HospitalInspections.org

Based on review of facility policy and procedure, observation, and interview with staff, it was determined the facility failed to ensure the confidentiality of patient medical record (MR) for 1 of 13 patient's currently admitted to the facility. This affected an unsampled patient and had the potential to negatively affect all patients served by the hospital.

Findings include:

Administrative Policy and Procedure
Confidentiality and Security of Medical Records
Revised 12/2010

Policy...

17. Record Security- Each unit has a distinct patient record storage area to assure secure and confidential filing and storage of patient records. Records are kept out of view from patients..."

1. On 11/7/16 at 1:10 PM the surveyor observed through the window of the locked chart room, an open patient medical record. The open MR was unattended by a staff member and revealed documentation of the patient's Initial Psychiatric Evaluation and Interpretative Summary.

The surveyor observed at 1:15 PM, 3 non employee persons enter the building while the MR was open for view.

In an interview conducted on 11/9/16 at 10:05 AM Employee Identifier,1, Administrator confirmed the above mentioned findings.

Based on review of medical records (MR) and interview it was determined the facility nurses failed to:

1. Document wound assessments and wound care provided.

2. Document intravenous (IV) fluids start and stop times, flushes of the IV line every 4 hours (q 4 h) and the correct amount of solution used to flush the line.

3. Conduct nursing assessment of patients exhibiting signs of over medication, dehydration and address each patient's medical needs.

This affect 3 of 10 medical records reviewed. This affected MR # 6, # 10 , # 2 and had the potential to affect all patients served by this facility.


Findings include:

1. MR # 6 was admitted to the facility 10/28/16 with a diagnosis of Dementia with Behavioral issues.

A physician's order present in the medical record dated 10/30/16 at 8:30 AM documented the following:
Treatment to skin tear to right forearm, clean with NS (normal saline), pat dry, apply TAO (triple antibiotic ointment), cover with steristrips x 1 and PRN (as needed), monitor for s/s (signs/symptoms) of infection, DC (discontinue) when healed.

The Treatment Record for October 2016 included documentation of initials of a nurse providing care to the skin tear 10/30/16 and 10/31/16 at 10:00 AM.

The Treatment Record for November 2016 included documentation of initials of a nurse monitoring the right forearm twice a day per the initials of the nurse.

An interview was conducted with Employee Identifier (EI) # 3, Medication Nurse for 11/9/16, at 9:45 AM regarding the provision of wound care to MR # 6. EI # 3 stated that they only looked at her arm that they had not provided any wound care to the area, it was scabbed over.

The Non-Ulcer Weekly Progress Note was provided to the surveyor for MR # 6 at 7:30 AM on 11/9/16 which included three entries:

1. 10/30/16 , " Skin tear noted to right forearm red dried drainage noted, 0.5 x 2.0 cm (centimeter) x 0.01 cm, initiated treatment until healed no s/s (signs/symptoms) of infections noted."

2. 11/6/16, " Skin tear to right forearm shows scab, healing well, no s/s of infection noted."

3. 11/13/16, " Skin tear to right forearm shows scab and is intact, no s/s of infection noted."

The third note was dated 4 days in the future from the 11/9/16 date provided to the surveyor.

In an interview 11/9/16 at 9:10 AM with EI # 1, Administrator and EI # 2, Director of Nursing, the above information was confirmed.

2. MR # 10 was admitted to the facility 10/4/16 with a diagnosis of Vascular and Alzheimer's type Disease with Severe Behavioral Disorder.

A Physician's order dated 11/5/16 documented the following:

D5 1/2 NS (5% dextrose and 1/2 Normal Saline) at 100 ml (milliters)/hr (hour) x (times) 3 liters, may do at night if cannot do it while awake.

11/6/16 at 6:45 AM may leave IV site saline lock when awake and flush with 5 cc (cubic centimeters) NS every 4 hours...continue D5 1/2 NS at 100 ml/hr while sleeping.

The Medication Administration Record (MAR) revealed 11/5/16 the # 1 liter of fluids was signed off as adminstered on the IV fluids section. 11/6/16 and 11/7/16 MAR designated areas failed to have any documentation the patient received the intravenous fluids. 11/8/16 the MAR had documentation the # 2 liter of fluid was adminstered.

The Patient Care Notes dated 11/5/16 at 11:10 PM documented, " IV site initiated to right upper arm...24 gauge to right upper arm flushes easily... D 5 1/2 NS at 100 ml/hr started via pump."

11/6/16 at 2:01 PM, " Flushed with 10 cc's of 0.9% Sodium Chloride at this time."

11/6/16 at 6:01 PM, " Flushed with 10 cc's of 0.9% Sodium Chloride at this time."

The nurse flushed the IV with 10 cc of NS, the order was for 5 cc's of NS to flush every 4 hours.

The MAR dated 11/7/16 included documentation the flushes were completed at 10:00 AM, 2:00 PM and 6:00 PM, the amount administered was 5 cc.

MR # 10 failed to receive the 3 liters of fluid in 3 days as expected from the physician's order.

In an interview 11/9/16 at 9:40 AM with Employee Identifier (EI) # 2, Director of Nursing, confirmed the above documentation and stated it was a mistake in documentation.

3. MR # 2 was admitted to the facility 7/13/16 with the diagnosis of Alzheimer's Type Dementia with Behavioral Disturbances.

The Interdisciplinary Master Treatment Plan documentation reveals Psychiatric Problems as:
1. Medication Noncompliance 7/15/16
2. ADL's 7/15/16

A review of the Medication Administration Record (MAR) and the Patient Care Notes revealed the patient received PRN (as needed) medications for behaviors as follows:
7/13/16 Geodon 10 mg (milligrams) IM 4:30 PM for combative behaviors with staff and another patient and Geodon 10 mg IM at 5:30 PM for combative behavior.
7/13/16 at 9:30 PM Trazodone 50 mg po given to promote rest.
7/14/16 at 9:25 AM Geodon 10 mg IM combative with another patient and 10:15 AM Geodon 10 mg IM combative.
7/14/16 1:00 PM Haldol 3 mg IM and Ativan 1 mg IM for combative behaviors.
7/15/16 10:10 PM Trazodone 50 mg po given for insomnia.
7/16/16 7:30 PM Geodon 10 mg IM for combative behavior.
7/16/16 7:50 PM Haldol 3 mg IM and Ativan 1 mg IM for combative behavior.
7/17/16 7:25 PM Geodon 10 mg IM for combative behavior.
7/19/16 11:45 AM Geodon 10 mg IM for combative behavior.

7/14/16 at 5:00 AM a clean catch urine specimen was collected to determine if the patient had a urinary tract infection (UTI) contributing to the increase in behavior problems.

The patient refused her/his routine medications 7/14/16 at 9:00 AM:
1. Colace 100 mg (milligrams) by mouth (po) every day
2. Lexapro 5 mg
3. Miralax 17 grams
4. Seroquel 50 mg.

The physician discontinued the following medications 7/15/16: Lexapro 5 mg po qd (everyday), Seroquel 50 mg po qd and qhs (every night).

The physician ordered the following medications 7/15/16: Mag Oxide 400 mg po BID (twice a day) times 1 day, Depakote sprinkles 375 mg po HS which she/he was medicated with times 5 days, Seroquel 75 mg po everyday which she/he was medicated with times 3 days.

The physician ordered the following medications 7/18/16 Zydis 10 mg po HS, 7/22/16 Zydis 5 mg po qd was added, Cipro 500 mg po BID x 7 days related to possible UTI and it was discontinued 7/23/16. Keflex 500 mg po TID (three times a day) x 10 days for UTI was started 7/22/16. Zyprexa Zydis 5 mg po at lunch was started 7/25/16.

The patient had multiple medication changes for her/his condition from 7/13/16 through 7/25/16 which included antipsychotic medications.

The Case Management Progress notes documented by the Licensed Practical Nurse, EI # 4 included the following information:

7/20/16 at 3:58 PM- Treatment team meeting with Dr..., DON (Director of Nursing) and social worker. Patient was started on Zydis d/t (due to)
her Seroquel not working. Chest x-ray and urinalysis ordered. Social worker had a conference with the patients son...with ... was notified of patients progress and medication changes.

7/26/16 at 12:00 noon spoke with ... and she stated that right now she would not be able to take the patient back with her cognition. She/he could not answer her questions appropriately; she did state that she will take her back once her medications were adjusted...

7/27/16 at 12:54 PM treatment team meeting with Dr..., social worker and Assistant DON (Director of Nursing)...Patient is not ready for discharge at this time.

7/27/16 4:30 PM Social Service Progress Notes, " Social worker spoke with son on the phone on this date... Patient's son expressed concern regarding ... being called to assess patient and patient being drowsy during assessment. Patient's son expressed concern that facility was called following a medication change to assess patient. Social worker stated this was miscommunication and that patient was not ready for discharge and Dr... is not recommending discharge. Social worker apologized for miscommunication..."

7/27/16 7:00 PM Patient Care Notes , " Late entry from 7/27/16 3:30 PM spoke with patient's daughter regarding her mothers medication discussed all changes and what they were for she expressed concern that her mother was drowsy and I explained that she was alert and participating in activities. I also explained that the MD (medical doctor) was going to see her the
following day."

Master Treatment Plan Problem notes, 7/27/16 at 10:40 AM, " Treatment team in session today with Dr...No family in attendance. Patient has not received any PRN's (as needed) for behavior x 7 days. Patient still resistive with care and argumentative with staff. Patient has been drowsy in AM x 2 days..."

7/28/16 8:00 AM Patient Care Notes, " Patient isolates from staff/other patients but does engage in conversation/ patient cooperative at present ..."
9:00 AM Patient Care Notes, daughter arrived unscheduled, requesting her mother be discharged- " Going to send to local Hospital for medical care".
Patient left AMA (Against Medical Advice).

The patient presented to Huntsville Hospital Emergency Room by ambulance 7/28/16 at 11:20 AM and was admitted to the floor.

The History and Physical from the local hospital dated 7/28/16 documented , " Unable to give history because of state of stupor...psychogeriatric unit...became drowsy, could not eat and was unresponsive; and therefore, they brought her to the emergency room from where she was admitted to the hospital... General Physical Examination: On examination, there is an elderly lady, unresponsive. Even with deep pain stimulation, she does not open her eyes or respond. She is in no acute cardiorespiratory distress... Assessment and Plan: Dementia with superimposed acute delirium of the hypo-alert form...With regards to issues of polypharmacy, she/he is on multiple psychotropic agents and therefore, I am going to hold them for now and re-evaluate and monitor."

The Emergency Room Physician note dated 7/28/16 documented, " Appears to be clinically dry with elevated sodium and BUN (Blood Urea Nitrogen) and Creatinine/ leading to likely polypharmacy--Dr...to admit, patient confused nonfocal with dry mucous membranes Intravenous fluid bolus."

In an interview 11/8/16 at 2:25 PM with EI # 2, DON, stated that the patient was talking in full sentences, the daughter wanted her transferred, we called Emergency Transport transport patient, patient could sit up; eating and drinking.

Based on review of agency policy, medical records (MR) and interview with staff it was determined the facility failed to ensure the physician's orders for laboratory (lab) tests were followed in 2 of 10 records reviewed, MR # 9 and MR # 1 and had the potential to affect all patients served by the facility.

Findings include:

Policy & Procedure
Physician Orders

Policy: All orders for diagnostic procedures, treatment, and medication and transfer or disposition will be recorded legibly in ink or type written, dated, and signed by the physician.

Procedure:

7. No patient is to receive treatment, medication, a procedure or special diet without a physician's order.

8. A licensed nurse will note each type of order by writing noted.... This acknowledges the order was carried out.


1. MR # 9 was admitted to the facility on 10/27/16 with diagnoses including Major Neurocognitive Disorder, Vascular type with Behavioral Disturbance, and Psychosis.

Review of the order dated 10/31/16 at 4:05 PM revealed the following:

CBC (Complete Blood Count), CMP (Complete Metabolic Profile), VPA (Valproic Acid), and NH3 (Ammonia) on 11/3/16 in am (morning).

Further review of the order dated 10/31/16 revealed documentation the order was noted x (times) 2 on 10/31/16 at 1630 and signed off by an LPN (Licensed Practical Nurse) and RN (Registered Nurse). There was also 2 24 hour chart checks dated 11/01/16 at 0040 and 11/2/16 at 0300.

Review of the laboratory results in the medical record revealed a CBC. CMP, VPA and NH3 was collected on 11/2/16 at 0955. There was no order to obtain these lab tests on this date.

An interview conducted on 11/9/16 at 9:15 AM with Employee Identifier # 2, Director of Nursing, confirmed the lab tests were drawn a day early and had no explanation as to why.



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2. MR # 1 was admitted to the facility on 7/8/16 with diagnoses including Dementia with Behavioral Disturbances, Neurocognitive Disorder Severe with Behavioral Disturbances, and Hypertension.

Review of the 7/10/16 Physician's Order revealed the order for Stool Hemocults times 3 with the next 3 bowel movements (BM) for anemia.

Review of the nursing flow sheets revealed documentation the patient had a bowel movement on 7/12/16, 7/13/16, 7/15/16, 7/16/16 and 7/17/16. There was no documentation the test for Hemocult Stools were performed.

Review of the 7/18/16 Physician's Order revealed the duplicate order for Stool hemoccult times 3 with next 3 BM activity for Anemia.

Review of the nursing flow sheet revealed documentation the patient had 2 BM's on 7/18/16 and 7/19/16, and 7/21/16 the patient had 1 BM. There was no documentation the test for Hemocult Stools were performed.

In an interview conducted on 11/9/16 with EI # 2, the above mentioned findings were confirmed.

Based on review of medical records (MR), interviews and policy and procedure, it was determined in 4 of 10 records reviewed the facility failed to ensure:

1. The treatment plan was revised and updated as needed with changes in the patient's condition.

2. The treatment plan was individualized to meet the needs of the patients.

This affected MR # 6, # 2, # 10 and # 9 and had the potential to affect all patients in the facility.

Findings include:

Administrative Policy and Procedure:
Treatment Plan:

Policy: Each patient will have an individual comprehensive treatment plan that will be based on an inventory of the patient's strengths and disabilities. The treatment team will meet no less than every 7 days to review the treatment plan.

Procedure:
" 5. The treatment plan should include:
a. Both physical and mental problems that are actively being treated...
6. The treatment plan should be started on admission and an initial treatment plan completed within 72 hours. Staff completing the plan should sign, date and title the plan. Each staff should review and sign the plan.
7. The interdisciplinary treatment team meets weekly to review and accept changes to the master treatment plan...
8. c. Problems and interventions may be added anytime during the course of treatment.
9. Each patient's master treatment plan is reviewed weekly by the treatment team to evaluate progress, need to continue treatment, changes in interventions and status of discharge...
b. If the patient is not making progress, a revision of the problems, goals, and/or interventions will be considered.
c. Newly identified problems will be considered for additions to the master treatment plan..."


Medical Record findings:

1. MR # 6 was admitted to the facility 10/28/16 with a diagnosis of Dementia with Behavioral issues.

The Interdisciplinary Master Treatment Plan documentation reveals Psychiatric Problems as:
1. Depression 10/28/16
2. Violence 10/28/16
3. Insomnia 10/28/16
4. Elopement 10/30/16

A review of the Medication Administration Record (MAR) and the Patient Care Notes revealed the patient received PRN (as needed) medications for behaviors as follows:
10/28/16 Geodon 10 mg (milligrams) IM (intramuscular) at 5:00 PM for wandering and combative with staff.
10/29/16 Seroquel 50 mg po (by mouth) at 11:08 AM for wandering into other patient's rooms and Geodon 10 mg IM at 3:45 PM for combative behavior with MHT (Mental Health Technician).
10/30/16 Trazodone 50 mg po for insomnia at 1:00 AM and Geodon 10 mg IM at 7:33 AM for behaviors.
11/3/16 Geodon 10 mg IM 9:45 PM for anger and behaviors.
11/4/16 Seroquel 50 mg po at 1:30 PM for behaviors.
11/5/16 Seroquel 50 mg po at 7:45 AM and Geodon 10 IM at 8:40 PM for behaviors.
11/6/16 Seroquel 50 mg po at 7:45 AM for agitation and mania this information was from the Patient Care Notes, it was not documented on the MAR.
11/7/16 Seroquel 50 mg po at 1:30 PM wandering with exit seeking behavior and Geodon 10 mg IM at 6:00 PM.

The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 11/2/16 by the treatment team members:
Psychiatric Problems

Problem 1: Depression-improving, " patient doesn't interact with people well. Patient is always irritable when spoken to and difficult to redirect. Revisions/updates marked yes.

Problem 2: ADL (activities of daily living) Patient has received 4 PRN's since admission...for combative behavior and resistance to care. Revisions/updates marked yes, but none were listed.

Problem 3: Insomnia...patient is sleeping good takes Trazodone 50 mg po every night and Melatonin 4.5 mg po every night for sleep. Revisions/updates marked yes, but none were listed.

Problem 4: Elopement patient still wandering in hallway...wander guard in place. Revisions/updates marked yes, but none were listed.

The Treatment Plan failed to have any revisions to the plan documented on the forms dated 11/2/16.

The Problem list for numbers 1, 2, 3 and 4 had documentation of long-term goals and short term goals dated 10/28/16, 11/2/16 and 11/9/16 with target dates listed as 11/2/16, 11/9/16, 11/16/16.

However the facility staff failed to document any revisions to the goals only changed the dated start and the end target date.

In an interview 11/9/16 at 9:10 AM with Employee Identifier (EI) # 1, Administrator and EI # 2, Director of Nursing the above information was confirmed.

2. MR # 10 was admitted to the facility 10/4/16 with a diagnosis of Vascular and Alzheimer's type Disease with Severe Behavioral Disorder.

The Interdisciplinary Master Treatment Plan documentation reveals Psychiatric Problems as:
1. Insomnia 10/4/16
2. Assault 10/4/16
3. Agitation 10/4/16

The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 10/12/16 by the treatment team members:
Psychiatric Problems listed above 1, 2, and 3 each indicated Revision/updates yes, but none were listed.


The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 10/19/16 by the treatment team members:
Psychiatric Problems listed above, each indicated Revision/updates yes, but none were listed.


The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 10/26/16 by the treatment team members:
Psychiatric Problems listed above and the addition of a fourth problem: ADL each problem indicated Revision/updates yes, but none were listed.


The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 11/2/16 by the treatment team members:
Psychiatric Problems listed above and the addition of a fourth problem: ADL each problem indicated Revision/updates yes, but none were listed.

However the facility staff failed to document any revisions.

In an interview 11/9/16 at 9:40 AM with EI # 1, Administrator confirmed the above information.

In an interview 11/9/16 at 9:40 AM with EI # 2, Director of Nursing was asked about changes to the treatment team plan related to the IV (Intravenous) fluids required by the patient. An additional page was provided to the surveyor dated 11/5/16 labeled Problem D Fluid Volume Deficit.

This additional form was not in the medical record provided to the surveyor to review 11/8/16.

3. MR # 2 was admitted to the facility 7/13/16 with the diagnosis of Alzheimer's Type Dementia with Behavioral Disturbances.

The Interdisciplinary Master Treatment Plan documentation reveals Psychiatric Problems as:
1. Medication Noncompliance 7/15/16
2. ADL's 7/15/16

A review of the Medication Administration Record (MAR) and the Patient Care Notes revealed the patient received PRN (as needed) medications for behaviors as follows:
7/13/16 Geodon 10 mg IM 4:30 PM for combative behaviors with staff and another patient and Geodon 10 mg IM at 5:30 PM for combative behavior.
7/13/16 at 9:30 PM Trazodone 50 mg po given to promote rest.
7/14/16 at 9:25 AM Geodon 10 mg IM combative with another patient and 10:15 AM Geodon 10 mg IM combative.
7/14/16 1:00 PM Haldol 3 mg IM and Ativan 1 mg IM for combative behaviors.
7/15/16 10:10 PM Trazodone 50 mg po given for insomnia.
7/16/16 7:30 PM Geodon 10 mg IM for combative behavior.
7/16/16 7:50 PM Haldol 3 mg IM and Ativan 1 mg IM for combative behavior.
7/17/16 7:25 PM Geodon 10 mg IM for combative behavior.
7/19/16 11:45 AM Geodon 10 mg IM for combative behavior.

The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 7/20/16 by the treatment team members:
Psychiatric Problems listed above.
A review of the Treatment Plan revealed revised written in above each intervention for each problem indicated, Revision/updates yes, but none were listed.

The Clinical Update and Evaluation of Patient's Response to Treatment page 1 of 3 was dated 7/27/16 by the treatment team members:
Psychiatric Problems listed above.
A review of the Treatment Plan revealed revised written in above each intervention for each problem indicated, Revision/updates yes, but none were listed.

However the facility staff failed to document any revisions for the treatment plan review on 7/20/16 and 7/27/16.

A review of the final treatment plan after discharge 7/28/16 revealed documentation under the problems and above the interventions written in " revised 7/26/16 " for each problem.

In an interview 11/8/16 at 2:25 PM the surveyor asked EI # 2, Director of Nursing, why " revised 7/26/16" was added. EI # 2 stated that the target date for the goal was 7/25/16 and they has to revise the treatment plan to extend the target date to 8/7/16.




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4. MR # 9 was admitted to the facility on 10/27/16 with diagnoses including Major Neurocognitive Disorder, Vascular type with Behavioral Disturbance, and Psychosis.

The Interdisciplinary Master Treatment Plan (MTP) provided on 11/8/16 revealed the following problems identified:
Psychiatric Problems
1. ADL 10/27/16
2. Non-Compliance 10/27/16
3. Agitation 10/27/16
4. Insomnia 10/27/16

Medical Problems
A. Fall 10/27/16

Review of the MTP Clinical Update and Evaluation of Patient's Response to Treatment revealed the Treatment Team Members signed and dated the update on various dates from 11/2/16 to 11/4/16. Further review revealed Problem 1-4 and Medical Problem A each were marked Yes indicating Revisions/Updated were made but there was no documentation of the specific revision/update.

The surveyor asked if the Treatment Plan was revised or updated to reflect the need for Physical Therapy (PT) ordered on 10/29/16 and Speech Therapy (ST) ordered on 11/2/16. A single page Treatment Plan for Problem A which documented 11/1/16 PT consult to evaluate and tx (treat) and 11/2/16 ST consult was provided to the surveyor on 11/9/16.

An interview was conducted on 11/9/16 at 9:15 AM with EI # 1 who confirmed the above findings.