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Based on record review, and interview the hospital failed to ensure patients at risk for harm to themselves or others received care in a safe setting. This deficient practice was evidenced by failing to ensure measures were in place to mitigate the safety risk of contraband including shoe strings for 1 (#13) of 2 (#13, #21) sampled patients admitted to the Recovery Unit.

Findings:

Review of the medical record on 02/05/18 for patient #13 revealed a PEC (Physicians Emergency Certificate) dated 08/11/17 documented the patient was dangerous to self, dangerous to others, unwilling, and unable to seek voluntary admission. The physician had marked a question mark over the indicator box for suicidal and homicidal. Further review revealed CEC (Coroner's Emergency Certificate) dated 08/11/17 revealed dangerous to self, dangerous to others, and unwilling. There were question marks over suicidal and homicidal as well.

Review of the hospital occurrence report dated 08/13/17 at 12:00 p.m. revealed patient #13had attempted suicide. The patient #13 was found by staff with a string around her neck hanging from the backside of the bedroom door.

Review of Patient #13's Nurse Progress Notes dated 08/13/17 at 11:53 a.m. revealed an MHT had to push patient's door open noticing strings from hanging from the outside of the door. Patient was hanging on the other side of the door. MHT removed string from her and placed patient on the floor. Patient was breathing when found and began crying when released from strings.

Interview on 02/07/18 at 8:35 a.m. with S3BH Director confirmed that she was aware of the suicide attempt by patient #13 on 08/13/17 at 11:53 a.m. S3BH Director stated that all patients are searched for contraband in the ED department and again upon admission to the Recovery Unit. All strings from shoes, hoodies, pants, jackets and any clothing that could be used for a ligature are taken upon admission from the patients. She further stated that she did not know where the patient got the shoestring from to attempt her suicide.

Interview with S1CEO on 02/05/18 at 3:00 p.m. confirmed that she was unaware of the incident occurrence and stated that LDH-HSS had not been notified of the occurrence.


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Based on record review and interview, the hospital failed to ensure incidents of alleged neglect were reported to LDH within 24 hours of discovery. This deficient practice was evidenced by:
1) failure to report an attempted hanging for 1 (#13) of 2 (#13,#21) sampled patients reviewed that were involved in incidents.; and
2) failure to report the elopement of a patient (#21) for 1 of 2 (#13, #21) sampled patients reviewed that were involved in incidents.

Findings:

Review of the hospital policy titled, Abuse and Neglect Document Number A_001, revised November 2010, revealed in part: It is the policy of the hospital to provide guidelines to report suspected abuse, neglect and unsafe conditions of dependent adults, elders, and children.
Purpose: To establish guidelines for personnel to recognize and report suspected abuse/neglect of child or adult victims. To meet the requirement of the Adult Protective Service Law. To assure that cases of suspected abuse/neglect be properly evaluated by the state designated agency. To attempt to stop further abuse, neglect of the individual. To establish guidelines to report suspected abuse, neglect, and unsafe conditions or individual's inability to care for self.
4. The hospital will submit a self-report within 24 hours of having knowledge of the allegations. The report will include the required information from LDH.

1) Failure to report the attempted suicide of a patient to LDH within 24 hours of discovery.

Review of the medical record on 02/05/18 for patient #13 revealed a PEC (Physicians Emergency Certificate) dated 08/11/17 documented the patient was dangerous to self, dangerous to others, unwilling, and unable to seek voluntary admission. The physician had marked a question mark over the indicator box for suicidal and homicidal. Further review revealed CEC (Coroner's Emergency Certificate) dated 08/11/17 revealed dangerous to self, dangerous to others, and unwilling. There were question marks over suicidal and homicidal as well.

Review of the hospital occurrence report dated 08/13/17 at 12:00 p.m. revealed patient #13 had attempted suicide. Patient #13 was found by staff with a string around her neck hanging from the backside of the bedroom door.

Interview with S1CEO on 02/05/18 at 3:00 p.m. confirmed that she was unaware of the incident occurrence and stated that LDH-HSS had not been notified of the occurrence.

2) Failure to report the elopement of a patient to LDH within 24 hours of discovery.

Review of Patient #21's medical record revealed an admission date of 10/18/17 with admission diagnoses of Bipolar Disorder and Suicidal Ideations with plan for hanging or gunshot wound. Further review revealed the patient's legal status was PEC and assessed as danger to self. Additional review revealed the patient had a Physician's order for documented observation checks every 15 minutes.

Review of the hospital provided incident reports revealed Patient #21 had eloped from the hospital's Psychiatric Unit at 11:43 a.m. on 10/19/17. Further review of the incident report revealed the following summary of the event: Patient #21 was upset and took a swing at the physician. The patient went outside to smoke and jumped the fence on the west side of the fence. S2CNO was notified. Local law enforcement was notified. Retrieved at 11:55 a.m.

In an interview on 2/5/18 at 3:30 p.m. with S1CEO, she confirmed she had not reported Patient #21's elopement to LDH as alleged neglect within 24 hours of the incident.


25119

Based on quality plan review and interview the hospital failed to identify opportunities for improvement and changes related to patient safety that would lead to improvement in quality of patient care. This deficient practice was evidenced by the hospital's failure to identify issues with maintaining patient supervision and monitoring as ordered on the inpatient Psychiatric Unit as problems to be addressed through the hospital wide QAPI program.

Findings:

Review of the hospital's QAPI plan revealed no documented evidence that issues identified by the survey team related to maintaining patient supervision and monitoring as ordered on the inpatient Psychiatric Unit was identified as a problem to be addressed through the hospital wide QAPI program.

In an interview on 2/7/18 at 9:50 a.m. with S1CEO, she confirmed the issues identified by the survey team related to maintaining patient supervision and monitoring as ordered on the inpatient Psychiatric Unit had not been identified as a problem to be addressed through the hospital wide QAPI program. S1CEO agreed the issues with patient monitoring and supervision on the inpatient Psychiatric Unit should have been identified as problems to be addressed through the hospital's QAPI plan.


38777

Based on record review, observation, and interview, the hospital failed to meet the requirement for the Condition of Participation for Nursing as evidenced by:

1) Failure of the RN to ensure patients admitted to the hospital's psychiatric unit with a PEC (Physicians Emergency Certificate) for being questionably suicidal had a completed suicide risk assessment by a nurse or physician before being placed on a standard observation level of every 15 minutes during waking hours for 1 (#13) of 1 patient sampled with an attempted suicide. This deficient practice resulted in a patient wrapping a shoestring around their neck and hanging themselves from a bedroom door (See findings tag A-0395); and

2) Failure of the RN to ensure MHT staff performed and accurately documented q (every) 30 minute checks at night, as ordered, and failure to ensure a patient (#1) on Close Observation was maintained within staff line of sight at night, on patients who had been admitted to the hospital's inpatient psychiatric unit as being a danger to themselves and/or others for 7 (#1, #R3, #R4, #R5, #R6, #R8, #R10) of 7(#1, #R3-#R6, #R8, #R10) patients observed, on a hospital provided video recording, of the night shift of 2/4/18-2/5/18 from 1:00 a.m. - 7:02 a.m. (a total of 6 hours and 2 minutes). The video reviewed provided a camera view of the left side of the psychiatric unit which housed the following rooms: 200 a/b, 201 a/b, 202 a/b, 203 a/b, 212 a/b, 214 a/b, and 215 a/b. A direct view of Patient #1's room was included in the referenced rooms. The video revealed the patients referenced above had not been observed for the following time frames: 2:02 a.m. - 3:02 a.m. (1 hour with no observations); 3:03 a.m. - 4:02 a.m. (59 minutes with no observations); 4:03 a.m. - 7:02 a.m. (2 hours and 59 minutes with no observations) (See findings in tag A-0395); and

3) Failure of the RN to ensure 8 current inpatients (#1, #R1, #R2, #R3, #R4, #R6, #R8, #R9) on the hospital's inpatient psychiatric unit were observed and documented on every 15 minutes as ordered on the day shift of 2/5/18 for 8 of 8 current female inpatients observed out of a total patient sample of 30 and a random patient sample of 10 (See findings in tag A-0395); and

4) Failure of the RN to ensure a patient with orders for close observation (#2) was observed in the direct line of sight of MHT staff for 1(#2) of 2 (#1, #2) observed sampled patients with orders for close observation out of a total patient sample of 30 and a random patient sample of 10 (See findings in tag A-0395).

Based on record review, observation, and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by:

1) Failure of the RN to ensure patients admitted to the hospital's psychiatric unit with a PEC (Physicians Emergency Certificate) for being questionably suicidal had a completed suicide risk assessment by a nurse or physician before being placed on a standard observation level of every 15 minutes during waking hours for 1 (#13) of 1 patient sampled with an attempted suicide. This deficient practice resulted in a patient wrapping a shoestring around their neck and hanging themselves from a bedroom door; and

2) Failure of the RN to ensure MHT staff performed and accurately documented q (every) 30 minute checks at night, as ordered, and failure to ensure a patient (#1) on Close Observation was maintained within staff line of sight at night, on patients who had been admitted to the hospital's inpatient psychiatric unit as being a danger to themselves and/or others for 7 (#1, #R3, #R4, #R5, #R6, #R8, #R10) of 7(#1, #R3-#R6, #R8, #R10) patients observed, on a hospital provided video recording, of the night shift of 2/4/18-2/5/18 from 1:00 a.m. - 7:02 a.m. (a total of 6 hours and 2 minutes). The video reviewed provided a camera view of the left side of the psychiatric unit which housed the following rooms: 200 a/b, 201 a/b, 202 a/b, 203 a/b, 212 a/b, 214 a/b, and 215 a/b. A direct view of Patient #1's room was included in the referenced rooms. The video revealed the patients referenced above had not been observed for the following time frames: 2:02 a.m. - 3:02 a.m. (1 hour with no observations); 3:03 a.m. - 4:02 a.m. (59 minutes with no observations); 4:03 a.m. - 7:02 a.m. (2 hours and 59 minutes with no observations); and

3) Failure of the RN to ensure 8 current inpatients (#1, #R1, #R2, #R3, #R4, #R6, #R8, #R9) on the hospital's inpatient psychiatric unit were observed and documented on every 15 minutes as ordered on the day shift of 2/5/18 for 8 of 8 current female inpatients observed out of a total patient sample of 30 and a random patient sample of 10; and

4) Failure of the RN to ensure a patient with orders for close observation (#2) was observed in the direct line of sight of MHT staff for 1(#2) of 2 (#1, #2) observed sampled patients with orders for close observation out of a total patient sample of 30 and a random patient sample of 10; and

5) Failure of the RN to ensure Neurological check assessments were performed as ordered every 4 hours for 1 (#27) of 2 (#26, #27) sampled patients reviewed for acute out transfers to a higher level of care out of a total patient sample of 30 and a random patient sample of 10.

Findings:

Review of the hospital policy titled, "Close Observation, 1:1," policy number: 000-000, last reviewed/revised: 5/13/15, revealed in part: Purpose: To provide guidelines for monitoring and assisting patients who pose a safety risk and in order to maintain physical and/or emotional well-being of the patient as well as others. Policy: It is the policy of this hospital to provide and initiate close observation for patients exhibiting behavior warranting increased staff supervision and external control.
Procedure: 1. Identify patients of special concern and document specific behavior validating the need of increased supervision and control.
2. Inform the attending psychiatrist or their designee and secure an order for close observation or one to one care.
3. If the patient's behavior indicates a safety risk to themselves and/or others, immediately institute close observation procedures or one to one care and then secure an order.
4. Specify type and frequency of observation.
a. Type of Close Observation includes but is not limited to: i. suicide precautions; ii. Homicidal precautions; iii. Behavioral precautions, iv: fall precautions; v. elopement precautions.
b. frequency: i. routine monitoring: staff observes and documents the patients behavior every 15 minutes while awake and every 30 minutes while asleep.
ii. Close observation: constant visual observation of the identified patient by an assigned staff member. The patient must remain within line of sight of the staff member at all times.
5. Document close observation procedures in the medical record.
a. describe the patient's behavior and status b. note the level of observation and frequency of staff contact. c. identify patient's response. D. maintain the observation levels until discontinued by the attending psychiatrist.
6. Observation status changes require a new order from the attending psychiatrist.
7. The close observation form will be completed for the duration of the close observation period and become part of the patient's permanent medical record.

1) Failure of the RN to ensure patients admitted to the hospital's psychiatric unit with a PEC for being questionably suicidal had a completed suicide risk assessment by a nurse or physician before being placed on a standard observation level of every 15 minutes.

Review of the medical record on 2/05/18 for Patient #13 revealed a PEC dated 8/11/17 documented the patient was dangerous to self, dangerous to others, unwilling, and unable to seek voluntary admission. The physician had marked a question mark over the indicator box for suicidal and homicidal. Further review revealed CEC (Coroner's Emergency Certificate) dated 8/11/17 revealed dangerous to self, dangerous to others, and unwilling. There were question marks over suicidal and homicidal as well.

Review of the hospital occurrence report dated 8/13/17 at 12:00 p.m. revealed Patient #13 had attempted suicide. Patient #13 was found by staff with a string around her neck hanging from the backside of the bedroom door.

Review of Patient #13's Nurse Progress Notes, dated 8/13/17 at 11:53 a.m., revealed an MHT had to push the patient's door open noticing strings hanging from the outside of the door. Patient #13 was hanging on the other side of the door. The MHT removed the string from the patient and placed the patient on the floor. Patient #13 was breathing when found and began crying when released from the strings.

Review of Patient #13's Initial Nursing Admission Assessment, dated 8/11/17, revealed the section titled "Initial Screening for Self Harm Potential" had not been completed.

Review of Patient #13's Progress Notes, dated 8/12/17, revealed patient is isolating in her room, somnolent. Patient avoiding eye contact and keeps head down staring at the floor. Patient tearful.

Review of Patient #13's Psychiatric Evaluation, dated 8/14/17 at 6:17 p.m., revealed the evaluation had been conducted after Patient #13's suicide attempt on 8/13/17.

Review of Patient #13's medical record with S18IT revealed the patient had been admitted on 8/11/17. Further review on 02/05/18 by S18IT confirmed that there was no documented Suicide Risk Assessment completed by the RN on admission.

In an interview on 2/05/18 at 3:00 p.m. with S1CEO, she confirmed that there was no documentation of a Suicide Risk Assessment completed for Patient #13 on admission, but there should have been.


2) Failure of the RN to ensure MHT staff performed and accurately documented q (every) 30 minute checks at night, as ordered, and failed to ensure a patient (#1) on ordered Close Observation was maintained within staff line of sight at night.

On 2/6/18 at 10:00 a.m. an observation was made of a hospital provided video recording to review staff observation/monitoring of patients on the inpatient psychiatric unit on the night shift of 2/4/18-2/5/18. S2CNO assisted with review of the recording and S1CEO was present during the review. The time interval reviewed was from 1:00 a.m. - 7:02 a.m. (a total of 6 hours and 2 minutes). The video reviewed provided a camera angle which focused on the left side of the psychiatric unit which housed the following rooms: 200 a/b, 201 a/b, 202 a/b, 203 a/b, 212 a/b, 214 a/b, and 215 a/b. The referenced camera angle also included a direct view of Patient #1's room (Patient #1 was on ordered Close Observation- defined as the patient must be kept in the direct line of sight by staff at all times). The video revealed no staff was located outside of Patient #1's room to maintain direct line of sight of the patient, as ordered. Patient #1 was observed exiting her room at 1:56 a.m. with no staff observed keeping the patient within their direct line of sight. Patient #1 was observed returning to her room at 2:01 a.m. and again no staff was observed maintaining the patient in their direct line of sight. Patient #1 remained in her room for the rest of the interval observed. The video revealed Patients #1, #R3, #R4, #R5, #R6, #R8, and #R10 had not been observed by MHT staff, or nursing staff, for the following time frames: 2:02 a.m. - 3:02 a.m. (1 hour with no observations); 3:03 a.m. - 4:02 a.m. (59 minutes with no observations); and 4:03 a.m. - 7:02 a.m. (2 hours and 59 minutes with no observations). Patients #R3, #R4, #R5, #R6, #R8, and #R10 were on ordered q 15 minute checks on the dayshift and q 30 minute checks at night.

Patient #1
Review of Patient #1's medical record revealed an admission date of 1/26/18 with an admission diagnosis of Psychosis. Further review revealed the patient's legal status was PEC due to being dangerous to self and others. Additional review revealed the patient had been brought to the hospital's emergency department on an order of protective custody because of visual hallucinations, psychotic behavior, history of drug use (methamphetamines), depression, anxiety, and Bipolar Disorder.

Review of Patient #1's Physician's Orders revealed an order on 2/2/18 at 3:17 p.m. for Close Observation. Additional review revealed the order to discontinue Close Observation had not been written until 2/5/18 at 11:00 a.m.

Review of Patient #1's observation sheets, dated 2/4/18-2/5/18, revealed no documented evidence that the patient was Close Observation status. Further review revealed Patient #1 had been documented on, by staff, as having been observed every 30 minutes.

Patients #R3, #R4, #R5, #R6, #R8, and #R10
Review of the observation sheets, dated 2/4/18-2/5/18, for Patients #R3, #R4, #R5, #R6, #R8, and #R10 revealed the patients were on ordered q 15 minute checks on the dayshift and q 30 minute checks at night. Further review revealed the patients had been documented on, by staff, as having been observed every 30 minutes.

In an interview on 2/7/18 at 9:15 a.m. with S13MHT, he indicated he had worked the night shift of 2/4/18-2/5/18, but really couldn't remember much about that night because he had worked so many shifts in a row. He reported he "guessed" he had been assigned the above referenced patients for continuity of care. S13MHT reported he had not been told Patient #1 was on Close Observation. S13MHT reported when he was assigned female patient on Close Observation he would have positioned himself outside of the patient's room, looking at them from the doorway, due to the patient being female. S13MHT said he did not want to be in the room with female patients at night. S13MHT had no explanation for his failure to perform rounds as ordered on all of his assigned patients when he was told of the lapses in the patients' supervision observed during review of the video recording.

In an interview on 2/7/18 at 9:22 a.m. with S29RN, she indicated she had been working on the inpatient psychiatric unit for about 3 months. S29RN indicated she could not remember "right off hand" if anyone had been on ordered Close Observation level on the nightshift of 2/4/18-2/5/18. S29RN reported the nursing staff would have informed MHTs in report if any patients had been on any type of increased supervision level. S29RN indicated the unit had received an admission around the time of the recording, but could offer no explanation for the failure of staff to perform rounds as ordered on patients when she was told of the lapses in patient supervision observed during review of the video recording.

In an interview on 2/6/18 at 11:00 a.m. with S1CEO, she confirmed, after review of the video recording with surveyors, that the MHT staff and the nursing staff had failed to perform patient observations as ordered on Patients #1, #R3, #R4, #R5, #R6, #R8, and #R10. S1CEO also confirmed S13MHT (staff member assigned to Patient #1) and the nursing staff had failed to ensure Patient #1 had been maintained within staff line of sight as was required when a patient was placed on ordered Close Observation. S1CEO indicated Close Observation at night would have required the staff member assigned to the patient to observe the patient either from the doorway or in the patient's room in order to maintain them in direct line of sight. S1CEO verified the order for Close Observation for Patient #1 had not been discontinued until 2/5/18 at 11:00 a.m. and should therefore have been maintained until that time. S1CEO indicated Patient #1 had been placed on Close Observation when she was admitted due to a prior attempt to commit suicide by hanging in this hospital in 2015. S1CEO reviewed the Observation sheets for Patients #1, #R3, #R4, #R5, #R6, #R8, and #R10 and confirmed the patients had been documented on, by staff, as having been observed every 30 minutes. S1CEO verified the documentation was inaccurate because the patients had not been observed every 30 minutes. S1CEO also confirmed S16LPN had signed off on the observation sheets indicating she had checked and verified their correctness. S1CEO reported administrative staff had only reviewed video recordings of the inpatient psychiatric unit as part of incident investigations and not as a routine method of monitoring staff performance of supervision of patients on the inpatient psychiatric unit.

In an interview on 2/7/18 at 9:50 a.m. with S1CEO, she confirmed the hospital had not identified the issues noted by the survey team related to failure of the staff to maintain patient supervision and monitoring as ordered on the inpatient Psychiatric Unit as a current problem, prior to the survey.

3) Failure of the RN to ensure 8 current inpatients (#1, #R1, #R2, #R3, #R4, #R6, #R8, #R9) on the hospital's inpatient psychiatric unit were observed and documented on every 15 minutes as ordered on the day shift of 2/5/18.

On 2/5/18 at 3:05 p.m. an observation was made of the inpatient psychiatric unit. During the observation an interview was conducted with S15MHT regarding the current patient assignments. S15MHT indicated he had been assigned responsibility for the male patients on the unit. S15MHT indicated S12MHT was responsible for the female patients (Patients #1, #R1, #R2, #R3, #R4, #R6, #R8, and #R9), but she had gone on break at 2:30 p.m. and had handed off her assignment to S11MHT. S15MHT reported he did not know where S12MHT's clipboard with the female patients' observation sheets was currently located.

In an interview on 2/5/18 at 3:10 p.m. with S10RN (Charge), she indicated S12MHT should have asked permission to go on break and she had not been aware she was on break. S10RN had not known where S12MHT's observation sheets for Patients #1, #R1, #R2, #R3, #R4, #R6, #R8, and #R9 were located when the surveyors inquired about their location and she had not known which staff member may have had them.

In an interview on 2/5/18 at 3:15 p.m. with S17WC (Ward Clerk) she reported she had found S12MHT's clipboard with Patients #1, #R1, #R2, #R3, #R4, #R6, #R8, and #R9's observation sheets in the cubby shelf behind the nurses' station. S17WC reported S11MHT had left at 3:00 p.m. and had apparently not handed off the clipboard with the patient observation sheets to another staff member when he left for the day.

Review of Patients #1, #R1, #R2, #R3, #R4, #R6, #R8, and #R9's observation sheets on 2/5/18 at 3:15 p.m. revealed the patients had last been rounded on at 2:30 p.m. (45 minutes with no documented q 15 minute observations).

In an interview on 2/5/18 at 3:25 p.m. with S1CEO she confirmed Patients #1, #R1, #R2, #R3, #R4, #R6, #R8, and #R9 had no documentation of q 15 minute rounds for 45 minutes (2:30 p.m.- 3:15 p.m.). S1CEO indicated there was a system breakdown on the inpatient psychiatric unit and a communication failure between MHT and nursing staff, especially with patient responsibility hand-off communication.

4) Failure of the RN to ensure a patient with orders for close observation (#2) was observed in the direct line of sight of MHT staff.

Review of Patient #2's medical record revealed the patient was admitted on 2/1/18 with an admission diagnosis of Depression with Psychosis. Further review revealed the patient's legal status was PEC due to being suicidal, dangerous to self, and being unable to seek voluntary admission. Further review of the PEC revealed the patient had reported he had stabbed himself in the chest with a pitchfork because he was mad at himself for something. No injuries were evident on exam.

Review of Patient #2's medical record revealed an order for Close Observation on 2/1/18 at 9:09 p.m. Further review revealed no documented evidence that the order had been discontinued.
Review of Patient #2's observation record for 2/5/18 revealed no documented evidence that the patient was on ordered Close Observation.

On 2/5/18 at 11:00 a.m. an observation made of the psychiatric unit dining room. S14MHT was asked which staff member was assigned to maintain line of sight contact with Patient #2 at all times due to the patient being on Close Observation and he replied, "I am not sure." S14MHT was then asked where Patient #2 was he replied he was not sure and confirmed the patient was not in the dining room. S14MHT reported maybe the patient was in his room.

On 2/5/18 at 11:15 a.m. an observation was made of Patient #2's room and the patient was not in his room.

On 2/5/18 at 11:30 a.m. Patient #2 was observed walking down the hall unattended by staff.

In an interview on 2/5/18 at 11:10 a.m. with S10RN-Charge, she reported, after review of Patient #2's electronic medical record that the last orders for Patient #2 indicated the patient was removed from 1:1 status and was placed on Close Observation. S10RN-Charge indicated she had not assigned Patient #2 as Close Observation when she had made assignments at the beginning of the shift that morning. S10RN-Charge indicated it was up to the discretion of the nurse to assess the patients as to whether they should remain at their ordered observation level. S1CEO was present during the observations and interviews and verified it was her understanding that patient observation level decreases/discontinuation were by physician order only and not based on the discretion of the nurse.

In interview on 2/5/18 at 12:03 p.m. with S2CNO, he confirmed discontinuation of patient levels of observation was by physician's order and not left up to the discretion of the nurse. When told Patient #2 had not been placed on Close Observation per S10RN-Charge, he indicated he was surprised because he was told in report that morning that there were 2 patients (Patient #1 and Patient #2) on Close Observation on the Psychiatric Unit.

5) Failure of the RN to ensure Neurological check assessments were performed as ordered every 4 hours.

Review of Patient #27's medical record revealed the patient was admitted on 12/1/17 at 10:15 a.m. to rule out a subdural hematoma status post fall. Further review revealed the patient was transferred out to an area hospital for a higher level of care due to a diagnosed subdural hematoma (diagnosed per CT scan imagery) on 12/1/17 at 5:07 p.m.

Review of Patient #27's medical record revealed a physician's order written on 12/1/17 at 11:00 a.m. for neurological check assessments every 4 hours.

Review of Patient #27's nursing assessments revealed the initial nursing assessment was performed on 12/1/17 at 10:15 a.m. Further review revealed no documented evidence that neurological checks had been completed every 4 hours as ordered. Additional review revealed no other assessment had been documented until the patient's transfer assessment on 12/1/17 at 5:09 p.m.

In an interview on 2/6/18 at 3:30 p.m. with S18IT (staff assisting with chart navigation) she confirmed, after review of Patient #27's electronic medical record, that the neurological checks had not been completed as ordered every 4 hours and confirmed they should have been completed as ordered.










25119

Based on occurrence report reviews, record reviews, and interviews the hospital failed to ensure medication administration errors were documented in the patient's medical record and reported to the attending physician for 3 (#17, #18, #19) of 5 medical records reviewed for known errors from a total sample of 30 medical records. Findings:

Patient #17
Review of the hospital occurrence report dated 08/24/17 revealed patient #17 received incorrect dose of Prozac on 08/22/17 and 08/23/17.

Review of the medical record on 02/06/18 at 3:20 p.m. for patient #17 by S2CNO confirmed there was no documentation of physician notification of the medication error in the medical record.

Patient #18
Review of the hospital occurrence report dated 08/10/17 revealed patient #18 received incorrect type of Risperdal medication on 08/09/17.

Review of the medical record on 02/06/18 at 3:20 p.m. for patient #18 by S2CNO confirmed there was no documentation of physician notification of the medication error in the medical record.

Patient #19
Review of the hospital occurrence report dated 07/12/17 revealed patient #19 received incorrect medication of Librax on 07/11/17.

Review of the medical record on 02/06/18 at 3:20 p.m. for patient #19 by S2CNO confirmed there was no documentation of physician notification of the medication error in the medical record.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality and safety. This deficient practice was evidenced by the hospital having patients' beds, available for use with a nurse call feature on the handrails that was non-functional for 6 patient beds observed on the hospital's inpatient unit.

Findings:

Observations of the hospital inpatient unit were made on 2/5/18 from 3: 40 p.m. - 3:55 p.m. The observations revealed 6 patient beds with non-functional nurse call features on the siderails of the beds. The nurse call feature on the 6 beds' siderails was pressed during the observation and no alert of any type was generated when it was pressed and the staff alert light over the patient room doors also failed to light up. S19RN confirmed, during the observation, that the nurse call feature was non-functional on the siderails of the patient beds.

Based on observations and interview, the hospital failed to ensure the infection control officer's responsibility for identifying, reporting, investigating, preventing, and controlling infections and communicable diseases included the maintenance of a sanitary hospital environment. This was evident by:
1) clean bedside commodes stored in the Emergency Department's (ED) patient restroom;
2) ventilation ducts in the kitchen were not clean.

Findings:

1) An observation was conducted on 2/5/18 at 08:35 a.m. of three bedside commodes covered with plastic covers in the emergency room patient restroom.

In an interview conducted on 2/5/18 at 8:35 a.m. S5EDManager verified the bedside commodes in the restroom were clean and being stored in the patient restroom.

2) An observation on 2/6/18 at 11:35 a.m. of the kitchen revealed fuzzy grey matter on the vent blowing air near the toaster and fryer and the vent near the two compartment sink just above stored knives.

In an interview conducted on 2/6/18 at 11:40 a.m. S7Dietary verified there was a fuzzy grey matter on the vents. She also verified the stored knives below the vents were clean.