HospitalInspections.org

Based on document review, observation and interview, it was determined for 7 of 7 inpatient psychiatric units (Adolescent, General Adult, Dual Diagnosis, Women's Program, Transitional Care, Intensive Treatment, and Geriatric Units ) and 6 of 10 (Pts #1, 2, 3, 4, 5, and 7) clinical records reviewed, that the Hospital failed to ensure patients' rights were protected. As a result, the Condition of Participation for Patient Rights, 42 CFR 482.13, was not met.

Findings include:

1. The Hospital failed to ensure safety unit checks were conducted, as required. See deficiency at A-144A.

2. The Hospital failed to ensure a plastic bag was not in a patient bathroom. See deficiency at A-144B.

3. The Hospital failed to ensure safety precautions were conducted every 15 minutes, as required by policy. See deficiency at A-144C.

4. Tthe Hospital failed to ensure a physician's order was written for a patient placed in restraint/seclusion. See deficiency at A-168.

5. The Hospital failed to ensure restraints were not ordered as a PRN (as needed). See deficiency at A-169.

6. The Hospital failed to ensure patients were not restrained longer than allowed. see deficiency at A-171.

A. Based on document review and interview, it was determined that for 7 of 7 patient care units in the Hospital (Adolescent, General Adult, Dual Diagnosis, Women's Program, Transitional Care, Intensive Treatment, and Geriatric Units), the Hospital failed to ensure safety unit checks were conducted, as required. This could potentially affect the safety and well being of the average daily census of 128 patients in the Hospital.

Findings include:

1. The Hospital policy entitled, "Safety Unit Checks," (Revised 11/14) reviewed on 6/7/17 at approximately 8:00 AM required, "I. Purpose: To provide and maintain a safe physical environment for patients ...on the unit. II. Policy: A. Each day the charge nurse/designee shall make unit rounds, including a visual scan of each patient's room, to check for unauthorized items ...and property damage ...III. Procedures ...6. In the event of an injury to a patient ...completes an incident report that ensures that appropriate steps, including follow-up have been implemented."

2. The Adolescent Unit Safety Check Sheets for the months of April 2017, May 2017, and June 2017 were reviewed on 6/7/17 at approximately 8:00 AM. The documentation of daily checks was not found as required on: 4/1/17; 4/3/17; 4/8/17; 4/10/17; 4/13/17; 4/15/17; 4/17/17; 4/23/17; 4/25/17; 4/29/17; 4/30/17; 5/1/17; 5/2/17; 5/8/17; 5/12/17; 5/13/17; 5/14/17; 5/15/17; 5/19/17 through 5/22/17; 5/2617; 5/27/17; 5/28/17; 5/30/17; and 5/31/17; 6/1/17; 6/3/2017; and 6/6/17.

3. The General Adult Unit Safety Check Sheets for May and June 2017 were reviewed on 6/7/17 at approximately 8:45 AM. The documentation of daily checks was not found as required on May 1-22, 2017 and May 24-30, 2017.

4. The Dual Diagnosis Unit Safety Check Sheets for May and June 2017 were reviewed on 6/7/17 at approximately 9:00 AM. The documentation of daily checks was not found as required on May 1-23, 2017 and June 1-6, 2017.

5. The Women's Program Unit Safety Check Sheets for May and June 2017 were reviewed on 6/7/17 at approximately 9:10 AM. The documentation of daily checks was not found as required on May 1-20, 2017.

6. The Transitional Care Unit Safety Check Sheets for May and June 2017 were reviewed on 6/7/17 at approximately 9:15 AM. The documentation of daily checks was not found as required on: May 15-24, 2017; May 26-28, 2017; and May 30, 2017.

7. The Intensive Treatment Unit Safety Check Sheets for May and June 2017 were reviewed on 6/7/17 at approximately 9:20 AM. The documentation of daily checks was not found as required on: May 1-21, 2017; May 26-28, 2017; May 30, 2017; May 31, 2017; and June 1-4, 2017.

8. The Geriatric Unit Safety Check Sheets for May and June 2017 were reviewed on 6/7/17 at approximately 9:20 AM. The documentation of daily checks was not found as required on May 1-26, 2017; May 27, 2017; and May 31, 2017.

9. The Director of Performance Improvement and Risk Management (E #3) stated, during an interview on 6/7/17 at approximately 2:20 PM, that the Unit Safety Checks should be done every shift; however, the policy requires daily unit safety checks.


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B. Based on document review, observational tour, and interview, it was determined, for 1 of 3 patient bathrooms, the Hospital failed to ensure that a plastic bag was not in a patient bathroom, potentially injurious to 4 adolescent patients (Pts. #7 - 10) on suicidal precautions.

Findings include:

1. On 6/7/17 at 11:30 AM, the Hospital policy titled, "Contraband", effective 11/2014, was reviewed. The policy did not include plastic bags as contraband.

2. On 6/7/17, between 8:55 AM and 10:30 AM, an observational tour was conducted in the adolescent unit. A plastic bag was in a waste container in a patient bathroom (no number on the room) across from the nursing station.

3. On 6/7/17 at 1:00 PM, an interview was conducted with (E #3). E #3 stated that plastic bags are contraband and not permitted on the unit due to suffocation risk [for suicidal patients].

C. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #7), the Hospital failed to ensure a patient on suicide precautions was monitored every 15 minutes, as required by policy.

Findings include:

1. On 6/7/17 at 11:00 AM, the Hospital policy titled, "Observation Levels", effective November 2014, was reviewed. The policy required, "... Special precaution procedures can be initiated by physician or nursing staff when a patient may be considered to be an increased risk for harm to self, others, or property... A Patient Round Sheet reflects the patient's location and observed behaviors, [and is] completed every 15 minutes..."

2. On 6/7/17 at 9:45 AM, Pt. #7's clinical record was reviewed. Pt. #7 was a 17 year old female, admitted on 6/4/17, with a diagnosis of major depressive disorder. Pt. #7's admission orders dated 6/4/17 at 11:50 PM, included suicidal precautions. Pt. #7's "Patient Safety Precautions Record" dated 6/6/17, included 15 minutes close observation for suicide. However, 15 minute checks were missing on 6/7/17 between 10:15 PM and 11:15 PM, for 1 hour.

3. On 6/7/17 at 11:20 AM, an in interview was conducted with a Registered Nurse (E #4). E #4 stated that she did not know why Pt. #7's safety check sheet was not completed, but it should have been completed.

A. Based on document review and interview, it was determined, for 2 of 5 clinical records reviewed (Pts. #3 & #5) for patients in restraint, seclusion, or physical hold, the Hospital failed to ensure a physician's order was written for a patient placed in restraint/seclusion.

Findings include:

1. On 6/7/17 at 11:25 AM, the Hospital policy titled, "Restraint and/or Seclusion", effective 11/2014, was reviewed. The policy included, "II. Definitions... A. Restraints... 3. Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving... B. Non Restraints... 3. Time out is a restriction of a patient... to a designated area from which the patient is not physically prevented from leaving... Patient must voluntarily accept the time out... Time out is not to last more than 30 minutes."

2. On 6/7/17 at 1:25 PM, Pt. #3's clinical record was reviewed. Pt. #3 was a 43 year old male, admitted on 3/17/17, with a diagnosis of schizophrenia. Pt. #3's "Restraint/Seclusion Order Sheet" dated 3/19/17 at 10:10 PM, included a "manual hold", because "patient attacked staff". However, a "RN Progress Note" dated 3/20/17 at 3:05 AM, included, that on 3/19/17 "...At 9:45 PM, Patient lunged at and made physical contact with Mental Health Technician. Patient placed on manual hold... Patient escorted to seclusion room... Patient remained in seclusion room with door open, being monitored by staff until 10:05 PM. Patient offered water and snacks..." Pt. #3 returned to his room, but "after 30 minutes patient remains confused. Placed in quiet room for the remainder of the shift..."

3. On 6/7/17 at 2:20 PM, an in interview was conducted with the Director of Performance Improvement and Risk (E #3) and the Director of Nursing (E #6). E #6 stated that Pt. #3 was not in seclusion because the seclusion room door was left open and the Nurse documented the incident incorrectly.

4. The clinical record of Pt #5 was reviewed on 6/7/17 at approximately 1:50 PM. Pt #5 was a 16 year old female admitted on 4/15/17 with a diagnosis of disruptive mood dysregulation disorder. Pt #5's clinical record contained a Restraint/Seclusion Order Sheet dated 4/21/17 that included a physician's order for manual hold and 4 point mechanical restraints. Documentation indicated that Pt #5 was placed in a manual hold on 4/21/17 from 3:55 PM to 4:12 PM and then 4 point leather restraints from 4:31 PM to 5:30 PM (19 minutes later). The clinical record lacked a second physician order for the placement of the mechanical restraints following the manual hold.

5. Pt #5's clinical record contained a Restraint/Seclusion Order Form dated 5/1/17 that required 4 point mechanical restraints. The order form indicated that Pt #5 was placed into a manual hold prior to the mechanical restraints without a physician's order.

6. An interview was conducted with the Director of Performance Improvement and Risk (E #3) and the Director of Nursing (E #6) on 6/7/17 at approximately 2:20 PM. E #3 and E #6 stated that there should have been a second order for the restraints because of the time lapse and there was no order for the patient to be placed in a manual hold.

Based on document review and interview, it was determined that for 3 of 5 clinical records (Pts #2, 4, and 5) reviewed of patients in restraint, the Hospital failed to ensure that restraint orders did not include a PRN (as needed) component.

Findings include:

1. The Hospital policy entitled, "Restraint and/or Seclusion," (Effective date:11/14) reviewed on 6/6/17 at approximately 11:00 AM required, "Policy...G. No PRN or standing orders for restraint or seclusion are permitted."

2. The clinical record of Pt #2 was reviewed on 6/7/17 at approximately 1:40 PM. Pt #2 was a 14 year old female admitted on 4/5/17 with a diagnosis of major depressive disorder. Pt #2's clinical record contained Restraint/Seclusion Order Sheets dated 4/17/17, 4/18/17 at 2:26 PM and 2:50 AM, and 4/19/17 that required "Manual Hold". The orders further included a signed physician's statement that indicated, "If needed for emergency management, restraint/seclude for..."

3. The clinical record of Pt #4 was reviewed on 6/7/17 at approximately 1:45 PM. Pt #4 was a 28 year old female admitted on 3/21/17 with a diagnosis of schizoaffective disorder. Pt #4's clinical record contained Restraint/Seclusion Order Sheets dated 4/6/17 and 4/30/17 that required "Manual Hold". The orders further included a signed physician's statement that indicated, "If needed for emergency management, restraint/seclude for..."

4. The clinical record of Pt #5 was reviewed on 6/7/17 at approximately 1:50 PM. Pt #5 was a 16 year old female admitted on 4/15/17 with a diagnosis of disruptive mood dysregulation disorder. Pt #5's clinical record contained Restraint/Seclusion Order Sheets dated 4/21/17, 4/26/17, and 4/29/17 that required "Manual Hold". The orders further included a signed physician's statement that indicated, "If needed for emergency management, restraint/seclude for..."

5. The Director of Nursing (E #6) stated, during an interview on 6/7/17 at approximately 2:30 PM, that the order did indicate that restraint/seclusion could be used as PRN.

Based on document review and interview, it was determined that for 3 of 5 (Pts #2, 4, and 6) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure patients were not restrained longer than allowed.

Findings include:

1. The Hospital policy entitled, "Restraint and/or Seclusion," (effective date:11/14) reviewed on 6/6/17 at approximately 11:00 AM required, "Policy...J. restraints/seclusions orders...4 hours for adults (18 years and older), 2 hours for children and adolescents age 9 - 17...Procedures...12. Completes required documentation regarding patients in restraint including..."

2. The clinical record of Pt #2 was reviewed on 7/7/17 at approximately 1:40 PM. Pt #2 was a 14 year old female admitted on 4/5/17 with a diagnosis of major depressive disorder. Pt #2's clinical record contained Restraint/Seclusion Order Sheets dated 4/19/17 and 4/20/17 at 9:00 AM and at 4:25 PM that indicated Pt #2 had been placed into 4 point mechanical restraints. The order forms lacked either the time Pt #2 was placed into restraints and/or removed, to assure Pt #2 was not restrained longer than the policy allowed.

3. The clinical record of Pt #4 was reviewed on 6/7/17 at approximately 1:45 PM. Pt #4 was a 28 year old female admitted on 3/21/17 with a diagnosis of schizoaffective disorder. Pt #4's clinical record contained Restraint/Seclusion Order Sheets dated 3/22/17 at 7:30 AM, 10:45 AM, and 4:30 PM and 3/25/17. The orders failed to include the maximum hours allowed, as required by the order form.

4. The Director of Nursing (E #6) stated, during an interview on 6/7/17 at approximately 2:30 PM, that the documentation did not indicate the time of restraint usage.

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed for ordering of medications, the Hospital failed to ensure medications were obtained and administered as ordered.

Findings include:

1. The Hospital policy entitled, "Written Medication Orders," (reviewed December 2015) reviewed on 6/7/17 at approximately 1:15 PM required, "...B. Nursing...2. Nursing forwards the written order copy to the pharmacy in a timely manner."

2. The Hospital policy entitled, "After Hours Procurement of Medications," (reviewed December 2015) reviewed on 6/7/17 at approximately 1:20 PM required, "I. Policy: The pharmacy shall maintain a limited supply of commonly used drugs in a specially designated location for urgent/emergent use."

3. The clinical record of Pt #1 was reviewed on 6/6/17 at approximately 10:15 AM. Pt #1 was a 14 year old female admitted on 4/19/17 with diagnoses that included, major depression and suicide ideation. Pt #1's clinical record included physician's admitting orders dated 4/19/17 at 11:00 PM that included, Pt #1's home medication record that included: home medications - Zoloft (anti-depressant) and Melatonin (hormone used for sleep) and the last time taken was 4/18/17. Documentation included that the physician's order was faxed to the pharmacy on 4/21/17.

Pt #1's clinical record included a Medication Administration Record with the initial date of 4/21/17. The record indicated that Pt #1's Zoloft (Sertraline) 125 mg was started on 4/20/17; however, the first documented dose was on 4/21/17. Pt #1's Melatonin 5 mg was started on 4/21/17.

4. MD #1 stated during the interview on 6/6/17 at approximately 1:00 PM, "When a patient is admitted, the way medications are ordered is through the med reconciliation. I check continue home meds or discontinue the meds. I continued the home meds of the patient (Pt #1)."

5. A registered nurse (E #4) stated during the interview on 6/7/17, "When a patient is admitted and we get orders from the doctor, the home medications are reviewed and the physician decides which ones to keep. The order is then sent to the pharmacy."

6. On 6/7/17 at approximately 12:15 PM, the Pharmacist (E #5) was interviewed. E #5 stated, "When a patient is admitted at night and is in need of medications, there is a night cabinet available for use. In the morning, we would get the form and the order from the cabinet and fill the order. Looking at my computer, I see the first medication that was sent from the pharmacy was on 4/21/17. There is no documentation in the night cabinet book to indicate the patient received a dose upon admission. The order for the medication is dated 4/19/17 at 11:00 PM and signed by the doctor on 4/20/17 at 10:00 AM but was not faxed to us until 4/21/17."