The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|BAPTIST MEM HOSP/ GOLDEN TRIANGLE INC||2520 5TH ST N COLUMBUS, MS 39701||Oct. 4, 2017|
|VIOLATION: MEDICAL STAFF - ACCOUNTABILITY||Tag No: A0049|
|Based on Emergency Department (ED) and Behavioral Unit record review for Hospital #1, ED record review for Hospital #2, staff interview, and policy review, Hospital #1's Governing Body failed to ensure that the medical staff is accountable for the quality of care provided to Patient #1, one of four patients reviewed. Patient #1 lost 14.1 pounds, experienced two (2) falls, and sustained multiple wounds, bruising and a coxxyx decubitus in nine (9) days.
Cross Refer to A144 for the Governing Body's failure to ensure Patient #1 received adequate quality of care while a patient in their Behavioral Unit.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on Emergency Department (ED) and Behavioral Unit record review for Hospital #1, ED record review for Hospital #2, staff interview, and policy review, the facility (Hospital #1) failed to ensure Patient #1 (one of four patients reviewed) had the right to receive care in a safe setting. Patient #1 lost 14.1 pounds, experienced two (2) falls, and sustained multiple wounds, bruising and a coxxyx decubitus in nine (9) days.
On 09/27/17 the State Agency received a complaint against Hospital #1 from Patient #1's family which stated: "(Patient #1) was referred to (Hospital #1) by his neurologist... to regulate his medication. (Patient #1) was admitted on July 13, 2017. He was to stay for 14 days. (Patient #1) walked into (Hospital #1) in physically good shape. (Hospital #1) only allowed visits twice a week for one hour. The first visit (family members) went to (Patient #1) was in bad shape. He had a wound on his upper left cheek bone. Saturday, July 22, after 9 days when (wife) arrived to visit (Patient #1), He needed immediate medical attention. He had several wounds on his back side, ankles and cheek. He also had bruises and lost a great deal of weight. He was unable to stand or walk. After an incident where (Patient #1) had an accident using the restroom, (Hospital #1) had a catheter placed, when urinating was not an issue for (Patient #1). They also restrained him so he could not get up and wander. (Patient #1) needed assistance eating and drinking. The amount of weight loss he suffered in 9 days shows he was malnourished during his short stay there. July 22, (wife) had to use Power of Attorney to get (Patient #1) out of (Hospital #1), where he had to be carried out on a stretcher. (Wife) immediately took him to (Hospital #2). Nurses at (Hospital #2) immediately took pictures of (Patient #1's) wounds to document his treatment. (Patient #1) stayed at (Hospital #2) for almost two weeks before being moved to nursing home to receive wound care. He was not able to walk again. He was not able to urinate without a cath (catheter) resulting in many UTIs (Urinary Tract Infections). He was unable to recover from the treatment he endured at (Hospital #1). (Patient #1) passed away September 19, 2017."
Record review for Patient #1 revealed he was admitted to Hospital #1's Behavioral Unit through their Emergency Department (ED) on Thursday, 7/13/17 after his neurologist referred him to regulate his medication. Review of the ED Arrival Information revealed Patient #1 was ambulatory when he arrived. "70 y.o. (year old) male presents to the ED with combative behavior X 4 months. Per his wife, pt (patient) was Dx (diagnosed ) with Parkinson's Dementia in late 2011. He has a history of an enlarged prostate. Past Medical History... blockage in heart (30%)... Surgical History... cardiac cath - 30% blockage. He was put in a nursing home in 03/2017. Since then, he has shown combativeness and aggressiveness toward his caregivers, going as far as grabbing them by their arms. His wife reports that he sometimes threatens to hit her, which he has never done in the past. The wife denies him biting or throwing objects... Pt's wife wishes to get his medicine regulated." On 7/13/17 a foley catheter was inserted for specimen collection. Admission assessment dated [DATE] at 2235 (10:35 p.m.) revealed Patient #1 was given a fall risk score of 10. Documentation on the same date gave the patient a Fall Risk Score of 7. Safety Interventions were documented as: "Activity supervised; fall prevention program maintained..." On admission Patient #1 weighed 154 pounds/ 69.9 kilograms. There was no other documented weight for the patient during his stay at Hospital #1. He was ordered a Regular Diet AHA (American Heart Association)/ Low Saturated Fat. There was no documented evidence Patient #1 had pressure ulcers, bruises or skin breaks on admission. A
A Patient Care Timeline for Patient #1 dated 7/15/17 at 18:55:00 (6:55 p.m.) revealed an unwitnessed fall. "Tech (technician) reports that pt was found in dayroom on closed unit lying on stomach & looked to have fallen. Pt non-verbal and unable to answer questions. Passive ROM (range of motion) performed to bilateral upper and lower extremities. Pt grimaced when moving right arm and cracking noise was noticed when moving left leg. No skin tears noted..." The physician was notifed and xrays of head, hip and left elbow were ordered. No injuries were noted. Spouse was notifed of fall. At 8:41 p.m. a Registered Nurse (RN) progress note stated, "Patient alert, confused, answer to simple questions in soft, quiet voice. Attempted to get out of geri-chair, redirected pt back to chair... Foley catheter patent draining blood tinged with sediment urine.."
Psychiatry Daily Progress Note dated 7/18/17 revealed, "Patient has not been eating and drinking... I will start NS (Normal Saline) at 100cc an hour and monitor the patient closely. Dietary nutrition supplements Breakfast, Lunch, Dinner: Adult Ensure Enlive - Vanilla."
A Patient Care Timeline for Patient #1 dated 7/20/17 at 15:30 (3:30 p.m.) revealed an unwitnessed fall. "Staff reports finding pt out of chair, laying on floor on his right side. Pt non-verbal and unable to answer questions appropriately. Passive ROM performed to bilateral upper and lower extremities without noticable issues..." The physician and spouse were notifed.
On 7/22/17 at 12:07 p.m. a MD Progress Note stated, "... Cellulitis left cheek - will consider abx (antibiotic)..."
RN Progress Note dated 7/22/17 at 1:22 p.m. revealed, "approx (approximately) 1250 (12:50 p.m.) - writer was asked to come to patient's room. Observed redness and eschar like skin to coccyx area. Performed peri-care..." "approx 1350 (1:50 p.m.) - patient's wife came to desk during visitation demanding and irritable that her husband 'has gotten worse' since he's been here for 2 weeks now... 'I know how to take care of him! I just want to take him home now!"
Patient #1 was discharged Against Medical Advice (AMA) on Saturday 7/22/17 at 1:55 p.m.
On 10/3/17 at 11:30 a.m. an interview with the RN Charge Nurse revealed, "Patient was admitted from... Personal Care Home because he was not eating and was losing weight, getting combative and his behavior was aggressive. Upon admission he had bedsores. A wound care consult was made... one was made for Nutrition and Physical Therapy..."
On 10/3/17 at 12:00 p.m. the Director of Behavior Health confirmed that the admission report contained no documented evidence of pressure sores, bruises or skin breaks.
An interview with the Assistant Administrator on 10/3/17 at 2:50 p.m. revealed that the wound care nurse had been consulted, however the patient left AMA before the wound care nurse could see him. At 3:15 p.m. the Assistant Administrator was asked about the lack of weights after the admission weight for Patient #1. She stated, "We only do daily weights if the patient has cardiac problems."
Record review revealed no documented evidence that Patient #1 had been placed in restraints during his stay at Hospital #1. During an interview with the Director of Behavioral Health on 10/3/17 at 3:30 p.m. confirmed that Patient #1 had never been placed in restraints.
On 10/4/17 at 9:10 a.m. an interview with Mental Health Tech (MHT) #1 revealed that he did not witness the fall on 7/20/17. He stated he found Patient #1 lying on the floor in the dayroom by his geri-chair. He immediately called for the Charge Nurse who came and assessed him.
Review of Hospital #1's "Patient Rights" policy (last review 03/17) revealed: "Policy: (Hospital #1) Behavioral Health Care supports and protects the human, constitutional, and statutory rights of each patient and their family ...The Rights and Responsibilities of the Behavioral Health Patient ... 9. You have the right to receive care and treatment in a safe setting, free from abuse or harassment and in the least restrictive environment possible for particular symptoms and or illness and includes access to protective services ..."
Review of Hospital #2's record for Patient #1 revealed that he arrived at the ED on Saturday 7/22/17 at 3:59 p.m. per private vehicle/wheelchair. History of Present Illness stated, "Has history of Parkinson's and Dementia... today is nonverbal, not walking, and poorly responsive. Did recently have Foley and has fallen with head injury. Past Medical History... blockage in heart (30%)... Surgical History... cardiac cath - 30% blockage... Physical Exam: ... Head: abrasion with redness around it to left cheek... ENT: mucous membranes dry... Abdomen:... Bowel sounds hypoactive..." His diagnosis included: "Final: Primary: Mental status changes, Additional: dementia, Parkinson's disease.." He was admitted to a medical - surgical unit for observation. His admission weight was 63.5kg (139.9 pounds). A loss of 14.1 pounds since his admission to Hospital #1 on 7/13/17 (nine days). A progress note dated 7/24/17 revealed an unstagable wound to coccyx. Patient #1 was discharged to Swing Bed services on 7/25/17.
|VIOLATION: THERAPEUTIC DIETS||Tag No: A0629|
|Based on Emergency Department (ED) and Behavioral Unit record review for Hospital #1, ED record review for Hospital #2, staff interview, and policy review, the facility (Hospital #1) failed to ensure Patient #1 (one of four patients reviewed) had his nutritional needs met. Patient #1, with a compromised nutritional status and a medical condition adversely affected by his nutritional intake, sustained a 14.1 pound weight loss in his nine (9) day stay.
Cross Refer to A144 for the facility's failure to ensure Patient #1 had his nutritional needs met.