HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to ensure that each patient had the right to personal privacy as one-to-one patient observations were conducted without physician orders and without clear assignment for 3 of 3 patients (Patients #1, #4 and #6) on such precautions. In addition, the facility had no clear and specific policy to address one-to-one patient observation.

Findings were:

Facility policy #605.1 entitled Patient Monitoring and Precautions, last reviewed 4/14, included the following:
"C. An RN must contact the attending physician to get a physician's order for a one to one monitoring for Special Precaution. The order will document the reason for the increased level of monitoring. The physician reviews the level of monitoring and signs the order for each 24 hour period ..."

A review of the clinical record of Patient #1 included the following nursing note: 12/19/16 at 1:30 a.m.
" ...Requires MHT x2 for 1:1 monitoring ..." The record also included the following physician order: 12/19/16 at 8:40 p.m. - "1:1 Close Observation." Thus, the patient was placed on one-to-one observation prior to receiving a physician's order. The record contained no other orders regarding continuing this level of observation nor an order to discontinue it.

The clinical record for Patient #4 included nursing documentation that she had been on a one-to-one observation status. The record included no physician order for such observation.

The clinical record for Patient #6 included a physician's order for "1:1 monitoring" on 2/28/17 at 6:45 a.m. The next order related to the monitoring was on 3/7/17 at 3:30 p.m. which stated, "Discontinue 1:1." Nursing documentation reflected that Patient #6 had continued to be observed on a one-to-one status during the interim.

In an interview with Staff #2, the Chief Nursing Officer, on the afternoon of 3/22/17 in a facility meeting room she was asked about the documentation required by the facility for one-to-one patient monitoring. She stated, "It doesn't really say anything in our policy. I know a lot of places have special forms and usually they're required to document on the person more often than every 15 minutes." When asked how the facility knew exactly which staff was assigned to a one-to-one observation, she stated, "We can't really go back. It would just be what's on the regular observation sheet. There would have been breaks for the staff member with an assignment like that, so the sheets don't accurately show who was with the patient ...We don't have any special instructions in our policy about one-to-ones. All we have is that sentence or two in that patient monitoring policy. We need to re-write that."

Based on staff interviews and observation, the facility failed to ensure the safety of each patient by having light fixtures in patient rooms which were not tamper-proof.

Findings were:

A tour of the 20-bed GeriPsych Unit of Allegiance Behavioral Health was conducted on the afternoon of 3/22/17 with Staff #2, CNO. Patient rooms included plastic and metal fluorescent light fixtures affixed at shoulder height in each room. The fixtures posed a possible danger to patient safety as the hard plastic was within easy reach and could potentially be broken by patients, allowing for access to the fixture's light bulb and hard edges. The CNO concurred that the light fixtures needed removal. She stated, "We can fix these immediately."

Based on a review of facility documentation and staff interviews, the facility failed to ensure legible progress notes were included in each patient record which justified the admission and continued hospitalization of patients by the physician responsible for the care of the patients in 10 of 10 clinical records.

Findings were:

A review of ten patient clinical records was conducted for current and recently discharged patients on the afternoon of 3/22/17. Each patient record reviewed included handwritten progress notes by Staff #3, facility psychiatrist and medical director. The handwriting could not be deciphered by the CNO when requested. When the medical director was asked to read his notes to this surveyor, he also had some difficulty.

In an interview with the CEO and CNO on the afternoon of 3/22/17 in the facility meeting room, they confirmed the legibility of the physician's handwriting was an issue. The CEO stated, "Maybe we can use some of our software to address this."

Based on a review of facility documentation and staff interviews, the facility failed to implement its own policy related to the administration of emergency psychoactive medication for 10 of 10 patients. In addition, the hospital had no clear policy or procedure related to physician notification of an elevated patient blood sugar level for 1 of 1 patients (Patient #8) with such a level.

Findings were:

Facility policy #217.2 entitled Now Order for Involuntary Emergency Administration of Psychoactive Medication, adopted 1/11, included the following:
"2. The "NOW" order form is completed by the physician, or nurse in the case of a telephone order. The physician must evaluate the patient and authenticate the order within 1 hour of medication administration ..."

A review of patient clinical records on the afternoon of 3/22/17 revealed that 10 of 10 patient records included the administration of emergency psychoactive medications. In each record, the orders for emergency medications had not been authorized by a physician within one hour according to the facility policy.

The record for Patient #8 had a physician's order for accuchecks to be performed each morning. The patient's blood sugar level on the morning of 3/16/16 was 161. There was no additional documentation regarding this level. There was no facility policy regarding elevated blood sugar levels, and no instruction included on the form on which the results were noted which instructed the individual taking the blood sugar when to notify a physician or nurse.

The above findings were confirmed with the hospital CEO and CNO in an interview on the afternoon of 3/22/17 in the facility meeting room.