HospitalInspections.org

Based on the nature of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.13, PATIENT'S RIGHTS, was out of compliance.

A144 - Standard: Privacy and Safety - the patient has the right to receive care in a safe setting. The facility failed to ensure patients remained safe during multiple intervals throughout the day in 10 of 30 medical records reviewed (Patients #3, #4, #6, #9, #10, #11, #16, #20, #22, and #28). This failure created the potential for negative patient outcomes including self-harm or harm to others without medical staff awareness.

A168 - Standard: Restraint or Seclusion -the use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. The facility failed to obtain orders to safely discontinue restraints or seclusion in 3 of 5 medical records reviewed for restraint documentation. This failure created the potential for an unsafe patient care environment, in which the responsible ordering provider was not aware of the patient's current psychiatric status.

A175 - Standard: Restraint or Seclusion - The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. The facility failed to monitor patients in mechanical restraints in 1 of 2 mechanical restraint charts reviewed. The failure created the potential for an unsafe patient care environment, in which the physical and emotional safety and needs of the patient were not met.

Based on document reviews and interviews, the facility failed to ensure patients remained safe during multiple intervals throughout the day in 10 of 30 medical records reviewed (Patients #3, #4, #6, #9, #10, #11, #16, #20, #22, and #28).

This failure created the potential for negative patient outcomes including self-harm or harm to others without medical staff awareness.

FINDINGS:

POLICY

According to Patient Safety, at the beginning of each shift, the Team Lead for Mental Health Workers will assign responsibility for completing the "Patient Observation" form that documents patient location and behaviors during the shift. The Team Lead and/or Nurse will ensure the "Patient Observation" round are occurring every 15 minutes during each working shift, seven days per week. Observation checks on each patient occur a minimum of every 15 minutes and/or according to their observation level. Patient location and behavior will be documented on the "Patient Observation" form.

1. The facility did not ensure patients' locations were being observed according to the patient's ordered observation level and the facility policy.

a) The following medical records revealed extended periods of time when staff did not follow physician ordered level of observation or the Patient Safety policy regarding observing the patient's location:

i) Review of Patient #20's medical record revealed s/he was put in seclusion on 01/21/16 at 9:00 p.m. for violent behavior, being a danger to self and a danger to others. Patient #20 was released from seclusion 15 hours later at 01/22/16 at 12:00 p.m. Patient #20's location was not observed for 3 hours and 38 minutes after being released from his/her episode of seclusion for violent behavior.

Patient #20 was placed into seclusion again on 01/22/16 at 3:38 p.m., for violent behavior and being a danger to others. S/he remained in seclusion for 23 hours and was released at 01/23/16 at 3:15 p.m. Patient #20's location was not observed on a Patient Observation sheet for a total of 15 hours and 45 minutes after being released from seclusion for being a danger to others.

Patient #20's location was not observed for a total of 20 hours during his/her stay at the facility. This was in contrast to the facility's Patient Safety Policy.

ii) Review of Patient #22's medical record revealed s/he had been admitted because s/he felt like killing another resident at a different facility. Additionally, a physician ordered fall precautions on 2/23/16 at 2:32 p.m. On 2/24/16 it was reported Patient #22 had fallen twice, hit head and transferred to another facility for a computerized tomography (CT) scan. After the scan, Patient #22 returned to the facility. Patient #22's location was not observed on the Patient Observation form for 5 hours and 45 minutes during the remainder of his/her stay at the facility at the following times:

- 02/25/16 at 1:30 p.m. until 3:00 p.m.

- 03/1/16 at 6:15 p.m. until 7:30 p.m.

- 03/13/16 at 6:00 p.m. until 7:30 p.m.

- 03/22/16 at 7:45 p.m. until 9:15 p.m.

iii) Review of Patient #9's medical record revealed s/he was admitted for a strong desire to beat someone to death with his/her bare hands. Patient #9 had a criminal history of similar physical violence. On 09/2/16 Patient #9's location was not observed from 2:15 p.m. until 3:15 p.m.

Similar findings were found in the medical records of Patients #3, #4, #6, #10, #11, #16, and #28, in which the patient's location was not observed on the Patient Observation form per the facility's Patient Safety Policy.

b) During an interview on 12/08/16 at 10:35 a.m. Mental Health Worker (MHW) #1 stated patients' locations were supposed to be documented every 15 minutes during the day and night. S/he stated it was unacceptable to not have a location documented for patient's every 15 minutes. MHW #1 stated the 15 minute checks were important because the patients in the facility were at a risk for elopement, self-harm or could cause harm to other patients if they were not watched closely.

During the same interview with MHW #1 s/he confirmed s/he was one the MHWs responsible for observation checks for Patient #9 on 09/2/16 at 2:15 p.m., during the time when the location was not documented on the Patient Observation form. MHW #1 stated s/he must have been on break at the time the location was not documented. MHW #1 stated although s/he was on break, the Patient Observation form should have been filled out by whomever covered the break time. S/he stated this was usually a nurse, team lead or security. MHW #1 stated patients of the facility should be watched closely at all times for their safety.

c) During an interview on 12/08/16 at 3:12 p.m. Registered Nurse (RN) #2 stated patients' location should be documented on the Patient Observation form every 15 minutes. S/he stated the observation checks were important because the patients could do a lot of harm to their bodies in 30 minutes. RN #2 stated patients at the facility were often suicidal or wanted to harm themselves. RN #2 stated it was the responsibility of the RN or MHW to record the location of the patient every 15 minutes. S/he stated there should not be a gap when the patient's location was not documented.

d) During an interview on 12/08/16 at 3:22 p.m. MHW Supervisor and Program Coordinator (Supervisor) #7 stated no matter where the patient was or what the patient was doing, their location should be documented on the Patient Observation form. S/he stated the expectation was for the staff to be diligent and gaps of time when the location was not observed should not occur. Supervisor #7 stated the gaps of time the location of patients were not accounted for on the Patient Observation form looked like the patients had not been monitored.

e) During an interview on 12/08/16 at 11:45 a.m. Nurse Practitioner (NP) #5 stated the standard level of observation for patients at the facility included observation checks every 15 minutes. S/he stated patient observations were to make sure the patients were safe and not harming themselves. NP #5 stated it was a requirement of staff to follow observation orders.

f) During an interview on 12/08/16 at 1:05 p.m. Medical Director (Director) #4 stated when every 15-minute observation checks were ordered on patients, s/he expected every 15-minute observation checks to be done for the patient.

During the same interview with Director #4, s/he confirmed missing observation checks on Patient #22's Patient Observation form. Director #4 stated s/he was completely unaware of missing observation checks. S/he stated these observation checks had to happen so harm did not occur to the patients.

g) On 12/08/16 at 2:28 p.m., an interview was conducted with the Director of Nursing (DON) #6 and the Executive Vice President (VP) #3. Director #6 stated observational checks every 15 minutes were to ensure patient safety and should have been documented on the patient observation form. VP #3 confirmed there were gaps in the ordered 15-minute patient observation gaps. S/he stated the observation checks were expected to be done to make sure the patients were safe.

Based on document reviews and interviews, the facility failed to obtain orders to safely discontinue restraints or seclusion in 3 of 5 medical records reviewed for restraint documentation.

This failure created the potential for an unsafe patient care environment, in which the responsible ordering provider was not aware of the patient's current psychiatric status.

FINDINGS:

POLICY

According to Seclusion and Restraint a completed Seclusion and Restraint (S/R) order label will be placed in the patient's chart and signed by the ordering Doctor within 24 hours. A doctor's order to terminate seclusion or mechanical restraint must be obtained prior to patient's release. The Registered Nurse (RN) will ensure that the S/R Order label is complete, signed and dated within 24 hours by the Ordering Doctor, the attending Provider, and the person performing the 1-hour Face-to-Face evaluation.

REFERENCE

According to the Seclusion and Restraint Check-List staff must obtain a Physician Order to end seclusion or mechanical restraint.

1. The facility did not obtain physician orders to release patients from restraints or seclusion in 3 of 5 charts reviewed.

a) Review of Patient #19's medical record revealed a Registered Nurse (RN) initiated an order for 4-point mechanical restraints on 10/31/16 at 10:20 p.m. due to violent behavior and being a danger to self and other. Documentation of a 1 hour face to face evaluation revealed Patient #19's mechanical restraint start time of 10:45 p.m. and an end time of 11:10 p.m. No physician order was documented to release Patient #19 from the mechanical restraints.

b) Review of Patient #5's medical record revealed an order for seclusion on 12/02/16 at 7:10 p.m. due to violent behavior and being a danger to self and others. According to the S/R Flowsheet Patient #5 was in seclusion on 12/02/16 at 7:08 p.m. and was released from seclusion at 10:06 p.m. No physician order was documented to release Patient #5 from seclusion.

Further review of Patient #5's medical record revealed an order for seclusion on 12/03/16 at 8:40 p.m. for showing violent behavior and being a danger to self and to others. According to the S/R Flowsheet Patient #5 was in seclusion on 12/3/16 at 8:51 p.m. and was released from seclusion on 12/4/16 at 8:40 a.m. No order can be found that stated it was safe to release Patient #5 from seclusion at that time. This was in contrast to facility policy.

c) Review of Patient #20's medical record revealed an order for seclusion on 01/21/16 at 8:00 p.m. due to violent behavior and being a danger to others. According to the S/R Flowsheet Patient #20 was in seclusion on 1/21/16 at 7:30 p.m. and was released from seclusion on 01/22/16 at 12:00 p.m. No physician order was documented to release Patient #20 from seclusion.

Further review of Patient #20's medical record revealed an order for seclusion on 01/22/16 at 3:53 p.m. due to violent behavior and being a danger to others. According to the S/R Flowsheet Patient #20 was in seclusion on 01/22/16 at 4:00 p.m. and was released from seclusion on 01/23/16 at 3:15 p.m. No physician order was documented to release Patient #20 from seclusion. This was in contrast to facility policy.

d) During an interview on 12/08/16 at 3:12 p.m. RN #2 stated a discontinue order for seclusion or restraints should have been obtained by the physician before the patient was released.

e) During an interview on 12/08/16 at 11:45 a.m., Nurse Practitioner (NP) #5 stated an order to discontinue restraints or seclusion on a patient was needed to release a patient.

f) During an interview on 12/08/16 at 2:28 p.m. Executive Vice President #3 stated the expectation was for all facility staff to follow the seclusion and restraint policy. According to the Seclusion and Restraint policy a doctor's order to terminate seclusion or mechanical restraint must be obtained prior to patient's release.

Based on document review and interviews the facility failed to monitor patients in mechanical restraints in 1 of 2 mechanical restraint charts reviewed.

The failure created the potential for an unsafe patient care environment, in which the physical and emotional safety and needs of the patient were not met.

FINDINGS:

POLICY

According to Seclusion and Restraints (S/R) staff will observe the patient at least every fifteen (15) minutes and such observation, along with the behavior of the patient, will be recorded each time on the S/R Flowsheet.

1. The facility could not provide documentation of monitoring a juvenile patient while mechanical restraints were applied.

a) Review of Patient #19's medical record revealed a Registered Nurse (RN) initiated an order for 4-point mechanical restraints on 10/31/16 at 10:20 p.m. due to violent behavior and being a danger to self and others. Documentation of a 1 hour face to face evaluation revealed Patient #19's mechanical restraint start time of 10:45 p.m. and an end time of 11:10 p.m. Patient #19 was in mechanical restraints for 25 minutes. No S/R flowsheet could be provided for Patient #19.

b) During an interview on 12/08/16 at 10:35 a.m., Mental Health Worker (MHW) #1 stated 15 minute checks were required when a patient was mechanically restrained. S/he stated documentation on the restraint flowsheet included why the patient was mechanically restrained and how the patient behaved. MHW #1 stated a patient's airway and pain should also be assessed while a patient was mechanically restrained. MHW #1 stated the S/R flowsheet should have been present to make sure nothing happened to the patient while mechanically restrained.

c) During an interview on 12/08/2016 at 3:12 p.m., RN #2 stated when a patient was in 4-point mechanical restraints the RN should have assessed circulation and should have made sure skin was intact under the restraints. This should have been documented on a S/R flowsheet. RN #2 stated an MHW sits with the mechanically restrained patients and should document every 15 minutes on the S/R flowsheet and the observation sheet, accounting for where the patient was and how the patient responded to being restrained.

d) During an interview on 12/08/16 at 12:42 p.m., Executive Vice President (VP) #3 stated a S/R flowsheet should have been present in Patient #19's medical record. VP #3 stated the S/R flowsheet could not be located for the time Patient #19 was in mechanical restraints, this was against facility policy. S/he further stated facility employees were expected to follow policy.

Based on document reviews and interviews, the facility failed to ensure seclusion and restraint orders were signed and dated by the ordering provider in 3 of 5 medical records reviewed for restraint documentation (Patients #5, #15 and #19).

This failure resulted in incomplete restraint and seclusion orders .

FINDINGS:

POLICY

According to the policy, Seclusion and Restraint, a completed Seclusion and Restraint (S/R) order label will be placed in the patient's chart and signed by the ordering Doctor within 24 hours. A doctor's order to terminate seclusion or mechanical restraint must be obtained prior to patient's release. The Registered Nurse (RN) will ensure that the S/R Order label is complete, signed and dated within 24 hours by the Ordering Doctor, the attending Provider, and the person performing the 1-hour Face-to-Face evaluation.

1. The facility failed to ensure restraint and seclusion telephone orders were signed by the ordering physician in 3 of 5 medical records reviewed for restraint and seclusion documentation.

a) On 12/07/16, review of Patient #19's medical record revealed 3 physical restraint orders dated 10/30/16, 11/01/16, 11/05/16 and 1 mechanical restraint order dated 10/31/16 with no ordering psychiatric provider signature present.

b) On 12/07/16, review of Patient #5's medical record revealed 2 seclusion orders each dated 12/04/16 and 2 seclusion/physical restraint orders dated 12/02/16 and 12/03/16 with no ordering psychiatric provider signature present.

c) On 12/07/16, review of Patient #15's medical record revealed a physical restraint order dated 10/20/16 with no ordering psychiatric provider signature present.

d) During an interview on 12/08/16 at 3:12 p.m. Registered Nurse (RN) #2 stated, a provider had 24 hours to sign a telephone restraint or seclusion order. S/he stated the RN taking the order would sign the order and indicate on the form the name of the provider. RN #2 stated the ordering provider should sign the order the next day. RN #2 stated if this did not happen the Medical Records Department would contact the provider to sign the order.

e) During an interview on 12/08/16 at 1:20 p.m., Medical Director #4 stated restraint orders should be co-signed by the ordering provider within 24 hours. S/he expected facility staff to follow policy.

Based on observation, interviews, and document review, the facility failed to ensure drugs stored in the medication refrigerators were kept at temperatures to ensure the efficacy and safety of medication.

This failure created the potential for patient to receive improperly stored medication increasing the risk of negative patient outcomes.

FINDINGS:

POLICY

According to Refrigerator Temperatures, Monitoring, temperatures will remain between 34 and 41 degrees and freezers below 0 degrees. Minor adjustments may be done and rechecked in one hour. Any deviations or concerns requiring additional maintenance will be reported to the Facilities Manager via a Work order request. Notice will also be given to the Infection Control Nurse. Any items being stored in a malfunctioning refrigerator will immediately be removed and stored in another properly functioning refrigerator. Any medications needing to be moved to another refrigerator will be moved according to directions in the Medication Management and Administration policy and procedure.

According to Medication Management and Administration, medication requiring refrigeration will be stored immediately upon delivery and following use, at a temperature between 36 degrees and 46 degrees Fahrenheit. Nursing will be present when Security conducts daily recordings of medication refrigerator temperatures. The observed temperatures are documented daily on the Refrigerator Temperature Log. When temperatures are observed to be outside the standard range the nurse will immediately make slight adjustments to the refrigerator control and recheck the temperature in one hour. If unable to stabilize the refrigerator temperature within recommended ranges, the Facilities department will be notified, and all medications moved to a properly controlled refrigeration unit.

REFERENCES

According to the manufacturer's recommendation, Lorazepam should be stored in a refrigerator.

According to the manufacturer's recommendation, Tuberculin Purified Protein Derivative should be stored between 36 degrees and 46 degrees Fahrenheit.

1. The facility did not maintain medication refrigerator temperatures within a set range, 36 degrees and 46 degrees Fahrenheit, to ensure medication safety and efficacy.

a) During a tour of the facility on 12/05/16 at 4:35 p.m., Building C's medication refrigerator was observed to contain medication vials of Lorazepam, a sedative, and Tuberculin Purified Protein Derivative. A review of the Refrigerator/Freezer Temperature Log for Building C's Medication refrigerator revealed the following dates outside of the facility's expected temperature parameters.

-Month of August 2016: 4th, 5th, 6th and 7th

-Month of November 2016: 7th, 8th, 9th, 11th, 12th, 17th, 18th, 19th, 25th, 29th and 30th

-Month of December 2016: 2nd and 4th

b) During an interview on 12/08/16 at 3:12 p.m. Registered Nurse (RN) #2 stated s/he thought the policy had recently changed and RNs were now in charge of checking the medication refrigerators. RN #2 stated this was a new process and security used to do it. S/he did not think any of the RNs had been trained on what to do if the temperature was out of range. RN #2 assumed maintenance would need to be notified. S/he explained it was important for medications to be stored in a refrigerator kept within a certain range so the medications did not go bad.

c) During an interview on 12/08/16 at 2:19 p.m., Registered Pharmacist (Pharmacist) #9 explained security was in charge of checking the medication refrigerator in the morning and evening. This was in contrast to RN #2's statements. Pharmacist #2 stated s/he did not know what training the facility staff received regarding managing refrigerator temperature, but the staff should have known what to do for out of range temperatures.

Review of the Refrigerator/Freezer Temperature Log sheets was done during the same interview with Pharmacist #9. S/he expected documentation when the refrigerator was adjusted for out of range temperatures. Pharmacist #9 stated there was no documentation regarding the adjustment of the temperature per the log sheets. Pharmacist #2 explained some medications were sensitive to temperature and can become inactive if not kept within specific ranges.

d) During an interview on 12/08/16 at 2:28 p.m., Executive Vice President (VP) #3 stated no one had notified her regarding the out of range temperatures and this should have been done. VP #3 stated s/he relied on the RNs to notify her regarding out of range temperatures in the medication refrigerators.