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PALOMAR HEALTH DOWNTOWN CAMPUS 555 EAST VALLEY PARKWAY ESCONDIDO, CA 92025 July 15, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and record review, the hospital failed to provide sufficient space in the Behavioral Health Unit (BHU) quiet room for staff to restrain 1 of 34 sampled patients (Patient A) according to facility policy.

As a result, Patient A was restrained in a prone position and was at risk for restricted breathing.

Findings:

Patient A was admitted to the hospital's BHU on 7/8/16 at 6:56 P.M., with symptoms of psychosis (mental disorder causing loss of reality) and mania (abnormal excitement and overactivity), according to the admission History and Physical.

During an interview on 7/14/16 at 8 A.M., LN 2 stated when she entered the quiet room, Patient A was prone on the mattress on the floor between the bed frame and the wall with his head facing left. LN 2 stated one staff member was holding each of Patient A's extremities and the patient was still thrashing. LN 2 stated she administered an IM (shot given in a muscle) injection of Haldol 10 mg (used to control behavior) and Benadryl 50 mg (used to sedate). LN 2 stated the patient continued flailing and yelling and was uncontrollable. She stated prone position was not typically used and staff discussed moving Patient A into a supine position. LN 2 stated she did not feel it was safe as he was positioned between the bed frame and the wall and there was not enough room to reposition him safely. LN 2 stated Patient A could have injured himself or staff on the metal bed frame if staff attempted to move him.

On 7/14/16 at 9 AM the BHU quiet room was observed. The door opened inward. Directly across the room from the door, was a large window made of plexi-glass. The room contained a bed frame bolted to the floor and a mattress. The area between the window and the door was the length of the mattress and the area between the bed frame and the wall was only wide enough to fit the mattress. (This is the area where the staff described restraining Patient A prone). Measurements of the quiet room were provided by the facility. The back wall (opposite the door) which had the window was 8 foot 6 inches wide and the space between the head of the bed frame and the back wall was 2 feet 1 inch. The width of the room between the bed frame and the right side wall measured 3 feet 7 inches, which was the same as the mattress.

During an interview on 7/14/16 at 10:50 A.M., LN 1 stated he pushed open the door to the quiet room and Patient A ran into the window with his shoulder first. LN 1 stated the patient did this three times. LN 1 stated he grabbed Patient A from behind to prevent him from running into the window again. LN 1 stated he turned the patient around and the patient elbowed him in the ribs. He stated, at that time other staff brought the patient down to the mattress on the floor in a prone position. LN 1 stated it was unsafe to attempt to move the patient into a supine position due to the room layout and the patient's violent behavior.

During an interview on 7/14/16 at 5 P.M., LN 3 stated Patient A ran full speed into the window and bounced off twice. He stated he went on the left side of the bed frame and LN 1 went on the right side (over the mattress on the floor) toward the patient. LN 3 stated LN 1 grabbed Patient A from behind in a bear hug as he attempted to run toward the window again. Then LN 1 turned the patient away from the window towards the mattress on the floor directly in front of him. LN 3 stated staff then restrained Patient A in a prone position on the mattress on the floor. LN 3 stated, CPI training (Nonviolent Crisis Intervention training each staff member receives prior to working on the unit) teaches staff to use the " control maneuver " to restrain a patient and not to restrain in the prone position. (The maneuver involves one staff member on each side of the patient to place them in a forward position bent at the hip). LN 3 stated, it was not possible to use the CPI maneuver on Patient A due to the confined space of the room. LN 3 stated it was not safe to attempt to move the patient into a supine position.


According to the hospital's policy entitled, Restraint for Violent and Self Destructive Behavior, revised 4/8/13, "... Physical Restraint: Any manual method... that immobilizes or restricts the ability of a patient to move his/her arms, legs, torso, or head freely... Prone restraint is prohibited. Prone restraint is hazardous and potentially lethal restraint position due to risk of cardiac and respiratory complications..."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Licensed Nurses failed to reassess 4 of 34 (21, 24 ,25, 27)sampled patients after administration of pain medication.

As a result, patients 21, 24, 25, and 27 were at risk for unrelieved pain.

Findings:

1. Patient 21 was admitted on [DATE] for a cesarean section (C/S), according to the admission History and Physical ( H&P).

On 7/14/16 at 2:45 P.M., Patient 21's electronic record was reviewed with the OB Unit Supervisor (US 1).

According to the physician's order dated, 7/12/16 at 7:05 P.M., Patient 21 was to receive Percocet 5/325 (opioid pain medication) mg as needed for moderate to severe pain.

According to the Electronic Medication Administration Record (EMAR), the LN administered 2 tablets of Percocet on 7/14/16 at 7:45 P.M., for complaint of severe pain (9/10). US 1 confirmed there was no documentation which indicated the LN reassessed Patient 21 for effectiveness of the pain medication.


2. Patient 24 was admitted on [DATE] for a repeat cesarean section, according to the H&P.

On 7/15/16 at 9:15 A.M., Patient 24's electronic medical record was reviewed with the Director of Quality Management (DQM 1).

According to the physician's order dated, 7/11/16 at 5:40 P.M., Patient 24 was to receive 1 tab of Percocet for mild pain (1-3 out of 10) and 2 tabs for moderate to severe pain (4-10 out of 10).

According to the EMAR, the LN administered 1 tablet of Percocet on 7/14/16 at 2:02 P.M. when Patient 24 complained her pain was 6/10. DQM 1 confirmed Patient 24's pain was not reassessed until 5:33 P.M.

3. Patient 25 was admitted to the hospital for an induction of labor on 7/11/16, according to the admission H&P.

On 7/15/16 at 9:15 A.M., Patient 24's electronic medical record was reviewed with the Director of Quality Management (DQM 1).

According to the physician's order dated, 7/12/16 at 16:39 P.M., Patient 24 was to receive 1 tab of Tylenol with Codeine as needed for pain.


According to the EMAR, the LN administered 1 tablet of Tylenol with Codeine on 7/15/16 at 12:28 A.M. when Patient 25 complained of pain. DQM 1 confirmed Patient 25's pain was not reassessed until 3:52 A.M.

4. Patient 27 was admitted on [DATE], according to the admission H&P.

On 7/15/16 at 9:15 A.M., Patient 24's electronic medical record was reviewed with the Director of Quality Management (DQM 1).

According to the physician's order dated, 7/12/16 at 3:46 P.M., Patient 27 was to receive 1 tab of Percocet for mild pain (1-3 out of 10) and 2 tabs for moderate to severe pain (4-10 out of 10).

According to the EMAR, the LN administered 1 tablet of Percocet on 7/14/16 at 9:01 P.M. when Patient 27 complained her pain was 7/10. DQM 1 confirmed Patient 24's pain was not reassessed until 12:02 A.M. on 7/15/16 when Patient 27 reported her pain was 6/10. The LN documented she administered 1 tab of Percocet to Patient 27 at that time. The LN did not reassess the patient for effectiveness of the medication until 4 A.M.

During an interview on 7/14/16 at 2:45 P.M., US 1 stated the LNs should have reassessed the patients 1 for effectiveness of the pain medication within 1 hour after administration.

According to the hospital's policy entitled, Pain Assessment and Management, revised 1/13/16, "... Reassessment of pain intensity level and sedation level will be within 60 minutes after PO (by mouth) opioid medication..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the Licensed Nurses (LNs) failed to administer pain medication according to physician's order for 2 of 34 sampled patients (24, 27)

As a result, Patients 24 and 27 were at risk for unrelieved pain.

Findings:

1. Patient 24 was admitted on [DATE] for a repeat cesarean section, according to the H&P.

On 7/15/16 at 9:15 A.M., Patient 24's electronic medical record was reviewed with the Director of Quality Management (DQM 1).

According to the physician's order dated, 7/11/16 at 5:40 P.M., Patient 24 was to receive 1 tab of Percocet (opioid pain medication) for mild pain (1-3 out of 10) and 2 tabs for moderate to severe pain (4-10 out of 10).

According to the EMAR, the LN 5 administered 1 tablet of Percocet on 7/14/16 at 2:02 P.M. when Patient 24 complained her pain was 6/10. DQM 1 confirmed LN 5 should have administered 2 tablets of Percocet as ordered by the physician.

LN 5 was unavailable for interview during the survey.

2. Patient 27 was admitted on [DATE], according to the admission H&P.

On 7/15/16 at 9:15 A.M., Patient 24's electronic medical record was reviewed with the Director of Quality Management (DQM 1).

According to the physician's order dated, 7/12/16 at 3:46 P.M., Patient 27 was to receive 1 tab of Percocet (opioid pain medication) for mild pain (1-3 out of 10) and 2 tabs for moderate to severe pain (4-10 out of 10).

According to the EMAR, the LN 6 administered 1 tablet of Percocet on 7/14/16 at 9:01 P.M. when Patient 27 complained her pain was 7/10. DQM 1 confirmed Patient 24's pain was not reassessed until 12:02 A.M. on 7/15/16 when Patient 27 reported her pain was 6/10. LN 6 documented she administered 1 tab of Percocet to Patient 27 at that time. DQM 1 confirmed LN 6 did not follow the physician's order and should have administered 2 tabs each time.

LN 6 was unavailable for interview during the survey.
The OB Unit Manager was unavailable for interview during the survey.

During an interview on 7/15/16 at 12 P.M., DQM 1 stated the LNs were expected to follow physician's orders for administration of medications.

According to the hospital's policy entitled, Medication Administration, revised 11/9/15, "...Verify the medication name, strength, and dosage form are correct..."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on interview and medical record review, the facility failed to ensure that nursing staff completed a behavioral advanced directive form for 2 out of 34 patient charts reviewed. (4, 31)
Findings:
Medical record reviews were conducted on 7/14/16 at 11:00 A.M. and 7/15/16 at 10:00 A.M.

1. A review of Patient 4's medical record indicated that on 6/23/12 at 1:21 P.M. Patient 4 was admitted to the Behavioral Health Unit (BHU) from the Emergency Department (ED). A review of the form entitled "Behavioral Health Advance Directive" specified the form was regarding De-Escalation or the Use of seclusion or behavioral restraint to be completed by the RN at the time of admission per interview with patient and/or family. Page 1 of the form listed a section regarding whether the patient had any medical conditions, a section for RN assessment of developmental, gender issues, history of sexual or physical abuse, disabilities, medications, suicidal gestures, cognitive or dementia, age language or cultural issues. Page 2 of the form listed boxes next to choices regarding patient preferences for items or activities that would help them feel better, items that make patients feel worse, family or friends that may participate in the patient's care, family to notify in the event of seclusion or restraint and patient rights to be free of restraints that are not indicated. Page 2 of the form was left blank and the space for Patient signature and RN signature was left blank. There was no documentation by the RN that Patient 4 was unable or unwilling to cooperate with obtaining the information.

2. A review of Patient 31's medical record indicated that on 6/27/16 at 4:26 P.M. Patient 31 was admitted to the BHU from the ED. Page one Section A regarding patient medical conditions was blank and Section B regarding the RN assessment was blank. Page two of the Behavioral Health Advance Directive form was blank and not signed by the patient and or family or the RN. There was no documentation by the RN that Patient 31 was unable or unwilling to cooperate with obtaining the information.
A review of the hospital's undated policy and procedure entitled "Medical Record Entries, Content and Completeness" was conducted on 7/14/16 at 3:50 P.M. The policy indicated that "all entries in the medical record must be legible, complete, dated, timed and authenticated".

An interview with the BHU RN was conducted on 7/15/16 at 10:40 A.M. The RN stated that the behavioral Advanced Directive Form is used to obtain helpful information for staff to implement to help the patients to avoid further agitation and help with their care. The RN stated that some patients are unable or unwilling to cooperate and the Nursing staff cannot always complete the form. The RN stated that the Nurse completing the form is responsible for documenting the reason why the form cannot be completed.

An interview with the Nurse Manager was conducted on 7/14/16 at 11:30 A.M. She stated that the nursing staff should have completed the advance directive and condition of admission forms and if they could not obtain the information that they should document the reason why it cannot be completed.