HospitalInspections.org

The hospital failed to provide 1 of 23 Patient care in a safe setting by exposing the patients on the unit to a patient that is covid-19 positive.

Findings Include:
Through interview with staff # 3 the hospital was unaware that the patient was covid positive unit the mother called and reported the patient being Covid-19 positive.

Through interview hospital staff #2 reported that Patient #2 was admitted into the hospital and in a regular room. Once the patient was discovered to be covid positive the patient was separated from her roommate and placed into a blocked room. The roommate was placed in a blocked room and to date has not revealed any signs or symptoms of Covid-19.

Through record review Patient #2 was screened at intake. A covid-19 test was administered by an outside source. The results returned the following day. The results of the test was that Covid-19 was Detected.

Policy
The hospital Policy on Patient Rights dated 07/2020 reflected, "It is the Policy of the Hospital to ensure the patient's rights are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statues and rules and only if the exercise of those rights would constitute harm to the patient or others."

The hospital Policy on Assessment/Reassessment dated 04/2019 reflected, "All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan."

The hospital Levels of Observation and Special Precautions policy dated 04/2020 reflected, "It is the policy of the hospital to maintain safety and provide quality care to patients while maintaining their dignity and respect. (Dangerous to self, Dangerous to others), Level of Observation; (Physician may order, Special Precautions, Q15 minute checks, Q5 Observation, Line of Sight, One to One Observation, Suicide Precautions).

The hospital Policy on Infection Prevention and Control Plan dated 06/2020, reflected, "The Program is based on sound epidemiological principles and evidence-based information for reducing healthcare associated infections (HAIs) and monitoring community associated infections (CAIs). Evidence-based information gathered from CDC and Prevention., NHSN, Department of Public Health (state, local). OSHA and the joint commission."

The hospital Policy on Covid-19 Screening and Screening Log dated 08/2021 reflected, "To decrease the risk of Covid-19 infection in the hospital and reduce the risk of the spread the following screening procedure has been put in place."

The hospital failed 1 of 1 Patient (Patient #1) by no administering in accordance with the orders of the practiioniro or the practitioners responsible for the patient's care as specified under 482.12(c), and acceptd standards of practice. All drugs administered or under supervision of, nursing or other personnel in accordance with Federal and State laws abd regulations, including applicable licensing requirement, and in accordance with the approved medical staff policies and procedures.

Findings Include
Through interview with hospital Staff #5, Patient #1 was ordered Topriamate Trplemdo XR 200mg. The hospital did not have the (XR 200mg version of Topiramate Trokendi). The hospital only had Topriamate Trokendi 100mg and they attempted to change his prescription to give him the 100mg version of the medication twice a day verses his 1 daily administration of the XR200mg. Patient #1 refused all medication because he did not trust the hospital.

Policy
The hospital Policy on Patient Rights dated 07/2020 reflected, "It is the Policy of the Hospital to ensure the patient's rights are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statues and rules and only if the exercise of those rights would constitute harm to the patient or others."

The hospital Formulary Policy dated 09/2021 reflected, "The hospital has a Drug Formulary, which has been developed by the Pharmacy and Therapeutics Committee and approved by the Medical Staff ...The medications are selected on the basis of the patient need and safety and not solely on economics."

The hospital Policy on Non-Formulary Medications dated 09/2019 reflected, "It is the policy of Haven Behavioral Healthcare that providers should use formulary drugs whenever possible. Non-formulary drugs may be used in the facility only after the provider has determined that a drug available on our formulary is not appropriate, provided that the drug has not been specifically prohibited by the Medical staff from use in the facility ...Patients who are admitted on medication(s) which are not on the formulary will be provided those medication(s) without the restrictions of this policy."

The hospital Pharmacy Quality Improvement Program dated 12/2018 reflected, "The Pharmacy Department will develop and employ a Quality Improvement Program (which functions within the overall context of the hospital's Quality Improvement Program) to assess and regulate the quality of the service within the hospital."

The hospital Pharmacy Infection Control Policy dated 06/2021 reflected, "The hospital will institute an infection control policy to monitor and prevent the dispensing and administration of contaminated medications and to prevent in-house spread of infection. All Pharmacy personnel shall follow the guidelines for personal hygiene used throughout the facility to provide cleanliness, to maintain a clean environment, and prevent the spread of bacteria from the pharmacy to other areas of the hospital."

The hospital Policy on Medication Administration dated 09/2021 reflected, "No medication will be administered which does not conform to the guidelines outlined in the following policies."

The hospital Policy on Medication Administration dated 09/2021 reflected, "No medication will be administered which does not conform to the guidelines outlined in the following policies."

The hospital failed 1 of 1 Patient (Patient #1) by the Delivery of Services medication was offered to that was not the same medication that the Patient was taking at home in order to provide patient safety, drugs must be distributed in accordance with applicable standards of practice, consistent with Federal and State law.


Findings Include
Through interview with hospital Staff #5, Patient #1 was ordered Topriamate Trplemdo XR 200mg. The hospital did not have the (XR 200mg version of Topiramate Trokendi). The hospital only had Topriamate Trokendi 100mg and they attempted to change his prescription to give him the 100mg version of the medication twice a day verses his 1 daily administration of the XR200mg. Patient #1 refused all medication because he did not trust the hospital.

Policy
The hospital Policy on Patient Rights dated 07/2020 reflected, "It is the Policy of the Hospital to ensure the patient's rights are protected and maintained. All patients are informed of their rights verbally and in writing upon admission. Any limitation of the patient's rights shall be made in accordance with applicable statues and rules and only if the exercise of those rights would constitute harm to the patient or others."

The hospital Formulary Policy dated 09/2021 reflected, "The hospital has a Drug Formulary, which has been developed by the Pharmacy and Therapeutics Committee and approved by the Medical Staff ...The medications are selected on the basis of the patient need and safety and not solely on economics."

The hospital Policy on Non-Formulary Medications dated 09/2019 reflected, "It is the policy of Haven Behavioral Healthcare that providers should use formulary drugs whenever possible. Non-formulary drugs may be used in the facility only after the provider has determined that a drug available on our formulary is not appropriate, provided that the drug has not been specifically prohibited by the Medical staff from use in the facility ...Patients who are admitted on medication(s) which are not on the formulary will be provided those medication(s) without the restrictions of this policy."

The hospital Pharmacy Quality Improvement Program dated 12/2018 reflected, "The Pharmacy Department will develop and employ a Quality Improvement Program (which functions within the overall context of the hospital's Quality Improvement Program) to assess and regulate the quality of the service within the hospital."

The hospital Pharmacy Infection Control Policy dated 06/2021 reflected, "The hospital will institute an infection control policy to monitor and prevent the dispensing and administration of contaminated medications and to prevent in-house spread of infection. All Pharmacy personnel shall follow the guidelines for personal hygiene used throughout the facility to provide cleanliness, to maintain a clean environment, and prevent the spread of bacteria from the pharmacy to other areas of the hospital."