HospitalInspections.org

Observation and review of employee files and interview of the Director of Employee Relations (Human Resources-HR) on 02/27/15 revealed that employee files were incomplete for all required information such as background checks and cardiopulmonary resuscitation (CPR) certification. This was evident for 3 out of 10 employee files reviewed. It should also be noted that only one out of these three employees was indirectly involved (as a clinical coordinator) with the patient #1's care .
The findings were:
Employee #8, a 3rd floor employee had CPR certification that expired on 01/08/15, 49 days past due as of the date of the survey. Inquiry to the HR staff by the surveyor as to when the employee's certification would be updated revealed that the employee was currently on leave.
Employee #9 was hired by the hospital on 04/01/13 and based on the employee file review has worked in multiple states such as Florida and Ohio. A background request was submitted on the employee per interview of the Director of Employee Relations (Human Resources-HR), but the HR staff member responsible for ensuring the completion of this check failed to follow through. The employee has been working at the hospital since 2013 and almost 2 years later has not had a completed background check.
Employee #10 was hired 09/24/12 in the hospital security service and did not have a criminal background check from 2012 to present, 29 months after hire and 7 months short of three years of employment.
Failure by the HR staff to consistently follow the hospital process for verifying employee qualifications, certifications, and conducting criminal background checks potentially places patients at risk for receiving care by unqualified staff.

Based on observation and review of the hospital's investigation, review of the local sheriff's investigation between 12/26/14-01/19/15, review of the patient's medical record, review of the job description for the clinical coordinator, and interview of the risk management and licensed administrative nursing staff, it was determined, that a patient clinical coordinator and the assigned licensed nursing staff failed to evaluate a patient who injured an employee when providing the patient care. The patient's behavior was noted as combative and agitated.
The findings were:
Patient #1 was 87 years old and was brought to the emergency department on 12/05/14 by the emergency medical services (911) for a suspected stroke. The patient was a full code and had multiple medical conditions that included dementia, hypothyroidism, and a history of kidney cancer.
Patient was identified by family members as being a "sundowner" (a behavioral condition that presents when the sun is setting or evening descends characterized by increased confusion and restlessness often associated with Alzheimer's disease and other mixed dementias). The patient required a sitter beginning on 12/05/14 at 22:51 that continued through 12/07/14 at 20:38 for agitation, confusion, pulling at medical devices, and unsteadiness (Fall Risk).
On 12/07/14 while on 3West, the patient became agitated, restless, yelling, screaming, and was noted as "combative" between 05:18 and 05:55. The patient broke a fingernail on the right hand, 2nd finger, down to the edge of the nail bed with noted to be bleeding prior to the beginning of the night shift. The patient's nail remained attached and first aid was applied (cleansed wound with normal saline, applied Tegaderm-bandage and a skin consult requested). Patient was described as having "flailing," began pulling at the intravenous site, and was chewing and biting the dressing to the finger. Although, the patient's behavior was as typically described as restless, confused, agitated, and pulling at medical devices, on 12/07/14, documentation indicates that the patient's behavior escalated resulting in an employee's injury. The assigned Patient Care Technician (PCT who was functioning as a sitter) attempted to console and calm the patient while trying to prevent the patient from leaving the bed, potentially falling, or pulling at the intravenous site. During this process the PCT/sitter incurred a scratch to the face and neck that required assessment and treatment in the emergency room department.

A review of the patient's care plan or plan of care started on 12/05/14 @ 20:28 did not identify and address the patient's increased confusion and wandering as indicated by the need for the patient to have a sitter. By 12/06/14 the patient is noted as agitated, confused, a fall risk, and pulling at medical devices. Not only did the care plan not address these issues, but it was not updated to reflect the patient's "sundowning" behavior.

Review of the patient's medical record, interview of the Risk Management Staff, and the 3rd floor licensed nursing director on 02/27/15 revealed and confirmed that the "clinical coordinator" on 3 West was aware of the patient's behavioral presentation on 12/07/14 at 05:15, and the coordinator directed the PCT to go to the emergency department for care and treatment. Further the patient medical record review, revealed that the clinical coordinator and the assigned nursing staff failed to enter a chronological account and assessment of the patient's events in real time for the morning of 12/07/14. Interview of the 3rd floor nursing director and review of the Prince George's County Sheriff 's interview of the clinical coordinator on 01/03/15, confirmed that the clinical coordinator did not: assess the patient after the incident for potential injury, did not enter a note in the patient's medical record to reflect the guidance provided the employee, document notifying the patient's family about the incident and the patient's room change, outline follow up interventions such as timely notification to the nursing administration (3rd floor nursing director) about the incident, and ensuring that staff document in real time for accuracy and completeness of the patient's medical record.

Based on observation and review of the patient ' s medical record and interview of the Risk Management Staff on 02/26/15-02/27/15 and 03/03/15, it was determined that the 3rd floor licensed nursing staff failed to identify, address, and update Patinet#1's care plan as related to behavior.
See A-0395 for details.

Based on observation and review of the patient's medical record, interview of the Risk Management Staff and 3rd floor licensed administrative nursing staff, it was determined that the clinical coordinator and the assigned licensed nursing staff failed to document thoroughly and completely in real time the events of the patient care incident of 12/07/14 with related follow-up interventions.
See A-0395 for details.