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.
| MENTAL HEALTH INSTITUTE | 1200 EAST WASHINGTON STREET MOUNT PLEASANT, IA | Nov. 26, 2013 |
| VIOLATION: GOVERNING BODY | Tag No: A0043 | |
| Based on review of the Medical Staff Bylaws/Rules and Regulations, Medical Team meeting minutes, credential files, and staff interview the Governing Body failed to assume full responsibility for the governance and operation of the facility. The following examples confirmed this determination. - The governing body failed to ensure that: the Medical Staff included a periodic review and evaluation of patient care and treatment for all physicians providing patient care services at the facility; the medical staff made a recommendations to the governing body prior to the reappointment of the physicians; and the Medical Staff was accountable to the governing body for the quality of care and treatment provided to the facility's patients. - The governing body failed to ensure the Quality Assurance Performance Improvement (QAPI) committee, reviewed, coordinated, and monitored all physicians with clinical privileges, providing care and treatment to patients on the Adult Psychiatric and Dual Diagnosis units. The cumulative effect on these systemic failures and deficient practices resulted failure of the Governing Body's ability to appropriately review and evaluate physicians and make any corrective action needed related to quality of care and services to patients. Refer to A0049. |
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| VIOLATION: MEDICAL STAFF - ACCOUNTABILITY | Tag No: A0049 | |
| Based on review of facility documents, the Medical Staff Bylaws/Rules and Regulations, Medical Team meeting minutes, credential files, and staff interview, the governing body failed to ensure medical staff reviewed, monitored, and evaluated the quality and appropriateness of patient care services for 2 of 3 psychiatric physicians on staff. (Physician B, and C). The facility's medical staff consisted of 3 psychiatrists practicing at the psychiatric facility at the time of the survey. Findings include: 1. The following documents were reviewed. Review of the Current Roster of Medical Staff Members revealed Physicians B and C were identified by the facility as members of the Medical Staff at the facility. Physicians B and C provided care and services to all patients on alternating weekends. During an interview on 11/19/13 at 3:20 PM, the Superintendent said, although both physicians were contracted, they would have the same privileges as Physician A, the Primary Psychiatric Physician and Clinical Director. These privileges would include, but were not limited to admitting patients, prescribing medications, changing treatment modalities, and encompass all facets of direct patient care for inpatients of both the acute psychiatric unit and dual diagnosis unit. Review of "Quality Assessment Performance Improvement Plan" (QAPI) dated 2013, revealed the following in part, ..."Medical staff evaluation and monitoring; The monitoring and evaluation of medical staff will be done by the clinical director and other members of the Medical Staff at their annual evaluation/review, as per Medical Staff Bylaws...The QAPI committee will review, approve, or revise, monitors and identify any additional activities to be monitored...the clinical performance of individuals with clinical privileges is evaluated through monitoring services that have been approved by Medical Staff...this program is designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient/client care; pursue opportunities to improve said care, and resolve problems efficiently and effectively." Review of "Bylaws, Rules and Regulations of the Medical Staff" adopted by the Medical Staff on 5/8/12, and approved by the Governing Body on 5/11/12, revealed the following in part, ..."Active Medical Staff shall actively participate in...peer review...reappointment process...shall be made bi-annually...the clinical director (or designee) shall address: ...peer recommendation for continued membership...all reappointments to the Medical Staff will be reviewed by the clinical director (or designee) and other members of the Medical Staff. All recommendations shall be submitted to the Superintendent and Governing Body for review and approval." Review of "Governing Body" revised 12/12, revealed the following in part, ..."The governing body develops, directs, and supports the mission of the institute through such means as...performance appraisal...performance improvement..the executive committee will review processes to assure...adequate delivery of care." Review of Medical Team Meeting Minutes from 12/12/12 to 11/13/13, signed by the Superintendent, revealed no evidence of peer review prior to appointment/reappointment by the medical team/staff members. Medical team members identified on the meeting minutes included the Superintendent, Clinical Director, the Associate Nursing Practitoner (ARNP), Administrator of Nursing (AON), the Business Manger and the Health Information Director (HIM). Staff L, RN and the Quality Assurance Chair, was not identified as a member of the medical team. Review of the credential files for Physicians B, and C revealed no evidence of an objective evaluation of the Physicians B and C's current clinical competency and ability to practice with reasonable skill and safety and/or peer review prior to reappointment. Review of document "Peer Review" presented by Staff K, HIM Director to the survey team on 11/20/13 at 10:00 AM, revealed the following in part, ..."We have not reviewed charts on the two doctors [Physician B or C] contracted from Independence as they would write doctor's orders and progress notes, but they do provide patient care. Staff K signed the document. 2. During an interview on 11/20/13 at 1:00 p.m., the Superintendent acknowledged the facility failed to evaluate the quality and appropriateness of patient care and services provided by Physician B or C. The Superintendent said he was unaware that they had even completed a peer review for either physicians, for the "past 15 years". Additionally, the Superintendent said that they had never considered Physician B or C as "their" physicians because they were contracted to provide services on the weekend and he was not aware that they needed to be included in the peer review process. During an interview on 11/21/13 at 7:15 AM, Staff L, RN and Quality Assurance Chair, said she was not involved with the peer review process. Staff L said, although the QAPI policy references periodic evaluation of all physician's care and services, she did not recall at any time in the past 6 years while she was Chair of the QAPI committee, that they had discussed or reviewed the quality or clinical performance of physicians with privileges at their facility. Additionally, Staff L said the Health Information Director (Staff K) was responsible for ensuring peer review was completed for all of the physicians at the facility. 3. The governing body lacked information from the peer review process by the medical staff, including the quality and appropriateness of the patient diagnosis and/or treatment furnished by psychiatric doctors in the Physicians B and C's credential files at the time of reappointment. |
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| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on review of policies/procedures, documentation, and staff interviews, the facility failed to implement systems that assured a safe and functional environment for patients with a psychiatric diagnosis on the adult psychiatric patient care areas and patients with psychiatric and substance abuse diagnosis on the dual patient care areas. The facility identified a census of 14 patients on the Dual Diagnosis unit, and 9 patients on the Adult Psychiatric Unit at the time of the survey. Although facility staff was aware of the conditions that posed a risk to patients with psychiatric and substance abuse diagnosis, some of whom were suicidal, the facility failed to: - Ensure the nurse conducts a complete nursing assessment when a patient returns to the facility after an unauthorized departure. - Ensure an appropriate nursing interview when a patient returns to the facility after an unauthorized departure to determine if the patient used alcohol or other drugs or over the counter medications. - Ensure physician notification of acute changes in physical and mental status for a period of time after return of a patient from an unauthorized departure. - Ensure timely emergency treatment for dextromethorphan poisoning when a patient returns to the facility after an unauthorized departure. - Ensure staff followed facility policy for monitoring vital signs, documentation in the patient's medical record, nursing protocols and elopement precautions. - Ensure nursing staff followed policies and procedures, conducted a complete assessment, interviewed the patient after an unauthorized departure to determine if they ingested any type of substances while they were gone from the facility. - Ensure staff followed facility policy for monitoring patients on swallowing and or suicide precautions. - Ensure personal care items or cleaning chemicals was not available to patients on swallowing or suicidal precautions. - Ensure staff followed facility policy for monitored distribution of personal hygiene items to patients that allowed a patient on swallowing precautions to swallow a toothbrush and require medical intervention for removal of the toothbrush from the patient's stomach. - Ensure staff maintained a safe environment for psychiatric patients on swallowing or suicide precautions by minimizing risk factors, and securing cleaning solutions on housekeeping carts in hallways making them unavailable to patients at risk for swallowing them. - Ensure the maintenance of a safe environment by staff and an effective system for provision of care and treatment and adequate supervision for patient's with psychiatric and substance abuse diagnoses and/or suicidal tendencies is extremely important in maintaining patient safety. Staff vigilance in assessing acute changes in physical and mental status after returning to the facility from an unauthorized departure and monitoring personal hygiene items and the patient's whereabouts if they are on swallowing and/or suicide precautions is critical in order to prevent these patients from harming themselves and/or other patients. The cumulative effect on these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of patients, with psychiatric and substance abuse diagnoses in a safe environment. (Refer to A144) |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on review of documents, medical records, staff interview, and policies, nursing staff failed to complete an assessment and interview for 1 of 1 sampled patients who left the hospital on an unauthorized departure (Patient #2). The patient had a known history of abusing cough syrup with many previous hospitalization s to treat dextromethorphan overdose prior to his admission to the dual diagnosis unit and nursing staff failed to assess for acute changes in the patient's physical and mental status or ask the patient about what happened while he was away from the hospital after returning from the unauthorized departure. The hospital had a census of 14 patients on the Dual Diagnosis Unit, and 9 patients on the Adult Psychiatric Unit at the time of the survey. The Center for Psychiatric Care program guide for the hospital identified the dual diagnosis unit as an open unlocked unit for patients requiring minimum supervision and care/treatment for psychiatric illness and addiction to alcohol and/or other drugs and the adult psychiatric unit as a closed locked unit for patients requiring intensive care/treatment for adult psychiatric illnesses. It was hospital protocol to admit the patient to the locked adult care psychiatric unit when a patient returns from an unauthorized departure. Failure to assess Patient #2's physical and mental status and interview the patient after he returned from an unauthorized departure resulted in the registered nurse (RN) P obtaining an order for Thorazine from the Physician C for the patient's complaints of depression/anxiety. The registered nurse administered 50 milligrams (mg) of Thorazine orally to the patient within a half hour of the patient's return to the hospital. At the time, the RN was unaware that the patient had ingested 4 bottles of cough syrup during the his brief unauthorized departure. The nurse's failure to assess the patient and ask the patient whether he used any substances while away from the hospital resulted administration of another drug in addition to the four bottles of cough syrup he consumed during the unauthorized departure. There was a 15 hour delay of emergency treatment for the cough syrup (dextromethorphan) poisoning for Patient #2. The surveyors identified an Immediate Jeopardy based on the findings related to Patient #2. The Surveyors notified the Superintendent and Administrator of Nursing (AON) of the Immediate Jeopardy situation on 11/25/13 at 4:00 PM. Based on findings, the Superintendent and AON developed a written corrective action plan and immediately implemented the plan on 11/25/13. The immediate corrective action plan included actions to educate all staff for appropriate nursing assessments and changes in nursing assessment forms including specific questions to ask the patients upon return from an unauthorized departure. Policies were updated to prevent further incidents from occurring that could result in harm to patients. The surveyors confirmed the immediate corrective actions taken by the Superintendent, AON and hospital staff abated the Immediate Jeopardy on 11/26/13 at 10:20 AM. Findings include: 1. The "Unauthorized Departure" report for Patient #2, dated 4/5/13, 7:15 PM, revealed the following in part: Patient #2 was a voluntary committal, left at approximately 7:15 PM, wearing a hoodie, shorts, and tennis shoes. The Administrator of Nursing (AON) was notified of the patient's departure at 7:48 PM. The local Police Department was notified at 7:33 PM. The local police returned patient to the hospital at approximately 7:55 PM. The AON was notified of patient's return at 8:07 PM. Staff T, RN and house supervisor signed the report. The report lacked documentation describing the patient's status at the time of his return to the hospital and admission to the locked adult psychiatric unit and lacked information about the patient's activities while away from the hospital. 2. The "Critical Incident" report for Patient #2, dated 4/6/13, revealed in part: The type of incident: was an Unauthorized Departure. The description of incident was that Patient #2 left grounds on Friday 4/5/13, at 7:15 PM. On 4/6/13, at 10:28 AM., Patient #2 reported stealing 4 bottles of Delsym cough syrup and drinking the cough syrup between 7:15 and 7:55 PM on 4/5/13. Patient exhibited symptoms of diaphoresis (profuse sweating), flushing, elevated pulse and blood pressure. Staff I, RN, notified Physician C who advised staff to contact the poison control center. The poison control center advised an emergency department (ED) evaluation. Resident Treatment Workers (RTWs) took the patient to the local hospital's ED at 12:30 PM, 15 hours after the patient returned to the hospital from the unauthorized departure. The AON and Superintendent were notified. 3. Review of Patient #2's medical record revealed the following information. a. The "Nursing Admission Assessment" dated 4/1/13 showed Patient #2 informed nursing staff at the time of admission that he had a history of addiction to cough syrup and requested treatment for the addiction. The document showed the patient ingested cough syrup 1 and 1/2 weeks prior to admission to the hospital. b. A History and Physical by Physician D, dated 4/1/13, revealed the patient was admitted on a voluntary basis to the dual diagnosis program at the hospital. The patient was admitted to the adult psychiatric unit previously on 3/22/13 for suicidal ideation after ingesting 4 bottles of Delsym cough syrup and smoking K2 (a drug that mimics the effects of marijuana but has more side effects). The patient had 3 prior hospitalization s for the same reason in the past month. The patient was judged unable to function independently, because of continued relapses with abuse of cough syrup, and had been living in institutional facilities for the past 2 years. The patient stated he had been formally diagnosed with paranoid type Schizophrenia for the past year and has struggled with Major Depressive Disorder for a number of years. He has made 5 or 6 suicide attempts, mostly by overdosing. His diagnoses include Major Depressive Disorder without Psychotic features, history of Schizophrenia and Dextromethorphan dependence. His short term goals were listed as he will not use cough syrup and will participate in the dual diagnosis program on a daily basis. His long term goal was listed as he will be 100% committed to sobriety with no use of cough syrup. c. Nursing progress notes dated 4/1/13, at 12:18 PM, revealed the patient was admitted to the adult psychiatric unit initially at 12:18 PM, and transferred to the dual diagnosis unit at 3:13 PM. From 4/1/13 to 4/5/13 the patient participated in individual and group therapies with clinical staff including but not limited to psychiatric nurses, psychiatrists, psychologists, social workers, activity therapists and resident treatment workers. - Nursing progress notes dated 4/5/13 at 7:20 PM, revealed the patient refused to participate in treatment and attend group therapy. The nurse informed the patient that if he refused to participate and attend group therapy that it would result in write ups and if he had enough write ups, it would show he was not participating in treatment. Non-participation in treatment, could result in possible discharge from the program. - Nursing progress notes dated 4/5/13 at 7:20 PM, revealed the patient was out in front of the hospital talking with Staff S, RTW, and then he walked off the premises. A state car was sent to look for patient in surrounding area. The patient was a voluntary admission but he had a history of suicide attempts and substance abuse. The patient had a history of paranoia and hearing voices and hallucinations. Staff T, RN/Nursing supervisor signed the entry. - Nursing progress notes dated 4-5-13 at 7:55 PM, revealed the patient walked directly out of the unit door and down the stairs. Staff accompanied the patient as he walked out the front door and made multiple attempts to convince the patient from leaving the premises. The patient told staff that he just needed to walk and clear his head and would be back in an hour. The nursing supervisor sent staff to find the patient and when they located the patient, he refused to return to the hospital with them. The patient told staff that he was frustrated that there might be a write up. Patient was returned to the hospital by a police officer at 7:55 PM, and stated he had a cigarette at local store while he was gone. Staff S, RTW, signed the entry. - Nursing progress notes dated 4/5/13 at 8:09 PM, revealed the patient was checked for contraband and given a breathalyzer test upon return to the hospital and placed on the adult psychiatric unit. Nursing notes lacked an assessment of the patient's physical status or mental status, and an interview with the patient to find out if he had ingested or used any substances while he was gone. Nursing staff failed to notify the on-call-physician of the unauthorized departure. Staff P, RN signed the entry. - Nursing progress notes dated 4/5/13 at 8:35 PM, revealed the patient complained of depression and anxiety. Staff P contacted Physician C, and obtained an order for Thorazine (an anti-psychotic medication) 50 mg orally every 6 hours. Staff P administered the Thorazine at 8:30 PM. Staff P signed the entry. Nursing notes lacked an assessment of the patient's physical status and vital signs at the time the patient complained of depression and anxiety or at the time she administered the medication. - Nursing progress notes, dated 4/6/13 at 2:21 AM, revealed RTW staff responded to the patient's request for assistance after falling. Staff asked the patient if he was "ok" and the patient said he was "unhurt". Progress notes lacked evidence of vital signs or notification to nursing staff of the fall. Staff Q, RTW signed the entry. - Nursing progress notes, dated 4/6/13 at 2:53 AM, revealed RTW staff heard a noise coming from the patient's room and found Patient #2 lying on the floor in front on the door. The patient told staff he did not remember falling and said he was "ok" and he did not hit his head. RTW staff documented at about 2:15 AM, they had heard the patient screaming and when they asked him to stop, the patient said he did not know why he was screaming. RTW staff asked the patient if he needed anything or if he was hurt and the patient said he was fine. Staff encouraged the patient to lie down and try to go back to sleep and documented they would continue to monitor the patient until 7:00 AM. The progress notes lacked evidence of vital signs or notification to nursing staff of the second fall and the screaming. Staff R, RTW signed the entry. At the time of the entry it had been approximately 7 hours since the patient returned to the hospital after the unauthorized departure. - Nursing progress notes dated 4/6/13 at 5:40 AM, revealed Staff P documented the patient had "bizarre" behaviors throughout the night. Nursing notes lacked any assessment of the patient's physical and mental status or an assessment to determine if the patient's suffered any injuries from falling twice or vital signs to determine if there were any significant changes in pulse or blood pressure. Staff P signed the entry. At the time of the entry it has been 9 hours and 45 minutes since the patient returned to the hospital after the unauthorized departure. - Nursing progress notes dated 4/6/13 at 10:28 AM, revealed the patient was heard to scream out and observed in his room. The patient was diaphoretic (profuse sweating) with facial flushing, and an unsteady gait. The patient's Blood pressure (BP) was 114/110, pulse 111. At this time, the patient admitted drinking 4 bottles of Delsym cough syrup the prior evening at approximately 7:30 PM to nursing staff. Staff I, RN, notified Physician C who advised them to contact the poison control center. The poison control center advised the nursing staff to send the patient to an emergency department for evaluation and the poison control center staff said they would call ahead and advise the hospital what labs to draw. Hospital staff planned to transport the patient to the local hospital for emergency. - Nursing progress notes dated 4/6/13 at 11:13 AM, Staff F, RN, assessed the patient. Staff F documented the following in part: ...I could tell that he was intoxicated on some sort of substance. When I asked him what he had taken, he responded, "I drank 4 bottles of cough syrup." He had a blank look on his face, his pupils were dilated and constricted very slowly. The patient's BP was 142/112, pulse was 114, speech slurred and the patient was very slow to respond. His gait (ability to walk) was very unsteady. 4. An Emergency Department (ED) note dated 4/6/13 at 11:39 AM, revealed the following in part: - Chief complaint: Intoxication. - History of Present Illness: ...Last night about 7:30 PM patient ingested 4 bottles of Delsym. Hospital staff brought him to the ED this morning when he seemed obtunded (mentally dulled). - Assessment/Plan (A/P) by the ED physician: Dextromethorphan poisoning, moderate...some evidence of hallucinations, no evidence of seizures...has come through about 15 hours and metabolically, he is alright...he is not safe to be on his own, but is observed at the mental health hospital and they can manage his obtunded condition per their report...The half life of dextromethorphan at about 4 hours and should be getting out of his system pretty quickly and things should be resolving, otherwise we will do some scans. No evidence of falls or trauma to his body. He does not appear to be in immediate threat as far as the intoxication to himself if observed. 5. An "External Consultation note completed by Physician C, dated 4/6/13, at 12:55 PM, revealed the following in part, ...Patient/client diagnosis: Evaluate for overdose Delsym cough syrup...Client stated he ingested 4 bottles of Delsym cough syrup at approximately 7:30 PM, on 4/5/13. Diaphoretic face, flushed face, unsteady gait, slowed verbal response, BP 114/111, pulse 111...Potential risk and Precautions: Returned from the local hospital's ED with written instructions to repeat a white blood cell count, urine drug screen and observe for seizures due to drug interactions (with his current medications). 6. Patient #2's treatment plans, dated 4/1/13 through 5/2/13, and reviewed by weekly by the interdisciplinary team lacked any additions that addressed the unauthorized departure, assessment, evaluation of the patient's condition upon his return, or intervention for monitoring the patient for relapse in sobriety with no use of cough syrup. 7. Interviews were conducted with the following staff familiar with Patient #2. a. During an interview on 11/21/13 at 7:45 PM, Staff N, Registered Pharmacist (RPH) at the hospital, said Delsym cough syrup enters the brain releasing dopamine (a chemical produced in the brain) creating a feeling of euphoria. Staff N said the most common side effect would be an increased heart rate and if taken in a large amount it could potentially be fatal. Staff N said in his opinion, if a patient ingested 4 bottles of Delsym they may be light-headed, extremely drowsy, unsteady, the heart rate and blood pressure may increase and they would be at an increased risk for falling. Staff N said, if you combined the cough syrup with Thorazine 50 mg there would be increased drowsiness. Staff N said if nursing staff suspected a patient had ingested 4 bottles of Delsym he would recommend the patient be transferred to an emergency department to be evaluated by a physician. Review of drug information for Dextromethorphan revealed the indicated maximum dosage for adults is 120 mg (4 teaspoons) in 24 hours according to the prescribing information. Warnings and precautions included but not limited to nausea or vomiting, drowsiness, light-headedness. If symptoms continue consult a physician or seek medical attention. Improper use of this medication (abuse) may result in serious harm including brain damage, seizure and/or death. b. During an interview on 11/21/13 at 8:15 AM, Physician A, Psychiatrist and Clinical Director, said he would expect nursing staff to ask a patient who left the hospital on an unauthorized departure where they had been and if they had purchased or consumed any substances or in this case cough syrup. Physician A said nursing staff would be trained to take the patient's vital signs and monitor the patient closely and document the results in the medical record. After reviewing Patient #2's medical record, Physician A said after the first fall the doctor should have been notified and at the very least a sitting and standing blood pressure (BP) should have been taken to determine if the patient was having signs and symptoms of a drug interaction or overdose. Physician A said after the second fall, at the very least another set of vital signs should have been taken and a physician notified, because there was a pattern. At the conclusion of the interview, Physician A said the potential outcomes for this patient could have been serious injury after falling, and with the combined administration of Thorazine and 4 bottles of cough syrup the patient could experience a sudden drop in BP placing him at a potential for harm and further injury. c. During an interview on 11/21/13 at 8:25 AM, the Superintendent acknowledged nursing staff failed to complete an assessment and check vital signs when Patient #2 returned to the hospital after an unauthorized departure. The Superintendent said, in his opinion, the nurse should have done more. d. During an interview on 11/21/13 at 8:45 AM, Staff L, RN and Nursing Supervisor said nursing staff would be trained to complete a physical assessment for patients who left the hospital on an unauthorized departure and returned. Staff L said the assessment should include checking the patient for physical injuries, taking vital signs, and an assessment of their mental status. Additionally, interviewing the patient to determine where the patient went, what the patient did, and especially asking the patient if he or she had taken any substances. Staff L said staff would be trained to document this in the patients' medical records and it should be documented on an incident report. When asked if she was able to locate an incident report on the unauthorized departure, Staff L said no, but she recalled an e-mail that Staff F sent. Staff L acknowledged nursing staff failed to complete a physical assessment and/or vital signs when Patient #2 exhibited a change in status and behavior on 4/6/13 and failed to notify the physician. An e-mail from Staff F to Staff L and the Staff A, the Administrator of Nursing (AON), dated 4/6/13 at 2:00 PM, revealed the following information. On Friday evening, Patient #2 went to a local supermarket. He returned and was placed on the locked adult psychiatric unit. According to the charting for 4/5/13 night shift and 4/6/13 day shift he was found on the floor on two separate occasions and did not know why. He was also screaming on a consistent basis. No vital signs were taken, even though staff knew he had been off grounds. On Saturday morning, Staff F assessed him. Staff F wrote "as soon as I saw him, I immediately knew that there was something wrong. Right away I asked him what he had taken, it took no prodding, he stated 4 bottles of Delsym." "This was at the very least twelve hours later...I only want you all aware that this did happen and if there is some corrective action that can be taken to ensure that maybe it won't happen again? These kinds of things make me fear for our patient's safety..." e. During an interview on 11/21/13 at 10:20 AM, Staff I, RN said, on 4/6/13 around 9:30 AM, the patient was screaming and when they went to the patient's room and asked what was wrong, Patient #2 said he had taken 4 bottles of Delsym cough syrup the night before to get "high". Staff I said she felt this was "a very lethal dose and the patient was fortunate to live". Staff I said prior to change of shift at report on the morning of 4/6/13, Staff P reported the patient had been up all night acting bizarre. Staff I said at the very least the physician should have been contacted when the patient's status changed and that this would be a standard of nursing. Staff I said she knew right away, after seeing Patient #2 that morning that he had ingested something the night before and after notifying Physician C, the patient was taken to the local hospital's Emergency Department (ED) by hospital staff. f. During a interview on 11/21/13 at 10:35 AM, the AON confirmed that patients who are admitted to the dual diagnosis unit cannot be forced to stay at the hospital if they want to leave and that nursing staff are trained to do everything in their power to persuade them to stay. The AON acknowledged nursing staff failed to complete an assessment, monitor vital signs for any adult changes, and notify the physician of falls. The AON confirmed that nursing and RTW staff received training to complete these tasks. The AON confirmed there had been a delay in emergency treatment for 15 hours for Patient #2, and this could have been potentially harmful to the patient's safety and well being. When asked what a reasonable psychiatric nurse would do in a similar situation, the AON said knowing the patient's background on the dual diagnosis unit, there should have been a complete physical and mental assessment and an interview with the patient, when he returned to the hospital after the unauthorized departure, to determine whether he had taken any substances. g. During an interview on 11/25/13 at 3:25 PM, Staff P, acknowledged she failed to complete an assessment and check vital signs when Patient #2 returned to the the hospital after the unauthorized departure. Staff P acknowledged she failed to contact a physician when the patient fell . Staff P stated she normally did not complete an assessment or take vital signs when a patient returns after an unauthorized departure. Staff P stated she would start taking a set of vital signs and complete an assessment when patients returned after any unauthorized departure. Staff P acknowledged she failed to ask Patient #2 if he had ingested any substances during the time he was gone. Staff P stated she does not ask when a patient returns after an unauthorized departure if they ingested any substances. Staff P stated she would start asking these questions when patients return after an unauthorized absence. h. During an interview on 11/26/13 at 6:40 AM, Staff Q, said he heard a "bam'' on 4/6/13 at 2:21 AM, and found Patient #2 lying on the floor in his room. Staff Q confirmed RTW staff received training to take vital signs after a patient falls and acknowledged they failed to do so. Staff Q said the patient acted "drunk" that night, was argumentative, unstable and "definitely" not alert. Staff Q acknowledged that he failed to document the behaviors in the patient's medical record nor did he report this to the nurse. i. During an interview on 11/26/13 at 10 AM, Staff F, RN, said at the time of shift change report on 4/6/13, Staff P reported Patient #2 left the premises the night before and went to a local store and returned to the hospital. Staff P reported the patient had been acting bizarre all night. Staff F said Staff CC, RTW, approached her approximately 10:00 AM, to report Patient #2 was acting "strangely" and asked if they would assess the patient. Staff F said the patient's pupils were dilated and it was "obvious" that the patient had taken some type of substance. Staff F said the patient was unsteady, his speech was slurred, his responses were slow, and his BP was elevated. Staff F said the patient readily admitted he had taken 4 bottles of cough syrup from the local store when asked. Staff F expressed concern with nursing and RTW staff for failing to take vital signs, complete an assessment, and ask the patient if he had taken anything at the time the patient returned from the unauthorized departure. Staff F said, since it's identified very clearly in the patient's chart that cough medicine was his "drug" of choice, that clearly these questions should have been asked. Staff F said the impact to Patient #2 was a delay in necessary emergency treatment. Staff F said nursing staff failed to complete a through assessment, monitor vital sign before and after the patient fell , and notify the physician of of the falls and acute changes in the patient's behaviors. j. During an interview on 11/26/13 at 1:00 PM, Staff T, RN,, said when Patient #2 returned after the unauthorized departure, she did not recall the patient behaving unusually or acting like he was under the influence of drugs. Staff T stated normally she does not ask when a patient returns after an unauthorized departure if they ingested any substances. Staff T stated she would start asking questions regarding whether the patient used any substances when patients return after an unauthorized departure. Staff T said that this was "definitely a learning experience for all nursing staff". 8. The following documents were reviewed. a. The "Patient Rights and Responsibilities" dated 3/6, revealed the following in part, ..."You have the right to the best care and treatment available in this hospital...have your treatment plan reviewed periodically." b. The "Department of Administrative Services - RN Job Description" dated 6/08, revealed the following in part, ..."Assesses patient/client's (holistic) health needs; develops a nursing diagnosis...and evaluating/monitoring the on-going nursing care in compliance with professional standards of quality care." c. The "Department of Administrative Services - RTW Job Description dated 3/12, revealed the following in part, ..."Performs basic clinical tests such as taking temperature, pulse, respiration and BP, records information relating to a resident's...significant changes in behavior or attitude on medical charts...knowledge of patient care and basic nursing procedures." d. The undated hospital policy, "Registered Nurse Essential Functions" revealed the following in part, ..."must utilize nursing process in provision of psychiatric nursing care...must be able to decide when patient condition requires attention of the doctor accurately...document daily activities and patient progress for all assigned patients...must be able to describe patient condition accurately." e. The hospital policy, "Vital signs", last reviewed 8/13, revealed the following in part, ..."Vital signs are taken as a means of observing change(s) in a patient's/client's condition; and as an aid for diagnosis...documentation: BP, pulse and respiration are charted on the flow sheet under the appropriate headings...if there are significant observations which must be kept for medical purposes; the vital signs should be included in the team notes." f. The hospital policy, "Charts and Charting Procedure", last reviewed 2/13, revealed the following in part, ..."To provide an orderly, consistent form of documentation throughout the hospital...Any unusual incident or behavior should be timely noted even if minimum requirements have been met...all nursing staff are responsible for charting. This includes RN's...and RTW's...documentation by nursing staff includes but it not limited to...Temperature, Pulse, Respiration (TPR), BP...unauthorized departure; include details...and all circumstances relating to the incident." g. The hospital policy, "Approved Nursing Protocols", last reviewed 4/13, revealed the following in part, ..."RN staff shall use their professional licensure to established modalities and protocols for patients...to provide a set of established protocols approved by medical staff for nursing to be able to enter into a patient's medical record...the following protocol/modality orders...shall be entered into the [electronic medical record system] and performed by a RN according to appropriate nursing judgement: ...vital signs...neuro checks (an evaluation of the functioning of a patient's nervous system to ascertain if there are acute changes in the patient's level state of awareness)". h. The hospital policy, "Elopement Precaution" last reviewed 2/12, revealed the following in part, ..."The treatment plan should be reviewed and additions made in regard to elopement." i. The signature page for the "Verification of Policies Read" from May 2012 through April 2013 revealed Staff P, an RN, Staff Q and R, RTWs verified they had read nursing policies and understood and were responsible for the contents of the policy[ies] by their signatures. II. Based on observation, medical record review, hospital policy review and staff interviews, the hospital failed to provide adequate supervision for 1 of 1 patients on swallowing precautions, (Patient #1) to prevent the patient from ingesting personal care items or cleaning chemicals. The hospital administrative staff reported a census of 14 patients in the dual diagnosis unit and 9 patients in the adult psychiatric unit at the time of the survey. Failure to provide adequate supervision for patients on swallowing precautions could allow the patients to obtain items or substances that the patient should not have and swallow them causing harm to the patient. Findings include: A. Incident 1 1. Review of Patient #1's medical record revealed an admitted [DATE] by court order with diagnoses for Mood Disorder, Intermittent Explosive Disorder and Borderline Intellectual Functioning. The patient was placed on 15 minute checks at time of admission. The patient not placed on any other precautions at the time of admission because nursing and physician assessments ruled out the need for them. 2. Review of the Client Profile - Order Details, (Physician's orders) revealed on 10/16/13 at 9:11 PM, Physician A, a psychiarist, placed the patient on swallowing foreign objects precautions with no discontinuation date. Staff were to not allowed to give the patient any items the patient could swallow or ingest. On 10/22/13 at 12:46 PM, Physician A ordered the patient should not have a regular toothbrush or any other items that could be swallowed. On 10/25/13 at 1:36 PM, Physician A ordered 1 to 1 observation for Patient #1. 3. Patient #1's Progress Note Report included the following documentation regarding the patient swallowing the toothbrush: On 10/19/13, Patient #1 asked Staff H for his hygiene basket to take a shower. Staff H gave the hygiene basket to the patient without checking the basket first. Staff H did not check the basket because the items that could be swallowed should have been removed. Staff H assumed the basket did not contain a toothbrush. The patient reported to staff E, he had swallowed a toothbrush. Staff H checked the basket and observed a toothbrush in it. Staff E and G searched the bathrooms and patient's room, but did not locate another toothbrush. Staff H said another staff reported the patient had 2 toothbrushes. On 10/19/13 at 1:54 PM, Staff E, RTW documented; Patient #1 came to (Staff E) and asked to talk in private. This writer took the patient to the quiet room and the patient asked " what would happen if I swallowed a toothbrush? " Staff E asked the patient if he did and he said " yes " . Staff E notified the Registered Nurse (RN). Staff have observed the patient on swallow precautions this shift. Will continue to monitor. On 10/19/13 at 3:21 PM, Staff I, RN documented; The patient stated he swallowed a toothbrush out of his hygiene box. The hygiene box contained a toothbrush. The patient stated he swallowed the other toothbrush. The patient exhibited no signs of distress. he walked about the unit laughing and talking. The patient asked when he could go to the hospital. Staff moved the patient to side a room wearing hospital sweats. Physician C, was notified and no new orders were received. On 10/19/13 at 8:19 PM, Staff P, RN documented; Staff have observed patient on swallowing precautions this shift with no distress noted. The patient made a phone call to his mother and grandmother. The patient ate a bag of popcorn and chips with salsa after he ate supper. Patient requested this RN call the doctor, but informed the doctor is aware of the problem and never gave new orders. Will continue to observe closely for any distress or signs the doctor would need to be called. On 10/19/13 at 9:25 PM, Staff V, RTW, documented; The p |
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| VIOLATION: MEDICAL STAFF | Tag No: A0338 | |
| Based on review of documents, Medical Staff Bylaws/Rules and Regulation, policy/procedure, and staff review the Medical Staff failed to ensure that every physician providing care to patients, received peer recommendation for reappointment, and was accountable to the governing body for the quality of care provided to patients, for 2 of 3 psychiatric physicians. (Physician B, and C). The following examples confirmed this determination: - The Medical Staff Committee failed to evaluate all physicians for the quality of care and appropriateness of treatment provided to patients by the hospital. - The Medical Staff Committee failed to ensure the Quality Assurance Performance Improvement (QAPI) committee, reviewed, coordinated, and monitored all individuals with clinical privileges and providing care and treatment to patients on the Adult Psychiatric and Dual Diagnosis units. - The Medical Staff Committee failed to conduct peer recommendations for all physicians prior to reappointment for clinical privileges. - The Medical Staff Committee meetings failed to include periodic appraisals of all members of the medical staff and/or the peer review process. The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the quality and competency of the care provided to patients by its medical staff, which could potentially threaten the safety of all patients receiving care at the hospital. Refer to A0340 |
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| VIOLATION: MEDICAL STAFF PERIODIC APPRAISALS | Tag No: A0340 | |
| Based on review of Quality Performance Plans, Medical Staff Bylaws/Rules and Regulation, Medical Team meeting minutes, and staff interview, the Medical Staff failed to ensure that every physician providing care services to patients, received peer recommendation for reappointment, and was accountable to the governing body for the quality of care provided to patients, for 2 of 3 psychiatric physicians. (Physician B, and C). The hospital's medical staff consisted of 3 psychiatrists at the time of the survey. Findings include: 1. Review of Current Roster of Medical Staff Members, dated 11/18/13, revealed Physicians B and C were identified by the Superintendent as members of the Medical Staff at the facility, provided care and services to all patients on alternating weekends. During an interview on 11/19/13 at 3:20 PM, the Superintendent said although both physicians were contracted they would have the same privileges as Physician A, Primary Psychiatric Physician and Clinical Director. Review of "Quality Performance Improvement Plan" (QAPI) dated 2013, revealed the following in part, ..."Medical staff evaluation and monitoring; The monitoring and evaluation of medical staff will be done by the clinical director and other members of the Medical Staff at their annual evaluation/review, as per Medical Staff Bylaws...The QAPI committee will review, approve, or revise, the monitors and identify any additional activities to be monitored...the clinical performance of individuals with clinical privileges is evaluated through monitoring services that have been approved by Medical Staff...this program is designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient/client care; pursue opportunities to improve said care, and resolve problems efficiently and effectively." During an interview on 11/21/13 at 7:15 AM, Staff L, RN/Quality Assurance Chair/ Coordinator said she was not involved with the peer review process. Staff L said that although the QAPI policy references periodic evaluation of all physician's services and care, she did not recall a time in the 6 years that their committee discussed or reviewed the quality or clinical performance of physicians with privileges at their facility. Additionally, Staff L said Staff K, Health Information Director, was responsible for "making sure" peer review was completed for all of the facilities psychiatric physicians. Review of "Bylaws, Rules and Regulations of the Medical Staff" adopted by the Medical Staff on 5/8/12, and approved by the Governing Body on 5/11/12, revealed the following in part, ..."Active Medical Staff shall actively participate in...peer review...reappointment process...shall be made bi-annually...the clinical director (or designee) shall address: ...peer recommendation for continued membership...all reappointments to the Medical Staff will be reviewed by the clinical director (or designee) and other members of the Medical Staff. All recommendations shall be submitted to the Superintendent and Governing Body for review and approval." Review of "Governing Body" revised 12/12, revealed the following in part, ..."The governing body develops, directs, and supports the mission of the institute through such means as...performance appraisal...performance improvement..the executive committee will review processes to assure...adequate delivery of care." Review of Medical Team Meeting Minutes from 12/12/12 to 11/13/13 and signed by the Superintendent, revealed no evidence of reviewing physician credential files for qualifications for appointment/reappointment by the medical team members. Medical team members identified on the meeting minutes including but not limited to the Superintendent, Clinical Director, the Advanced Registered Nurse Practitioner (ARNP), Administrator of Nursing (AON), the Business Manger and the Health Information Director (HIM). Review of credential files for Physician's B, and C revealed no evidence of an objective evaluation of current clinical competency and ability to practice with reasonable skill and safety. Review of document "Peer Review" presented by Staff K, HIM Director to the survey team on 11/20/13 at 10:00 a.m., revealed the following in part, ..."we have not reviewed charts on the two doctors [Physician B or C] contracted from Independence as they would write doctor's orders and progress notes, but they do provide patient care. Staff K signed the document. 2. During an interview on 11/20/13 at 1:00 PM, the Superintendent acknowledged the facility failed to ensure the medical staff evaluated the quality and appropriateness of patient care and services provided by Physician B or C. The Superintendent said that the facility had never completed peer review for either physician since they started providing care for patients on the weekend, to relieve the Clinical Director, for the "past' 15 years. Additionally, the Superintendent said that they had never considered Physician B or C as "their" physicians and he was not aware that they needed to be included in the peer review process. The medical staff failed to review and appraise the qualifications of Physicians B and C through a peer review process at regular intervals to determine whether the patient care provided by the physicians was appropriate for continued privileges at the psychiatric hospital. The medical staff failed to complete the peer review process and forward the information to the governing body to take final action based on the quality of the patient care provided by the physicians. |
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| VIOLATION: UTILIZATION REVIEW | Tag No: A0652 | |
| Based on review of Quality Performance Improvement Plan, Bylaws/Rules and Regulations of Medical Staff, and staff interview the hospital failed to have a utilization review (UR) plan and a designated committee that reviewed professional services provided by the hospital and by members of the medical staff to patients who were entitled to benefits under the Medicare and Medicaid programs. Findings include: 1. Review of facility policies and procedures showed the hospital lacked evidence of a UR plan and/or policies and procedures. a. Review of "Quality Performance Improvement Plan" (QAPI) dated 2013, revealed the following in part, ...Objectives...Utilization Review: This committee assures that patients/clients receive quality and appropriate care in a timely manner, consistent with available resources. Patient/client records are reviewed on a routine basis, within specific time frames, for documentation to justify their continued stay at the Mental Health Institute. These indicators are of patient/client care, are are reported to the Performance Improvement Committee...the following areas of responsibility are specifically assigned and indicators reported, noting any findings and action (s) taken, with follow up, as appropriate...monitor area: ...Utilization review, function responsibility: Utilization Review Committee/Executive committee." During an interview on 11/21/13 at 7:15 AM, Staff L, RN/QAPI Chair/ Coordinator acknowledged the hospital did not have a UR committee and they failed to follow that "part" the QAPI plan. b. Review of Bylaws/Rules and Regulations of the Medical Staff, revised date 5/12, revealed the following in part, ..."The governing body develops, directs, and supports the mission of the institute through such means as...Performance Improvement is designed to increase the quality of patient service and all supporting processes by defining specific goals...the hospital leadership will assure that our key measures indicate an improvement trend. The executive committee will review processes to assure appropriate resources are allocated for delivery of care." During an interview on 11/21/13 at 11:40 AM, the Superintendent acknowledged that the facility failed to follow that segment of the Bylaws and the facility had already begun to correct this problem. 2. During an interview on 11/20/13 at 11:00 AM, the Administrator of Nursing (AON) said the facility did not have a UR program or committee currently and as far as she knew they had never had a UR plan. The AON said that when she first started, approximately 3 years ago, she didn't know if the hospital needed a UR committee and to this day she still didn't know. In a follow up interview on 11/26/13 at 1:10 PM, the AON said she located UR committee meeting notes from 6/16/10, and said after that meeting, the committee apparently disbanded and were no longer active. The AON acknowledged the facility lacked a UR plan, and confirmed that UR was defined in in the QAPI plan. Additionally, the AON acknowledged the hospital failed to follow that "portion" of the QAPI plan. During an interview on 11/21/13 at 11:40 AM, the Superintendent acknowledged the facility failed to have a UR plan and a designated UR committee. The Superintendent added the AON had voiced concern about not having a UR plan or committee 3 years ago and he failed to follow through with this concern. The Superintendent said that this would be addressed immediately. |
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| VIOLATION: OPO AGREEMENT | Tag No: A0886 | |
| Based on document review, policy review and staff interviews, the hospital lacked a current Iowa Donor Network agreement. The hospital had a census of 9 patients in the Acute Psychiatric Unit and 14 patients in the Dual Diagnosis program at the time of the survey. Failure to have a signed contract between both parties legally prevents patients, and/or families of its patients, with the opportunity to consider tissue and organ donation and the Iowa Donor Network to provide twenty four hour availability by phone trained personnel qualified to evaluate potential eye, tissue, or organ donors to determine medical suitability for donation. Findings include: Review of the hospital's Iowa Donor Network agreement stated in part... "2. This agreement shall remain in effect for a period of four years from the date of execution and shall replace any and all agreements for organ and tissue procurement between the two parties." The Chief Executive Officer for the Iowa Donor Network signed and dated the document on 10/19/09. The facility Superintendent signed and dated the document on 10/23/09. Review of the facility policy Organ Procurement Policy reviewed on 11/13 revealed in part... "5. The review of this policy shall occur every two years in conjunction with Iowa Donor Network. The Iowa Donor Network agreements shall be renewed at that time. During an interview on 11/20/13 at 2:35 PM, Staff A, Administrator of Nursing stated the hospital did not have a current copy of the Iowa Donor Network agreement. Staff A said if Staff K, Business Manager could not find a current copy of the agreement, the hospital would have to obtain a current copy. During an interview on 11/21/13 at 9:15 AM, Staff U reported the hospital did not have a current Iowa Donor Network agreement. The facility called the Iowa Donor Network staff to obtain a copy of the agreement. On 11/21 at 11:20 AM, Staff U provided the surveyor with the expired copy of the Iowa Donor Network agreement. |
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| VIOLATION: PATIENT CARE ASSIGMENTS | Tag No: A0397 | |
| Based on review of documents, medical records, staff interview, and policies, nursing staff failed to complete an assessment and interview and close monitoring following the return to the hospital after an unauthorized departure for 1 of 1 patient (Patient #2). Patient #2 had a known history of abusing cough syrup with many previous hospitalization s to treat dextromethorphan overdose prior to his admission to the dual diagnosis unit and nursing staff failed to assess for acute changes in the patient's physical and mental status or ask the patient about what happened while he was away from the hospital after returning from the unauthorized departure. The failure of the nursing staff to assess, interview, and closely monitor Patient #2 resulted in a 15 hour delay in emergency treatment for dextromethorphan overdose. The patient ingested 4 bottles of cough syrup containing dextromethorphan while on unauthorized departure from the hospital. The hospital had a census of 14 patients on the Dual Diagnosis Unit, and 9 patients on the Adult Psychiatric Unit at the time of the survey. Findings include: 1. The "Unauthorized Departure" report for Patient #2, dated 4/5/13, 7:15 PM, revealed the following in part: Patient #2 was a voluntary committal, left at approximately 7:15 PM, wearing a hoodie, shorts, and tennis shoes. The Administrator of Nursing (AON) was notified of the patient's departure at 7:48 PM. The local Police Department was notified at 7:33 PM. The local police returned patient to the hospital at approximately 7:55 PM. The AON was notified of patient's return at 8:07 PM. Staff T, RN and house supervisor signed the report. The report lacked documentation describing the patient's status at the time of his return to the hospital and admission to the locked adult psychiatric unit and lacked information about the patient's activities while away from the hospital. 2. The "Critical Incident" report for Patient #2, dated 4/6/13, revealed in part: The type of incident: was an Unauthorized Departure. The description of incident was that Patient #2 left grounds on Friday 4/5/13, at 7:15 PM. On 4/6/13, at 10:28 AM., Patient #2 reported stealing 4 bottles of Delsym cough syrup and drinking the cough syrup between 7:15 and 7:55 PM on 4/5/13. Patient exhibited symptoms of diaphoresis (profuse sweating), flushing, elevated pulse and blood pressure. Staff I, RN, notified Physician C who advised staff to contact the poison control center. The poison control center advised an emergency department (ED) evaluation. Resident Treatment Workers (RTWs) took the patient to the local hospital's ED at 12:30 PM, 15 hours after the patient returned to the hospital from the unauthorized departure. The AON and Superintendent were notified. 3. Review of Patient #2's medical record revealed the following information. a. The "Nursing Admission Assessment" dated 4/1/13 showed Patient #2 informed nursing staff at the time of admission that he had a history of addiction to cough syrup and requested treatment for the addiction. The document showed the patient ingested cough syrup 1 and 1/2 weeks prior to admission to the hospital. b. A History and Physical by Physician D, dated 4/1/13, revealed the patient was admitted on a voluntary basis to the dual diagnosis program at the hospital. The patient was admitted to the adult psychiatric unit previously on 3/22/13 for suicidal ideation after ingesting 4 bottles of Delsym cough syrup and smoking K2 (a drug that mimics the effects of marijuana but has more side effects). The patient had 3 prior hospitalization s for the same reason in the past month. The patient was judged unable to function independently, because of continued relapses with abuse of cough syrup, and had been living in institutional facilities for the past 2 years. The patient stated he had been formally diagnosed with paranoid type Schizophrenia for the past year and has struggled with Major Depressive Disorder for a number of years. He has made 5 or 6 suicide attempts, mostly by overdosing. His diagnoses include Major Depressive Disorder without Psychotic features, history of Schizophrenia and Dextromethorphan dependence. His short term goals were listed as he will not use cough syrup and will participate in the dual diagnosis program on a daily basis. His long term goal was listed as he will be 100% committed to sobriety with no use of cough syrup. c. Nursing progress notes dated 4/1/13, at 12:18 PM, revealed the patient was admitted to the adult psychiatric unit initially at 12:18 PM, and transferred to the dual diagnosis unit at 3:13 PM. From 4/1/13 to 4/5/13 the patient participated in individual and group therapies with clinical staff including but not limited to psychiatric nurses, psychiatrists, psychologists, social workers, activity therapists and resident treatment workers. - Nursing progress notes dated 4/5/13 at 7:20 PM, revealed the patient refused to participate in treatment and attend group therapy. The nurse informed the patient that if he refused to participate and attend group therapy that it would result in write ups and if he had enough write ups, it would show he was not participating in treatment. Non-participation in treatment, could result in possible discharge from the program. - Nursing progress notes dated 4/5/13 at 7:20 PM, revealed the patient was out in front of the hospital talking with Staff S, RTW, and then he walked off the premises. A state car was sent to look for patient in surrounding area. The patient was a voluntary admission but he had a history of suicide attempts and substance abuse. The patient had a history of paranoia and hearing voices and hallucinations. Staff T, RN/Nursing supervisor signed the entry. - Nursing progress notes dated 4-5-13 at 7:55 PM, revealed the patient walked directly out of the unit door and down the stairs. Staff accompanied the patient as he walked out the front door and made multiple attempts to convince the patient from leaving the premises. The patient told staff that he just needed to walk and clear his head and would be back in an hour. The nursing supervisor sent staff to find the patient and when they located the patient, he refused to return to the hospital with them. The patient told staff that he was frustrated that there might be a write up. Patient was returned to the hospital by a police officer at 7:55 PM, and stated he had a cigarette at local store while he was gone. Staff S, RTW, signed the entry. - Nursing progress notes dated 4/5/13 at 8:09 PM, revealed the patient was checked for contraband and given a breathalyzer test upon return to the hospital and placed on the adult psychiatric unit per hospital protocol. Nursing notes lacked an assessment of the patient's physical status or mental status, and an interview with the patient to find out if he had ingested or used any substances while he was gone. Nursing staff failed to notify the on-call-physician of the unauthorized departure. Staff P, RN signed the entry. - Nursing progress notes dated 4/5/13 at 8:35 PM, revealed the patient complained of depression and anxiety. Staff P contacted Physician C, and obtained an order for Thorazine (an anti-psychotic medication) 50 mg orally every 6 hours. Staff P administered the Thorazine at 8:30 PM. Staff P signed the entry. Nursing notes lacked an assessment of the patient's physical status and vital signs at the time the patient complained of depression and anxiety or at the time she administered the medication. - Nursing progress notes, dated 4/6/13 at 2:21 AM, revealed RTW staff responded to the patient's request for assistance after falling. Staff asked the patient if he was "ok" and the patient said he was "unhurt". Progress notes lacked evidence of vital signs or notification to nursing staff of the fall. Staff Q, RTW signed the entry. - Nursing progress notes, dated 4/6/13 at 2:53 AM, revealed RTW staff heard a noise coming from the patient's room and found Patient #2 lying on the floor in front on the door. The patient told staff he did not remember falling and said he was "ok" and he did not hit his head. RTW staff documented at about 2:15 AM, they had heard the patient screaming and when they asked him to stop, the patient said he did not know why he was screaming. RTW staff asked the patient if he needed anything or if he was hurt and the patient said he was fine. Staff encouraged the patient to lie down and try to go back to sleep and documented they would continue to monitor the patient until 7:00 AM. The progress notes lacked evidence of vital signs or notification to nursing staff of the second fall and the screaming. Staff R, RTW signed the entry. At the time of the entry it had been approximately 7 hours since the patient returned to the hospital after the unauthorized departure. - Nursing progress notes dated 4/6/13 at 5:40 AM, revealed Staff P documented the patient had "bizarre" behaviors throughout the night. Nursing notes lacked any assessment of the patient's physical and mental status or an assessment to determine if the patient's suffered any injuries from falling twice or vital signs to determine if there were any significant changes in pulse or blood pressure. Staff P signed the entry. At the time of the entry it has been 9 hours and 45 minutes since the patient returned to the hospital after the unauthorized departure. - Nursing progress notes dated 4/6/13 at 10:28 AM, revealed the patient was heard to scream out and observed in his room. The patient was diaphoretic (profuse sweating) with facial flushing, and an unsteady gait. The patient's Blood pressure (BP) was 114/110, pulse 111. At this time, the patient admitted drinking 4 bottles of Delsym cough syrup the prior evening at approximately 7:30 PM to nursing staff. Staff I, RN, notified Physician C who advised them to contact the poison control center. The poison control center advised the nursing staff to send the patient to an emergency department for evaluation and the poison control center staff said they would call ahead and advise the hospital what labs to draw. Hospital staff planned to transport the patient to the local hospital for emergency. - Nursing progress notes dated 4/6/13 at 11:13 AM, Staff F, RN, assessed the patient. Staff F documented the following in part: ...I could tell that he was intoxicated on some sort of substance. When I asked him what he had taken, he responded, "I drank 4 bottles of cough syrup." He had a blank look on his face, his pupils were dilated and constricted very slowly. The patient's BP was 142/112, pulse was 114, speech slurred and the patient was very slow to respond. His gait (ability to walk) was very unsteady. 4. An Emergency Department (ED) note dated 4/6/13 at 11:39 AM, revealed the following in part: - Chief complaint: Intoxication. - History of Present Illness: ...Last night about 7:30 PM patient ingested 4 bottles of Delsym. Hospital staff brought him to the ED this morning when he seemed obtunded (mentally dulled). - Assessment/Plan (A/P) by the ED physician: Dextromethorphan poisoning, moderate...some evidence of hallucinations, no evidence of seizures...has come through about 15 hours and metabolically, he is alright...he is not safe to be on his own, but is observed at the mental health hospital and they can manage his obtunded condition per their report...The half life of dextromethorphan at about 4 hours and should be getting out of his system pretty quickly and things should be resolving, otherwise we will do some scans. No evidence of falls or trauma to his body. He does not appear to be in immediate threat as far as the intoxication to himself if observed. 5. Interviews were conducted with the following staff familiar with Patient #2. a. During an interview on 11/21/13 at 7:45 PM, Staff N, Registered Pharmacist (RPH) at the hospital, said Delsym cough syrup enters the brain releasing dopamine (a chemical produced in the brain) creating a feeling of euphoria. Staff N said the most common side effect would be an increased heart rate and if taken in a large amount it could potentially be fatal. Staff N said in his opinion, if a patient ingested 4 bottles of Delsym they may be light-headed, extremely drowsy, unsteady, the heart rate and blood pressure may increase and they would be at an increased risk for falling. Staff N said, if you combined the cough syrup with Thorazine 50 mg there would be increased drowsiness. Staff N said if nursing staff suspected a patient had ingested 4 bottles of Delsym he would recommend the patient be transferred to an emergency department to be evaluated by a physician. Review of drug information for Dextromethorphan revealed the indicated maximum dosage for adults is 120 mg (4 teaspoons) in 24 hours according to the prescribing information. Warnings and precautions included but not limited to nausea or vomiting, drowsiness, light-headedness. If symptoms continue consult a physician or seek medical attention. Improper use of this medication (abuse) may result in serious harm including brain damage, seizure and/or death. b. During an interview on 11/21/13 at 8:15 AM, Physician A, Psychiatrist and Clinical Director, said he would expect nursing staff to ask a patient who left the hospital on an unauthorized departure where they had been and if they had purchased or consumed any substances or in this case cough syrup. Physician A said nursing staff would be trained to take the patient's vital signs and monitor the patient closely and document the results in the medical record. After reviewing Patient #2's medical record, Physician A said after the first fall the doctor should have been notified and at the very least a sitting and standing blood pressure (BP) should have been taken to determine if the patient was having signs and symptoms of a drug interaction or overdose. Physician A said after the second fall, at the very least another set of vital signs should have been taken and a physician notified, because there was a pattern. At the conclusion of the interview, Physician A said the potential outcomes for this patient could have been serious injury after falling, and with the combined administration of Thorazine and 4 bottles of cough syrup the patient could experience a sudden drop in BP placing him at a potential for harm and further injury. c. During an interview on 11/21/13 at 8:25 AM, the Superintendent acknowledged nursing staff failed to complete an assessment and check vital signs when Patient #2 returned to the hospital after an unauthorized departure. The Superintendent said, in his opinion, the nurse should have done more. d. During an interview on 11/21/13 at 8:45 AM, Staff L, RN and Nursing Supervisor said nursing staff would be trained to complete a physical assessment for patients who left the hospital on an unauthorized departure and returned. Staff L said the assessment should include checking the patient for physical injuries, taking vital signs, and an assessment of their mental status. Additionally, interviewing the patient to determine where the patient went, what the patient did, and especially asking the patient if he or she had taken any substances. Staff L said staff would be trained to document this in the patients' medical records and it should be documented on an incident report. When asked if she was able to locate an incident report on the unauthorized departure, Staff L said no, but she recalled an e-mail that Staff F sent. Staff L acknowledged nursing staff failed to complete a physical assessment and/or vital signs when Patient #2 exhibited a change in status and behavior on 4/6/13 and failed to notify the physician. An e-mail from Staff F to Staff L and the Staff A, the Administrator of Nursing (AON), dated 4/6/13 at 2:00 PM, revealed the following information. On Friday evening, Patient #2 went to a local supermarket. He returned and was placed on the locked adult psychiatric unit. According to the charting for 4/5/13 night shift and 4/6/13 day shift he was found on the floor on two separate occasions and did not know why. He was also screaming on a consistent basis. No vital signs were taken, even though staff knew he had been off grounds. On Saturday morning, Staff F assessed him. Staff F wrote "as soon as I saw him, I immediately knew that there was something wrong. Right away I asked him what he had taken, it took no prodding, he stated 4 bottles of Delsym." "This was at the very least twelve hours later...I only want you all aware that this did happen and if there is some corrective action that can be taken to ensure that maybe it won't happen again? These kinds of things make me fear for our patient's safety..." e. During an interview on 11/21/13 at 10:20 AM, Staff I, RN said, on 4/6/13 around 9:30 AM, the patient was screaming and when they went to the patient's room and asked what was wrong, Patient #2 said he had taken 4 bottles of Delsym cough syrup the night before to get "high". Staff I said she felt this was "a very lethal dose and the patient was fortunate to live". Staff I said prior to change of shift at report on the morning of 4/6/13, Staff P reported the patient had been up all night acting bizarre. Staff I said at the very least the physician should have been contacted when the patient's status changed and that this would be a standard of nursing. Staff I said she knew right away, after seeing Patient #2 that morning that he had ingested something the night before and after notifying Physician C, the patient was taken to the local hospital's Emergency Department (ED) by hospital staff. f. During a interview on 11/21/13 at 10:35 AM, the AON confirmed that patients who are admitted to the dual diagnosis unit cannot be forced to stay at the hospital if they want to leave and that nursing staff are trained to do everything in their power to persuade them to stay. The AON acknowledged nursing staff failed to complete an assessment, monitor vital signs for any adult changes, and notify the physician of falls. The AON confirmed that nursing and RTW staff received training to complete these tasks. The AON confirmed there had been a delay in emergency treatment for 15 hours for Patient #2, and this could have been potentially harmful to the patient's safety and well being. When asked what a reasonable psychiatric nurse would do in a similar situation, the AON said knowing the patient's background on the dual diagnosis unit, there should have been a complete physical and mental assessment and an interview with the patient, when he returned to the hospital after the unauthorized departure, to determine whether he had taken any substances. g. During an interview on 11/25/13 at 3:25 PM, Staff P, acknowledged she failed to complete an assessment and check vital signs when Patient #2 returned to the the hospital after the unauthorized departure. Staff P acknowledged she failed to contact a physician when the patient fell . Staff P stated she normally did not complete an assessment or take vital signs when a patient returns after an unauthorized departure. Staff P stated she would start taking a set of vital signs and complete an assessment when patients returned after any unauthorized departure. Staff P acknowledged she failed to ask Patient #2 if he had ingested any substances during the time he was gone. Staff P stated she does not ask when a patient returns after an unauthorized departure if they ingested any substances. Staff P stated she would start asking these questions when patients return after an unauthorized absence. h. During an interview on 11/26/13 at 6:40 AM, Staff Q, said he heard a "bam'' on 4/6/13 at 2:21 AM, and found Patient #2 lying on the floor in his room. Staff Q confirmed RTW staff received training to take vital signs after a patient falls and acknowledged they failed to do so. Staff Q said the patient acted "drunk" that night, was argumentative, unstable and "definitely" not alert. Staff Q acknowledged that he failed to document the behaviors in the patient's medical record nor did he report this to the nurse. i. During an interview on 11/26/13 at 10 AM, Staff F, RN, said at the time of shift change report on 4/6/13, Staff P reported Patient #2 left the premises the night before and went to a local store and returned to the hospital. Staff P reported the patient had been acting bizarre all night. Staff F said Staff CC, RTW, approached her approximately 10:00 AM, to report Patient #2 was acting "strangely" and asked if they would assess the patient. Staff F said the patient's pupils were dilated and it was "obvious" that the patient had taken some type of substance. Staff F said the patient was unsteady, his speech was slurred, his responses were slow, and his BP was elevated. Staff F said the patient readily admitted he had taken 4 bottles of cough syrup from the local store when asked. Staff F expressed concern with nursing and RTW staff for failing to take vital signs, complete an assessment, and ask the patient if he had taken anything at the time the patient returned from the unauthorized departure. Staff F said, since it's identified very clearly in the patient's chart that cough medicine was his "drug" of choice, that clearly these questions should have been asked. Staff F said the impact to Patient #2 was a delay in necessary emergency treatment. Staff F said nursing staff failed to complete a through assessment, monitor vital sign before and after the patient fell , and notify the physician of of the falls and acute changes in the patient's behaviors. j. During an interview on 11/26/13 at 1:00 PM, Staff T, RN,, said when Patient #2 returned after the unauthorized departure, she did not recall the patient behaving unusually or acting like he was under the influence of drugs. Staff T stated normally she does not ask when a patient returns after an unauthorized departure if they ingested any substances. Staff T stated she would start asking questions regarding whether the patient used any substances when patients return after an unauthorized departure. Staff T said that this was "definitely a learning experience for all nursing staff". 6. The following documents were reviewed. a. The "Department of Administrative Services - RN Job Description" dated 6/08, revealed the following in part, ..."Assesses patient/client's (holistic) health needs; develops a nursing diagnosis...and evaluating/monitoring the on-going nursing care in compliance with professional standards of quality care." b. The "Department of Administrative Services - RTW Job Description dated 3/12, revealed the following in part, ..."Performs basic clinical tests such as taking temperature, pulse, respiration and BP, records information relating to a resident's...significant changes in behavior or attitude on medical charts...knowledge of patient care and basic nursing procedures." c. The undated hospital policy, "Registered Nurse Essential Functions" revealed the following in part, ..."must utilize nursing process in provision of psychiatric nursing care...must be able to decide when patient condition requires attention of the doctor accurately...document daily activities and patient progress for all assigned patients...must be able to describe patient condition accurately." d. The hospital policy, "Vital signs", last reviewed 8/13, revealed the following in part, ..."Vital signs are taken as a means of observing change(s) in a patient's/client's condition; and as an aid for diagnosis...documentation: BP, pulse and respiration are charted on the flow sheet under the appropriate headings...if there are significant observations which must be kept for medical purposes; the vital signs should be included in the team notes." e. The hospital policy, "Charts and Charting Procedure", last reviewed 2/13, revealed the following in part, ..."To provide an orderly, consistent form of documentation throughout the hospital...Any unusual incident or behavior should be timely noted even if minimum requirements have been met...all nursing staff are responsible for charting. This includes RN's...and RTW's...documentation by nursing staff includes but it not limited to...Temperature, Pulse, Respiration (TPR), BP...unauthorized departure; include details...and all circumstances relating to the incident." f. The hospital policy, "Approved Nursing Protocols", last reviewed 4/13, revealed the following in part, ..."RN staff shall use their professional licensure to established modalities and protocols for patients...to provide a set of established protocols approved by medical staff for nursing to be able to enter into a patient's medical record...the following protocol/modality orders...shall be entered into the [electronic medical record system] and performed by a RN according to appropriate nursing judgement: ...vital signs...neuro checks (an evaluation of the functioning of a patient's nervous system to ascertain if there are acute changes in the patient's level state of awareness)". g. The hospital policy, "Elopement Precaution" last reviewed 2/12, revealed the following in part, ..."The treatment plan should be reviewed and additions made in regard to elopement." h. The signature page for the "Verification of Policies Read" from May 2012 through April 2013 revealed Staff P, an RN, Staff Q and R, RTWs verified they had read nursing policies and understood and were responsible for the contents of the policy[ies] by their signatures. |
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