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.
|UNIV. OF VERMONT - FLETCHER ALLEN HEALTH CARE||111 COLCHESTER AVE BURLINGTON, VT 05401||April 2, 2014|
|VIOLATION: PATIENT RIGHTS: ACCESS TO MEDICAL RECORD||Tag No: A0148|
|Based on record review and confirmed through staff interview the facility failed to acknowledge a request for clinical records for one patient. (Patient #1). Findings include:
Per review Patient #1's electronic medical record included a handwritten request, by the patient, dated 1/24/14, for copies of his/her medical records, back to September 2013. During interview, on the afternoon of 4/2/14, the Directory of Regulatory Compliance stated that per his/her discussion with the Health Information Management (HIM) department, although the request had been scanned into the medical record there was no evidence that the request by Patient #1, dated 1/24/14, for his/her medical records had been received or acted upon by HIM department.
|VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY||Tag No: A0143|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the hospital failed to identify gender concerns during the provision of care for a patient whose rights to privacy had been limited. (Patient #3) Findings include:
Per record review, Patient #3 , [AGE] was admitted on [DATE] for medical/psychiatric hospitalization as a result of a significant suicide attempt. Due to ongoing suicidal ideation and significant psychosis, it was determined by the treatment team to place Patient #3 on constant observation. Per hospital policy Observation of Patients - Inpatient Psychiatry published 5/15/2013, "Constant observation" is defined as: "Continuous direct visual observation. Direct visual observation for this purpose includes observation of a patient's visual appearance (at a minimum face and neck) and behavior. Includes direct visual observation of patients in the bathroom, unless an order to allow unobserved bathroom use has been obtained from a LIP."
Per Nursing note for 3/4/14 states " Pt. started shouting, increased anxiety and agitation, slamming fists and his/her body on walls in hallway, slammed and broke door - stating that he can't even go to the bathroom without ladies looking at him. Unable to calm himself down and code was called." An Emergency Intervention Note for 3/4/14 written by a psychiatrist called to assess Patient #3 after the Code 8 (behavioral emergency) states: " Per nursing, patient became acutely agitated at approximately 11:30 PM in the setting as the result of being annoyed with 1:1. He was frustrated with a lack of privacy since being on constant observation.". A Medical Student Inpatient Psychiatry Daily Progress Note also acknowledges Patient #3's distress stating ".....due to increased agitation that seemed to stem from frustration with having a female 1:1 follow him into the bathroom. "
Per interview on 4/2/14 at 1:20 PM the Nurse Manager for Shepardson 3 and 6 (Inpatient Psychiatry) confirmed the present "Observation of Patients" policy does not address the use of same gender individuals during observation of patients using the bathroom. Further acknowledging staffing may not be able to facilitate this due to staff male/female ratio on both inpatient psychiatry units. At 2:10 PM on 4/2/14 the Nurse Manager did acknowledge every attempt would be made to not have a male staff member observing a female patient using the bathroom when the patient is on constant observations. Per review of staff schedules for the week of 3/2/14-3/8/14 for both Shepardson psychiatry units 3 and 6, staff assigned included between 1 and 5 males on each shift. On Shepardson 3, the unit where Patient #3 was hosptalized on [DATE] male staff included: 2 on days, 1 on evenings and 2 on nights.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on interview and record review, the hospital failed to provide sufficient interventions to assure a patient with an identified elopement risk remained protected and safe from further elopement attempts for 1 applicable patient. (Patient #3) Findings include:
Per record review, Patient #3, with a diagnosis of schizophrenia and psychosis, was admitted voluntarily to Shepardson 3 inpatient psychiatry unit after a significant suicide attempt. Patient #3 was noted to have frequent auditory hallucinations and had been known to be highly impulsive. On 3/17/14 Patient #3 was provided a pass which allowed the patient, while accompanied by his/her mother, to leave Shepardson 3. After approximately 40 minutes in the hospital cafeteria Patient #3 became angry and upset with his/her mother and walked out of the hospital. The patient's mother returned to Shepardson 3 and informed staff Patient #3 had walked out of the hospital. Per hospital security Incident Report, security was notified at 10:40 AM "...to be on the lookout for a missing patient ". Within 15 minutes Patient #3 was found walking in a road towards a parking lot. Patient #3 was then escorted back into the hospital and returned to Shepardson 3. Per Inpatient Psychiatry Daily Progress Note for 3/17/14 the psychiatrist states "Per RN, the patient told his/her mother s/he would ' rather be dead ' than comply with her wishes....apparently was upset about going to the cafeteria and being around people when s/he preferred to stay in his/her room.
Upon return to the unit, staff placed a 1:1 at the door entrance to Shepardson 3 to prevent further elopement by Patient #3. However, at 11:17 AM as a staff member opened the unit door, Patient #3 was able to exit the unit and elope. Security was notified at 11:20 AM. Staff from Shepard 3 also began a search and found Patient #3 at an outside entrance to the McClure building having a cigarette. The patient was escorted by staff and security back to Shepard 3 at 11:40 AM.
The Inpatient Psychiatry Daily Progress Note also states "On interview with attending, (patient ) said that during his/her second attempt (elopement) s/he was thinking of 'Suicide, man'....'I just get so angry with myself....All of a sudden' ". Patient #3 further admits that s/he had left the unit thinking s/he would kill himself/herself. It was determined due to the patient's risk of harm, high impulsivity and threatened suicide on this day, Patient #3 met criteria for involuntary treatment. Patient #3 was transferred to Shepardson 6 for a more secure environment in an effort to prevent future elopements.
Plan of Care note by Nursing on Shepardson 6 on 3/18/14 at 16:12 states " Seemed hesitant to talk about his/her recent " escape Attempts". Observed patient looking towards the entrance/exit of unit multiple times when someone was exiting/entering the unit and looking down hallways as if trying to find something while trying to engage in conversation. When asked if s/he had any intent of injury to self or others, patient stated " Of course, I just tried to escape from the hospital " .
Per hospital policy Elopement/Late Return from Authorized Time Away - Inpatient Psychiatry published 12/20/12 notes that if "a patient who has been authorized by physician order to be away from the inpatient unit will be considered a "late return" 30 minutes after the scheduled end of the authorized time away from the unit". Per interview on 4/1/14 at 12:59 PM the Interim Assistant Nurse Manager for Shepardson 3 and 6 confirmed the elopement policy and stated "After returning from first incident they placed someone at the door and during that time s/he followed someone out the door".