HospitalInspections.org

Based on observation and review of two patients (patient #42 and patient# 43)medical records and interview of the hospital nursing staff, it was determined that the hospital failed to query patients regarding if they had an Advance Directive or if they would like to execute an Advanced Directive.
The findings include:
Patient #43 was admitted on 11/27/12 severely burned after falling on a stove and Patient #42 was admitted on 10/20/12 with severe burn following a gasoline sparked fire were both admitted to the Burn Intensive Care Unit in critical condition. The review of the nursing assessments revealed a blank space where the nurse would query the patient regarding advance directives. Because of the criticality of the patient this section of the assessment may need to be deferred until family or significant other can provide the information. Further review of the medical records revealed that when the family or significant others did present to the hospital they were not asked if the patient had an advance directive. On January 22, 2013 while reviewing the medical record this area remained blank.
It is essential due to how critically ill these patients are that the advance directive query be completed as soon as possible so the practitioner can comply with the patient's care/treatment directives and/or follow their directive regarding the surrogate decision maker.

Based on interview with Administrative staff, and review of the Security Trainers Manual for Handling Aggressive Patients, the hospital's process for nurse monitoring of the safety of physical restraint techniques used by security fails to include nursing and other clinical staff in the training as evidenced by:
Interview with hospital administration revealed that Security Personnel are the only employees who are trained in, and perform manual restraint holds, transport and carries of violent and non-violent patients, though both Security and RNs are trained in mechanical restraint techniques.
The Security Trainer's Manual states that "Security will always take direction from medical staff. Security will never put a patient in restraints or seclusion without direction from medical staff." However, the clinical staff are not trained in manual holds used by security. Without appropriate training, the clinical monitoring cannot ensure that the holds are appropriate and safe and in accordance with security staff training.
Review of The Security Trainer's Manual revealed brief detail as to how manual holds, transport and carries are performed. Excerpts as follows, revealed possible unsafe and undue use of patient joints as contact points as follows:
Geriatric hold - " ...When a patient is not cooperative, the security officer approaches the patient (straight on), grabbing the wrists of the patient ... "
Handling Aggressive Patients - " The team is then shown how to hold a patient down by holding the wrists, ankles, and shoulder area, " and " the team is shown that one officer can restrain both ankles ...Instructors reinforce the importance of Teamwork and following medical staff's direction. "
Further interview with Corporate Security Administrators revealed that security staff use various technique models to perform holds, transports, and carries. Interviews revealed that security staff are taught to hold patients above and below joints. Further, and stated on inquiry, is that no known injuries have resulted from Security staff manual restraint interventions. There was also no documented evidence of previous injuries to patient .
Based on the fact that clinical staff are not trained to monitor these manual restraint interventions, discrepancies were noted between the techniques outlined in the written manual and the processes described by security. In addition, documentation to substantiate the use of safe techniques that do not involve holding patient joints could not be found.

Based on a review of the hospital Violent/Self-Destructive Behavior Policy for seclusion, and the record of patient #1, the hospital failed to discontinue seclusion at the earliest possible time. The findings include:
Patient #1 is a 20-year-old male admitted to the behavioral health unit on 1/16/2013 for aggressive, psychotic behaviors. Patient #1 became very agitated and threatening on the unit. Interventions to calm patient #1 failed, and he required seclusion where he received Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg intramuscularly. Seclusion began at 0300 on 1/17/2013. A nursing note of 0315 states in part, "Patient began to throw stress ball, which he was allowed to have, at the wall. Patient eventually (within 5 minutes) calmed himself and finally lyed (sic) down on mat. Patient is currently asleep ... "
The hospital's policy for Locked Door Seclusion (LDS) for Acute Psychiatric Unit & Emergency Department Only (effective 04/1/2012) states under Release, Discontinuation of Seclusion:
"1. The RN who has demonstrated and documented competency , may discontinue seclusion based on the assessment of a patient's need for seclusion and, ...
4. Release, discontinuation of seclusion occurs when the patient is no longer exhibiting behaviors that justified the use of seclusion. "
A face to face nurse practitioner note of 0331 states, in part, " Pt continued to yell and threaten staff from inside of the seclusion room and flipped over his mattress several times. After 10 minutes, pt lay down on the mat and fell asleep. Pt continues to sleep in the seclusion room ... "
Nursing assessment notes of 0500 and 0700 indicated that patient #1 was asleep and would be assessed on awakening. While many other assessment details could be gathered when patient #1 awakened, the primary assessment focus for these two-hour RN assessments was to determine if seclusion needs to continue. The finding that patient #1 was sleeping, was of itself, the determining assessment factor indicating that seclusion should have be discontinued when patient #1 "calmed himself" and fell asleep. At that time, staff could have opened the seclusion room door, thereby discontinuing the intervention, and continued to monitor patient #1 while he slept. The hospital failed to release patient #1 at the earliest possible time

Based on document review and staff interviews, it was determined that one outpatient department was performing several performance improvement projects that were not accounted for in the hospital's QAPI program.

While the hospital-wide QAPI program tracks standard indicators of quality and safety for all departments, including all outpatient areas, the Outpatient Cardiac Rehabilitation clinic is performing several extra quality improvement projects, the results of which are being reported to the clinic's external professional affiliations, not to the hospital's QAPI program.

Based on document review and staff interviews, it was determined that the hospital failed to implement preventive actions and mechanisms specific to fall prevention in one ancillary department. In this department, it was determined that the hospital also failed to set clear expectations for safety.

In interviews with the radiology manager, a radiology technologist, and a radiology technology student advisor conducted during the department review on January 22, 2013, the staff could not verbalize the mechanism by which they could identify patients at high risk of fall, and could not verbalize fall prevention techniques in use throughout the hospitals. Each staff person guessed a different way to identify patients at high risk, and all were incorrect. The radiology technologists rely on a verbal report from the nurse on the unit that is sending the patient, or on information included as part of the order. The fall risk assessment and interventions in use are found in each patient's electronic medical record, but is is not clear that the radiology techs have access rights to these parts of the medical record, or the time to look up each patient they are testing to identify the risks.

The hospital uses a standardized hand off process to exchange information between nursing shifts and between nursing units in the event of a patient transfer, but no standardized hand off exists for patients who are transported to ancillary departments for testing. In addition, while the hospital QAPI program tracks patient safety indicators from all departments, the knowledge and process deficits in imaging services had not been previously identified.

Based on review of 48 open medical records, it was determined that 2 of the 48 open medical records had incomplete nursing assessment.

Based review of medical records for patient #42 and patient #43, the medical records were incomplete because the nursing assessment had areas that were blank such as the advance directive query. There was no process to ensure the incomplete areas of the nursing assessment were revisited to complete the form.

Based on interview, and a review of the emergency department and radiology resuscitation carts, is it revealed that 1. Cart checklists were incomplete or not done, 2. One cart was found unlocked, and 3. The same cart was not replaced after its use. The findings include:

On January 22, 2013 while conducting an onsite validation survey at the Johns Hopkins Bayview Medical Center the surveyors completed a tour of the hospital's Emergency (ED) and Radiology Departments. At the time of the tour, emergency resuscitation carts were examined to ensure that all necessary equipment was available, secured by lock, fully operational and had been checked by staff to ensure that the cart was ready and safe for use.

The resuscitation carts contain items such as medications needed for advanced life support, (cardiopulmonary resuscitation), a defibrillator, anaphylaxis box, tubes such as endotracheal tubes, tracheostomy tubes, an oxygen canister, suction catheters, blood tubes, arterial blood gas kits, sterile water vials, alcohol swabs, tape, IV start kits, syringes and IV solutions in addition to other items.

However, at the time of the ED tour, interview with staff and the clinical nurse specialist, it was determined that although the daily equipment checklist for the carts had been assigned to designated ED nurses, the checklists for December 2012 through January 21, 2013 indicated that there were multiple days in which the daily emergency equipment checklist was either partially completed or not completed at all. The dates included: December 7, 18, 20, 25, and 31, 2012 and January 2, 4, 6, and 7, 2013.

In addition, during tour of the Radiology/Nuclear Medicine Department, one resuscitation cart was found unsecured by a lock. When the Radiology RN was queried in regards to the cart being unsecured and fully operational if needed for an emergency, the RN informed the surveyor that the cart had been used for an emergency the prior week, but had not been replaced even though she had called for a replacement. Staff failed to follow up to ensure a replacement cart was obtained, and the daily checks of the emergency equipment also failed to indicate that the cart had been used and was in need of replacement.