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CENTERPOINTE HOSPITAL 4801 WELDON SPRING PARKWAY SAINT CHARLES, MO Oct. 20, 2011
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
Based on record review and interview the facility failed to ensure all medication orders are complete for nine patients (#1, #11, #12, #19, #20, #21, #2, #3, and #22) of 28 records reviewed as evidenced by an absence of authentication (physician signature, time and date) as outlined in Medical Staff Rules and Regulations. This failure to authenticate patient orders places all patients at risk for transcription/medication error. The facility census was 72.

Findings included:

1. Record review of the facility policy titled, "Medical/Professional Staff Orders - Transcription:
- For inpatient services, all orders must be dated and authenticated as outlined in Medical Staff Rules and Regulations
- If the order is received verbally, the nurse will indicate by writing "TO" for telephone order or "VO" for verbal order when writing an order - followed by the name of the physician, the nurses; first initial and last name, and title.
- All orders for medication and/or treatment for patients admitted to the hospital shall be in writing.
- Orders must be dated, timed, and authenticated promptly by the ordering practitioner.
- An order shall be considered to be written if dictated in person to a licensed nurse and authenticated by the ordering practitioner, attending physician, or another responsible physician, such as covering, rounding, or co-attending within 24 hours (or shorter time period as may be required by a Hospital program, policy, or law).

2. Record review for Patient #1 on 10/18/11 showed the following incomplete physician orders:
- VO written on 10/03/11 at 4:25 PM for Lopressor (lowers blood pressure) 50 milligram (mg - a unit of measure) po (by mouth) give at 9:30 PM. Physician P failed to authenticate order with signature, date and time.
- TO written on 10/03/11 at 4:00 PM for KCL (Potassium) to be given at hour of sleep (HS) both the AM and evening doses. Physician P failed to date and time authentication signature.

During an interview with Staff L, Registered Nurse (RN) Charge nurse for the Acute Adult unit on 10/18/11 at 11:30 AM, Staff L verified the lack of physician authentication for Patient #1's orders.

3. Record review for Patient #11 on 10/18/11 showed the following incomplete physician orders:
- TO written on 10/14/11 at 5:00 AM showed an order for Digoxin (heart medication) level this AM. Physician P failed to sign, date and time the order.
- TO written on 10/13/11 at 6:50 PM for admission to the facility, including patient medication orders. Physician N failed to time his/her signature.

During an interview on 10/18/11 3:45 PM, Staff M, Safety and Risk Coordinator verified the lack of physician authentication of orders.

4. Record review for Patient #12 on 10/18/11 showed the following incomplete orders:
- TO written on 10/16/11 at 11:10 PM for decrease Clindamycin (anti-bacterial) to 450 mg three times a day (TID). Physician R failed to sign, date and time the order.
- TO written on 10/14/11 at 3:45 PM for increase in MS Contin (decreases pain) to 30 mg TID and give Clindamycin (anti-bacterial) 500 mg now and TID. Physician R failed to sign, date and time the order.
- TO for sliding scale insulin (decreases blood sugar) written on 10/14/11 at 3:45 PM. Physician R failed to sign, date and time the order.
- TO written on 10/16/11 at 1:00 PM for Synthroid (hormone) 0.175 mg now and each AM. Physician P failed to sign, date and time the order.

During an interview on 10/18/11 at 2:45 PM, Staff M, Safety and Risk Coordinator verified the lack of physician authentication of orders.

5. Record review for Patient #19 on 10/20/11 showed the following incomplete orders:
- Admission medication orders written on 10/17/11. Physician N signed but failed to time his/her authentication.
- TO written on 10/18/11 at 1:00 AM for order clarification for Risperdal (antipsychotic medication). Physician N failed to sign, date and time order.
- TO written on 10/18/11 at 1:00 PM for Mobic (pain, swelling relief) 15 mg each day, Naphcon (constrict) eye drops, and Ferrous Sulfate (iron replacement) 325 mg each day. Physician failed to sign, date and time the orders.

During an interview on 10/20/11 at 9:50 AM, Staff X, RN Charge Nurse verified the lack of physician authentication of orders.

6. Record review for Patient #20 on 10/20/11 showed the following incomplete orders:
- Physician P wrote an order on 10/17/11 for KCL (potassium supplement) 20 milliequivalent (meq) times one. Physician P signed and dated order but failed to time the order.
- TO written on 10/16/11 at 9:00 AM for Macrobid (inhibits urinary tract infections) 100 mg two times a day (BID). Physician P signed the order but failed to date and time the signature.
- TO written on 10/16/11 at 3:00 PM for Amoxicillin (antibiotic) 500 mg every 8 hours on 10/20/11 at 6:30 AM. Physician P signed the order but failed to date and time the order.
- TO written on 10/15/11 at 10:16 AM for Imitrex (for headache) 50 mg once a day as needed, may repeat times one if migraine (headache) persists two hours after first dose. Physician P signed the order but failed to date and time the signature.

During an interview on 10/20/11 at 9:45 AM, Staff X, RN Charge Nurse verified the lack of physician authentication of orders.

7. Record review for Patient #21 on 10/20/11 showed the following incomplete orders:
- Physician P wrote an order on 10/10/11 to decrease Lasix (fluid pill) 20 mg daily times 3 days, elevate lower extremities when in bed, Mag Citrate (laxative) one bottle times one.
- Physician N wrote an order on 10/7/11 for medication for Tegretol (treat depression) 200 mg BID. Physician N failed to time order.
- VO written on 10/5/11 at 9:05 PM for increase Seroquel (mood elevator). Physician N failed to date and time signature.
- Physician N wrote an order for Suboxone (treat narcotic addiction) 4 mg TID. Physician failed to time the order.
- VO written on 10/6/11 at 1:47 PM for Suboxone 4 mg now. Physician N failed to time his/her signature.
- Physician P wrote an order on 10/6/11 for Lasix (fluid pill) 40 mg daily times 3 days and Amoxicillin (antibiotic) 500 mg TID times seven days. Physician P failed to time his/her signature.
- TO written on 10/3/11 at 9:00 PM for Visine (treat eye irritation) eye drops one drop as needed. Physician P failed to sign, date and time the order.
- APN Q wrote order on 10/03/11 at noon to increase Seroquel (mood elevator) to 200 mg AM and 2:00 PM and then to increase to TID. APN Q wrote order for Lithium Carbonate (to treat excited mood) 300 mg TID. Physician N failed to date and time his/her signature.
- APN Q wrote order on 09/29/11 at 2:50 PM for increase Baclofen (decreases muscle spasms) to 10 mg TID. Physician N failed to date and time his/her signature.
- TO order written on 9/29/11 at 7:00 PM for Suboxone (treat narcotic addiction) ? mg sublingual (under the tongue) BID. Physician N failed to date and time his/her signature.

During an interview on 10/20/11 at 10:15 AM, Staff X, RN Charge Nurse verified the lack of physician authentication of orders.




8. Record review on 10/20/11 at 12:30 PM of Patient #2's medical record showed an order dated 10/18/11 at 11:10 AM for Seroquel (medication used for depression and bipolar disorder [severe mood swings]) 75 milligrams (mg) po (by mouth) q (every) AM/q 1430 (2:30 PM)/q HS (bedtime) that failed to have the physician signature.

During an interview on 10/20/11 at 12:30 PM, Staff I, Registered Nurse (RN) confirmed that the physician failed to sign the Seroquel order.

9. Record review of Patient #3's medical record showed discharge orders that included Ritalin (drug used for hyperactivity) 20 milligrams ( mg.) three times a day, Abilify (drug used for mood swings) 2.5 mg. daily, and Tenex (drug used for impulsiveness) 1 mg three times a day written 10/18/11 that was not timed by the physician.

10. Record review of Patient #22's medical record showed the Admission/Medication Reconciliation orders (nurse verified on admission what medication, exact dosage and times the patient took medications at home) and physician ordered same medication, dosage and times while patient in hospital. Physician signed and dated the order but failed to time the order.

During an interview on 10/20/11 at 12:30 PM, Staff I, RN confirmed that the orders were not authenticated by the physician.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, record review and interview the hospital failed to provide an adequate number of licensed nurses and/or mental health technicians to provide monitoring of patients when:
-The hospital's practice is to move the children who are on Sexual Abuse Management 2 (SAM 2) precautions to a dayroom/activity room and the children sleep on a mattress on the floor instead of the hospital monitoring the children in their assigned rooms at night;
-The Child Unit slept a child in the dayroom overnight due to the child being on a Sexual Abuse Management watch affecting one patient (Patient #3) of eight patients on the night of 10/17/11 - 10/18/19;
-The Adolescent Unit slept four (Patients #4, #6, #10, #13) of nineteen patients overnight in other rooms such as an activity room, a dayroom room or a seclusion room due to these patients being on a Sexual Abuse Management watch on the night of 10/17/11 - 10/18/11.

The facility census was 72.

Findings included:

1. Record review of policy titled, "Precautionary Levels at CenterPointe Hospital," Policy Number: CSN 5.19, Origination Date 04/01/03, Date Last Revised 11/30/10, Approval Date 12/07/10, showed: SAM 2: This precaution is ordered for any patient who is a perpetrator of sexual assault, currently sexually acting out, or currently in treatment for sexual misconduct. This identified patient has demonstrated major sexual acting out behaviors or is a sexual abuse victim with current sexual preoccupation. These patients are not to be in their room at the same time as their roommate.

2. Record review of policy titled, "Sexual Abuse Management," Policy Number: CSN 5:20, Origination Date: 06/07/07; Date Last Revised: 09/12/11; Approval Date: 09/13/11, showed:
Procedure - Adolescent and/or child patients will be placed on sexual abuse management precautions according to defined levels of sexual acting out behaviors.
Process:
-All children and adolescents admitted to the units with identified sexual acting out behaviors will be placed on appropriate sexual precautions.
-The Medical Doctor (MD) or Registered Nurse (RN) will place a patient on the appropriate level of sexual precaution.
-The level of SAM precaution will be evaluated daily by the Charge Nurse and Nurse Manager/Nursing Supervisor.
-A change in the level of precautions requires treatment team recommendations based on clinical criteria and requires final approval of the MD and Nursing Administration, and is followed by a written order.
-When two or more patients on SAM 2 precautions are sleeping in a dayroom a staff member will be assigned to sit in the dayroom to maintain visual oversight of all patients. If a patient's mattress is placed on the floor, the sheets must be removed the next morning after use and thoroughly sanitized before the mattress is replaced on the bed frame, as in the infection Control Manual Appendix G.
-II. Levels/Precautions
SAM 2: Sexual Abuse Management (Perpetrator of sexual assault, currently acting out, or currently in treatment for sexual misconduct. Identified sexually abused victim with current sexual preoccupation. Major sexual acting out behavior = fondling, inappropriate touching such as touching others; breasts, buttocks, or genital area, public display of masturbation.)
-Observed and assessed every fifteen (15) minutes and documented on daily rounds sheet.
-Door to room is always open.
-Patient with current acting-out behavior or a history of sexual acting out behavior is not to be in room at the same time as roommate (i.e., room time, bed time, hygiene time, etc.)

3. Record review of policy titled Nursing Staffing Plan, Policy Number: HR 2.01, Origination Date: 04/01/03, Date Last Revised: 09/13/11, Approval Date: 09/13/2011, showed: Staffing for patient care is based on acuity, level of care needed for the psychiatric patient and regulatory requirements.
-Patient Acuity: Acuity guidelines include patient behaviors, functional deficits, level of observation required, nursing interventions needed, activities scheduled for the oncoming shift, medications required for each individual patient and treatment procedures.
The acuity level of patients will be evaluated two hours prior to change of shift. Additional staff (above the minimum staffing allocated on the Hospital Staffing Table [the basic staffing plan]) will be added based upon the following Acuity Rating System:

Acuity Rating Scale Per Unit (Per Precaution, Per Patient)
Level of Observation Acuity Points Acuity Staffing Additions
Suicide Precaution 2 2 Points 30 Points = 8 hrs of MHT
Assault Precautions 2 1 Point 15 Points = 4 hrs of MHT
Elopement Precautions 1 Point 15 Points = 4 hrs of MHT
One-to-one Staffing (1:1) 30 Points 30 Points = 8 hrs of MHT

Staffing for Child Unit Nights is as follows:
1-6 Patients 1 RN 0 LPNs 1 MHT
7-10 Patients 1 RN 0 LPNs 1 MHT
11-15 Patients 1 RN 1 LPN 1 MHT

Staffing for the Adolescent Unit Nights is as follows:
1-6 Patients 1 RN 0 LPNs 1 MHT
7-10 Patients 1 RN 0 LPNs 1 MHT
11-13 Patients 1 RN 1 LPN 1 MHT
14- 16 Patients 1 RN 1 LPN 1 MHT
17-20 Patients 1 RN 1 LPN 1 MHT

Review of this policy showed staffing is not adjusted upward to accommodate for monitoring of SAM 2 children. The review showed classification of a child as a SAM 2 is not part of the acuity calculation for staffing.

4. The failure to include SAM 2 children in the staffing plan resulted in failure of the hospital to monitor the SAM 2 patients in their assigned rooms.

5. Observation on 10/17/11 at 11:05 PM, of the Acute Child Unit showed Patient #3 was sleeping on a mattress on the floor in the day room with staff watching her/him from the nurse's desk.

During an interview on 10/17/11 at 11:15 PM, Staff E, RN Charge Nurse, stated the following:
-Patient #3 was sleeping in the day room because of sexually acting out with his/her teddy bear and he/she was placed on SAM 2 precautions;
-The routine practice is when the kids act out they are brought to the Day Room 1, across from the nurse's desk, or Day Room 2, diagonally across from the nurse's desk, or the quiet room;
-If the kids are of different gender, or ages then they will split them up into the different rooms and request another staff person from the house supervisor;
-When the kids are off of the SAM 2 precautions they are placed back into their assigned room and bed when they were admitted .

6. During an observation on 10/18/11 at 12:14 AM, on the Child Unit, showed one registered nurse (RN), Charge Nurse, Staff E, and one mental health tech (MHT), Staff D, working.

7. Record review of the Child Unit census sheet showed Patient #3's room assignment is to room 36 B. The census sheet also showed all patient rooms in the Child Unit had at least one child assigned to each room with no unoccupied rooms available as follows:
-Room 31 had one patient;
-There is no patient room 32 - the room numbers jump from room number 31 to room number 33, there is not a room numbered 32;
-Room 33 had one patient;
-Room 34 had one patient;
-Room 35 had one patient;
-Room 36 had two patients;
-Room 37 had one patient;
-Room 38 is closed with no patients (the room is closed and unable to have patients admitted to it)
-Room 39 had one patient.

8. During an interview on 10/18/11 at 12:26 AM, Staff E, Charge RN, stated that if there is more than one child that has to sleep in the activity room or the day room or quiet room/seclusion room then a staff person is assigned to sit at the door and watch the children. If only one child is in the activity room/day room then a staff person is not assigned to watch the child. Staff E confirmed this is the routine practice to monitor SAM 2 children at night. The facility failed to provide staffing to monitor patients in their assigned rooms.

9. During an interview on 10/18/11 at 12:35 AM, Staff E, Charge RN, confirmed that no other child other than Patient #3 had been removed from his/her room for the night to sleep on a mattress on the floor in the dayroom. The facility failed to provide staffing to monitor patients in their assigned rooms.

10. During an interview on 10/18/11 at 1:00 AM, Staff E, Charge RN, stated the routine practice is if a new patient is admitted and there is a bed available, but it is the wrong gender bed, than the new patient will be assigned a wrong gender room and bed, and "slept out" of the room in the activity room, day room or the seclusion/quiet room (if a seclusion/quiet room is available). Then in the morning the patient room assignments are changed to accommodate the new admission. Staff E stated "slept out" means the patient sleeps in a room such as the activity room, the dayroom, or if the seclusion/quiet room is available the patient can sleep in that room instead of the patient's assigned room.

11. During an observation on 10/18/11 at 1:16 AM on the Adolescent Unit showed three staff members working as follows:
-Charge Nurse, RN, Staff F;
-LPN, Staff G; and
-MHT, Staff H.

12. During an interview on 10/18/11 at 1:29 AM - 1:44 AM with Staff F, RN Charge Nurse, stated the census on the Adolescent Unit is 19 and Unit capacity is also 19. Staff F stated no children are on a one-to-one tonight and the following children are "sleeping out" of their rooms due to being classified as SAM 2 children:
-Patient #13, is sleeping on a mattress on the floor in Room 14 which is a dayroom; his/her assigned room is 13B;
-Patient #4, is sleeping on a mattress on a box bed in the seclusion room (not on the floor);
-Patient #6 is sleeping on a mattress on the floor in the activity room and his/her assigned room is 18A;
-Patient #10, is sleeping on a mattress on the floor in the activity room and his/her assigned room is 19A.
Staff F stated "sleeping out" means the children sleep in a room other than their assigned hospital room such as an activity room, a dayroom or a seclusion room (when one is available). The practice is children are moved out of their rooms at night because they are classified as SAM 2 children. Moving the SAM 2 children out of their rooms at night is how the hospital protects the children who are roommates of SAM 2 children as the SAM 2 children are never to be in a room alone with another child. There isn't staffing to monitor the SAM 2 children at night in their assigned rooms when they have a roommate so the children are moved out of their rooms.

13. During an observation on 10/18/11 at 1:44 AM, on the Adolescent Unit, two children are found sleeping on a mattress on the floor in the dayroom, Patient #6 and Patient #10. Mental Health Tech Staff H, is sitting at the door of the activity room monitoring these two patients. Patient #4 is found in the seclusion room sleeping on a box bed. Patient #13, is found sleeping on a mattress on the floor in Room 14 which is a dayroom. The facility failed to provide staffing to monitor patients in their assigned rooms.

14. Record review of the Adolescent Unit census sheet for the night of 10/18/11 - 10/19/11 showed the Unit as full. Seven of the nineteen children are classified as SAM 2 and have the following room assignments:
- Patient #13, in room 13B, is classified as a SAM 2 and is sharing a room with Patient #31, in bed 13A who is not a SAM 2 classification;
-Patient #29, in room 15 with no bed assignment of Bed A or Bed B, is classified as SAM 2 and no roommate assigned;
-Patient #7, in room 17A and Patient #14, in room 17B are both are classified as SAM 2;
-Patient #6, in room 18A, is classified as a SAM 2 and shares a room with Patient #32, in bed 18B who is not classified as a SAM 2;
-Patient #10, in room 19A and Patient #30, in 19B are both classified as SAM 2.

15. Record review of the Adolescent Unit staffing for the night of 10/18/11 - 10/19/11 showed three staff members who worked as follows:
-Staff F, RN, Charge Nurse;
-Staff G, LPN; and
- Staff FF, MHT, was assigned to monitor SAM 2 patients in the dayroom.
This review confirmed some children classified as SAM 2 children continue to be moved out of their rooms at night and sleep with their mattresses on the dayroom floor for monitoring instead of the hospital staffing to monitor the children in their assigned rooms.

16. During an interview on 10/20/11 at approximately 1:00 PM Patient #13 stated he/she was angry about having to sleep on a mattress on the floor in the dayroom. He/she stated he/she wanted to sleep in his/her own room. He/she stated he/she does not know why he/she had to sleep on a mattress on the floor in the dayroom. It makes him/her feel like he/she has done something bad and is being punished for it. He/she stated he/she has to move the mattress his/herself without assistance from the staff. He/she stated the mattress is not cleaned before it is put back on the box frame. No one told him/her anything about cleaning the mattress after it has been on the floor. He/she stated the sheets are not changed after the mattress has been on the floor. He/she confirmed other patients are also being made to sleep on a mattress on the floor in the dayrooms.

17. On 10/20/11 from approximately 1:09 PM to 1:30 PM interviews were attempted with Patients #4, #6 and #10, but they did not want to participate in an interview.