HospitalInspections.org

Based on a review of documentation, the governing body failed to ensure that the medical staff has current bylaws which are implemented and enforced.

Findings were:

In a review of the clinical record for patient #1, the following was noted:
Patient #1 became aggressive and assaultive toward staff and peers and was placed in a personal restraint on 2-28-18 from 4:20 am to 4:22 am. Nursing notes state:
" 2-28-18 at 4:45 am - "Pt [patient] had previously pulled staff hair @ [at] 0251 [2:51 am] and received Zyprexa Zydis. Pt [#1]continuously got more aggressive, pt then hit staff and pulled off staff glasses, pt was ordered Haldol 10mg [milligram] Ativan 2mg Benadryl 50mg, pt unwilling to take meds willingly, placed pt in approved CPI [crisis prevention & intervention] hold to administer IM [intramuscular] meds. Pt was released @ 0422 [4:22 am], at 0425 [4:25 am] pt attempted to hit staff, staff deflected hit per CPI and attempted to turn pt. Pt then tripped on pt own slip on sandals and hit face on wall, L [left] nare bleeding until 0445 [4:45 am], [staff #5] notified placed pt on neuro assessment protocol, med consult placed. Noted that pt consciousness has had no change to consciousness ..."

Patient #1 again became aggressive and was placed in seclusion from 5:01 am until 6:18 am. A verbal/telephone order for the restraint and seclusion was given by [staff #5].

Review of the credentialing file for staff #5 revealed no delineated privileges and no letter indicating active appointment.

Facility Governing Board Bylaws state, in part:
"Article 2, General Provisions:
...
2.5 Staff Appointment and Privileges:
In order for any LIP [licensed independent practitioner] or AHP [allied health professional] to practice in the Hospital, such individual must first be appointed to either the Medical Staff or the AHP Staff and be granted specific Clinical Privileges."

The above was confirmed in an interview with the CEO and Director of PI/Risk Management on the afternoon of 4-4-18.

Based on a review of documentation, the facility failed to ensure the patient's right to care in a safe setting.

Findings were:

A review of the observation sheets completed throughout patient #1's stay revealed the following gap in monitoring:
" 3-14-18 - No monitoring was documented from 11:40 pm until 12:00 am.

A review of the observation sheets completed throughout patient #2's stay revealed the following gap in monitoring:
" 3-11-18 - No monitoring was documented from 11:30 am until 12:00 pm.
" 3-15-18 - No monitoring was documented from 4:30 pm until 5:00 pm.

Facility policy PC-032 titled "Observations, Patient" states, in part:
"Policy:
In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [registered nurse]. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level.
Procedure:
The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change:
" 15 minute
" 5 minute
" One-to-one
...
Documentation of Observations:
" Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following ..."

The above was confirmed in an interview with the CEO and Director of PI/Risk Management on the afternoon of 4-4-18.

Based on a review of clinical records, the facility failed to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care.

Findings were:

Patient #1 was both restrained and secluded on 2-28-18. A review of patient #1's treatment plan revealed an initial treatment plan done at the time of [patient #1's] admission on 2-28-18 and a master treatment plan completed on 3-2-18. The master treatment plan contained no documentation of patient #1's restraint and seclusion on 2-28-18. There was no update to the treatment plan performed until 3-13-18.

Facility policy PC-047 titled "Treatment Planning" states, in part:
"Policy:
Each patient's treatment shall be guided by a multidisciplinary treatment plan. The treatment plan is the tool used by the physician and multi-disciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals.
Procedure:
...
5.0 Treatment plan updates shall be documented at least weekly, as the physician and treatment team asses(sic) the patient's current clinical status, review progress toward treatment plan goals, and make necessary modifications.
...
7.0 A review of the patient's Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made."

The above was confirmed in an interview with the CEO and the Director of PI/Risk Management on the afternoon of 4-4-18.

Based on a review of documentation, the facility failed to ensure that orders for restraint or seclusion were not written as a standing order or on an as-needed basis.

Findings were:

A physician's order for patient #1 (written on 2-28-18 at 4:15 am by staff #5) stated, in part "May initiate personal restraint if necessary".

Facility policy PC-043 titled "Restraint" states, in part:
"Policy:
...
" Restraint may only be ordered by a practitioner (Physician, Nurse Practitioner or Physician Assistant). Orders for restraint shall never be written as a standing order or on [an] as needed basis (PRN). "

The above was confirmed in an interview with the CEO and Director of PI/Risk Management on the afternoon of 4-4-18.