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Based on medical records reviews, policy reviews and interviews, the facility failed to protect and promote patient rights and ensure that patients received acceptable care in a safe environment.

Findings include:

1. The hospital failed to properly notify a patient of his rights prior to a surgical procedure. See Citation at A 117.

2. Staff did not properly execute consent forms. See Citation at A 131.

3. The facility failed to provide a patient with information on advance directives. See Citation at A 132.

4. The facility failed to provide a safe environment for patients and staff. See Citation at A 144.

5. Staff failed to monitor patients that had received "drugs used as restraints" as required. See Citation at A 160.

6. The facility failed to have a seclusion room available as an option for least restrictive intervention to address patient behavior that is violent or self-destructive to self or others.
See Citation at A 162.

7. Staff failed to use the least restrictive intervention in the treatment of a patient.
See Citation at A 165.

8. Staff failed to implement use of "drugs used as restraints" in accordance with safe, appropriate restraint techniques as determined by hospital policy in accordance with State law. See Citation at A 167.

9. Chemical and physical restraint orders were written inappropriately as standing orders or on an as needed basis (PRN). See Citation at A 169.

6. The staff failed to arrange a safe and appropriate discharge for a patient. See Citation at A 799.

Based on medical record reviews, the facility failed to notify a patient of his rights as required. MR #20.

Findings include:

MR #20 was not given information on his rights as a patient. A review of this record revealed the patient had not received information regarding his rights up to 48 hours after admission and prior to undergoing a surgical procedure. The patient was intubated and sedated during the course of his treatment to prevent wound dehiscence.

Based on medical record reviews, the facility did not formulate properly executed consents for 2 of 30 medical records reviewed. This was found in MR #11 and #20.

Findings include:

1. Consent forms for anesthesia services were incomplete. In MR #11, the consent form for anesthesia was not dated, was not signed by the patient or authorized representative, and was not signed by the anesthesiologist. Furthermore, the type of anesthesia administration to be used was not indicated on the form. In addition, the operation to be performed, "ORIF R Hip Fx" did not have the laterality spelled out (right hip).

2. A consent form was incomplete. In MR #20, the consent form dated 10/18/10 for anesthesia did not indicate who the anesthesiologist would be.

Based on medical record reviews, it was determined the facility did not provide a patient with information on advance directives. MR #20.

Findings include:

MR #20 was not provided the opportunity to formulate an advance directive. A review of MR #20 on October 19, 2010 revealed the patient who had been admitted on October 17, 2010 and had undergone surgery, had not been given information on advance directives. Therefore the patient was not provided the opportunity to formulate an advance directive.

Based on observations and interviews, the facility failed to provide a safe environment for patients, visitors and staff.

Findings include:

1. During a tour of the ICU on October 19, 2010 at approximately 2:30 PM, a 2.5" circular, 2" deep hole was observed in the middle of the hallway floor in front of the nurses' station. This poses a tripping hazard and it does not facilitate proper cleaning of the unit. This finding was verified by Staff #11 at that time.

2. Two bags of soiled linen were noted on the floor in the dirty utility room at 11:40 AM on October 19, 2010 on 3 North. This poses the risk of further contamination and infections on the unit.

3. There were two saline filled 10cc syringes in an unlocked cabinet near patient's room 376 on 3 North on October 19, 2010. This condition provides a potential for patients to harm themselves by inappropriate use of self injection of air or other solutions. These findings were verified by Staff #11 at that time.




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4. During observation between 11:40 AM - 12:40 PM of Reid 4, the Psych Unit, on 10/19/10, and witnessed by Staff #12 and #3, the following were observed:

4.a) Three (3) Adult oxygen sensors with expiration dates of 12/09 were found in the storage cabinet in the medication room.

4.b) At 11:50 AM, a 500mls bottle of opened 0.9% Sodium Chloride without a date and time of opening on it was noted in a storage cabinet in the medication room.

4.c) At 11:55 AM, 5mls of 0.9% Normal Saline prefilled syringe with the expiration date of 7/09 was found in the storage cabinet in the medication room.

4.d) At 12:10 PM, two (2) unwrapped cuffed mouth gags were seen in the crash cart.

4.e) At 12:15 PM, one of the beds in Room 408 was noted with a hole in the wooden foot board which measured 2 feet by 8 inches and ran the whole length of the bed in a hollow shape big enough for a patient to hide in it. The wood trim of the bed was also noted missing, exposing rough edges on the outside edge of the bed where the patient would sit if sitting on the bed with the leg on the floor. The presence of the bed on the unit created a source of danger to patients who may choose to hide in the hollow core of the bed. It was noted that the beds on the unit had similar foot boards with the pre-scored, but intact design in the wood which could be kicked in by patients to create the hollow seen in this particular bed.

4.f) At 12:20 PM, one (1) gray love seat with multiple areas of torn vinyl (some measuring 8 inches by 2 inches) was observed in the day room.

4.g) At 12:21 PM, two (2) blue love seats with cracks and rips in the vinyl covers were noted in the day room. The presence of these cracked and ripped pieces of furniture pose infection control concerns as the furniture can never be adequately sanitized. This was explained to Staff #3 who witnessed the findings.

4.h) During observation of the Psych Unit, a quiet room was identified adjacent to the nurses' station with a window in the wall where staff can observe the patient in the room. A room appropriate for seclusion was not observed on the unit. During interview, Staff #3 stated that the facility does not seclude patients. However, the facility has an existing written policy and procedure for the seclusion of patients as documented on the Policy and Procedure entitled, "Behavioral Health Restraints/Seclusion" revised 11/09.

Based on medical records reviews and staff interviews, the facility used PRN and STAT psychotropic medications to manage the patients' behaviors when they were not a part of the standard treatment for the patients' conditions; facility also failed to assess the patients for less restrictive measures and to monitor the patients' responses to the PRN and STAT medications by performing vital signs observations. This is evident in 6 of 30 medical records reviewed. MR #s 3, 4, 5, 6, 7 and 8.

Findings include:

1. Monitoring was not done for patients that had been given drugs used as restraints. On October 18, 2010 at 10:45 PM, the patient MR #8 refused his medications and was described as becoming increasingly agitated. The patient was given Ativan 2mgs IM, Haldol 5mgs IM, and Vistaril 100 mg IM stat. The staff did not document that other less restrictive interventions such as de-escalation, time-out, and the use of a quiet room were offered to the patient before administering the IM stat medications.

2. During the review it was revealed that there was no documented observation of the patient's vital signs after the administration of the IM Stat medications. During interview on 10/19/10 at 12:40 PM, Staff #3 stated that vital signs and close monitoring were not routinely performed for patients who received IM or PO stat or PRN medications.

Staff #3 stated that staff did document that they observed patients on the unit every 15 minutes. This observation, which was recorded on the form "Patient Check Sheet," does not include taking and recording vital signs of the patients, it merely establishes the location of the patient on the unit.

3. A review of the facility policy and procedure "Behavioral Health Restraints/Seclusion," revised 11/09, stated under the sub-topic "Medication": "Drugs used as restraints are not practiced at Putnam Hospital Center."
The following are observed examples of drugs used as restraints that treatment staff administered to the patients:

a) MR #3 was given Haldol 5mgs PO PRN every 4 hours as needed for agitation on 10/15/10 at 10:45 PM. The patient was also given Ativan 2mgs PO PRN on 10/16/10 at 11:00 AM and 6:00 PM for agitation. On 10/17/10 the patient had the PRN doses of Ativan at 10:11 AM, 2:36 PM and at 3:00 AM on 10/18/10. In addition, the patient had repeated doses of the PRN Haldol at 12:55 PM, 5:55 PM on 10/17/10 and another dose on 10/18/10 at 3:00 AM. The repeated uses of these psychotropic medications did not lead the facility to review the patient's psychotropic medication regimen and titration of the drugs needed by the patient to remain calm within the environment.

b) MR #4 was given Haldol 5mgs PO every 4 hours as needed for anxiety on 10/17/10 at 9:30 PM and on 10/18/10 at 6:10 PM.

c) MR #5 was given a PRN dose of Ativan 2mg PO every 4 hours as needed at 2:05 PM on 10/13/10 and a repeat dose at 6:00 PM. This same patient was given Haldol 5mgs PO on the same day at 2:05 PM and at 9:30 PM.

d) MR #6 was given Haldol 5mgs PO PRN for anxiety on 10/07/10 at 2:00 PM and on 10/08/10 at 5:30 AM, 1:00 PM and at 6:17 PM. There were no review of the repeated uses of this PRN dose.

e) MR #7 was given Ativan 2mgs PO every 4 hours as needed on 10/17/10 at 3:47 PM and on 10/18/10 at 11:30 AM.

Based on observation and medical record review, the facility failed to have a seclusion room available to help ensure the patient's right to least restrictive intervention in addressing patient behavior that is violent or destructive to self or others.

Findings include:

See A 165.

Based on medical record review and staff interview, the facility did not use the least restrictive option in the treatment of a patient.

Findings include:

The patient MR #28 was admitted at the facility from 4/7/10 to 4/14/10. During the admission period, the patient was on standing doses of the following PO medications:
Thorazine 600mgs at bedtime.
Seroquel 400mgs at bedtime
Trazodone 100mgs at bedtime
Cogentin 2mg at bedtime
Zoloft 50mg in the morning
Risperdal 2mg bid
Ativan 1mg tid

The patient's diagnosis included intermittent explosive disorder, rule out bipolar disorder. On 4/7/10 at 9:15 AM, the patient displayed unsafe behaviors towards self "banging head on wall and window in her room and raising hands to staff in a threatening manner" and was medicated with Haldol 5mgs IM, Ativan 2mgs IM and Vistaril 100mgs IM as noted on the "Authorization for Administration of Supplemental Psychotropic Medication" and nurses' progress notes. The same doses of the IM medications were repeated at 5:00 PM and 6:45 PM.

In addition, the patient was placed in 4 point restraint for 1 hour fifteen minutes between
9:15 AM and 10:30 AM. The facility did not have a seclusion room to manage the patient in a least restrictive environment. Consequently, the staff physically restrained the patient in four (4) point restraints in addition to using medications as a restraint.

Based on review of facility policy, the facility failed to implement use of "drugs used as restraints" in accordance with safe and appropriate restraint techniques as determined by hospital policy in accordance with State law.

Findings include:

See A 160, Finding # 3.

Based on medical record reviews and interviews, it was determined that physicians wrote orders for physical restraints, and drugs used as restraints, as needed. This was found in MRs #1, #3, #4, #5, #6, and #7.

Findings include:

1. MR #1 was discharged from the facility in an ambulance with instructions to physically restrain the patient as needed. This 70 year old patient who had been admitted to the Behavioral Health unit on May 24, 2010, had a history of Psychosis with multiple medical problems which included Traumatic Brain Injury, Hypertension and CVA with left sided weakness. The patient was wheelchair dependent for mobilization and his psychiatric status had been stabilized approximately 6 weeks prior to his discharge. Physical restraints were never utilized during his hospitalization. A review of the patient's discharge paperwork revealed that a prescription to "Restrain PRN For Safety" had been sent with the ambulance crew for the patient's transport to the Department of Social Services on July 23, 2010. This is not in keeping with this regulation.

This finding was verified by Staff #2, the Medical Director of the Mental Health Unit, during an interview on October 20, 2010 at approximately 11:30 AM. She stated that it was the ambulance company's policy to transport patients with an order for restraints.

2. See A 160, Findings # 3 a), b), c), d), e).

Based on medical record reviews and interviews, it was determined that the medical staff did not provide quality care for 3 patients reviewed (MR #1, #2 and #16).

Findings include:

1) a. Medication orders were not written according to acceptable standards of practice as required by law. MR #2 was admitted in respiratory distress and with an altered mental status on 10/17/10. The patient had multiple medical co-morbidities which included severe COPD, Hypertension, Type II Diabetes Mellitus, Pulmonary hypertension, Chronic Atrial Fibrillation, DVT with IVC filter and heart failure. The patient was intubated and attached to a ventilator. On October 18, 2010 at 3:38 AM, a hospitalist wrote an order for "Ativan Drip, titrate for Sedation". The physician failed to document the dose, concentration, diluent, and parameters for the administration of this drug. This is not in keeping with acceptable standards of practice. This contributed to a medication error and the patient becoming heavily sedated for at least 24 hours. Reference citation at A 404 item #2.

b. A follow-up order on 10/18/10 for "prolonged sedation" was not timed and revealed "Lorazepam 0.5mg/ml (40mg added to NS or D5) final volume= 80ml was written by a pulmonologist, another physician. This order does not specify the type of solution in which the medication should have been mixed.

c. These findings were witnessed and verified by Staff #6 and #13.

d. A similar incomplete medication order was noted for MR #2 when Vasopressin was ordered continuously on 10/18/10 but the type of solution was not documented. This is particularly significant considering the patient's history of Hypertension, Diabetes Mellitus and response to D50W and Lasix which had been given by EMS when she was found unresponsive prior to her arrival to the ED.

2) a. In MR #16, the orders for titrated Dopamine and Vasopressin on 10/20/10 did not specify the type of solution for mixing the medications. This is also significant for this patient whose co-morbidities included End Stage Renal Disease on hemodialysis, Congestive Heart Failure and Diabetes Mellitus.

b. In addition, page 2 of the "'Ventilator' Standing Orders" form indicate Morphine Sulfate, Hydromorphone and Midazolam drips can be prepared in NS or D5W.

c. This was verified by Staff #13 on October 21, 2010 at approximately 11:45 AM.

3. MR #1 was admitted to the Behavioral Health Unit for Psychosis on May 24, 2010. His medical history was significant for Traumatic Brain Injury secondary to MVA with right anterior temporal lobe injury, Hypertension, Prostate Cancer, memory impairment, High Cholesterol, Hemorrhoids and CVA with left sided weakness. On July 6, 2010, the patient told the Patient Advocate/Director, Patient Relations that he needed 2 life saving surgeries, one for his hemorrhoids and the other for his prostate. The next day the patient underwent an Incision and Drainage for his hemorrhoid by a G.I. specialist but his concerns regarding his prostate was never addressed. Furthermore, he was discharged on July 23, 2010 to the Department of Social Services without instructions for post hospital care or follow-up for this matter.

Based on observations, medical record reviews, reviews of policies and procedures and personnel files and interviews, it was determined the facility failed to ensure that patients received appropriate nursing care.

Findings include:

1. Patients were not appropriately triaged. See Citation at A 395.

2. Director of the Psychiatric Nursing Services did not have the appropriate qualifications to perform the duties in this position. See Citation at A 397.

3. Medications were not prepared and administered according to acceptable standards of practice. See Citation at A 404.

Based on medical record reviews, policy reviews and interviews, the facility did not ensure that patients arriving in the ED were evaluated appropriately. This was found in 4 of 30 medical records reviewed. These included MR #2, 18, 19 and 30.

Findings include:

Patients that arrived in the ED for emergency care were not triaged appropriately.

1. MR #18 is a 67 year old patient who was referred for shortness of breath, DVT right leg (positive on doppler) Stage IV Lung cancer on chemotherapy and stents at carotid, leg renal and abdomen. The patient's oxygen saturation was 83% on room air. The patient was triaged as 4 semi-urgent on a scale of 1-5, 5 being the least urgent.

2. In MR #30, a 90 year old patient arrived in the ED on 7/18/10 at 1:09 PM with a triage "chief complaint" of altered mental status. The "stated complaint" in the medical record revealed daughter states "he's mumbling, not answering questions" symptoms that had begun that morning. The nurse noted that the patient "vomited in triage and daughter states motion sickness from car ride." The patient was confused and unsteady on his feet. There was no evidence that the patient had a previous history of Dementia or Alzheimer Disease but he had a history of Hypertension. The patient was triaged as 4 ESI-Semi-urgent Reassess q2h. The patient was seen by the physician 3 hours later. The final diagnosis per discharge summary was Possible Cerebrovascular Accident versus Transient Ischemic attack. This was not an appropriate triage classification. This facility is a designated stroke center.

3. MR #19 presented with a history of shortness breath and was wheezing and having labored breathing. The patient was oxygen dependent on NRB mask and her vital signs included a B/P of 153/120. The patient was classified as 3-reassess in 1 hour.

4. Similar finding was noted in MR #2 who EMS noted to be unresponsive, cyanotic and being bagged in a skilled nursing facility. PMH included COPD, Atrial Fibrillation, Cancer, CHF and Hypertension. EMS administered Lasix and D50W which resulted in an improvement in the patient's mental status. The patient was placed on Bipap, however, the patient was classified as 4-semi-urgent.

Based on review of personnel files and staff interviews, the facility failed to provide documented evidence to prove that the mental health unit has a qualified director of psychiatric nursing services who participates in interdisciplinary formulation of individual treatment plans, gives skilled nursing care and therapy, and directs, monitors and evaluates the nursing care furnished.

Findings include:

1. The facility does not have a designated director of psychiatric nursing services who is qualified and has the necessary requirements and licensure to function in this role. Review of the personnel records of Staff #3 and Staff #9 on October 21, 2010 revealed that they do not have the specialized qualifications required to be the director of psychiatric nursing services for the mental health unit based on their respective education, experience and training. The specialized qualifications include a master's degree in psychiatric and mental health nursing, or its equivalent, as required to meet the criteria for exclusion from Medicare's Hospital Prospective Payment System under 412.27(d)(3)(i).
a) Staff #3 is the designated Director of the Mental Health unit. She has a master's degree in Social Work, but she is not a licensed nurse.
b) Staff #9 is the Vice President of Patient Care Services/Chief Operating Officer and is a registered nurse who has oversight of the mental health unit, but there is no documented evidence to show that she has a master's degree in psychiatric and mental health nursing, or its equivalent. Furthermore, Staff #9 does not directly participate in interdisciplinary formulation of individual treatment plans and does not directly provide skilled nursing care and therapy to the patients in the mental health unit as required under 412.27(d)(3)(i).

2. On 10/22/10, interview with Staff #3 and Staff #11 revealed that the director of the mental health unit is Staff #3 and the director of psychiatric nursing services for the mental health unit is Staff #9. Documented evidence of a qualified director of psychiatric nursing services was requested, but was not provided during the survey.

A. Based on observations, interviews, medical record reviews and policy reviews, the facility failed to ensure that the nursing staff prepared and administered drugs for 2 of 3 patients on titrated medications. This was found in MR #2 and #16.

Findings include:

1. Medications were prepared without complete and specific physician order as required by law. In MR #2, a 70 year old patient was admitted on 10/17/10 at 6:07 PM in respiratory distress and with an altered mental status. The patient had multiple medical co-morbidities which included severe COPD, Hypertension, Type II Diabetes Mellitus, Pulmonary hypertension and heart failure. The patient was intubated and attached to a ventilator. On October 18, 2010 at 3:38 AM, an order for prolonged sedation was written for "Ativan Drip, titrate for Sedation" which on 2 separate occasions was prepared by 2 nurses. Based on the medical record reviews on 10/19/10, it could not be determined in what concentration and type of solution the medication was mixed when both bags were prepared. This is not in keeping with acceptable standards of practice.

A follow-up order at 10:13 AM on 10/18/10 revealed "Lorazepam 0.5mg/ml (40mg added to NS or D5) final volume= 80ml. This does not specify the type of fluid in which the medication should have been mixed which indicates that both nurses made the decision for the type of solution in which the drug was mixed.

2. The drug for MR #2 was administered without an appropriate order. During observations of MR #2 on 10/19/10 at 4:05 PM, it was noted that Ativan 80mgs in 80 ccs of D5W was hung and connected to the patient, but it was on hold. There was no order for this concentration and dosage. The medication administration record (MAR) indicates "Ativan drip titrate to sedation" was initiated at 3:00 AM on 10/18/10 by a nurse. In addition, a review of other aspects of the medical record confirmed that the patient had received this preparation of Ativan. Consequently, the patient became heavily sedated, and remained moderately sedated up to 24 hours after the drug was stopped. The patient became less sedated the next day, approximately 48 hours after the drug was withheld.

3. A review of MR #2's MAR revealed the second bag of Ativan was not documented. The facility's "Medication Administration" policy item #11 states all medications that are administered must be documented on the MAR.

These findings were witnessed and verified by Staff #5 and #11.

4. In addition, Staff #5 stated on 10/19/10 at approximately 3:45 PM, that the staff only document on the MAR that a drug is administered when a new bag of titrated drug is hung. Therefore, it could not be determined how many and which members of staff adjusted the medication according to the titration scale.

5. A nurse failed to have another nurse witness the discarding of a controlled substance. During interviews conducted on 10/20/10 at approximately 3:15 PM, Staff #7 stated that she forgot to have the wasted Dilaudid, a controlled substance, witnessed by another nurse. An undetermined amount of 80 mgs Dilaudid mixed in D5W was discarded.


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B. Based on medical record review and staff interview, the facility failed to ensure that drugs are transcribed, prepared, and administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care. This is evident in 1 of 30 medical records reviewed which resulted in the patient receiving an improper dose and quantity of the medication ordered by the physician. MR #24

Findings include:

The physician ordered Ativan 1mg PO Q4hrs PRN Agitation - Max 4 doses in 24 hours on 5/10/10. The pharmacy transcribed the order into 0.5 x 2mg PO PRN every 4 hours for agitation and in the corner of the Medication Administration Record 1MG was entered as guidance for the dosage to be given by the nurse. On 5/15/10 at 00:45, the nurse administered an improper dose and quantity of the medication Ativan 2mgs PO to the patient creating a category "C" medication error which did not cause harm to the patient who ingested the wrong dose.

Based on interviews and medical record reviews, it was determined that a patient was not provided a safe and appropriate discharge. This was found in MR #1.

Findings include:

1. MR #1's discharge was not appropriate or safe. MR #1, a 70 year old patient with a history of Psychosis was admitted on May 24, 2010 to the behavioral health unit involuntarily after he had multiple falls including a fall through a second story window. The patient, who had a medical history that included but was not limited to Traumatic Brain Injury, Prostate Cancer, CVA and Hypertension, had impaired mobility as evident by his dependency on a wheelchair and rolling walker for mobilization for his left sided weakness. For example, on July 21, 2010, 2 days before the patient's discharge, the patient was able to move from "supine to sitting with supervision, increased time and effort, sit to stand with contact guard with assistance, ambulate with assistance, ambulate with rolling walker contact guard assistance of 40 feet" according to the physical therapist.

Throughout the patient's hospitalization, the patient's movement was limited to a wheelchair or a rolling walker. The latter required contact guard with assistance to a distance of 40 feet. The patient also required assistance with meeting his daily needs such as meal preparation.

The facility did not or was unable to place the patient in a home or skilled nursing facility prior to his discharge; however, he agreed on July 22, 2010 to be discharged to the Department of Social Services (DSS) for placement. According to the Patient Review Instrument (PRI) screen "the patient is no longer able to be maintained in community, now needs increased supervision in skilled nursing facility."

The patient was discharged in an ambulance inappropriately to the County Department of Social Services, Adult Protective Services (APS), on Friday July 23, 2010 where he was unable to transfer from the stretcher to a chair. The patient had declined a rolling walker prior to his discharge from the facility and there was no evidence that the patient was provided a leg lifter that he had requested on July 21, 2010 to aid in getting in and out of bed. Furthermore, there was no evidence that the patient was provided a wheelchair at the time of his discharge which was his only mode of independent mobilization during his 2 month stay at the hospital. This posed a risk for falls and injury since DSS would not have been able to place the patient in a shelter or provide other appropriate accomodation by the close of business that day. In addition, the patient could not have remained at the office of DSS unaccompanied and without assistance to meet his needs of daily living.

2. The patient was inappropriately discharged to DSS by ambulance with an order for "Restrain PRN For Safety." See Citation at A 169.

3. The patient's Patient Review Instrument (PRI) was not updated to facilitate appropriate placement. However, white correction fluid was used to alter the only PRI in the medical record. Two copies of the PRIs submitted to APS at DSS were obtained. The first PRI was dated May 26, 2010 ("Date of PRI Completion"), while the second was an identically handwritten copy of the first PRI except for the PRI completion date of July 16, 2010 and item's #20 and 21, which had been altered on top of white-out. Such alterations are not acceptable legal or professional practice.

4. The patient's medical care prior to discharge was inadequate. See Citation at A 347,
item # 5.