HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patients' environment was free of ligature risks. Findings:

An observation on 03/17/16 from 11:10 a.m. to 11:30 a.m. of the locked in-patient psychiatric unit with S1ADM present revealed the following observations:

The inpatient unit was observed to have 8 double occupancy rooms. Seven (7) of the 8 patient rooms (all patient rooms except room 103) were observed to have entry doors and bathroom doors with 3 separate door hinges set apart widely enough to allow for potential ligature risks.

S1ADM confirmed the door hinges could be used as a possible ligature points at the time of the observation.

Based on record review and interview, the hospital failed to ensure restrictive devices used in patient care were identified as restraints as evidenced by the use of a geri-chair with a lap tray for 1 of 1 (#2) sampled patients reviewed for restraint use. Patient #2 was placed in a geri-chair with a lap tray and the patient's condition prohibited her from being able to remove the tray from the geri-chair resulting in restriction of movement of her body.
Findings:


Review of the hospital policy titled Restraints and Seclusion Use, policy number: PC-1502, revealed in part:
Purpose: The hospital uses restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others.
Policy: It is the policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate safety of the patient, staff, and others.
Definitions: Restraint is: A. Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
Orders: B. Orders for the use of restraint or seclusion must be given by a Medical Doctor or Nurse Practitioner prior to their use.

Review of Patient #2's medical record revealed an admission date of 3/8/16. Further review revealed the patient was transported from the outpatient clinic to the inpatient hospital in a geri-chair with a lap tray secured over the patient's lap.

Review of Patient #2's physician's orders for 3/8/16 revealed no documented evidence of a restraint order.

Review of the hospital's investigative report recounting the investigation of Patient #2's death within 24 hours of admission, dated 3/8/16, revealed in part: Patient placed in geri-chair with tray table intact and transported to inpatient unit. Patient was admitted with the following presenting symptoms: abnormal involuntary movements (patient body shaking and patient talking at the same time.), anxiousness, restlessness (patient unable to sit still), disorganized thoughts (patient confused when speaking) and mood swings (mother reported patient having mood swings).

In an interview on 3/21/16 at 9:34 a.m. with S3RN, she confirmed she had admitted Patient #2 on 3/8/16. S3RN indicated Patient #2 had been transported from the outpatient clinic in a geri-chair with a lap tray and was admitted straight to the inpatient unit. S3RN further indicated she had not assessed whether the patient could remove the lap tray from the geri-chair. S3RN said Patient #2 had probably been unable to remove the lap tray based on the way she was moving and symptoms she was exhibiting. She said the lap tray had levers on each side that had to be pressed down simultaneously in order to release the tray and she doubted Patient #2 could have done that. S3RN confirmed there had been no restraint order/order for the geri-chair with lap tray on Patient #2's chart. She indicated she had not considered the geri-chair with a lap tray a restraint.


In an interview on 3/21/16 at 10:46 a.m. with S7MHT, she confirmed she had been working on the day Patient #2 was admitted to the inpatient hospital. S7MHT said she had transported Patient #2 from the outpatient clinic to the inpatient hospital. S7MHT indicated she had used a geri-chair with a lap tray secured across the patient's lap to keep the patient in the chair for transport between the 2 buildings (outpatient clinic and inpatient hospital). She confirmed the patient had remained in the geri-chair with the lap tray in place after transport to the inpatient hospital. S7MHT indicated Patient #2 had requested water and ice chips. She indicated the patient had been unable to hold the cup herself due to her tremors and movements. S7MHT said she had to place ice chips in the patient's mouth and had to hold the cup and straw for the patient to drink water.

Based on record review and interview, the hospital failed to ensure the use of restraints were in accordance with the order of the physician or other licensed independent practitioner who is responsible for the care of the patient for 1 (#2) of 1 patients reviewed with restraints. This is evidenced by placing a patient (Patient #2) in a geri-chair with a lap tray without a physician's order for the use of restraints. Patient #2's condition prohibited her from being able to remove the tray from the geri-chair resulting in restriction of movement of her body.
Findings:

Review of the hospital policy titled Restraints and Seclusion Use, policy number: PC-1502, revealed in part:
Purpose: The hospital uses restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others.
Policy: It is the policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate safety of the patient, staff, and others.
Definitions: Restraint is: A. Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
Orders: B. Orders for the use of restraint or seclusion must be given by a Medical Doctor or Nurse Practitioner prior to their use.

Review of Patient #2's medical record revealed an admission date of 3/8/16. Further review revealed the patient was transported from the outpatient clinic to the inpatient hospital in a geri-chair with a lap tray secured over the patient's lap.

Review of Patient #2's physician's orders for 3/8/16 revealed no documented evidence of a restraint order.

Review of the hospital's investigative report recounting the investigation of Patient #2's death within 24 hours of admission, dated 3/8/16, revealed in part: Patient placed in geri-chair with tray table intact and transported to inpatient unit. Patient was admitted with the following presenting symptoms: abnormal involuntary movements (patient body shaking and patient talking at the same time.), anxiousness, restlessness (patient unable to sit still), disorganized thoughts (patient confused when speaking) and mood swings (mother reported patient having mood swings).

In an interview on 3/21/16 at 9:34 a.m. with S3RN, she confirmed she had admitted Patient #2 on 3/8/16. S3RN indicated Patient #2 had been transported from the outpatient clinic in a geri-chair with a lap tray and was admitted straight to the inpatient unit. S3RN further indicated she had not assessed whether the patient could remove the lap tray from the geri-chair. S3RN said Patient #2 probably had been unable to remove the lap tray based on the way she was moving and symptoms she was exhibiting. She said the lap tray had levers on each side that had to be pressed down simultaneously in order to release the tray and she doubted Patient #2 could have done that. S3RN confirmed there had been no restraint order/order for the geri-chair with lap tray on Patient #2's chart. She indicated she had not considered the geri-chair with a lap tray a restraint.

In an interview on 3/21/16 at 10:46 a.m. with S7MHT, she confirmed she had been working on the day Patient #2 was admitted to the inpatient hospital. S7MHT said she had transported Patient #2 from the outpatient clinic to the inpatient hospital. S7MHT indicated she had used a geri-chair with a lap tray secured across the patient ' s lap to keep the patient in the chair for transport between the 2 buildings (outpatient clinic and inpatient hospital). She confirmed the patient had remained in the geri-chair with the lap tray in place after transport to the inpatient hospital. S7MHT indicated Patient #2 had requested water and ice chips. She indicated the patient had been unable to hold the cup herself due to her tremors and movements. S7MHT said she had to place ice chips in the patient ' s mouth and had to hold the cup and straw for the patient to drink water.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to ensure patient vital signs had been obtained and documented for 1 (#2) of 5 (#1-#5) sampled patient records reviewed.
2) failing to ensure MHTs had maintained observation levels and documented every 15 minute observations for 6 (#3,#R1,#R2,#R3,#R4,#R5) of 6 patients observed on every 15 minute check observation levels.
3) failing to document a patient's fall in the patient's medical record for 1 of 1 (#4) sampled patients reviewed for falls out of a total sample of 5 (#1-#5).

Findings:

1) Failing to ensure patient vital signs had been obtained and documented.

Review of Patient #2's medical record revealed an admission date of 3/8/16 at 1:30 p.m. with admission diagnoses of major depressive disorder and pseudo-seizures. Further review revealed the following co-morbid diagnoses: seizure disorder, hypothyroid, chronic kidney disease and hypertension. Additional review revealed Patient #2 expired in the hospital on 3/8/16 at 7:58 p.m.

Review of Patient #2's nursing notes revealed the patient had refused vitals on 3/8/16 at 1:30 p.m. Additional review revealed no documented evidence of further attempts to obtain vital signs on Patient #2.

Review of Patient #2's medical record revealed no documented evidence of vital sign assessments being conducted on Patient #2 from the time of the patient's admission to the time of the patient's death on 3/8/16. Review of Patient #2's vital sign graphic record revealed the following entry: 3/8/16, 1:30 p.m.: Refused. Additional review revealed no documented evidence of further staff attempts to obtain vital signs on Patient #2.

In an interview on 3/21/16 at 9:34 a.m. with S3RN, she indicated the frequency for routine vital signs was once a shift unless an increased frequency was ordered by the patient's physician or the nurse practitioner. S3RN confirmed vital sign assessments were obtained as part of the admission process. S3RN further indicated the MHTs were responsible for obtaining vital signs on the patients. S3RN confirmed another attempt to obtain vital signs should be made if the patient initially refused to have their vital signs assessed. S3RN said patient refusal of vital signs should be documented. She also said the MHTs informed the nursing staff if a patient had refused a vital sign assessment. S3RN confirmed there was only one entry on Patient #2's vital sign graphic record. She further confirmed the entry indicated the patient had refused the vital sign assessment on 3/8/16 at 1:30 p.m.

In an interview on 3/21/16 at 10:46 a.m. with S7MHT, she indicated the MHTs were responsible for obtaining patient vital signs. She confirmed vital signs were obtained on admission and once a shift. S7MHT indicated patient refusal of vital sign assessment should be reported to the patient's nurse and the refusal should be documented in the patient's medical record. S7MHT confirmed another attempt to obtain patient vital signs should be made after patient refusal.


2) Failing to ensure MHTs maintained observation levels and documented every 15 minute observations.

Review of the observation records for Patients #3, #R1, #R2, #R3, #R4, #R5 revealed all of the patients' observation levels were every 15 minute checks.

On 3/21/16 at 3:18 p.m. an observation was made of S7MHT's patient observation record documentation for Patients #3, #R1, #R2, #R3, #R4, #R5. Upon review, it was noted that S7MHTs observation sheets for Patient #3, #R1, #R2, #R3, #R4, #R5 had not been filled out since 2:30 p.m.
In an interview on 3/21/16 at 3:18 p.m. with S3RN, she confirmed S7MHT had been assigned to monitor Patient #3, #R1, #R2, #R3, #R4, #R5. S3RN indicated S7MHT had just returned from "taking out the trash." S3RN confirmed the last entries on the observation records for Patient #3, #R1, #R2, #R3, #R4, #R5 had been documented at 2:30 p.m. She also confirmed another MHT should have taken over monitoring of S7MHT's patients and should have completed their observation records.

In an interview on 3/21/16 at 3:29 p.m. with S2DON, she confirmed S7MHT should have handed off responsibility for Patients #3, #R1, #R2, #R3, #R4, #R5 to another staff member when she left the unit. S2DON also confirmed nursing staff did not sign off on the MHTs observation records every shift to verify completion.


3) Failing to document a patient's fall in the patient's medical record.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 63 year old admitted to the hospital on 01/07/16 at 5:00 p.m. with a diagnosis of Dementia with Behavior Disturbance. The record revealed the patient was admitted from a skilled nursing facility where she had been a patient for 2 days. Review of the record revealed the patient was transferred to an acute care hospital on 01/14/16 for dehydration.

Review of the record revealed Neurological checks were documented every 15 minutes from 12:45 p.m. to 7:30 p.m. on 01/13/16. There was no documentation in the record of why the neurological checks were done.

On 03/21/16 at 2:45 p.m., S12Medical Records provided all nursing documentation for the 24 hours of 01/13/16, printed from the electronic medical record. There was no documentation of why the neurological checks were implemented for the patient.

Review of the Hospital Occurrence Report dated 01/13/16 at 12:40 p.m. revealed the patient was ambulating in the hallway and was walking away from the nurse's station. The report revealed another patient stated Patient #4 was on the floor. The report revealed the patient was assisted up and no injury was noted. The report also revealed the Nurse Practitioner and the patient's spouse were notified of the patient's fall. The report indicated a fall assessment was conducted.

In an interview on 03/21/16 at 4:20 p.m., S2DON confirmed the patient sustained a fall on 01/13/16 and it was documented on an occurrence report. She confirmed the patient's fall was not documented in the medical record. She confirmed the occurrence report was not included in patient medical records.





30984

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing direct patient care had been evaluated as evidenced by failing to maintain documented evidence of skills competency evaluations, CPR certification, and Crisis De-Escalation competency for 1 (S11MHT) of 2 (S7MHT, S11MHT) direct patient care MHTs' personnel records reviewed for competency.
Findings:
S11MHT
Review of the personnel record for S11MHT revealed a date of hire of 02/18/16. Review of the application revealed no documented evidence of experience with the mentally ill or individuals with behavior disorders.
Review of the job description dated 02/18/16 revealed the job requirements were as follows: Relevant work and/or personal experience with the seriously mentally ill or individuals with emotional behavior disorders and; must maintain current CPR and CPI certifications in accordance with company policy.
Review of the New Hire Orientation form dated 02/18/16 revealed the section for documentation of CPR certification and EDGE certification was left blank.
Review of the form titled, Department Orientation revealed only the following documentation: EDGE/Bridge (non-violent de-escalation techniques): "Year completed: 16." The form was blank in the following sections: Position-Specific competency, Unit-Specific competency, MHT test, Restraint Competency. There was no documentation of any certifications or competencies in the personnel record.

In an interview on 03/21/16 at 4:40 p.m., S2DON confirmed the S11MHT did not have documentation of any competencies, did not have documentation of CPR certification, and she had not completed the EDGE training for crisis de-escalation. She confirmed the MHT was hired on 02/18/16 and had been assigned patients independently. She confirmed a MHT test was required and it had not been completed.