HospitalInspections.org

Based on interview, record review the hospital failed 1 of 1 Patient (Patient #2) by failing to administer on the orders of the practitioner or practitioners responsible for the patient's care.

Findings Include:

During Record Review Patient # 2's Medication Administration Record (MAR) failed to reveal that Patient #2 received the medication ordered by the practitioner on 08/29/2021 or 08/30/2021.

During the interview Staff # 2 Patient #2 did not have a MAR that remained on the unit and not placed in the medical record.
During the interview Staff #2 Patient #2 did not receive the medication as order by the physician on 08/29/2021 oe 08/30/2021

During the interview with Staff #3 identified that the Physician Orders revealed that Patient #2 was ordered Psych medication on 08/29/2021. Patient #2 did not receive the medication until 08/31/2021. Patient #2 did not reveal any adverse reactions as a result. Staff #3 indicated that in review of Patient #2's medical record revealed Patient #2 did have the proper consent to receive the Psych medications.

The hospital has started conducting meetings with Medication Administration Committee as well as a Medication Administration Audit tool.

The hospital Medication Administration Committee Minutes
" Policies revised, reviewed, and approve by committee. Polices will be sent to quality meeting and med exec meeting for approval. After final approval, a read and sign will be given to all nursing staff for education/training.
o 1036 Orders Med
o 1047 Pt. Identifiers Armbands
" Created MAR audit tool for nurses to complete.
o Training and education to house supervisors first for feedback.
o Training and education to all nurses this week
o Roll out on 09/06/2021.
o MAR audit box will be placed on each unit.
" Intake still using old photos of patients and it does not look like the patient during admission stay. Jessica will follow-up with Ryan.
" Email to staff that they must email pharmacy upon return to work when they have been away for greater than 2 weeks.
" Antony will add a laminated, approved abbreviation list to unit MAR's as quick reference for nursing staff.
" Antony will add a laminated reminder of resources for nurses. Example: If you need help with pulling meds, contact pharmacy or nursing leadership for assistance. Or, if you need someone to witness medication waste, contact pharmacy or nursing leadership.
" Corrective action plan for nurses:
o Antony will do 1:1 training for one hour all nurses that are reported on the incident reports.
o These will be completed within a week.



The hospital Medication Administration Audit Tool

Was there a physician order written by the provider or taken by the nurse?

Did nurse document name of physician giving the order and document their name on the order?

Did the nurse note the order after faxing (if applicable) and carrying out the order?

Was the medication order written correctly with date, time, route, dose, frequency, duration (if antibiotic) and indication specified?

Did the nurse ask the patient for their birthday and check against the birthday printed label on the MAR prior to administrating the medication?

Has consent been obtained and is it filled out appropriately?

Does the MAR reflect consent status?


Policy
The hospital policy on Neglect Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Patient Rights dated 07/17/2019, reflected, "The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States of Texas unless they have been restricted by specific provisions of law. The rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections, the right to acquire use, and dispose of property including contractual licenses, permits, privileges and benefits under law, the right to religious freedom and rights concerning domestic relations."

The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals."

The hospital Policy on Administration/Personnel dated 07/17/20219 reflected, "Perimeter Healthcare is dedicated to providing patient centered care and working to understand each individual's needs in order to supply excellent, differentiated treatment plans. We strive to employ passionate mental health professionals to ensure the highest level of care by providing hope and transforming lives ...Leadership Responsibility; The leaders of the Facility have defined responsibilities. These responsibilities are intended to further facilitate our ability to develop an environment that contributes to a quality system and patient safety ...Planning, formulation of specific goals, structure and functions to assure achievement of the Mission. The process includes information gathered from both internal and external customers. Management, the process of organizing, directing and coordinating the functions of the systems to achieve its goals ...Improvement, the process of regulating service activities to ensure achievement of goals through a continuous performance improvement process."

The hospital Policy on Precautions dated 08/14/2020 reflected, "Patients admitted to Perimeter Behavioral Hospital will be assessed for risks and severity of those risks and will be placed on precautions as required per physician order. Staff members will be trained on the implementation of specified precaution interventions and the ongoing subjective and objective assessments required. Early recognition and reporting are embedded in the Prevention, Preparation, and Performance process ...Care provided at Perimeter Behavioral Hospital Centers around maintaining a safe environment. Patients admitted are universally a potential threat to their own safety or that of others due to their illness and symptomatology. The design, furnishing, and supplies of each patient care area established with the intent to mitigate risks collectively. Observation rounds are conducted routinely every 15minutes. However, with each identified precaution set there are other measures enacted to diminish the risk of adverse events."

The hospital Policy on Health Information Management Services dated 06/15/2019 reflected, "A medical record is to be maintained for each individual who is evaluated and treated as inpatient or outpatient. The medical record shall be the central storage document for all patient health information. Documentation in the medical record must be sufficient to: identify the patient; support the diagnosis; justify the treatment; document the course and results; and promote continuity of care among health care providers."