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Based on record review and interview, the facility failed to ensure that 1 of 1 patients (#14) was not subjected to psychotropic medications as a form of restraint without first documentation attempts to manage the patient's behavioral symptoms in other ways. Findings include:

Policies:
Facility Policy "Restraint/Seclusion, revised 4/5/12, defines a chemical restraint as a drug that "has the temporary effect of restricting the recipient's freedom of movement; and is not a standard treatment for the recipient's medical or psychiatric condition."
1. "Restraint and or seclusion can only be used in emergency if needed to ensure the patient's physical safety, and only after the least restrictive interventions have been determined to be ineffective."

Facility Policy Medication Management, revised 6/29/09, states:
3. Diagnosis Requirement- "There is a documented diagnosis, condition, or indication for use in the Medical Record for each medication ordered."
5. a. PRN (as needed) Orders: "Indication for use is required when the drug has multiple indications for use."

Record Review:
1. On 5/19/12 at 2200 hours, 5 mg of Haldol and 1 mg of Ativan were given IM (intramuscularly) for "severe agitation/danger to self or others" with no documentation of severe agitation or danger to self or others, as stated in the physician's order as the required reason for administration.
2. On 5/20/12 at 2245 hours, 5 mg of Haldol and 1 mg of Ativan were given IM for "severe agitation/danger to self or others" with no documentation of severe agitation or danger to self or others, as stated in the physician's order as the required reason for administration.

Interview:
1. The above record review findings were verified by the Unit Nurse Manager on 7/17/12 from 1100-1430 hours. The Unit Nurse Manager stated that specific descriptions of patient #13's agitated behavior that necessitated the use of the above medications should have been documented in the patient's clinical record.

Based on record review and interview, the facility failed to ensure that 1 of 1 deceased patients (#14) was considered for autopsy per hospital protocol. Findings include:

Policy & Medical Staff Bylaw Review:
On 7/18/12 review of the Medical Staff Bylaws regarding patient autopsy procedures revealed no statement specifying how medical staff determine when a death is considered to be of natural causes or of medical-legal or educational interest.

Record Review:
1. On 7/18/12 review of patient #14's medical record revealed no documentation of attempts to ask the family if they would like to have the patient's body autopsied.
2. No documentation of how medical staff who documented patient #14's death arrived at the conclusion that the patient died of "natural causes" was found.
3. There was no documentation indicating that the death was expected.
4. The above findings were reviewed with the Director of Quality on 7/18/12 at approximately 1400 hours.

Interviews:
1. On 7/18/12 at approximately 1440 hours the Medical Director of Behavioral Health was asked to explain his note, dated 5/22/12, stating: "The death (of patient #14) was felt to be of natural causes." The Medical Director of Behavioral Health stated that he thought that is what the Medical Examiner (ME) stated to the Nurse (RN #2) who had called the ME to report the death. The Medical Director/Behavioral Health stated that he did not speak to the ME and did not have direct knowledge that the ME considered patient #1's death to be of natural causes.
2. The Medical Director/Behavioral Health also stated that he felt that patient #14's sleep apnea and failure to use his C-Pap machine may have contributed to his death. The Medical Director/Behavioral Health stated that the hospital leaves it up to the ME to decide if an autopsy should be done and that the family may request an autopsy.

Based on interview, policy and record review the facility failed to:
-Ensure that: a RN supervise and evaluate the nursing care for 2 of 2 patient's, one patient requiring medical equipment that was not implemented the other failed to receive medications for the treatment of a serious medical condition (A-0395).
-Ensure that: nursing staff develop and keep current nursing care plans relative to the use of a C-Pap machine for 1 of 1 deceased patient's (A-396).
-Ensure that: contract nurses were oriented to hospital policies and procedures relative to training in "crisis prevention intervention" (A-398).

Based on interview, record and policy review, the facility failed to ensure that 1 of 1 deceased patients (#14) and 1 of 1 current patients (#13) received care, monitoring and treatment to address medical diagnoses resulting in increased risk of negative outcomes. Findings include:

Patient #14:
Policies:
1. The facility was asked for policies and procedures explaining how the facility responds when a patient brings in a machine for treatment of sleep apnea and has a diagnosis of sleep apnea. No documents relating to these issues were provided by the conclusion of the survey.

Record Review:
From 7/11-7/18, review of patient #14's clinical record revealed:
1. Patient #14 was admitted to the facility on 5/16/12.
2. A C-Pap Machine was noted on the patient's Inventory of belongings at admission.
3. On 5/18/12 Medical Doctor #1 noted sleep apnea in the patient's list of diagnostic assessments.
4. Patient #14 was found dead in bed on 5/22/12 at 0916 hours.
5. Patient #14's medical record contained no documentation or the patient being offered assistance or encouragement to use the C-Pap machine.
6. No documentation indicating whether the C-Pap had been used at all during hospitalization was found.

Interviews:
1. On 7/18/12 from 1100-1430 hours, the Unit Nurse Manager stated that she was not aware of a policy that addresses how the facility responds to patients who come in with a diagnosis of sleep apnea and bring equipment for treatment of respiratory problems.
2. The Unit Nurse Manager stated that she was among the first responders when staff noticed that patient #14 was found dead on 5/22/12. The Unit Manager stated that she observed that the patient's C-Pap was not in use at the time of death.
3. On 7/18/12 at approximately 1440 hours the Medical Director of the Behavioral Health Unit was asked to comment on the facility's Occurrence Report concerning patient #14's death. The Unit Medical Director stated that the patient's sleep apnea and failure to use the C-Pap machine were likely factors in the patient's death.

Patient #13:
Policies:
1. On 7/17/12 at approximately 1030 hours the Pharmacy Director (PD) was asked if the facility has a policy on providing medications per physician's orders when they are not available. A policy regarding this issue was not provided prior to exit on 7/18/12.

Record Review:
From 7/11-7/18, review of a current patient's clinical record (patient #13's) revealed:
1. Patient #13 was admitted to the facility on 7/10/12 as a transfer from Botsford Hospital. The patient's Medical History that was faxed from Botsford Hospital to Doctor's Hospital on 7/10/12 and listed a diagnosis of HIV.
2. The name of the patient's guardian was listed on the "Doctor's Hospital Screening Data Sheet," dated 7/10/12. The HIV diagnosis was also listed on this document.
3. A Consult from Botsford Hospital, faxed to the facility on 7/10/12, regarding the HIV diagnosis, indicated confirmation of the HIV diagnosis and recommended continuing current HIV medications.
4. Upon admission to Doctor's Hospital, patient #13 had orders for medications for the treatment of HIV, that had been given at the transferring hospital (Botsford) but the medications were ordered as "patient to use own med" at Doctor's Hospital.
5. Starting on 7/11/12, the following medications for HIV were circled in the Medication Administration Record (MAR), indicating that they were not given according to the Unit Nurse Manager:
-Epivir 300 mg.
-Norvir 100 mg.
-Lexiva 700 mg.
-Ziagen 300 mg.
6. A 7/11/12 progress note states: "Pt (patient) to bring own meds for HIV. Group home notified. There was no notation of any attempt to contact the patient's guardian.
7. A 7/12/12 progress note documents another call to the patient's former group home, stating: "Left message re: need for medications to be brought from home." There was no documentation of any attempt to contact the patient's guardian or obtain the medications from the hospital pharmacy.

Interviews:
1. On 7/17/12 from 1000-1100 hours the Unit Manager verified that review of the MAR and progress notes confirmed that patient #13 had not received her HIV medications from 7/10/12-7/17/12.
2. On 7/17/12 at approximately 1030 hours the Pharmacy Director (PD) verified that patient #13 had not been provided with the above listed HIV medications by the facility. The PD stated that the facility does not stock the above medications and that: "We can call around and try to borrow it" but stated that she was not made aware that the medication was needed.
3. On 7/17/12 at approximately 1700 hours the Unit Manager stated that the facility had made arrangement for the patient's HIV medications to be brought in by the Group Home staff.
4. On 7/17/12 at approximately 1515 hours, Secretary #1 at the patient's guardian's office was asked if they had a record or recollection of any contacts initiated by Doctor's Hospital, attempting to arrange delivery of the patient's HIV medications. Secretary #1 stated that they had no documentation of any contacts in this regard from Doctor's Hospital and would have assisted had they been contacted.

Based on interview, record and policy review, the facility failed to ensure that 1 of 1 deceased patients (#14) had a care plan for a diagnosis of sleep apnea. Findings include:

Policies:
"Treatment Team Meeting," #50, revised 2/09, states:
"A Master Treatment Plan (MTP) shall be initiated within 25 hours of the patient's admission. The initial team meeting shall take place within 72 hours of the admission to the unit. The following shall be addressed in the treatment team meeting:
-Diagnosis
-List of problem(s)
-Identified needs beyond the scope of this program and action taken to meet those needs"

Record Review:
From 7/11-7/18, review of patient #14's clinical record revealed:
1. Patient #14 was admitted to the facility on 5/16/12. Patient #14's inventory of belongings upon admission included a C-Pap machine.
2. On 5/18/12 Medical Doctor #1 noted sleep apnea in the patient's listing of diagnostic assessments.
3. Patient #13's diagnosis of sleep apnea and use of a C-Pap machine were not included in the patient's Treatment Plan.


Interviews:
1. On 718/12 at approximately 1430 hours the Unit Nurse Manager stated that patient #14's clinical record did not contain a treatment plan for sleep apnea or use of a C-Pap machine.

Based on document review and interview the facility failed to ensure that contract nurse's were trained in crisis prevention intervention. Findings include:

An interview with Staff D (Director of Quality) on 7/18/12 at approximately 2:00 pm noted that it is the hospital's requirement that contractual nurses have Crisis Prevention Intervention (CPI) prior to providing services for the hospital. On 7/18/12 a review of the facility's "4 South AGENCY RN Orientation Checklist" revealed that the 3 page checklist did not include (CPI) training. On that same date at approximately 2:40 pm, Staff B (nurse manager) and Staff D (Director of Quality) were queried as to the facility's policy for crisis prevention intervention (CPI) training for nurses. Staff B replied, "No, there is no policy."