HospitalInspections.org

Based on record reviews and staff interview, the hospital failed to ensure a registered nurse supervised the nursing care for each patient. This deficient practice was evidenced by the nursing staff failing to ensure a patient's (#11) Lithium level was done as ordered by the physician for 1 (#11) of 2 (#11, #13) sampled patients reviewed for change in condition/hospitalizations from a total sample of 17 patients.

Findings:

Review of Patient #11's medical record revealed an admit date of 01/05/2021.

Review of Patient #11's Medication Administration Record revealed, in part: Lithium Carb 450 mg ER tab, start date 01/05/2021. Take 1 tablet by mouth twice a day. Further review of Medication Administration Records revealed the patient was administered the medication as ordered from 01/05/2021 through 01/14/2021.

Review of Patient #11's Physician Orders dated 01/11/2021 at 1:00 p.m. revealed, in part: Lithium level.

Review of Patient #11's medical record revealed no evidence of a Lithium level on 01/11/2021, 01/12/2021, 01/13/2021, and 01/14/2021.

Review of Patient #11's medical record revealed a Lithium level critical result of 1.80 mEq/L (reference range 0.60- 1.20 mEq/L) on 01/15/2021 at 9:40 a.m.

Review of Patient #11's Physician Orders dated 01/16/2021 at 11:10 a.m. revealed, in part: Send to Emergency Room related to Lithium toxicity and increasing symptoms.

In an interview on 06/02/2021 at 11:57 a.m., S2DON confirmed Patient #11's Lithium level was not done as ordered on 01/11/2021. S2DON indicated Patient #11 refused to have the lab drawn. S2DON confirmed there was no documented evidence the registered nurse notified the physician that the patient's Lithium level ordered on 01/11/2021 was not done.

In an interview on 06/03/2021 at 2:00 p.m. with S2DON, she reported the nursing staff should have been performing chart checks to capture any possible missed orders such as labs not being obtained as ordered. She indicated the missed Lithium level order should have been picked up if the chart checks had been performed properly.

Based on record review and interview, the hospital failed to ensure all patient medical records were accurately written and documentation was complete. This deficient practice was evidenced by failure to ensure patients' ordered precautions were documented on the patients' daily observation logs for 3 (#3, #8, #9 ) of 10 (#1-#10) patient records comprehensively reviewed from a total patient sample of 17.

Findings:

Review of the hospital policy titled, "Precautions", Policy Number: NUR-008, presented as current by S2DON, revealed the following, in part: Purpose of the policy is to provide staff with guidelines for monitoring patients that are placed on special precautions. Procedure (for all types of precautions): The MHT shall designate the precautions on the daily observation sheets.

Patient #3
Review of Patient #3's medical record revealed and admit date of 05/23/2021 with admission diagnoses of Schizophrenia and Bipolar Disorder. Further review revealed Patient #3 had physician's orders for every 15 minute observations and seizure precautions.

Review of Patient #3's Observation logs dated 5/23/2021 at 10:20 a.m., 5/24/2021 at 7:00 a.m. , and 5/28/2021 at 7:00 p.m. revealed seizure precautions were not documented on the logs.

Patient #8
Review of Patient #8's medical record revealed an admit date of 05/28/2021 with an admission diagnosis of major depressive disorder with psychosis.

Review of Nursing Admission Assessment dated 05/28/2021at 22:55 revealed that the patient was assessed as high risk for falls with a score of 5. Notation in scoring area states, "5+ High Risk**" and "**Initiate Fall Prevention + MCV Protocol as indicated by policy."

Review of the admit orders for Patient #8 dated 05/28/2021 at 22:50 revealed fall precautions were not ordered.

Review of the Observation Log for Patient #8 dates 05/28/2021 - 06/01/2021 revealed fall precautions were not documented on the logs.

Patient #9
Review of Patient #9's medical record revealed an admit date of 05/22/2021 with admission diagnosis of Chronic Paranoid Schizophrenia and Bipolar Disorder. Further review revealed Patient #9 had physician's orders for every 15 minute observations and aggression precautions.

Review of Patient #9's Observation logs dated 5/22/2021 at 08:15 a.m. and at 7:00 p.m. revealed aggression precautions were not documented on the logs.


In an interview on 06/02/2021 at 12:00 p.m. S2DON confirmed patients' ordered precautions should have been documented on the patients' observations logs. S2DON reviewed Patient #8's medical record and verified the patient should have been placed on fall precautions based on the Admission Assessment for fall risk. S2DON acknowledged that staff failed to initiate fall precautions, in an at risk patient, based on review of observation log documentation.

Based on record review, observation and interview, the hospital failed to control and distribute drugs and biologicals in accordance with applicable standards of practice. This deficient practice was evidenced by failure to ensure usable medication was returned to the MedDispense system and unusable medication was wasted in the MedDispense system as evidenced by storage of undistributed antipsychotic medications and antibiotics in the crash cart. The facility also failed failure to ensure a policy was developed for reconciliation of refused or non-administered medications.

Findings:

Review of the contracted pharmacy's policy titled, "Returning a Non-Narcotic Medication" dated October 1, 2014, revealed the policy was to "maintain the integrity of all medications added or restocked to the MedDispense system." This was not a policy to address reconciliation of refused or non-administered medication.

Direct observation on 06/03/2021 at 10:25 a.m. revealed 2 cups in the top drawer of the crash cart with several sealed individual doses of medication. The medication included Risperidone 2 milligrams- 2 tablets, Risperidone 0.5 milligrams- 2 tablets, Trazodone 50 milligrams- 1 capsule, Ciprofloxacin 500 milligram- 1 tablet, and Divalproex 500 milligram- 1 tablet. S3ADON was present and verified that the medication did not belong in the crash cart. She thought it might have been refused medication that had not been returned to the MedDispense system.

Interview on 06/03/2021 at 2:15 p.m., S2DON verified the observed medications referenced above did not belong in the crash cart. She stated usable medication should be returned to the MedDispense system and unusable medication should be wasted in the MedDispense system. She then looked through the hospital binder labeled "Policies and Procedures" for a policy addressing reconciliation of refused or non-administered non-narcotic medications. S2DON confirmed there was no policy to address reconciliation of refused or non-administered non-narcotic medications.

Based on observation and interview, the hospital failed to ensure the environment was maintained in such a manner to assure the safety and well-being of the patients. This deficient practice is evidenced by failing to ensure the environment in the psychiatric hospital was free from ligature risks.

Findings:

An observation on 06/02/2021 at 1:40 p.m. revealed a vestibule outside of rooms 5 and 6 with 7 foot ceilings containing acoustical tiles. The vestibule was accessible to patients and unable to be viewed from the nurses' station. 3 random tiles were pushed and they were not secured allowing access above the ceiling to hide contraband or pose a ligature risk. Above the tiles were wires and air conditioner ducts.

An observation on 06/02/20201 at 1:45 p.m. revealed a vestibule outside of a consultation room accessible to patients and not visible from the nurse's station. The area had 7 foot ceilings with acoustical tiles in the ceiling. 3 random tiles were pushed up and noted to be unsecured allowing access into the ceiling.

On 06/02/2021 at 1:46 p.m. S1CEO, who was present for the observations, verified the above referenced findings.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain a clean and safe environment due to multiple breaches in quality and safety observed in the environment of care at the offsite campus located within Hospital "A". This deficiency was also previously cited on 01/14/2021.

Findings:

Nutritional Area - Patient Dining Room 1
On 06/02/2021 at p.m. an observation was made of the nutritional area located in patient dining room 1 and of the dining room.
a. The carpet located adjacent to the cabinets/sink area was noted to have whitish/gray discoloration and blackish/greenish gray discoloration.;
b. Further observation revealed an area of the wall where the wall paper was split, separating from the wall and buckled and peeling off at the level of the baseboard;
c. Rust colored water stains were observed around a ceiling vent and the ceiling tiles were buckled; and
d. Metal frames securing ceiling tiles were noted to have rust colored stains on them.
e. the upper portion of the wood window sill in one of the windows to the outside was observed to be buckled and drooping.

Room - beds 14/15:
f. bubbled, peeling paint on the outer wall located above the baseboard and below the window.
g. window sill between the screen and the outside window noted to have bubbled paint, with a glob of a yellowish orange substance, apprximately the size of a golf-ball, on the sill and yellowish orange residue on the screen. There was greyish black residue also noted on the window sill.
There is a patient, #R1, currently being housed in this room.

Room - beds 16/17:
h. buckled, peeling paint above the baseboard with baseboard separated from wall located below the sink at the entry to the room.

End of uncarpeted hallway:
i. Buckled, warped ceiling tiles observed above the camera at the end of the hallway.

Shower Room:
j. Baseboard at entry of shower room was buckled, peeling, lifting from the wall. There was a patched area covered with a square of beige colored formica-like material.

Biohazard Room:
k. 2 large areas of buckled, peeling sheetrock was observed on the wall of the biohazard room. S3ADON, present during the observation, confirmed the wall damage had been caused by water intrusion and the maintenance department at the host hospital ( Hospital "A") had been made aware of the issue.

Patient Group Therapy Room/Patient Day Room :
l. Buckled, warped ceiling tiles observed on the outside facing perimeter of the room.
m. A large, circular blackish/greenish gray discoloration was observed on the carpet in the Patient Group Therapy Room.

In an interview on 06/02/2021 at 12:20 p.m. with S2DON and S3ADON, they reported there was still an ongoing problem, starting in 2019, with roof leaks that occurred when it rains, resulting in damage to the hospital from water intrusion. S2DON reported the water damage, repair, and water damage occurring again when it rains is a repeating cycle because the cause isn't repaired. S3ADON reported they would have to block the affected patient rooms until they could be repaired resulting in a decreased number of available inpatient beds. S2DON confirmed host Hospital "A" was responsible for repairs due to Seaside leasing the space from them for the offsite.

In an interview on 06/02/2021 at 2:00 p.m. with S1CEO, she confirmed there was still an ongoing problem with roof
leaks that occurred when it rains, resulting in damage to the hospital's offsite location from water intrusion. She reported Hospital "A" 's maintenance department was sent photos and descriptions of repairs that needed to be done. She further confirmed the issues with water intrusion resulted in inpatient rooms being blocked at times and unavailable for use until the rooms could be repaired. S1CEO, during the interview, presented a list of beds that had been blocked at the offsite due to maintenance/water problems from 08/01/2020 - 12/31/2020 and from 01/01/2021 - 05/31/2021. The lists were broken down by year and further broken down into monthly blocked bed counts. From 08/01/2020 - 12/31/2020 there was a total 211 beds that had been unavailable for use for varying amounts of time due to the need for repair of damage that had occurred from water intrusion. Further review revealed from 01/01/2021 - 05/31/2021 there was a total 171 beds that had been unavailable for use for varying amounts of time due to the need for repair of damage that had occurred from water intrusion.