HospitalInspections.org

Based on hospital policy reviews, observations during tours, and staff interviews, the hospital's nursing staff failed to ensure blood glucometer quality control solutions were dated and labeled when opened on 3 of 5 nursing units toured (Emergency Department, Medical -Surgical, Orthopedics).

The findings include:

Review of current hospital policy "Glucometer Responsibilities between the Laboratory and Nursing departments" dated 02/13 revealed "...Procedure: ...Once the QC (quality control) vials are open they are good for 90 days. It will be the responsibility of the person opening the vial to date it and post the exp (expiration) date also. ..."

Review of current hospital policy "ACCU-CHEK INFORM PROCEDURE" Policy No: 01-2104, dated 12/2008 revealed "Quality Control Policy: ...8. ...Glucose control solutions are stable for 3 months after opening or until the expiration date, whichever comes first. The date the vial is opened should be written on the vial label. ..."

Observations during tour on 01/16/2014 of the Emergency Department (ED), Medical-Surgical (Med-Surg) Unit, and Orthopedic (Ortho) Unit at 1550, 1615, and 1630 respectively, revealed each nursing unit had a blood glucometer used for testing patient blood glucose levels. Observations revealed one HI and one LOW QC solution vial for each glucometer. Observations revealed each glucometer's QC solution vials had been opened. Observations failed to reveal the dates opened labeled on the QC solution vials. Interview during tours with nursing unit staff and nursing management staff revealed the nursing staff were unable to determine the dates the QC solution vials were opened. Interview revealed the nursing staff are to label each vial with the date when opened. Interview revealed once opened, the QC solution vials are good for 90 days. Interview confirmed the nursing staff failed to follow hospital policy.

Interview on 01/16/2014 at 1620 with the hospital's Laboratory Director revealed once opened the QC solution vials for glucometers are good for 90 days. Interview revealed the staff member opening a new vial of QC solution is to date the label of the vial when opened. Interview confirmed the nursing staff failed to follow hospital policy.

Based on hospital policy reviews, medical record reviews, staff and physician interviews, the hospital staff failed to follow established policies to ensure an effective discharge plan to meet the discharge needs for 1 of 4 inpatients discharged (#4).

The findings revealed:

Review of current policy "Patient Discharge Process" Policy No: 01-0503 (Administrative), effective 12/18/2013, revealed "I. BACKGROUND AND PURPOSE: To facilitate the safe, timely and effective discharge (D/C) of patients from (Hospital A name). II. POLICY: The discharge process for patients admitted to (Hospital A name) is a multidisciplinary function overseen by the Utilization Management Department, but involves physicians, nursing, rehabilitation therapy, dietitian/nourishment and other services. Each patient is screened for discharge needs upon admission. All disciplines work together to ensure the needs of the patient are met after discharge. These needs include home health, DME (durable medical equipment), medication, and other post-discharge needs as appropriate. III. PROCEDURE: ...B. After hours, Weekends and Holidays 1. The Utilization Management Team designates on-call staff for weekends and Holiday coverage. On-call hours are 8:00 AM to 5:00 PM. The on-call schedule is posted in the House Supervisor's Office and maintained at the Hospital Switchboard. ...4. For patients with anticipated discharge dates falling on the weekend or a holiday, the Utilization Management Department is responsible for ensuring all agencies/services are scheduled as appropriate prior to the end of the day Friday or the day prior to the holiday. 5. Any changes to either the discharge date or level of care determination not noted on the Utilization Management report will result in an immediate call from the House Supervisor or Charge nurse to the Utilization Department team member on-call. The on-call Utilization Department team member will take care of any patient needs for home services either by phone or in-person, whichever is most appropriate for the individual case."

Review of current policy "Facilitating Care through the Discharge Process" Policy No: 01-2602, effective 11/21/2012 revealed "POLICY The purpose of this policy is to facilitate the safe, timely and effective discharge of patients from (Hospital A name). The discharge needs of each patient will be comprehensively assessed and planned to ensure timely discharge from the hospital into an appropriate environment in which they can be as independent as possible. Procedure: The Interdisciplinary approach to patient discharge process is the practice at (Hospital A name). Discharge Process: The Team meeting with nursing staff, physician and other disciplines provide an update of patient discharge plans assuring discharge criteria has been met and initiated. ...Necessary equipment, supplies and services are identified and ordered by the discharge planners. ..."

Review of current policy "Discharge of a Patient" Policy No: 08-0028 (Psychiatry), reviewed 11/2011, revealed "...III. PROCEDURE: Each patient's master treatment plan (MTP) will address the issue of discharge. The MTP will be reviewed weekly and updated as needed. The patient and family, if appropriate, will be encouraged to take an active role in discharge planning. ...2. Appropriate discharge or transfer placement will be secured. ...5. Appropriate referrals or transfers will be made for: more specialized treatment, home health or medical follow-up, community mental health, outpatient psychiatry, outpatient therapy with psychologist, community long-term care, or any other appropriate community programs or support services. 6. Arrangements for departure will be made for the patient on the date designated by his/her psychiatrist or LIP (licensed independent practitioner) and the treatment team. ..."

Review of current policy "Discharge Follow-Up Appts" Policy No: 08-0026 (Psychiatry), reviewed 11/2011, revealed "I. POLICY: It is the policy of this unit to schedule post-discharge follow-up appointments with appropriate agencies or offices prior to hospital discharge. II. PURPOSE: To maintain continuity of care and provide patients with resources to maintain stability after hospitalization. III. PROCEDURE: ...2. The social worker or discharge planner will contact the agency or office and schedule an appointment providing a brief explanation of services requested by the physician. ...7. Follow-up appointments may include, but are not limited to: a home health agency, physician's office, outpatient mental health agencies, or others. ..."

Closed medical record review on 01/15/2014 for Patient #4 revealed a 90 year old male admitted under involuntary commitment (IVC) petition to the hospital on 04/23/2013 (Admission #1) with an Axis I diagnosis of Dementia, mixed, vascular and Alzheimer's with behavior disturbance. Review revealed the patient was discharged on 04/27/2013 with a final Axis I diagnosis of Dementia with behavioral change. Review of the admissions History and Physical dictated on 04/24/2013 by Psychiatrist #1 revealed "...History of Present Illness: This is a first psychiatric hospitalization for (Patient #4 name) who is a 90-year-old gentleman with a prior history of dementia....He began having memory problems about a year ago. Remote memory is good but can't remember things that happened a few hours ago. It is reported that the patient has had evidence of hallucinations, mainly seeing people exiting the house and the family doesn't know about any auditory hallucinations. The family is very concerned due to this decline due to the visual hallucinations and due to the fact that he refuses to give up driving. He has become physically aggressive and agitated. He also has had two car accidents because of his confusion and family is admitting him for further evaluation and safety from his aggressive behavior. ...suicide/violence: no history of suicidal ideas, attempts or violence. ...Social History: The patient lives alone with his elderly wife who has also been declining in her ability to care for things and some medicine mismanagement. He has still continued to drive. ...legal/POA (Power of Attorney) issues: no known history of who is power-of-attorney or legal issues. ...Mental Status Exam: Patient appears his stated age. He is not very cooperative with the interviews, says he doesn't feel well, somewhat irritable, short with the interview and not wanting to talk. His mood is grumpy. Affect congruent. Thought processes organized. He denies suicidal and homicidal ideation, denies hallucinations, denies paranoia or obsessions right now. No evidence of associated symptoms or obsessions. He is alert to person only and....his insight and judgement are significant impaired. Neurologic Exam: Unremarkable. There is no sensory or motor deficits. Cranial nerves are intact. ...Patient Strengths: Patient appears to be in good health with good family support. Justification for Admission: Due to the patient's severe agitation in the emergency department requiring IV (intravenous) Ativan, as well as his refusal to stop driving and the safety of his home environment is really in question with an elderly wife, particularly because he is also not apparently taking medications well or appropriately. He needs to be in a safe secure environment until we can make sure things are going to be smooth at home or at least supervised if necessary. ...Plan: Will consider independent living evaluation, stabilize his agitation and assess medication needs. ..."

Review of a Progress Note written on 04/25/2013 at 1200 by a Social Worker revealed "...This clinician spoke by phone and in person with the patient's daughter (name) and communicated that most likely at discharge the patient will need to go home at least temporarily instead of a care facility since (1) he is his own guardian right now (2) he does not want to go to a care facility at this time. This clinician also provided the patient's daughter....with a letter from the treating psychiatrist recommending guardianship for the patient. This clinician informed the patient's daughter....about the details of pursuing emergency guardianship through an attorney or by herself and allowed that if she moved quickly enough emergency guardianship might be able to be secured in just a few days in which case it might be possible for the patient to go directly from (Hospital A name) to a care facility that she would designate as the assigned emergency guardian. This clinician shared clinical observations concerning the patient, especially regarding memory loss and verbal agitation concerning being at the hospital. This clinician provided details of the patient's current medication regimen. ...This clinician communicated to the rest of the professional treatment team, especially lead psychiatrist Dr. (Psychiatrist #1 name), the details about the conversation with the patient's daughter. Effectiveness: The patient's daughter....understood that the patient may need to go home for right now at discharge unless emergency guardianship can be pursued and obtained quite quickly. She said she is intent on pursuing guardianship and then getting the patient into a care facility for purposes of safety and well being immediately at the time of discharge from the hospital if possible. The patient's daughter....was attentive to all education provided about pursuing guardianship and all information shared in regard to clinical observations of the patient thus far. It is of note that she was often tearful during the encounter with this clinician and seemingly overwhelmed emotionally by the magnitude of her caretaking responsibilities (notes: she mentioned that her mother, the patient's wife, is also deteriorating as regards functions and may soon require care facility assistance as well, she also remarked that she herself will need to undergo shoulder surgery any day now.)"

Review of a "Letter" written by Psychiatrist #1 on hospital letterhead dated 04/25/2013 revealed "...To Whom It May Concern: Mr. (Patient #4 name) was admitted for treatment at (Hospital A name)....on April 23rd, 2013. ...a battery of tests has been performed to ascertain his (Patient #4) cognitive level of functioning plus ability to independently take care of himself. Most notable were the patient's scores of 16 out of a possible 30 on a Montreal Cognitive Assessment (MOCA) and 2 out of a possible 4 on a Clock Drawing Test. These test results leave significant concern regarding Mr. (Patient #4 name) cognitive level of functioning plus ability to independently take care of himself. Based upon case history, which notably includes loss of significant cognitive functioning capacity plus loss of ability to adequately attend to activities of daily living (ADLs), it is my professional opinion that Mr. (Patient #4 name) is at this point in time incapable of appropriately conducting his legal, social, and financial affairs. He is therefore presently in need of guardianship. ...Respectfully submitted, (handwritten signature of Psychiatrist #1)."

Review of a Psychiatry Progress Note dated 04/25/2013 (2 days prior to discharge) at 1330 by Psychiatrist #1 revealed "Recent Behaviors 'grumpy' resistant to personal care. Pt (Patient) reports he wants nothing to do with this place." Review revealed "Pertinent mental status exam findings irritable, profound lack of insight." Review revealed "Reason for Continued Hospitalizations" with "Unstable psychiatric symptoms" and "Safe placement for discharge" circled in ink by Psychiatrist #1.

Review of the "Geriatric Psychiatry Master Treatment Plan" for Patient #4 revealed the MTP was completed on Friday, 04/26/2013 (1 day prior to discharge). Review revealed an estimated length of stay "12 days." Review revealed visual hallucinations, verbal aggression and decreased memory and cognition listed as problem behavior issues. Review revealed no insight, decreased judgement, and placement issues listed as limitations and weaknesses. Review of the "Interdisciplinary treatment plan/goals" revealed "Psychiatrist: (Short-term goals): ...Behavior will exhibit less....agitation. He will no longer be resistive to assistance and will exhibit beginning insight into his gradually increased incapacity to drive, need for placement. (Long-term goals) Safe placement in appropriate level of care to be determined by his progression stabilization." Review revealed the Psychiatrist short-term and long-term goals were handwritten and signed by LIP #1 (a Nurse Practitioner) on 04/26/2013 at 0930. Further review revealed "Discharge Planner (DCP): (Short-term goals) Waiting on treatment/plan of care to determine LOC (level of care) need. (Long-term goals): Conf(erence) c (with) family guardianship issues to validate placement." Review revealed the Discharge Planner short-term and long-term goals were handwritten and signed by DCP #1 on 04/26/2013 at 0930. Further review of the MTP for Patient #4 completed on 04/26/2013 (Friday) failed to reveal any available documentation by the treatment team of a planned/anticipated discharge for 04/27/2013 (Saturday).

Review of a Psychiatry Progress Note dated 04/26/2013 at 1030 (1 day prior to D/C and after the MTP meeting) by LIP #1 revealed "Recent Behaviors 'I'm going to leave if I have to walk out in those woods.' Underlying agitation. All references lead back to when 'I was shot x 2.' ....Redirected from war but returns immediately - Anxious Inappropriate affect. Irritable presentation. Vague references to running away, living in woods. No insight." Review revealed "Pertinent mental status exam findings Remains irritable, s (without) insight and underlying confusion. Does not recall he vomited yesterday. Agitates Female peers." Review revealed "Reason for Continued Hospitalizations" with "Danger to Self" and "Unstable psychiatric symptoms" and "Medication adjustment" and "Safe placement for discharge" circled in ink by LIP #1. Further review failed to reveal any available documentation of a planned/anticipated discharge the next day on Saturday, 04/27/2013 by LIP #1.

Review of nursing documentation dated 04/27/2013 (Day of D/C) at 0900 by RN #1 revealed Patient #4 was assessed as Alert and Oriented X 1 (to person only). Review revealed "Other Pertinent information" as "POSS(IBLE) D/C TODAY IF DOCTOR ABLE TO TALK TO PT. DAUGHTER." Further review revealed "...Pt has been UPSET AND WANTS TO GO HOME." Review revealed "...Comments....I DON'T NEED TO (be) HERE I NEED TO GO HOME AND TAKE CARE OF MYSELF." Further review failed to reveal any available documentation by RN #1, that upon learning of the possible change in discharge date for Patient #4, an immediate call was made by the House Supervisor or Charge nurse to the Utilization Department team member (Discharge Planner) on-call; or of any documentation the on-call Utilization Department team member made arrangements for any patient needs for home services and/or follow-up appointments either by phone or in-person prior to Patient #4's discharge from the hospital on 04/27/2013.

Review of a Psychiatry Progress Note dated 04/27/2013 (Saturday, Day of D/C) at 1200 by LIP #1 revealed "Recent Behaviors Demanding to go home. Hard to Redirect but is not meeting criteria for further IVC. Spoke c daughter (name) who reports 30-45 days before she can get guardianship. She is quite agitated herself & hung up x 2. She states she will come & get him after all guns & vehicles are off the property where he lives....(Patient #4 name) demanding to leave & go home. Discussed c Dr. (Psychiatrist #1) - will D/C today. Encouraged Daughter to pursue guardianship and placement. Daughter (name) pushing male who came c her to help transport - Cursing about Discharge 'I hope....rots in hell.' - Angry about discharge Angry about meds - Unable to calm her or discuss how to proceed to get adequate level of care for her father." Review of "Plan for Continued Treatment: D/C today when daughter can arrange transportation. Offered Police transport but she hung up the phone."

Review of physician's orders revealed a physician's order dated 04/27/2013 at 1330 by LIP #1 to "D/C today c scripts for 1 mo(nth)...."

Review of nursing Discharge Note documentation dated 04/27/2013 at 1446 by RN #1 revealed "Voiced Understanding of Discharge Teaching Yes Ambulating Wheelchair Ambulating Unsteady Gait Blood Pressure 132/88 Breath Sounds Clear Discharged to Home Discharged to Care of HIS DAUGHTER Eye Contact Good Medications, Times, Dosages and Follow-up Appointment Explained to Patient....AND HIS DAUGHTER Patient Resistant with interactions. Patient is able to follow commands. Patient Taken to Vehicle by (staff name) Patient taken via wheelchair to vehicle. Personal belongings, scripts, discharge sheet and medications sent with PATIENT AND DAUGHTER. Patient is A + O X 1 (alert and oriented to person only). Pulse Regular Pulse Rate per minute 81 Respirations Even & Unlabored Respirations per minute 18 Skin Pink Warm Dry....Speech Clear Garbled Relevant Temperature 98."

Review of nursing documentation dated 04/27/2013 at 1501 by RN #1 revealed "...PATIENT D/C'D PER HIS REQUEST AND BY ORDER OF BURKE CO. SHERIFF SINCE NO ONE SHOWED UP FOR HIS HEARING; HE HAS NO GUARDIAN AND REPEATEDLY REQUESTED D/C. DTR. (daughter) [name] AND HER BROTHER (name) CARE FOR HIM. WENT OVER ALL D/C MEDS AND CARE THEY WERE VERY UPSET."

Review of Patient Discharge Instructions dated 04/27/2013 at 1545 for Patient #4 revealed "Activity Level As tolerated, unrestricted Care Instructions TAKE MEDICATIONS AS PERSCRIBED [sic] AND KEEP APPOINTMENTS AS SCHEDULED. Discharge Diagnosis DEMENTIA WITH BEHAVIOR DISTURBANCE Discharge Instructions Explained To Daughter Patient Follow Up Appointment With: DISCHARGE PLANNER WILL SET UP APPT AND CALL PATIENT AND HIS FAMILY WITH THE INFORMATION. Referral Required None Diet Regular. Patient/Significant Other Had Opportunity To Ask Questions Yes Patient/Significant Other Verbalized Understanding Yes Accompanied by/Relationship DAUGHTER (name) ...Discharged To/In Care of: Home with Family....Name of Facility Discharged To: HOME....Medications Prescriptions Given Patient education provided Mode of Discharge Wheelchair Mode of Transportation Car....Discharge Status Adequate Bowel Functioning Adequate Diet/Liquid Intake Adequate Urinary Output Afebrile Good Vital Signs Stable." Further review revealed "I fully understand the information included in my discharge intstructions [sic] and have been given the opportunity to ask questions." Further review revealed the hand written signature of Patient #4 on the line "Patient/Significant Other" and the hand written signature of RN #1 on the line "Caregiver." Review revealed the patient was given a prescription for Ativan 1 mg (milligram) take 1 by mouth every 4 hours as needed for anxiety, dispense #90; Haldol 1 mg by mouth twice per day unless too sedate, dispense #60; and Haldol 5 mg take 1/2 tablet by mouth daily as needed for agitation, dispense #15. Review revealed no refills were authorized. Further review failed to reveal any available documentation the patient's follow-up appointments were arranged prior to the patient's discharge from the hospital on 04/27/2013.

Review of the Discharge Summary for Patient #4 dictated 04/28/2013 by LIP #1 revealed and admission date of 04/23/2013 and a discharge dated of 04/27/2013 (4 days later). Review revealed a Discharge Diagnosis of Axis I: Dementia with behavioral change and Axis IV: Severe family conflict. Further review revealed "...DISCHARGE CONDITION: Stable, he came to us from (Hospital B) emergency department and hospital....He was admitted for observation (at Hospital B). During that period of time when he was admitted to the hospital, they told him he shouldn't be driving and he became extremely agitated, verbally aggressive and threatening and his daughter took out an involuntary, which lead to his admission here (Hospital A). ...he was given IV Ativan, because he got so agitated when they told him he wasn't supposed to drive. According to the notes from the emergency department and the nurse practitioner there (Hospital B), the patient has had a couple of minor motor vehicle accidents because of his driving skills and his inattentiveness. He has evidence of some dementia at home in that he has been unable to remember how (to) start his lawn mower and that sort of thing; however, no real evidence of getting lost or being unable to do his ADL's. ...He is 90 years old, he is a WWII (world war II) veteran and it is possible that he experienced some chemical warfare during the time he was in the trenches in WWII. ...He reports that he was shot twice when he was in the war. He can be quiet verbally demanding, but no physical aggression was noted on his admission here to the hospital. During this hospital stay (Hospital A), it has been quiet uneventful, until the day of discharge. The patient has been informed repeating while here that his reaction time is not sufficient for him to be driving anymore, and he takes that begrudgingly, but without agitation. He has been cooperative, mainly any problems with this gentleman have revolved mainly around his wanting to go home, and he would accept the fact that he was an involuntary commitment, but he was very aware of when he was eligible for discharge. He did know that he would have to go to court if we did not discharge him, and he was aware of mealtimes. He does have difficulty finding his room in the hospital here; however, the visual cues for finding his room are somewhat ambiguous. ...The family dynamics are of particular note with this gentleman, in that his daughter came into the emergency department and complained that he was driving and wanted the emergency department physician to tell him to stop driving. When that did occur, the patient became verbally hostile. On the discharge day, a phone call was initiated to the daughter, who became very agitated and was unwilling to take information, abruptly hanging up the phone twice when attempt was made to discuss the legal issues of maintaining this gentleman in the hospital. When she came to pick him up, she was verbally abusive to staff and physically aggressive and assaultive to the gentleman who was with her. His relationship to the patient was unidentified, but the daughter was pushing and shoving him in the hall during the discharge process. She refused to discuss his medications, the rationale for the medications, refusing to sign off on his discharge instructions. ...we discharged him on Haldol 1 mg twice a day, unless sedated to deal with the reported history of agitation. He did receive Haldol on Friday morning, prior to discharge, because he was so insistent on being discharged that he would go out and walk in the woods and live in the woods, rather than be here, but did not test the doors, did not make any behavioral movements toward that. Once he was told....his daughter was coming to get him, he was able to calm down and took a nap....The only real evidence of difficulty was that he was quite demanding about going home. He was compliant with his medication and with redirection. He had no complaints except being confined to the unit. It is of note that a letter was given to the daughter....indicating that he has dementia and that he will eventually need a guardian. It is questionable whether or not the family is, in fact, a good choice for guardian, given her (daughter) behavioral outbursts and verbal abuse of staff. His discharge mental status examination shows a 90-year-old gentleman who looks much younger that his stated age. His grooming is within normal limits. He is alert, oriented x 3. He is able to do all of his ADL's and his appetite has been good. His eye contact is good. His rapport is moderate, given the fact that he is agitated about being confined to a hospital when 'there is nothing wrong with me.' Psychomotor activity is within normal limits. He is able to ambulate without help. He is somewhat unsteady on his feet when he first stands up, and staff has been walking with him. He has had no aggressive outbursts. He is anxious and slightly agitated, but it is all related to his being admitted to the hospital and being confined. His speech is within normal limits, the quality and quantity is appropriate and he can easily converse about WWII and specifics of his early adulthood. He does get confused and forgetful about recent events. For examination, he cannot remember who is making rounds on him from day to day. He is not able to recall what he ate for breakfast the same day. His thought processes are somewhat perseverating and circumstantial about his mission here. There is no evidence of psychosis, no evidence of delusional material. No suicidal or homicidal thoughts. His main preoccupation is getting discharged from the hospital. The main problem with this gentleman is in the cognition area. He is oriented to himself, he has problems with memory. It is of note that his MOCA score is 10 out of 30. We wanted to get an independent living evaluation; however, his IVC did not allow us time to complete that desired evaluation. Insight and judgment were limited, and it continues to be recommend that this gentleman not drive. The daughter states that she removed the keys, removed all ammunition and firearms from the house, and in fact stated that she was going to remove the vehicles from the property to keep him from being tempted to drive. ...JUSTIFICATION FOR ADMISSION: Assessing the patient's safety, given his agitation on being informed that he could no longer drive. Evaluation of his dementia and his capacity to adjust to unpleasant information. PLAN: The plan is for him to return to home with his wife, given the behavior of his daughter on Monday, we will request that DSS (Department of Social Services) investigate for his safety at home. The daughter refused to give us the patient's care provider, however, the emergency department notes state that a Dr....is his doctor. We have no further information other than that. The patient was advised to call the unit if any situations or concerns arouse. Caregiver was advised to call 911 or go to the nearest emergency department if he (de)compensates."

Review of Discharge Planning documentation by DCP #1 on 04/29/2013 at 0910 (2 days post D/C) revealed "Rec. [received] call (retrieved fr. [from] vm [voicemail]) 4/27/ 3:16 fr (RN #1 name) on psych informed me (LIP #1 name) d/c (Patient #4 name) and dtr (daughter) had been called for transport."

Review of Discharge Planning documentation by DCP #1 on 04/29/2013 at 0913 (2 days post D/C) revealed "Family called w/discharge follow up information. Further review revealed "DSS Involvement No" and "Home Health No Needs" and "Primary Care Physician Appointment 05/20/2013 at 02:00" and "Tentative D/C Date/Time 05/07/2013 at 0000."

Review of Discharge Planning documentation by DCP #1 on 04/29/2013 at 1423 (2 days post D/C) revealed "Additional Notes dc faxed to Dr. (primary care physician name)."

Review of Discharge Planning documentation by DCP #1 on 04/30/2013 (3 days post D/C) at 1536 revealed "Additional Notes Faxed discharge summary @ (at) time of aptmt (appointment) re-schedule. (SEE PROGRESS NOTES FOR ADDITIONAL INFORMATION) D/C Summary Faxed to Primary Yes...Primary Care Physician Appointment 05/07/2013 01:45."

Review of Discharge Planning documentation by DCP #1 dated 04/30/2013 at 1538 (3 Days post D/C) revealed "Called patients primary care provider to reschedule the follow up aptmt due to medication script qty (quantity) @ D/C. I was able to get it moved up to 5/7/13 @ 1:45. I followed up on the home health (HH) referral sent to (HH agency name, telephone number) spoke with/RN....who confirmed getting the referral, calling the daughter to schedule the intake w/RN. She was told by....(DTR)....that (Patient #4 name) was taken to (Hospital C) for another IVC. (HH RN name) told me she didn't know what that meant and (DTR name) was rude to her but (HH agency name) closed out the referral. I called....(DTR) to inform of the aptmt. updt (update). and inquire into the home health referral but after I told her who I was she said 'well I'm at the hospital (Hospital C) doing another IVC because of you all' and hung up on me. ..."

Further record review of a Discharge Summary (Admission #2) for Patient #4 dictated 05/15/2013 by Psychiatrist #1 revealed the patient was subsequently re-admitted to the hospital on 05/01/2013 (4 days after discharge on 04/27/2013) with an admission diagnosis of Dementia with behavioral disturbances. The patient was treated, stabilized, and discharged on 05/13/2013 (12 days later) with a final discharge diagnosis of Dementia, mixed, moderate with behavioral disturbances, including aggression. The patient was discharged to a care facility with a locked unit.

Interview on 01/15/2014 at 1620 with RN #1 revealed she does not recall Patient #4. Interview revealed "I have heard the name, but no face." Interview revealed she was the nurse who discharged the patient on 04/27/2013, according to medical record documentation. Interview revealed at the time of the patient's discharge he was assessed as alert and oriented to person only. Interview revealed the patient was not sedated and had good eye contact. Interview revealed the patient was unsteady on his feet and discharged via wheelchair to the care of his daughter. Interview revealed "I remember he wanted to go home and the daughter was not pleased with the patient going home." Interview revealed "they just wanted us to keep him." Interview revealed "the patient had been scheduled to go home, but the daughter did not agree to take the patient home at first." Interview revealed the daughter finally agreed to take the patient home. Interview revealed "everything the D/C planner tried to do, the daughter did not want to do. The D/C planner would have set up a referral to a facility." Interview revealed the patient received verbal and written discharge instructions with the daughter present. Interview revealed the daughter refused to sign the discharge forms. Interview revealed the patient signed the forms himself, because he wanted to go home. Interview revealed "it was my understanding the patient was going to go home to be with or in the care of his family." Interview revealed the plan was to call DSS. Interview revealed she is unsure if DSS was contacted. Interview revealed the DSS referral would have been made by (DCP #1 name). Interview revealed the patient was discharged home with prescriptions for oral Ativan and Haldol. Interview revealed the patient and daughter was advised a D/C Planner would contact them the following week to arrange follow up appointments and referrals. Interview confirmed the family was not asked to administer the patient intramuscular medications (IM) at home.

Interview on 01/16/2014 at 1115 with Psychiatrist #1 revealed she remembered Patient #4. Interview revealed she was the attending physician for Patient #4 during his hospitalization from 04/23/2013 to 04/27/2013. Interview revealed as the attending physician she was "responsible for his care." Interview revealed he was a "grey area patient." Interview revealed "the patient had dementia, mild to moderate but still lived in the community. He walks, talks, makes decisions for himself, but they may not be good ones." Interview revealed the daughter was not easy to communicate with and it was difficult to exchange information with her. Interview revealed the daughter "wanted the patient contained in a safe environment and wanted us to do it." Interview revealed the patient had been demanding to leave the whole time he was hospitalized. Interview revealed the patient was admitted under IVC but no longer met IVC criteria. Interview revealed "so you have the choice of holding or discharge." Interview revealed "the question becomes, without a guardian how can you hold the patient for an indefinite amount of time?" Interview revealed she communicated (Saturday?) with Dr. (LIP #1) that she felt the patient did not need to be here and believed Dr. (LIP #1) misunderstood her, at the time to mean discharge the patient. Interview revealed "I did not authorize a discharge on 04/27/2013." Interview revealed "I would not discharge a patient on Saturday without the D/C Planner, Soci

Based on hospital policy review, observations during tour, and staff interview, the hospital staff failed to ensure medications stored in medication carts were secured when unattended on 1 of 4 inpatient nursing units toured (Med-Surg).

The findings include:

Review of current hospital policy "Medication Carts/Bins," Policy No: 10-3005, reviewed 08/2011, revealed "Purpose: All medications stored in medication carts and bins shall be accessible only to authorized personnel and stored to ensure stability and protection. Procedure: ...4. When unattended, the medications carts, cabinets and medication rooms are to be locked. ..."

Observation during tour of the Medical-Surgical (Med-Surg) Unit on 01/16/2014 at 1615, revealed a medication cart on wheels stored in the hallway. Observation revealed the medication cart was unattended and not in use by licensed staff. Observation revealed the medication cart contained medication drawers used for storage of medications for individual patient rooms. Observation revealed 3 drawers were easily opened by the surveyor. Observation revealed each drawer opened, contained individually packaged medications for patient use. Interview during tour with nursing management staff revealed medication carts should be secured at all times when not in use. Interview confirmed the medications being stored in the medication cart were unsecured and easily accessible by the surveyor. Interview confirmed the hospital staff failed to follow hospital policy.

Based on hospital policy reviews, medical record reviews, incident report reviews, and staff interviews, the hospital's Emergency Department (ED) staff failed to ensure ongoing assessment/reassessment of patients waiting for treatment/evaluation in the ED waiting room for 1 of 4 ED patients (#3) reviewed; and failed to obtain a physician's order for an IV (intravenous) access in 1 of 4 ED patients (#3) reviewed.

The findings include:
1. Review on 01/15/2014 of current ED Policy no. 2-0210, "ED TRIAGE PROCEDURE", revised 11/2013, revealed "PURPOSE: To provide prompt and adequate assessment of patient presenting to the Emergency Department. POLICY STATEMENT: All patients presenting to the Emergency Department will be assessed and categorized using the ESI (emergency severity index) Level Triage System... ." GUIDELINES revealed "...In the rare event no ED bed is immediately available, and patient acuity level permits, patients are taken to the triage area where the initial screening assessment is completed. These patients are then directed back to complete registration in the switchboard area. ...Every effort will be made to provide hourly checks on patients in the waiting area at which time updates on waiting times can be given. ..."

Review of current ED policy 12-0211, TRIAGE CATEGORIES, reviewed 11/2013, revealed "All patients who come to the Emergency Department will be handled according to category of priority. ...Class III....patients will have vital signs taken on admission and PRN (as needed). The minimum of documentation of vital signs will be every 4 hours with the exception of boarder patients which will have vital signs taken every shift and as indicated per patient condition. ..."

Review of current ED policy 12-0212, TRIAGE STANDARDS OF CARE, reviewed 01/20/11, revealed "PURPOSE: To define basic care guidelines for specific triage categories (not to be considered all inclusive) Documentation is to be done in the electronic medical record unless there is down time..." Review revealed "...CATEGORY III - SEMI URGENT: 1. Vital signs including pulse ox on admission and again as patient condition indicates not less than every 4 hours... ."

Review of current ED policy, NURSING ASSESSMENT AND DOCUMENTATION POLICY, revised 01/23/2013, revealed "PURPOSE: The charting process in the ED is unique from the customary practices established throughout (name of hospital). This policy will delineate and clarify the documentation standards for the Emergency Department. POLICY: ED Documentation standards for patients presenting to (name of hospital)." PROCEDURE: revealed ... "Ongoing Assessment: a. Ongoing objective and subjective assessments shall be documented every two (2) hours at a minimum. More frequently as clinically indicated. ..."

Closed ED record review on 01/15/2014 of Patient #3 revealed a 72 year old female who presented, ambulatory, to the ED on 12/30/2013 at 1428. Record review revealed the patient was triaged by RN #4 at 1530 (62 minutes after arrival). Review revealed a chief complaint of "...pain in her left calf starting yesterday. Feels the same as a previous clott [sic] 2 months ago in the same leg. ..." Review revealed at 1536 initial vital signs were assessed as blood pressure (BP) 137/80, Temperature (T) 98.1 Fahrenheit (F), Pulse (P) 97, Respirations (R) 18, and Oxygen Saturation (SpO2) 98%. Review revealed a pain assessment was performed using a numerical score (0 pain free, 10 worst pain) with an assessed score of 7/10. The patient was assigned an Acuity 3 (1 most severe, 5 less severe). Review revealed the patient was placed into the "ED WR (waiting room)" at 1536. Record review revealed at 2034 (4 hours 58 minutes after initial vital signs were assessed) the patient was assessed by RN #2 (in treatment room) and the nursing "Daily Focus Assessment Report" was completed. Record review revealed at 2035 (4 hours and 59 minutes after initial vital signs were assessed) the patient's vital signs were reassessed as BP 158/75, T 98.0 F, P 82, R 20, SaO2 98.0%. Review of ED physician documentation revealed a Medical Screening Examination was performed at 2137 (7 hours 9 minutes after arrival) with a "CLINICAL IMPRESSION" of "Pain: l (left) lower extremity" and "Superficial Thrombophlebitis (a circulatory problem that develops when a blood clot slows the circulation in a vein, either right under the skin or deeper in the leg.), LLE (Left Lower Extremity)." Review revealed "Disposition: home. Time 2157." Record review revealed the patient was discharged at 2213 (7 hours and 45 minutes after arrival). Record review failed to reveal any available documentation by the nursing staff the patient or her vital signs were reassessed while awaiting evaluation and treatment in the ED waiting room from 1536 to 2034 (4 hours and 58 minutes).

Continued record review revealed a "REFUSAL OF TREATMENT" form dated 12/30/2013 at 1557. Review of the form revealed documentation of two (2) different patient's names (#3, #8) on the form. Review revealed Patient #3's name was handwritten on a blank line at the top of the form and a preprinted sticker with Patient #3's name, patient and medical record numbers, birth date, and date of service placed on the lower right bottom of the form. Further form review revealed "This is to certify that (name of Patient #3 hand written on a blank line), a patient at (hospital name) is refusing treatment... and/or leaving the hospital prior to evaluation... ." Further form review revealed the handwritten signature of Patient #8 (not Patient #3) on the Patient Signature line at the bottom of the form. Review of the form revealed Patient #8 signed the form at 1557. Further form review revealed RN #3 signed as witness to the form at 1557. Continued record review revealed Patient #3 did not leave the hospital prior to evaluation or refused treatment as indicated on the Refusal of Treatment Form in the ED medical record.

Review on 01/15/2014 of incident report documentation completed by hospital staff on 01/01/2014 revealed "(name of Patient #8) left AMA (against medical advice) at 1700 (5pm). She was thought to have been (name of Patient #3) because of the signature on the AMA form. (Name of Patient #3) was still in the waiting room, and mistake was not noticed until 2022 (8:22pm). Mistake was corrected and (name of Patient #3) was taken back to a room in the ER (Emergency Room) to be seen. Neither the patient, nor her family members, came up to the window to check on her status. (Name of Patient #3) asked for a compliment/ complaint form and it was given to her daughter." Further review of the file revealed an Emergency Room - Outpatient Record for Patient #3 with a handwritten note that "pt (Patient #3) was accidentally signed out @ (at) 17:00 (5pm)." Review revealed the error was "noticed @ (at) 20:22 (8:30pm) (3 ? hrs [hours] later)." Further review of documentation revealed "She (Patient #8) was thought to have been (Patient #3) because of the signature on her AMA form. (Patient #3) was still in ER waiting room, and mistake was not noticed until 20:22 (8:22pm). Mistake was corrected and (Patient #3) was taken back to a room in the ER to be seen... ."

Interview with the Patient Access Supervisor on 01/15/2013 at 1600 revealed two patients (#3, #8) were in the ED at the same time with similar last names and Patient #3 was "incorrectly taken out of the system (computer system)." Interview revealed Patient #3 was taken "off the tracking board" and "no one knew she was there." Interview revealed "(Patient #8 name) was actually the patient who left."

Interview on 01/15/2014 at 1700 with Patient Access Technician (PAT) #1 revealed the ED was "very busy that day." Interview revealed a patient (Patient #8) approached to leave. ...Interview revealed that the incorrect patient (Patient #3) was taken out of the system. ...Interview further revealed PAT # 1 was not aware of this ever happening to anyone else.

Interview on 01/16/2014 at 0915 with RN #2 revealed when she called another patient back from the waiting room, that patient asked about Patient #3 who was still waiting in the ED waiting room to be evaluated. She (RN #2) then asked registration (PAT #1) about Patient #3. The staff realized Patient #3 was in the waiting room and needed to be seen even though her name was not on the "board." Interview revealed Patient #3 was carried "back" into a treatment room.

Interview on 01/16/2014 at 0930 with the ED Director revealed the ED was "very busy" on the day Patient #3 presented for evaluation. Interview revealed the ED does not staff a full-time triage nurse in the triage area. Interview revealed when a patient presents to the ED, patient access staff notify the nurses in the treatment area to come out and triage the patient. When asked if the ED had a policy for assessment/reassessment of patients waiting in the ED waiting room after triage; the interview revealed "yes, we do have a policy, but we are unable to follow it at times" and "that's why it would be wonderful to have a full-time triage nurse."

Consequently, the ED nursing staff failed to follow established policies for the assessment/reassessment of Patient #3; when the patient was discharged in error from the ED tracking board system by staff. The error resulted in a delay in examination and treatment for the patient.

2. Review of current ED policy 12-0212, TRIAGE STANDARDS OF CARE, reviewed 01/20/11, revealed "PURPOSE: To define basic care guidelines for specific triage categories (not to be considered all inclusive) Documentation is to be done in the electronic medical record unless there is down time..." Review revealed "...CATEGORY III - SEMI URGENT: ...4. IV access as needed. ..."

Closed ED record review on 01/15/2014 for Patient #3 revealed a 72 year old female who presented to the ED on 12/30/2013 at 1428 for complaints of "pain in her left calf starting yesterday. Feels the same a previous clott [sic] 2 months ago in the same leg." The patient was evaluated and discharged from the ED at 2213. Review of electronic ED nursing documentation dated 12/30/2103 at 2112 revealed an 18 gauge IV (intravenous) catheter was started at 2050 by an ED staff member. Further review revealed "IV Site started by: (ED Staff #1 name)..." Record review revealed no documented evidence of a written or CPOE (Computer Physician's Order Entry) physician's order for an IV access.

Interview on 12/16/2014 at 1030 with ED Staff #1 revealed he is an Emergency Medical Technician - Intermediate (EMT-I). ...Interview revealed he can start IV's under the supervision of the ED physician or registered nurse. Interview revealed the RNs document in the ED record the IV starts, specifying the name of the individual starting the IV. Interview confirmed he established the IV on Patient #3 per documentation in the medical record. Interview revealed he established the patient's IV per "protocol."

Concurrent interview on 01/16/2014 at 1030 with the ED Director revealed staff use a "protocol" that allows IV insertions (access). Interview revealed the policy (Triage Standards of Care) is used as the protocol.

Interview on 01/16/2014 at 1700 with the Chief Nursing Officer revealed IV insertions performed on patients must have a written or CPOE physician's order. Interview confirmed no available documentation of a physician's order for IV insertion for Patient #3 on 12/30/2013.

Based on medical record reviews and staff interviews, the hospital's Emergency Department (ED) staff failed to ensure accurate and complete medical records for 2 of 4 ED records reviewed (#3, #8).

The findings include:

1. Closed ED record review on 01/15/2014 for Patient #3 revealed a 72 year old female who presented to the ED on 12/30/2013 at 1428 for complaints of "pain in her left calf starting yesterday. Feels the same a previous clott [sic] 2 months ago in the same leg." The patient was evaluated and discharged from the ED at 2213. Record review revealed a "REFUSAL OF TREATMENT" form dated 12/30/2013 at 1557. Review of the form revealed documentation of two (2) different patient's names (#3, #8) on the form. Review revealed Patient #3's name was handwritten on a blank line at the top of the form and a preprinted sticker with Patient #3's name, patient and medical record numbers, birth date, and date of service placed on the lower right bottom of the form. Further form review revealed "This is to certify that (name of Patient #3 hand written on a blank line), a patient at (hospital name) is refusing treatment... and/or leaving the hospital prior to evaluation... ." Further form review revealed the handwritten signature of Patient #8 (not Patient #3) on the Patient Signature line at the bottom of the form. Review of the form revealed Patient #8 signed the form at 1557. Further form review revealed RN #3 signed as witness to the form at 1557. Continued record review revealed Patient #3 did not leave the hospital prior to evaluation or refused treatment as indicated on the Refusal of Treatment Form in the ED medical record.

Closed ED record review on 1/16/2014 for Patient #8 revealed a 54 year old female who presented to the ED on 12/30/2013 at 1333 for complaints of a fall down 4 steps the previous day with pain in her right knee since the fall. Review of the Emergency Department Triage Report revealed the patient was triaged at 1349 with vital signs documented on the Vital Signs Report at 1358. Further review revealed documentation by ED patient access staff (PAT #1) "pt left and signed out as AMA (against medical advice) @ (at) 17:00. Was thought to have been (Patient #3 name)." Further record review failed to reveal documentation in Patient #8's ED record of "A REFUSAL OF TREATMENT" form for the 12/30/2013 ED visit.

Interview with the Patient Access Supervisor on 01/15/2013 at 1600 revealed two patients (#3, #8) were in the ED at the same time with similar last names and Patient #3 was "incorrectly taken out of the system." Interview revealed "(Patient #8) was actually the patient who left." Interview confirmed Patient #8's and Patient #3's medical record contained inaccurate information. Interview confirmed Patient #8's ED medical record did not contain the "A REFUSAL OF TREATMENT" form signed by Patient #8 for the 12/30/2013 ED visit. Interview confirmed the form was placed in the ED medical record of Patient #3. Interview confirmed the form contained inaccurate patient names and demographic information.

2. Closed ED record review on 01/15/2014 for Patient #3 revealed a 72 year old female who presented to the ED on 12/30/2013 at 1428 for complaints of "pain in her left calf starting yesterday. Feels the same a previous clott [sic] 2 months ago in the same leg." The patient was evaluated and discharged from the ED at 2213. Review of electronic ED nursing documentation dated 12/30/2103 at 2112 revealed an 18 gauge IV (intravenous) catheter was started at 2050 by an ED staff member. Further review revealed "IV Site started by: (ED Staff #1 name), CNA (Certified Nursing Assistant)."

Interview on 12/16/2014 at 1030 with ED Staff #1 revealed he is not a CNA. Interview revealed he is an Emergency Medical Technician - Intermediate (EMT-I). Interview revealed he is an employee of the hospital and works in the ED. Interview revealed he can start IV's under the supervision of the ED physician or registered nurse. Interview revealed the RNs document in the ED record the IV starts, specifying the name of the individual starting the IV. Interview confirmed the professional credentials documented for ED Staff #1 in the ED record for Patient #3 were not correct and accurate.

Interview on 01/16/2014 with the ED Director revealed (ED Staff #1) is not a CNA, he is an EMT-I, with a job description allowing IV insertions. Interview revealed CNAs are not allowed to start IVs. Interview revealed this is a "computer issue." Interview confirmed Patient #3's ED record contained inaccurate documentation of ED Staff #1's professional credentials.

NC00094264
NC00089436