HospitalInspections.org

Based on policy review, medical record review, observations during tours, and staff interviews, the nursing staff failed to evaluate and supervise the delivery of patient care by 1) failing to follow hospital policy for care and maintenance of Intravenous infusions for 2 of 2 sampled patients (#16 and #17) and 2) failing to order suicide precautions or monitor a patient for safety per policy for 1 of 1 sampled patients voicing suicidal ideation reviewed. (#8)

The findings include:

1. Review of hospital policy, "Intravenous Therapy Management for Pediatric and Adult Patients, with revision date of August 15, 2015, revealed "....9. Infusion Set/Solution Replacement Schedule....b) All IV (intravenous) tubing will be labeled with the expiration date and time when placed....Documentation.....5. Label all intravenous site dressings with the following information. a) Insertion date b) Insertion time c) Initials of the clinician inserting catheter. 6. If dressing needs to be changed prior to site rotation, re-label the dressing with: a) Insertion date. 7. Dressing change date and initials of clinician performing dressing care."

A. Open medical record review of Pt (patient) #16 revealed a 36 year old male admitted to the hospital on 07/12/2016 for complaints of muscle cramps and fatigue with diagnosis of Acute Renal failure and Urinary Tract Infection. Review of physician's orders revealed "....hydrated with normal saline vigorously at 150 ml/hr (milliliters an hour)."

Observation of pt #16 on 07/14/2016 at 1015 revealed an IV (intravenous) site on right forearm with NS (normal saline) infusing on IV pump at 150 ml/hr and left antecubial (elbow area) heplock (device used to administer medicines or IV fluids). Further observation revealed no dates on tubing or dates, times of insertion or initials of person inserting the IV on the IV dressing.

Interview with clinical unit leader #1 on 07/14/2016 at 1030 revealed there were no dates on sites or tubing. Further interview revealed policy was not followed requiring dates on tubing and sites.

B. Open medical record of Pt #17 revealed an 83 year old male admitted on 07/11/2016 for shortness of breath with diagnosis of Acute kidney injury, acute blood loss anemia, and Upper GI (gastrointestinal) bleed.

Observation of pt #17 on 07/14/2016 at 1030 revealed left forearm heplock and left upperarm IV site with fluids infusing on pump. Further observation revealed no written dates on tubing or dates, times of insertion or initials of person inserting the IV on the IV dressing.

Interview with clinical unit leader #1 on 07/14/2016 at 1030 revealed there were no dates on sites or tubing. Further interview revealed policy was not followed requiring dates on tubing and sites.




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2. Review of Policy "Suicide Screening and Precautions", dated 11/17/2014, revealed "...POLICY A. Screening Patient for Suicide Risk. All inpatient and emergency department patients....will be screened for risk of suicide....Patients with a positive suicide risk screen are placed on suicide precautions....B. Order Required to Initiate Suicide Precautions. An order from a physician, physician's assistant or nurse practitioner is required to initiate suicide precautions. Exception: a nurse or ED behavioral health specialist may initiate suicide precautions in an emergency and then obtain an order within 1 hour....E. Types of Monitoring: Patient on suicide precautions will be monitored by a safety attendant on a 1:1 basis. Exceptions to 1:1....Inpatient Behavioral Health Units....Secured Access ED Rooms with Video Monitoring Equipment....A minimum of a 1:4 staff to patient ratio, exclusive of the person monitoring the video monitoring screens, will be maintained in the Secured Access Area. This staff member will be assigned to round in the area continuously documenting the condition /status/location of each patient on suicide precautions at least once every 15 minutes Non-BH suicide Precautions Observation Record.....F. Safety Attendants. Family/patient representatives/ friends may not be used as safety attendants. Safety attendants will: 1. Monitor for general appearance and behavior, respiratory status, skin color, and needs of the patient (nutrition, comfort, elimination needs, safety needs) 2. Document observations every 15 minutes. Emergency departments...will use the Non-BH Suicide Precautions Observation Record (in paper or electronic form). ..."
Closed medical record review for the named patient (Pt # 8), on 07/13/2016, revealed the patient, a 65 year old, arrived to the Emergency Department (ED) on 05/10/2016 at 2044 with chief complaints of cough and altered mental status. ED record review revealed a suicide risk screen at 2052 "...Does the primary Dx (diagnosis) or Problem for this visit require treatment for a behavior/emotional disorder?: No ; Is this hospitalization / visit related to substance abuse?" No ; Does your patient suffer from chronic pain, depression, sleeplessness, use of multiple narcotics?: No. ..." Review of ED Provider Note, date of service 05/10/2016 at 2055 revealed "...Patient is a 65-year-old white female who has some mild dementia and she recently has been treated with a PICC (peripherally inserted central catheter, a form of intravenous access that can be used for a longer period of time) line for IV home antibiotics for persistent UTI (Urinary Tract Infection)....So the family is not sure if this is acting out secondary to some type of infection such as a persistent UTI. The daughter states that she ran out of the home today she was very confrontational, and she has periods of crying and aggressive behavior. Patient also told family today. She was feeling suicidal and wanted to kill herself....Mental Health Evaluation Presenting symptoms: Aggressive behavior, agitation, depression and disorganized thought process. Presenting symptoms: no delusions, no disorganized speech, no hallucinations and no homicidal ideas. ..." Review of ED Provider Note did not reveal further documentation related to suicidal thoughts. Review did reveal the patient was having "...anxiety, feelings of worthlessness, irritability and poor judgment" and that "...Patient is extremely anxious and confrontational with her family member. Patient is walking around in the ER because she is unable to sit and be comfortable in the room. ..." Review of ED Patient Care Timeline revealed, on 05/11/2016 at 0019 "Access Consult - Psychiatry" and at 0046 "ED Disposition set to Behavioral Health". Timeline review revealed at 0256 "...BH (Behavioral Health) Access Screening....Patient states that she was very upset earlier today and made the statement that she did not want to live anymore. Caregiver states that patient has been experiencing a drastic mood swings.....Informed that patient has hx (history) of bipolar and schizophrenia, and family became concerned when she started voicing SI (suicidal ideation) with plan to hang herself. ..." At 0308, review revealed "...Potential Risk to Self- Suicidal threats/behaviors in past 6 months? Yes ; Suicidal Ideation or Suicide Threats; Yes ; Recent attempt to Harm Self?: No ; Intent for above: Yes....Patient able to reliably contract for safety?: No" Further Timeline review revealed, at 0507, "Patient's sitter remained with patient during the assessment at her request. Patient did acknowledge making the statement that she wanted to kill herself. Both the sitter and patient's son noted drastic changes in patient's behavior in the past week. Informed that she has been irrational and experiencing severe mood swings. Patient has an extensive psychiatric history according to her son....He communicates concerns for her safety as she has communicated SI with plan. ..." ED Timeline review did not reveal an order for suicide precautions. Review did reveal 15 minute safety checks began at 0530 and continued until the patient was admitted to the inpatient behavioral health unit. ED medical record review did not reveal evidence of a either a hospital sitter or 15 minute safety checks before 0530.
Review of a hospital schedule, dated 05/10/2016, revealed a list of sitters and assignments. Review revealed patient names and room numbers along with columns for 7am-3pm, 3pm-11pm, and 11pm-7am. Review revealed a sitter name under the column 7p11p (for 1900-2300), then an arrow and the number 18 under the column labeled 11p7a (2300 -0700).
Interview with MD # 1, on 07/14/2016 at 1440, revealed the 2055 time on the ED Provider Note was not the time the ED physician saw the patient, instead it was the time the physician was assigned as the ED attending. Interview revealed the time the physician saw the patient was not visible on the computer record as printed, but was available in the background and on some computer views. Interview revealed the actual time of the physician note was 05/10/2016 at 2324.
Interview with Nurse Manager (NM) # 1, on 07/14/2016 revealed that the first notation related to suicidal ideations occurred on 05/11/2016 at 0019. Interview revealed the sitter schedule indicates a sitter was sent to Pt # 8's ED room sometime during the night. The schedule showed, interview revealed, that a sitter was sent to room 18 on the 11-7 shift, but the schedule did not indicate what time this occurred. Interview revealed sitters document 15 minute safety checks. Further interview revealed sitters use a paper form rather than directly putting information into the computer. The paper forms, NM # 1 stated, are scanned into the computer. In this case, interview revealed, there was not a scanned form in the computer for Pt # 8 to indicate if there was 15 minute monitoring or a sitter present. Further interview revealed NM # 1 tried to find the actual paper form, but was not successful in locating it. Interview revealed there was nothing available to indicate Pt # 8 was monitored per policy in the ED after knowledge of suicidal ideation.
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