2/7/15. The medical provider stated later in the day on 2/7/15, patient #1 returned to the ER agitated and was moaning and groaning. Staff member D stated he ordered PRN Ativan and Toradol to be administered together because the patient was restless. Staff member D stated the patient was later transferred to a LTC and died.

First visit:
Review of patient #1's medical record showed an ER visit on 2/6/15 with admission into an observation bed. The patient had a fall and injured his face, nose, and hands. The patient woke up on 2/7/15 with a change in mood and demanded to go home. The provider verbally ordered the discharge of the patient at 3:37 p.m. The patient was escorted to his house by the local law enforcement. Patient #1 did not have family or friends who could be contacted.

Review of the facility's Rules and Regulations showed all admissions and discharges shall be done in writing.

Second visit:
Patient #1 was transported back to the ER at 5:11 p.m. on 2/7/15, an hour and half after he was discharged. The ambulance report showed the patient was wandering outside, did not know where he was, and was unsteady on his feet. The ER report showed the patient was agitated during the examination by the physician and Ativan 2mg IV was administered at 3:31 p.m. A radiology report dated 2/7/15 at 9:48 p.m., showed there was no evidence of intracranial hemorrhage, mass, or mass effect.

The patient was admitted to observation status on 2/7/15. During his observation status, the medical record showed no interventions for patient #1's change in mood and health status from the provider. The provider documented he requested a mental health evaluation for a possible placement in a psychiatric facility. The medical record did not reflect psychotic behavior.

Patient #1 was changed to inpatient status on 2/9/15, but a physician's order was not obtained until 2/10/15. Review of the inpatient stay from 2/9/15 to 2/17/15 reflected PRN Ativan 2mg, and PRN Toradol 15mg were administered routinely. The indications for use of these medications were missing. The record reflected that when patient #1 moaned or groaned, the Ativan and Toradol were administered. On 2/15/15, the use of PRN morphine 20ml every four hours was added without indications for use.

Restraints:
The use of four bed rails was implemented during the inpatient stay without an assessment, clinical justification, or physician's order. The restraint was used daily from 2/9/15 through 2/17/15.

Review of the facility policy titled Restraint of Patients reflected restraints were limited to an emergency situation. The policy reflected an assessment was to be completed prior to the use of a restraint and should be the last resort.

Advance Directive:
Review of the medical record reflected patient #1 was not provided information on advance directives on his first visit on 2/6/15. Patient #1 did not have a DNR on record and was a full code status until 2/16/15 when comfort care and a DNR was requested by an appointed guardian.

Hospice Care:
Patient #1 was to receive hospice services and was transferred to a LTC facility on 2/17/15. The hospice verbal orders were not signed as of 2/25/15. Patient #1 died on 2/18/15.

In interview on 2/25/15 at 1:30 p.m., staff member C, RN/ ER manager, stated verbal orders were used as a common practice in the facility. Staff member C stated a physician could be in the hospital and a telephone call will be made for orders for the nurse. Staff member C stated verbal orders should be complete and signed within 24 hours by a provider.

Based on record review and interview, the facility maintained verbal orders which were incomplete for one (#1) of twenty medical records reviewed. Findings include:

Review of patient #1's medical record showed verbal orders were missing indications for use for PRN (as needed) medications. The PRN medications ordered were Ativan and Toradol.

Review of the record showed Ativan 2mg was verbally ordered on 2/7/15 and the provider signed the order on 2/20/15. Toradol 15mg was verbally ordered on 2/8/15 and the provider signed the order on 2/20/15.

A verbal order for thickened liquids given on 2/12/15 was not signed, but thickened liquids were administered.

The hospice verbal admit order on 2/17/15 was not signed as of 2/25/15.

In interview on 2/25/15 at 12:30 p.m., staff member C, ED manager, stated verbal orders are used as a common practice. Staff member C stated it is not unusual for the medical provider to be in the building and call in a verbal order for a patient. Staff member C stated verbal orders should be signed within 24 hours and be complete.