HospitalInspections.org

Based on record review and interviews the hospital failed to ensure that all State laws were met as required. (Patient identifier is #1.)

Findings Include:

Review of New Hampshire Department of Health & Human Services' letter dated 4/12/11 to hospital administrator reveals that concerning a violation of the below described state law that the hospital was fined $2,000.00. In response the hospital waived its right to a hearing and paid a $1,500.00 fine as authorized in rule He-P 805.12 (b)(3)a.. No other appeals remain.
Review of Title XI Hospitals and Sanitaria Chapter 151 Residential Care and Health Facility Licensing Adverse Events reporting System Section 151:38 Hospitals and Ambulatory Surgical Centers Required to Report Adverse Events. - I. "Any hospital or ambulatory surgical center licensed pursuant to this chapter shall report to the commissioner the occurrence of any of the adverse health care events described in subparagraphs (a)-(f) as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved... (e) (5) Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility."

Review of the New Hampshire Code of Administrative Rules Chapter He-P Residential Care and Health Facility Rules indicates the following:

PART He-P 802 Rules for Hospitals:

"He-P 802.03 Definitions:..

(h) "Adverse event" means a negative consequence of care that results in unintended injury which may or may not have been preventable, and which is listed in RSA 151:37.

(u) "Department" means the New Hampshire department of health and human services, at 129 Pleasant St, Concord, NH 03301...

He-P 802.14 Duties and Responsibilities of All Licensees.

(q) Licensees shall, in accordance with He-P 802.15:

(1) Report all adverse events to the department as required by He-P 802.15(a)-(c);

He-P 802.15 Adverse Event Reporting.

(a) Pursuant to RSA 151:37, the hospital administrator or designee shall report to the department the following adverse events:


(a)(e) Environmental events including:

(5) Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility.

(b) If the hospital suspects an adverse event occurred, the hospital administrator or designee shall send a report to the department in electronic or paper format, within 15 days, including:

(1) Hospital information;

(2) Patient information;

(3) Event information; and

(4) Type of occurrence as listed in (a) above.

(c) For events reported in (b) above the hospital shall within 60 days provide the department:

(1) An analysis that includes the type of harm and contributing factors; and

(2) A corrective action plan that includes what corrective actions are planned, who is responsible for implementation, when the action will be implemented and what measurements will be used to evaluate the corrective action plan or the justification for not implementing a corrective action plan if the hospital determines that one is not required.

He-P 802.16 Organization and Administration.

(b) Each hospital shall have a full time administrator who:

(2) Shall be responsible to the governing body for the daily management and operation of the hospital including:
h. Ensuring development and implementation of hospital policies and procedures on:
6. Adverse event reporting; and

i. Notifying the department, directly or through delegation, as specified in He-P 802.15 of any adverse event involving a patient ..."


Review of Patient #1 medical record on 3/14/11 reveals in a progress note written by Staff F, RN dated 1/29/11 indicates at approximately 4:10 p.m. Patient #1 had an aggressive outburst while visiting with relatives and attempted to attack at family and staff that required physical restraint for safety. Patient #1 was released from the physical hold after 3 minutes. Patient #1 got up from the floor and went to the couch and then complained of pain to right leg/knee. Area assessed to be edematous, unable to bear weight to right leg. Patient #1 was transported to the hospital emergency department. Review of the hospital x-ray of the right femur revealed a fracture of the midfemoral shaft with angulation, displacement and overriding of the comminuted fracture fragments. There is associated soft tissue swelling.

Interviews on 3/14/11 with Staff A, Chief Operations Officer, Staff B, DON and Staff H, Director of Health Information revealed that Patient #1 was placed in a physical hold restraint for a short period of time and was sent to a local hospital emergency department for evaluation that revealed Patient #1 sustained a fracture of the right femur. Staff A, B and H confirmed that a report was submitted to Adult Protective Services and believed that was sufficient reporting and were unaware of the requirements of Adverse Event Reporting.

Based on review of medical records, interviews with hospital staff, and review of hospital policies and procedures, it was determined that the hospital failed to ensure the rights of patients.

Findings include:

The hospital failed to assure the rights of patients in that the hospital failed to ensure that the patient receives care in a safe setting. The hospital failed to ensure a secure environment, and failed to ensure the safety of a patient.

(Refer to A0144.)

Based on review of medical records, interviews with hospital staff, and review of hospital policies and procedures, it was determined that the hospital failed to ensure a patient receives care in a safe setting. 1) The hospital failed to ensure a secure environment and the physical and emotional safety of a patient with an injury requiring transportation to a medical hospital. (Patient identifier is: #1.)


Findings Include:
Review on 3/14/11 of the policy and procedure "Ambulance Transfers" effective date of 5/95 with a review date of 1/09 by Staff B, indicates the following:

Policy:
Will transfer patients via ambulance in a medical emergency or by physician order.

Purpose:
To ensure the timely transport of the patient to a receiving facility according to COBRA regulations, for effective continuing care.

Procedure1. Access ambulance service by dialing "9-9-1-1" for Emergency Transfer/Medical Aid.

2. If non-emergent, but patient still requires ambulances transport, call AMR ...to schedule arrival time, after obtaining MD order...

6. In an emergency transfer, notify appropriate personnel; DOC, (doctor on call), Shift Manager, and legal guardians. Ask if legal guardian is able to meet patient at ER.

7. Document physician's order to transfer inpatient's medical record.

8. In an emergency medical transfer, call Emergency Department or receiving facility to obtain accepting doctor's name and to give a report of the patient's status to a physician or registered nurse.

9. Document in Progress Note, reason for transfer, how patient was transferred and state in which patient left.

Review of the facility's policy for Medical Emergency Guidelines, with an effective date of 12/96 and review by Staff B, RN DON (Director of Nurses) on 1/09, that states "...staff will handle medical emergencies in a standardized manner to provide the best possible patient care. All employees are responsible to aid the victim of a medical emergency to their of preparedness and training.

Purpose: The purpose is of the following guideline is to ensure that medical emergencies are handled in an expedient manner, appropriate to the situation.

Procedure:
1. The first responder to the medical emergency is to assess the victim and start the proper treatment, call for assistance and stay with the victim..."


Review of the policy and procedure for the Transportation of Patients in Hospital Vehicles, with an effective date of 1/01 and review date of 4/09, which was reviewed by Staff B. Labeled for the Department of Administration.

" Purpose:
To assure the safe and appropriate transportation of patients to outside consultants, appointments and/or field trips, etc.

Policy: The hospital will provide transportation of hospital patients only for approved purpose and in strict accordance with established procedures as specified below.


Procedure:
1. Appointments...
4. Transportation Definition
Transportation will be provided for Medically indicated purposes. To transport patient to their own physicians when medically indicated and appointment times and booking has been arranged.
5. Decisions regarding the appropriateness of transporting patients will be determining by the patient's nurse manager.."


Review of the AMR (American Medical Response) contract reveals that the agreement was written on 12/29/99 that the contractor agrees:
"1. To provide emergency and routine ambulance transportation services to all patient, with a medically certifiable need for ambulance or chair transportation, without regard to the patient ' s ability to pay.."

A memo written by Staff B, on 4/24/09, indicates that AMR will provide all ambulance transfers for patients and to schedule an appointment for that transportation. In an emergency dial 911 and Trinity Emergency Medical Service will respond. That is the town's contracted ambulance service.

Review of Patient #1's medical record on 3/14/11 revealed that Patient #1 was admitted on 1/24/11 with diagnoses that includes mood disorder, autism, obsessive-compulsive disorder, attention deficit hyperactivity disorder attention and mental retardation. Review of psychiatric history completed 1/25/11 indicates Patient #1 has been having increasingly unmanageable behaviors at home and in public. Outbursts with aggression on a daily basis and has engaged in property destruction. Has been engaging in inappropriate sexual gestures, attempting to touch females. Behaviors also include spitting, kicking and throwing objects.

Review of Patient #1's admission medical assessment form indicates under existing physical conditions a check for yes and hand written in is right knee currently sprained, no break.

Review of the Physician's Orders reveals that on 1/25/11 all meds were discontinued except ibuprofen so that Patient #1 could be reassessed for medical interventions for given behavioral targets.

Review of Patient #1 medical record on 3/14/11 reveals in a progress note written by Staff F, RN dated 1/29/11 indicates at approximately 4:10 p.m. Patient #1 had an aggressive outburst while visiting with relatives and attempted to attack at family and staff which required physical restraint for safety. Patient #1 was released from the physical hold after 3 minutes. Patient #1 got up from the floor and went to the couch and then complained of pain to right leg/knee. Area assessed to be edematous, unable to bear weight on right leg. With the assist of 2 staff members Patient #1 was able to stand on left leg and stand and pivot into a wheelchair and Patient #1's was brought to room and again stand/pivoted on left leg onto bed. Staff F, RN, (Registered Nurse) removed Patient #1's right leg from pant leg for further assessment that revealed skin intact, no discoloration, firm grapefruit sized edema to outer aspect of right lower thigh above right knee. Range of motion from right knee to right foot limited, pedal pulse palpable. Ice applied. Staff C, RN, Nurse Manager was present for the assessment. Physician on call made aware and the decision was made to transfer to hospital (medical) for further evaluation. Notification made to the DPOA (Durable Power of Attorney). Staff F made call to AMR (American Medical Response) to procure ambulance for transportation. Staff F was told it would be a 2-hour wait. A decision was made to transport Patient #1 to the local medical hospital via facility van. Patient #1 assisted to wheelchair, (stand to pivot left leg with 2 assist). Full assist into van.

Interview with Staff F, RN on 3/14/11 at 3:20 p.m. Staff F indicated that after the physical hold Patient #1 was saying "ooh, ooh, leg hurt" and noted obvious swelling above the right knee area. Non-weight bearing. Wheeled Patient #1 to bedroom for a better assessment of the area. The area was about the size of a grapefruit, firm, intact, no discoloration, could move toes, limited range of motion, was able to sit up and down at hip area. Staff F believed it was probably a ligament or muscle problem. No other deformities, Normal vital signs, pale, warm and dry. Staff F believed that Patient #1 would need X-rays so called Staff C, who is the supervisor and did a second assessment with Staff C. Staff F indicated it was decided that due to the pain of Patient #1 and a wait of 2 hours for the ambulance was too long of a wait. Staff F indicated when asked what about an hour wait, that even an hour wait was too long. Staff F indicated that did not want to administer ibuprofen to Patient #1 in case Patient #1 needed something while at hospital emergency room. Staff F did call the hospital emergency room with a report on Patient #1. Staff F confirmed being aware that Patient #1 had a previous injury to the right knee and Patient #1 appeared to be stable and no there was no need to call 911.

Interview on 3/14/11 at 1:30 p.m. with Staff C, RN, Nurse Manager Staff C indicated receiving a phone call on 1/29/11 from the unit of Staff F and Staff F informed Staff C that a CPI (Crisis Prevention Intervention) and restraint had just happened with Patient #1. When Staff C arrived on the unit Patient #1 was observed lying on bed, the right outer thigh area had a hematoma that was tender to touch and was unsure if Patient #1 was able to move the right leg as right leg was out straight. Staff C indicated that in Staff C's opinion it appeared to be more muscle than anything bone. Staff C was unaware of what assessment had been previously done on Patient #1. Staff C was aware that the physician on call had been notified and the contracted ambulance AMR had been called for transport to the medical hospital emergency department. Staff C also indicated that Patient #1's condition did not appear to be an emergency and there was no need to call 911 so Staff C made the decision because the wait of 2 hours was too long to cancel the call to AMR to transport Patient #1 and to use the facility's mini-van to transport Patient #1 to the hospital emergency room.

Staff C indicated that the middle seat directly behind the driver was taken out of the facility's mini-van to accommodate Patient #1 for comfort. Patient #1 was brought to the van by wheelchair and Staff C and Staff E, Counselor assisted Patient #1 into the mini-van as Patient #1 was non-weight bearing on the right leg. Staff C and E assisted Patient #1 to stand onto the left leg. Staff E got inside the mini-van and grabbed Patient #1 under the arms while Staff C grabbed under the legs and then lifted Patient #1 into the mini-van to the back seat. Patient #1 was then seated for comforted and seat belted in placed. Staff C indicated that the facility has no transfer boards to assist with this type of transfer when asked about use of a transfer board. Staff C also indicated when asked about Patient #1's discomfort during the transfer that Patient #1 would state " ooh, ooh, ooh " upon movement, but then would be quiet when stopped moving.

Interview via phone on 3/15/11 with Staff D, counselor at 2:10 p.m. Staff D indicated not being medical personnel and that this is the first time in 2 ½ years that Staff D has used the mini-van for a transport to the emergency room. The mini-van is usually used for activities or appointments. Staff D was sitting up front in the passenger seat next to the driver and would turn head back to observe and talk with Patient #1.

Interview via phone on 3/16/11 with Staff I, counselor at 2:30 p.m. Staff I indicated not being medical personnel and that Staff I is an approved driver for the mini-van and was working as a float at the facility on 1/29/11. Staff I indicated having no special training for driving the mini-van but has a clean driving record. Staff I stated this was the first time having to drive someone to the emergency room. The mini-van is usually for pre-approved day trips and appointments. Staff I reported that the mini-van always uses 2 staff members when transporting. The mini-van has child locks on the back doors but was not used during the transport of Patient #1. Staff D and I left the facility about 5:15 p.m. with Staff D sitting next to driver up front in the passenger seat and would turn around and talk with Patient #1. Staff I recalls Patient #1's right upper leg area appeared to be a little swollen and Patient #1 did not want to bear weight. Did not notice any grimaces or a lot of pain. Patient #1 was noted during transport to be moving one leg to get comfortable but can't remember which one. Staff I indicates when arrived at the hospital Staff I went into the ER (Emergency room) and asked for assistance to get Patient #1 out of the mini-van. The ER staff came out and did not feel comfortable getting Patient #1 out of the mini-van into a wheelchair. The ER staff went back to retrieve a backboard, stretcher and more staff members to get Patient #1 out of mini-van.

Staff D and Staff I during their interview were asked about what procedures are there when transporting a patient who may become aggressive. Staff D or Staff I indicated they were unaware of any. Staff I indicated would pull over and implement CPI and hold if necessary. Staff D and Staff I were unaware if the child locks on the doors are required to be used during transport with Staff I reporting that during Patient #1's transport the child door locks were not used. Staff D and Staff I also indicated no awareness of being educated on the position/seating of the staff in the van to be able to observe and/or quickly intervene if a patient became aggressive.

Observation of the mini-van revealed that Staff D would have no control over Patient #1, while sitting in the front passenger seat.

Review of Patient #1's medical hospital x-ray on 1/29/11 of the right femur revealed a fracture of the midfemoral shaft with angulation, displacement and overriding of the comminuted fracture fragments with associated soft tissue swelling. Patient #1 was transferred to an out of state hospital for surgical repair of the right femur per request of Patient #1's activated responsible party
Review of the Merck Manual of Diagnosis and Therapy Section Injuries; Posioning Subject Fractures, Dislocations and Sprains indicates under Specific Fractures, Femoral shaft fractures: The usual injury mechanism is severe direct force or an axial load to the flexed knee. Fracture due to trauma causes obvious swelling, deformity and instability. Up to 1.5 L (liters) of blood for each fracture may be lost. Treatment is immediate splinting, then ORIF (open reduction internal fixation- surgical procedure).
Under common type of fracture lines it defines that comminuted fractures have more than 2 bone fragments and comminuted fractures include segmental fractures (2 separate breaks in a bone.). Under spatial relationship between fracture fragments it defines displacement as the degree to which the fractured ends are out of alignment with each other.

During interview on 3/14/11 with Staff A, Chief Operations Officer, Staff B, DON and Staff H, Director of Health Information confirmed that Patient #1 had a previously known sprain injury of the right knee, was admitted to facility due to increasingly aggressive behaviors which included spitting, kicking, throwing objects and also inappropriate sexual behaviors toward females. Staff A, B and H also confirmed that after the physical hold Patient #1 was noted with pain and swelling of the right outer thigh above the right knee and that Patient #1 was transported to the local medical hospital emergency department on 1/29/11 in the facility mini-van accompanied by 2 female counselors that are non medical personnel.

Based on observations and interview the hospital failed to store and handle food in a sanitary manner.

Finding include:

Observations on 5/16/11 between 12:00 p.m. and 12:30 p.m. of unit refrigerators revealed the following:

Madison Unit Refrigerator- partially consumed beverage bottles with no identification of persons consuming the drinks as required by the sign on the refrigerator. Open milk containers with no date as to when the carton was opened. An unwrapped partially eaten candy bar in freezer unit and. 1 to 2 inches frost build-up on all interior surfaces of freezer.

Harrison Unit Refrigerator- partially consumed beverage bottles with no identification of persons consuming the drinks as required by the sign on the refrigerator. A Styrofoam plate of cut up vegetables that was covered with no date of when it was prepared.

Observations on 5/16/11 between 12:30 p.m. and 1:00 p.m. of the kitchen revealed that in the dry storage area an opened 1 gallon container of rib sauce was not dated as to when it was opened. Interview with Staff M, Director Food Services revealed that the open date was unknown but Staff M put 5/16 as the open date. In the freezer it was observed that ice cream was stored in a "hotel pan" the ice cream was partially covered with plastic wrap and ice was observed on the surface of the ice cream. Staff M stated that ice cream was used at a function over the past weekend and staff would dispose of the ice cream.

Based on observations on 5/16/11 and 5/18/11 the hospital failed to maintain a baseboard heating unit and shower room tiles so a not present a hazard to patients.

Findings include:

Observation on 5/16/11 at 2:20 p.m. revealed that in the middle shower room on the Washington Unit a vertical run of tiles next to the shower stall was missing. The missing tiles provide a simple means to remove more tiles by patients.

Observation on 5/18/11 with Staff K, Director of Support Services, revealed that base board heating unit covers located in the Washington Unit day room area revealed that it had been repaired numerous times and that sharp edges existed on the sheet metal repairs. Staff K further stated that they were in the process of replacing baseboard covers and demonstrated the type of cover that would be less subject to destruction by the type of patient housed on this unit.