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Based on interview and record review, the hospital failed to ensure two of the two transfers from the BHU reviewed (Patients 45 and 63) were analyzed to determine the causes of the adverse events, creating the increased risk of unrecognized poor healthcare practices.

Findings:

1. The hospital's P&P titled Plan for Assessment/Reassessment of Patients reviewed 12/13, read in part, "All patients entering (hospital name) will receive an initial assessment, which takes into account their immediate and emerging needs."

Review of Patient 45's medical record on 12/9/14, showed the patient had a history of dementia, mental illness, and recurrent urinary tract infection.

The patient was admitted to the BHU on 11/12/14; however, the patient was transferred from the BHU to a medical floor nine days later due to dehydration. On the medical floor, the patient was given intravenous fluids and antibiotics, and returned to the BHU on 11/24/14.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 0920 hours, he stated he was not sure how the patient became dehydrated during her 11/12 through 11/21/14, BHU admission.

Review of the care plans developed for Patient 45's admissions to the BHU on 11/12/14 and readmission on 11/24/14, did not show the patient's functional ability to request or obtain fluids was assessed, the risk of dehydration was identified as a problem, a care plan was developed to prevent recurrent dehydration, or that the patient's fluid intake was monitored. Cross references to A0392, example #3 and A0396, example #4.

During an interview with the DON on 12/10/14 at 1345 hours, she stated there was no documentation to show an analysis of the incident or the reason for transfer was documented.

During an interview with the Performance Improvement Manager on 12/10/14 at 1350 hours, he stated he was not aware Patient 45 was transferred from the BHU due to dehydration. The Manager stated he relied upon the Department Director, DON, or CNO to call for an intensive analysis of a case and the case was not brought to his attention.

2. Patient 63's medical record was reviewed on 12/10/14. The patient was admitted to the BHU on 11/18/14, with a history of psychiatric problems but no history of seizures.

The nursing notes dated 11/18/14 at 2109 hours, indicated the patient was threatening and agitated and the psychiatrist ordered haloperidol (brand name is Haldol, an antipsychotic medication) 10 mg orally.

At 2145 hours, the patient was severely agitated and the psychiatrist ordered Geodon (generic name is ziprasidone, an antipsychotic medication) 20 mg IM At 2220 hours. The nursing note showed "Witnessed seizure after being given Geodon 20 MG IM."

At 2226 hours, an EKG was performed on Patient 63 and showed a sinus (normal) rhythm, and a QTc of 487 (the QTc is a measure of the electrical conduction of the heart [normal less than 440], if prolonged can lead to dangerous irregular heart rhythms).

The FDA drug warnings for ziprasidone included ziprasidone use should be avoided in combination with other drugs that are known to prolong the QTc interval. Additionally, clinicians should be alert to the identification of other drugs that have been consistently observed to prolong the QTc interval. Such drugs should not be prescribed with ziprasidone.

The FDA also issued a warning indicating Haldol could prolong the QTc. The updated labeling includes warning stating that Torsades de Pointes (ventricular tacchycardia) and QT prolongation have been observed in patients receiving haloperidol, especially when the drug is administered intravenously or in higher doses than recommended. Haloperidol is not approved for intravenous use.

Patient 63 was moved back to the ED for evaluation and was then admitted to a medical floor with cardiac monitoring ability. The ED physician's note read, "Given the cardiac nature of these medications patient requires admission to ensure no arrhythmia ensues."

Patient 63 subsequently left the hospital against medical advice.

During an interview with the Director of Pharmacy on 12/10/14 at 1415 hours, he stated he checked the medication-related events log. The Director of Pharmacy stated he was not aware of Patient 63's episode. The Director of Pharmacy stated immediate use single doses of medications were not subject to pharmacy oversight.