HospitalInspections.org

Based on review of documentation, staff interviews, and review of hospital policies the facility failed to ensure that patient received care in a safe setting. The facility staff failed to complete incident reports following the discovery of the patient's injuries.
Findings were:
Facility document entitled "Incident Reporting," states in part, "Policy: The Risk Management Program techniques must pro-actively focus on loss prevention, safety promotions, and detection of hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damages, and loss. Purpose: The Responsibility for completing an Incident Report rests with any facility staff member who witnesses, discovers, or has direct knowledge of an incident. An incident is an unanticipated happening which was not consistent with the routine care and/or operation of the facility and may have occurred due to a violation of policy and procedure. Procedure: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report as soon as practical after the incident is witnessed or discovered, before the end of the shift/work day.
Review of patient's medical record and facility policies on 08/30/16 revealed that the on 3/21/16 at 0045 nursing staff documented that the patient had a bruise in left zygomatic facial area that seems no more than 3 days old. No incident report was available.
On 3/20/16 at 1845 nursing progress note states in part, "throughout this shift pt. has been crawling on the floor in hall, leaning up against door frame of room. Pt. was checked by this nurse several times, assisted & redirected for safety. Pt has small bruises in various stages of healing." No incident report was available.
The above findings were confirmed by the Director of PI/Risk Management in the afternoon of 08/30/2016 in the facility's conference room.

Based on review of documentation, staff interviews, and review of hospital policies the facility nursing staff failed clarify a physician's order written as an "as needed" emergency medication. Nursing staff failed to obtain a physician order on five different occasions for the administration of a psychoactive emergency medication.

Findings were:

Review of facility policy entitled "Medication Administration," on the morning of 8/30/16 states in part, "Policy: No medication will be administered which does not conform to the guidelines outlined in the following policies.
Procedure: A. Orders: Only Practitioners who are lawfully authorized to prescribe and credentialed by the hospital may write orders for Medication. A complete medication order shall include the name of the drug, the dosage, and frequency of administration, the route of administration, the rationale and the date, time and signature of the prescriber. If medication orders are incomplete illegible or unclear, the nurse or pharmacy will clarify the order with the physician. Range orders are not acceptable. Resume Orders must be clarified with each drug name, dosage, and strength. Blanket orders such as "resume all orders" are not acceptable."
No policy documentation was observed on the psychiatric emergency medication.

Review of staff #3, #4, #5, #6, personnel files on the afternoon of 8/30/16 revealed no documentation of training on psychiatric emergency medications.

Review of patient #1 medical record on the morning of 8/30/16 revealed that an order was written by the physician as stated, " 3/14/16 at 1137 Zyprexa 10 mg IM Q (every) 4 hr. (hours) PRN (as needed) - agitation. The practitioner's order was transcribed and administered as such. Medical Record documentation revealed that the nursing staff administered the above psychoactive emergency medication to patient #1 five times. No additional orders were documented on the "Practitioner Order" for the administration of Zyprexa 10 mg IM on the dates indicated below. Patient #1 received the following psychoactive emergency medication for agitation on the following dates:
3/14/16 Zyprexa 10 mg was administered at time11:45 a.m. for agitation.
3/15/16 Zyprexa 10 mg was administered at time 0110 for agitation.
3/15/16 Zyprexa 10 mg was administered at time 2245 for agitation.
3/16/16 Zyprexa 10 mg was administered at time 0900 for agitation.
3/16/16 Zyprexa 10 mg was administered at time 2200 for agitation.

The above findings were confirmed by the Chief Executive Officer on the afternoon of 8/30/16. She stated, "We did some training at the Medical Executive Committee Meeting on 05/20/16 not to write or give orders for PRN Emergency Medications."