HospitalInspections.org

Based on observation, interview, and record review, the facility failed to provide furnishings that did not present a safety hazard to one of one patient (Patient #1) that had a history of suicidal ideation and recent previous suicide attempts. The patient was able to tie a sheet to the handle on her bed, drape the sheet across the bed and hang herself.

Findings included:

1) Record review for Patient #1 included that she had 4 suicide attempts during the current year. Her psychiatric assessment included that she intended to hang herself that day.

2) During a tour of the inpatient unit that Patient #1 was admitted to, and a tour of her room, the facility had beds with handles 8 inches off the floor that were to be used for restraint application.

3) In an interview with the surveyor on 05/18/11 at 2:00 PM the CNO/COO (Personnel #1) was asked how the patient had hung herself. The CNO/COO explained that the patient's bed was in the corner of the room with the head against one wall and one side of the bed against a wall. She stated the patient tied the sheet on one of the handles on the long side of the bed, draped the sheet across the bed, tied the sheet around her neck and covered her head to her chest with a blanket. The CNO was asked if this bed presented a safety hazard to this patient. She confirmed that it did.

Facility: "Patient Rights Policy" reflected:

"Basic Rights for All Patients...3. You have the right to a clean and humane environment in which you are protected from harm..."

Based on record review and interview, the facility did not assure that the inpatient nurse followed the facility policy of completing a nursing assessment within 8 hours of admission for 1 of 1 patient (Patient #1) after admission to the inpatient unit.

Findings included:

1) The medical record for Patient #1 included that the patient was admitted to the PES (Psychiatric Emergency Services) unit on 04/16/11. She was admitted to the inpatient unit at 12:15 AM on 04/17/11.

2) The inpatient nursing assessment completed by Personnel #2 was started at 11:37 AM and completed at 11:40 AM on 04/17/11.

3) In an interview with the surveyor on 06/06/11 at 1:45 PM the CNO/COO (Personnel #1)was asked approximately how long the nursing assessment should have taken to complete. She stated 20-30 minutes. She was asked how the nurse had completed the assessment in 3 minutes and completed the assessment before the patient arrived on the unit. She stated the nurse had copied the assessment of the PES unit nurse from the electronic record.

Facility Policy: "Organization Wide Patient Assessment" reflected:

"2. i. The admission assessment will be completed by the RN as soon as possible upon arrival to the nursing unit, but within 8 hours of admission for the inpatient, and patient in the Psychiatric Emergency Services (PES)..."

Based on record review and interview, the Director of Psychiatric Nursing (Personnel # 1) failed to assure that nursing staff followed the facility policy for transcribing and verifying physician ordered medications to the pharmacy, in that Patient #1 received medications that were not ordered for her.

Findings included:

1) Review of the medical record for Patient #1 included that she received Geodon on 04/16/11 at 6:53 PM, Seroquel at 9:37 PM and Dilantin at 9:39 PM. On 04/17/11 she received Geodon at 8:39 AM and 3:44 PM, Seroquel 100 mg at 9:00 AM and 300 mg at 8:51 PM, and Dilantin at 8:38 AM and 8:52 PM. There were no orders for these medications.

2) In an interview with the surveyor on 06/06/11 at 1:30 PM the CNO/COO (Personnel #1) was asked if there were other medication orders. She stated there were not. She was asked how Patient #1 received medications that were not ordered for her. She stated that the nurse transcribed the physician medication order and sent it to the pharmacy. The nurse failed to follow the facility policy in that she did not verify that the pharmacy filled the medication order correctly. The medications appeared on the patient's electronic list of medications and nursing staff administered the medications from that list.

Facility Policy: "Processing of Medication Orders/Medication Administration" reflected:
"Order Process Guideline...5. The nurse is responsible for making sure that all medication orders are transcribed appropriately by pharmacy on all shifts...7. The nurse will ensure that all medications are processed correctly..."

Based on record review and interview, the Director of Psychiatric Nursing (Personnel #1)did not monitor and direct nursing care, in that nursing staff failed to follow facility policies for transcribing and verifying physician orders sent to the pharmacy resulting in Patient #1 receiving medications that were not ordered; and the inpatient unit nurse did not conduct a patient assessment for Patient #1.

Findings included:

1) Review of the medical record for Patient #1 included that she received Geodon on 04/16/11 at 6:53 PM, Seroquel at 9:37 PM and Dilantin at 9:39 PM. On 04/17/11 she received Geodon at 8:39 AM and 3:44 PM, Seroquel 100 mg at 9:00 AM and 300 mg at 8:51 PM, and Dilantin at 8:38 AM and 8:52 PM. There were no orders for these medications.

In an interview with the surveyor on 06/06/11 at 1:30 PM the CNO/COO (Personnel #1) was asked if there were other medication orders. She stated there were not. She was asked how Patient #1 received medications that were not ordered for her. She stated that the nurse transcribed the physician medication order and sent it to the pharmacy. The nurse failed to follow the facility policy in that she did not verify that the pharmacy filled the medication order correctly. The medications appeared on the patient's electronic list of medications and nursing staff administered the medications from that list.

Facility Policy: "Processing of Medication Orders/Medication Administration" reflected:

"Order Process Guideline...5. The nurse is responsible for making sure that all medication orders are transcribed appropriately by pharmacy on all shifts...7. The nurse will ensure that all medications are processed correctly..."

2) The medical record for Patient #1 included that the patient was admitted to the PES (Psychiatric Emergency Services) unit on 04/16/11. She was admitted to the inpatient unit at 12:15 AM on 04/17/11.
The inpatient nursing assessment completed by Personnel #2 was started at 11:37 AM and completed at 11:40 AM on 04/17/11.

In an interview with the surveyor on 06/06/11 at 1:45 PM the CNO/COO (Personnel #1) was asked approximately how long the nursing assessment should have taken to complete. She stated 20-30 minutes. She was asked how the nurse had completed the assessment in 3 minutes and completed the assessment before the patient arrived on the unit. She stated the nurse had copied the assessment of the PES unit nurse from the electronic record.

Facility Policy for "Organization Wide Patient Assessment" reflected:

" 2. i. The admission assessment will be completed by the RN as soon as possible upon arrival to the nursing unit, but within 8 hours of admission for the inpatient, and patient in the Psychiatric Emergency Services (PES)... "

Based on observation, interview, and record review, the facility failed to provide furnishings that did not present a safety hazard to one of one patient (Patient #1) that had a history of suicidal ideation and recent previous suicide attempts. The patient was able to tie a sheet to the handle on her bed, drape the sheet across the bed and hang herself.

Findings included:

1) Record review for Patient #1 included that she had 4 suicide attempts during the current year. Her psychiatric assessment included that she intended to hang herself that day.

2) During a tour of the inpatient unit that Patient #1 was admitted to, and a tour of her room, the facility had beds with handles 8 inches off the floor that were to be used for restraint application.

3) In an interview with the surveyor on 05/18/11 at 2:00 PM the CNO/COO (Personnel #1) was asked how the patient had hung herself. The CNO/COO explained that the patient's bed was in the corner of the room with the head against one wall and one side of the bed against a wall. She stated the patient tied the sheet on one of the handles on the long side of the bed, draped the sheet across the bed, tied the sheet around her neck and covered her head to her chest with a blanket. The CNO was asked if this bed presented a safety hazard to this patient. She confirmed that it did.

Facility: "Patient Rights Policy" reflected:

"Basic Rights for All Patients...3. You have the right to a clean and humane environment in which you are protected from harm..."

Based on record review and interview, the facility did not assure that the inpatient nurse followed the facility policy of completing a nursing assessment within 8 hours of admission for 1 of 1 patient (Patient #1) after admission to the inpatient unit.

Findings included:

1) The medical record for Patient #1 included that the patient was admitted to the PES (Psychiatric Emergency Services) unit on 04/16/11. She was admitted to the inpatient unit at 12:15 AM on 04/17/11.

2) The inpatient nursing assessment completed by Personnel #2 was started at 11:37 AM and completed at 11:40 AM on 04/17/11.

3) In an interview with the surveyor on 06/06/11 at 1:45 PM the CNO/COO (Personnel #1)was asked approximately how long the nursing assessment should have taken to complete. She stated 20-30 minutes. She was asked how the nurse had completed the assessment in 3 minutes and completed the assessment before the patient arrived on the unit. She stated the nurse had copied the assessment of the PES unit nurse from the electronic record.

Facility Policy: "Organization Wide Patient Assessment" reflected:

"2. i. The admission assessment will be completed by the RN as soon as possible upon arrival to the nursing unit, but within 8 hours of admission for the inpatient, and patient in the Psychiatric Emergency Services (PES)..."

Based on record review and interview, the Director of Psychiatric Nursing (Personnel # 1) failed to assure that nursing staff followed the facility policy for transcribing and verifying physician ordered medications to the pharmacy, in that Patient #1 received medications that were not ordered for her.

Findings included:

1) Review of the medical record for Patient #1 included that she received Geodon on 04/16/11 at 6:53 PM, Seroquel at 9:37 PM and Dilantin at 9:39 PM. On 04/17/11 she received Geodon at 8:39 AM and 3:44 PM, Seroquel 100 mg at 9:00 AM and 300 mg at 8:51 PM, and Dilantin at 8:38 AM and 8:52 PM. There were no orders for these medications.

2) In an interview with the surveyor on 06/06/11 at 1:30 PM the CNO/COO (Personnel #1) was asked if there were other medication orders. She stated there were not. She was asked how Patient #1 received medications that were not ordered for her. She stated that the nurse transcribed the physician medication order and sent it to the pharmacy. The nurse failed to follow the facility policy in that she did not verify that the pharmacy filled the medication order correctly. The medications appeared on the patient's electronic list of medications and nursing staff administered the medications from that list.

Facility Policy: "Processing of Medication Orders/Medication Administration" reflected:
"Order Process Guideline...5. The nurse is responsible for making sure that all medication orders are transcribed appropriately by pharmacy on all shifts...7. The nurse will ensure that all medications are processed correctly..."

Based on record review and interview, the Director of Psychiatric Nursing (Personnel #1)did not monitor and direct nursing care, in that nursing staff failed to follow facility policies for transcribing and verifying physician orders sent to the pharmacy resulting in Patient #1 receiving medications that were not ordered; and the inpatient unit nurse did not conduct a patient assessment for Patient #1.

Findings included:

1) Review of the medical record for Patient #1 included that she received Geodon on 04/16/11 at 6:53 PM, Seroquel at 9:37 PM and Dilantin at 9:39 PM. On 04/17/11 she received Geodon at 8:39 AM and 3:44 PM, Seroquel 100 mg at 9:00 AM and 300 mg at 8:51 PM, and Dilantin at 8:38 AM and 8:52 PM. There were no orders for these medications.

In an interview with the surveyor on 06/06/11 at 1:30 PM the CNO/COO (Personnel #1) was asked if there were other medication orders. She stated there were not. She was asked how Patient #1 received medications that were not ordered for her. She stated that the nurse transcribed the physician medication order and sent it to the pharmacy. The nurse failed to follow the facility policy in that she did not verify that the pharmacy filled the medication order correctly. The medications appeared on the patient's electronic list of medications and nursing staff administered the medications from that list.

Facility Policy: "Processing of Medication Orders/Medication Administration" reflected:

"Order Process Guideline...5. The nurse is responsible for making sure that all medication orders are transcribed appropriately by pharmacy on all shifts...7. The nurse will ensure that all medications are processed correctly..."

2) The medical record for Patient #1 included that the patient was admitted to the PES (Psychiatric Emergency Services) unit on 04/16/11. She was admitted to the inpatient unit at 12:15 AM on 04/17/11.
The inpatient nursing assessment completed by Personnel #2 was started at 11:37 AM and completed at 11:40 AM on 04/17/11.

In an interview with the surveyor on 06/06/11 at 1:45 PM the CNO/COO (Personnel #1) was asked approximately how long the nursing assessment should have taken to complete. She stated 20-30 minutes. She was asked how the nurse had completed the assessment in 3 minutes and completed the assessment before the patient arrived on the unit. She stated the nurse had copied the assessment of the PES unit nurse from the electronic record.

Facility Policy for "Organization Wide Patient Assessment" reflected:

" 2. i. The admission assessment will be completed by the RN as soon as possible upon arrival to the nursing unit, but within 8 hours of admission for the inpatient, and patient in the Psychiatric Emergency Services (PES)... "