HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to obtain the patient's or patient's representative's consent prior to treatment with psychotropic medication for 2 of 5 patients under the age of 18 (Patients #1 and 8) in the medical record review sample. Findings included:

Review of hospital policies and documents review revealed:

"Medication Administration for Nursing" policy: " ...The MD ordering medications is responsible for obtaining the necessary consents prior to administration of the first dose of psychiatric medications, and for documenting such in the notes section of HCS or on the consent form. The nurse administering the first dose of new psychiatric medication must witness consents for patients and or guardians ..."

Review of medical record revealed:

A. Patient #1 (Admission 2/16/22)
1. "FINAL Physician Medication Orders" stated:
2/16/22 at 3:17PM the following medications were ordered:
-atomoxetine (for attention) ...80mg PO (by mouth) daily
-atomoxetine (for attention) ... 25mg PO daily
-paliperdone ER (for mood) ... 1.5mg PO BID (twice a day)
-divalproex ER (for mood) ... 250 mg PO AMHS (in the morning and at bedtime)

2/16/22 at 9:31 PM
-diphenhydramine injectable (aggression) ... 50mg IM (intramuscular) STAT

2/22/22 at 3:26 PM
-diphenhydramine (aggression) ... 50mg PO STAT

2/22/22
-diphenhydramine (aggression) ... 50mg PO STAT

2/24/22
-diphenhydramine (aggression) ... 50mg PO STAT

2/25/22
-diphenhydramine (aggression) ... 50mg PO NOW

2/28/22
-diphenhydramine (aggression) ... 25mg PO NOW

2. Medication Administration Record (MAR) shows:
-paliperidone given 2/16/22 - 3/3/22 (30 doses)
-atomoxetine given 2/17/22 - 3/3/22 (15 doses)
-divalproex given 2/16/22 -3/3/22 (30 doses)
-diphenhydramine given 2/16/22, 2/22/22, 2/24/22, 2/25/22, 2/28/22 (5 doses)

3. There is no evidence of consent given for these medications.

Findings confirmed by Chief Operating Officer (COO) A at 11:30 am on 5/5/22.

2. Patient #8 (admission 10/14/21)
1. "FINAL Physician Medication Orders" stated:
10/14/22
-hydroxyzine pamoate 25 mg PO QID (four times a day) PRN (as needed for anxiety)

2. Medication Administration Record (MAR) shows:
-hydroxyzine pamoate 25 mg given 10/18/21 - 10/22/21 (5 doses)

3. There is no evidence of consent given for this medication.


Findings confirmed by Chief Operating Officer (COO) A at 11:30 am on 5/5/22.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to keep 1 out of 5 patients under the age of 18 (Patient # 8) in the medical record review sample free from abuse. Findings included:

Review of hospital policies and documents review revealed:

"Behavior Management Program" policy: " ...The charge R.N. shall assess the patient for physical injury and notify the attending physician for appropriate follow-up treatment as soon as possible. The charge R.N. or other staff witnessing the incident in accordance with policy will complete an occurrence report ..."

"Reporting Suspected Victims of Abuse, Mistreatment, and Neglect" policy: "Abuse shall mean: the willful infliction of injury ...with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another ...Physical abuse is the intentional mistreatment of an individual that may cause physical injury (hitting, slapping, pinching, or kicking ...) ...An employee who hears from a patient or visitor, or observes a potential case of patient abuse .... Will immediately report it to their supervisor or hospital CEO. An Incident Report must also be completed regarding the incident ...The Hospital shall investigate the incident as soon as possible depending upon circumstances ...The Nurse Manager, Nursing Supervisor, or a member of the leadership team will inform the family/significant other ..."

Review of medical record revealed:
A. Patient #8 (admission 10/14/22)
1. Social Work Note written on 10/22/22 at 1:00pm states" met with pt (patient) who advised that a peer hit him in the chest area last evening ... between 6:00 - 7:00 PM. Notified the hospital Risk Manager (name given) of the incident, time, and location."

2. In an interview on 5/4/22 between 1:55PM and 3:30PM Chief Operating Officer A indicated that verbal complaints would only be put in the (incident) log if it couldn't be addressed at the time. They said if a patient was hit by a peer it should have been put into the (incident) log.

3. There is no evidence of facility follow up on this incident including: recording in the incident log, completion of an occurrence or incident report, or a nursing assessment for physical injury.

Findings confirmed with Chief Operating Officer A at 12:11PM on 5/5/22.

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 3 of 10 patients (Patient #1.4, and 8) in the medical record review sample. Findings included:

I. Review of hospital policies and documents review revealed:

"Rockford Center Job Description - Registered Nurse" states: " ...Registered Nurse provides direct nursing care to patients as prescribed by the physician ...Conducts ongoing and individualized nursing care duties as assigned and as dictated by the patient's condition in accordance with physician orders and facility protocols"

"Rockford Center Job Description - Licensed Practical Nurse" states: " ...LPN provides direct nursing care to patients as prescribed by the physician"

"Assignment of Patient Care" policy states, " ...Registered nurses are responsible for nursing care involving ... medical procedures, such as dressing changes, treatments..."

Review of medical record revealed:

A. Patient #4 (admission 4/6/22)

1. "Nursing Admission Assessment" Skin Integrity section, dated 4/6/22, included documentation of "Abscess to L (left) arm"

2. "Consult Form", dated 4/7/22, stated, " ...L (left) antecubital wound, pack with iodoform packing ...daily, cover with DSD (dry sterile dressing)/tape"

3. Physician's Orders, dated 4/9/22 at 8:30 AM, stated, "Discontinue the iodoform packing ...clean the wound with saline ...change the dressing daily x 5 days"

4. "Daily Nurse Progress Note":
a. Section labeled "Medical Assessment" stated, " ...If yes [to any section], document in the narrative."
b. "Skin" assessment documented as "no" for "Alteration in integrity, skin color changes, scratches, cuts" on the following dates and shifts:
- 4/7/22, day and evening shifts
- 4/8/22, day and evening shifts
- 4/9/22, day and evening shifts
c. "Treatment Plan Progress" narrative note section stated, "Note Observations, Interventions, and Progress Towards Treatment Plan Goals"
d. No documentation of wound to left antecubital, or dressing changes on the following dates:
- 4/7/22
- 4/8/22
- 4/9/22

In an interview on 5/5/22 at 1:34 PM Chief Operating Officer (COO) A indicated that nurses are to document medical interventions, such as wound care and dressing changes, on the "Daily Nurse Progress Note" form. At that time COO A confirmed no evidence of ordered dressing changes being done from 4/7/22 to 4/9/22.

II. Review of hospital policies and documents review revealed:

"Rockford Center Job Description - Registered Nurse" states: " ...Registered Nurse provides direct nursing care to patients as prescribed by the physician ...Conducts ongoing and individualized nursing care duties as assigned and as dictated by the patient's condition in accordance with physician orders and facility protocols"

"Rockford Center Job Description - Licensed Practical Nurse" states: " ...LPN provides direct nursing care to patients as prescribed by the physician"

"Patient Observation Policy" states: " ...Charge Nurse/Nursing Supervisor/Team Leader: ...Ensures the Patient Observation Rounds are occurring as ordered, 24 hours per day, seven days a week with reviewing the rounding sheet every four hours and then sign, date, and time ...RN/RS (recovery specialist) ...Clearly print employee's full name and initials in the appropriate section(s) of the patient observation form ..."

"Assignment of Patient Care" policy states, " ...Registered nurses ... are also responsible to provide oversight of the patient observation process ..."

Review of medical record revealed:

A. Patient #1 (Admission 2/16/22)
1. Physician's Orders revealed orders for:
a. On 2/16/22 at 2:42 PM - level of observation to be every 15 minutes, and precautions to include "self harm risk" and "suicidal precautions".
b. On 2/28/22 at 3:08 PM - precaution for "sexually aggression risk"

2. The "Patient Observation Record" showed:
a. Missing nurse supervision signatures for the following dates and time frames:
-2/16/22: 12Pm - 4PM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-2/17/22: 8AM - 12PM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-2/18/22: 4PM - 8PM, 8PM - 12AM (2/6 supervisory periods)
-2/19/22: 8AM - 12PM, 12PM - 4PM, 4PM - 8PM, 8PM - 12AM (4/6 supervisory periods)
-2/20/22: 4AM - 8AM, 8AM - 12PM, 12PM - 4PM, 4PM - 8PM, 8PM - 12AM (5/6 supervisory periods)
-2/21/22: 4AM - 8AM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-2/22/22: 4AM - 8AM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-2/23/22: 4PM - 8PM, 8PM - 12AM (2/6 supervisory periods)
-2/24/22: 12Pm - 4PM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-2/25/22: 4PM - 8PM, 8PM - 12AM (2/6 supervisory periods)
-2/26/22: 8AM - 12PM, 12PM - 4PM, 4PM - 8PM, 8PM - 12AM (4/6 supervisory periods)
-2/27/22: 4AM - 8AM, 8AM - 12PM, 12PM - 4PM, 8PM - 12AM (4/6 supervisory periods)
-2/28/22: 4AM - 8AM, 8AM - 12PM, 12PM - 4PM, 4PM - 8PM, 8PM - 12AM (5/6 supervisory periods)
-3/1/22: 4AM - 8AM, 8AM - 12PM, 4PM - 8PM, 8PM - 12AM (4/6 supervisory periods)
-3/2/22: 12Pm - 4PM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-3/3/22: 8AM - 12PM (1/3 supervisory periods)

b. Missing "Suicidal" and "Self-injury" precautions on the following dates:
-2/28/22 - after 3:15PM
-3/1/22
-3/2/22
-3/3/22
Findings confirmed by Chief Operating Officer (COO) A at 11:30 am on 5/5/22.

B. Patient #8 (admission 10/14/21)
1. The "Patient Observation Record" showed:
a. Missing nurse supervision signatures for the following dates and time frames:
-10/16/21: 8AM - 12PM, 12PM - 4PM (2/6 supervisory periods)
-10/17/21: 12PM - 4PM, 4PM - 8PM, 8PM - 12AM (3/6 supervisory periods)
-10/18/21: 4PM - 8PM, 8PM - 12AM (2/6 supervisory periods)
-10/20/21: 4PM - 8PM, 8PM - 12AM (2/6 supervisory periods)
-10/21/21: 8PM - 12AM (1/6 supervisory periods)
-10/22/21: 4PM - 8PM, 8PM - 12AM (2/6 supervisory periods)

Findings confirmed by Chief Operating Officer (COO) A at 11:30 am on 5/5/22.

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to administer medications in accordance with the practitioner's orders for 1 of 5 patients under the age of 18 (Patient #1) in the medical record review sample. Findings included:

Review of hospital policies and documents review revealed:

"Rockford Center Job Description - Registered Nurse" states: " ...Registered Nurse provides direct nursing care to patients as prescribed by the physician ...Administer patient medication as prescribed by physician. Assessing Vital signs and accu-checks prior to dispending medications ..."

"Rockford Center Job Description - Licensed Practical Nurse" states: " ...LPN provides direct nursing care to patients as prescribed by the physician ... Administer patient medication as prescribed by physician ...following up on vital signs and accu-check results prior to dispensing medications ..."

"Assignment of Patient Care" policy states, " ...Registered nurses are responsible for nursing care involving medication administration..."

Review of medical record revealed:

A. Patient #1 (admission 2/16/22)
1. "FINAL Physician Medication Orders" stated:
-With a start time of 2/17/22 at 8:00AM: "clonidine (for mood) ... 0.1mg PO (by mouth) QAM (in the morning) ...Notes: Hold (do not give) for SBP<90 DBP<60 (low blood pressure) HR<60 (low heart rate)"
-With a start time of 2/17/22 at 9:00PM: "clonidine (for mood) ...0.2mg PO (by mouth) QHS (at bedtime) ...Notes: Hold (do not give) for SBP<90 DBP<60 (low blood pressure) HR<60 (low heart rate)"

2. Medication Administration Record (MAR) shows:
Clonidine 0.1mg PO was given on the following dates and times:
-2/18/22 at 8:07AM
-2/19/22 at 7:42 AM
-2/20/22 at 8:49AM
-2/21/22 at 8:08AM
-2/23/22 at 7:42AM
-2/25/22 at 7:44AM
-2/26/22 at 7:41AM
-2/27/22 at 8:33AM
-2/28/22 at 7:53AM
-3/1/22 at 7:52AM
-3/3/22 at 7:58AM

Clonidine 0.2mg PO was given on the following dates and times:
-2/17/22 at 8:09PM
-2/18/22 at 8:10PM
-2/19/22 at 7:53PM
-2/20/22 at 8:04PM
-2/21/22 at 7:41PM
-2/22/22 at 8:32PM
-2/23/22 at 9:08PM
-2/24/22 at 7:17PM
-2/25/22 at 7:18PM
-2/26/22 at 8:17PM
-2/27/22 at 7:45PM
-2/28/22 at 8:59PM
-3/1/22 at 9:00PM
-3/2/22 at 8:00PM

3. Vital signs were recorded on the "Inpatient Corona Virus (COVID-19) Screening" form shows that vital signs were taken after morning clonidine administration on the following dates and times:
-2/18/22 at 8:21AM
-2/19/22 at 9:14 AM
-2/20/22 at 9:06AM
-2/21/22 at 8:40AM
-2/23/22 at 8:00AM
-2/25/22 at 8:00AM
-2/26/22 at 9:30AM
-2/27/22 at 9:55AM
-2/28/22 at 8:26AM
-3/1/22 at 8:00AM
-3/3/22 at 8:00AM

4. Vital signs were out of range for the administration of clonidine, per prescriber's orders on the following dates:
-2/21/22 Blood pressure 103/57
-2/22/22 Blood pressure 115/55
-2/23/22 Blood pressure 103/58
-2/26/22 Blood pressure 91/52
-2/28/22 Blood pressure 115/59
-3/1/22 Blood pressure 126/58

5. There is no evidence of provider notification for medication given out of ordered parameters.

6. There is no evidence of vital signs being taken in the evening prior to clonidine administration.

Interview with Chief Operating Officer (COO) A on 5/5/22 at 11:30 confirmed the above findings.