HospitalInspections.org

Based on record review and interview the hospital failed to provide the patient with written notice of its decision following a written grievance submitted by the patient's responsible party for 1 of 5 sampled patients (#5). Findings:

Review of the hospital ' s Grievance Policy & Procedure reflected the purpose of the policy was to provide an internal process for receiving, addressing and resolving complaints from patients, family members, legal guardians and/or patient representatives regarding grievances, patient rights violations, and/or ethical issues. Review of the hospital's policy reflected the grievance process would be initiated within seventy-two hours of receipt of the grievance. "

Further review of the grievance policy reflected that the initial resolution process should be completed within seven days and in the event circumstances prevented resolution within the time frame, the patient should be notified of the progress and the reason for the delay in resolution.

During an interview with S11, Administrative Assistant on 9/28/10 at approximately 11:30 a.m., S11 revealed that when she receives a grievance letter either by fax or hand delivered, she gives the original document to S5, RN, Director of Quality Services, and she stated she would also give a copy to the CEO/Administrator, S4, Chief Executive Officer (CEO).

Further interview with S11, Administrative Assistant revealed she received a call from patient #5 ' s father, and she directed his call to S5, RN, Director of Quality Services.

Interview with S5, RN, Director of Quality Services on 9/28/10 at 11:35 a.m. revealed she had received a grievance letter from patient #5 ' s, father. S5, RN confirmed she attempted to call the family concerning the grievance, but S5 stated she did not respond to the complainant by letter. S5 further stated that when she receive a complaint/grievance she document it on a log.

Review of the Grievance Log for July, 2010 reflected a grievance dated 7/9/10 for patient #5. Further review reflected the letter was received to Quality Services on 7/20/10 concerning an incident on 6/29/10. Documentation of the issue reflected the issue was concerning physicians ' care and overall treatment, and the issue was resolved on 8/23/10.

Further interview with S5, RN on 9/28/10 at 11:35 a.m. revealed she was responsible for grievances received. S5, RN stated she attempted to call the complainant (patient #5 ' s) father but was unable to reach him by telephone. #S5 confirmed she did not send a letter to patient #5 ' s responsible party concerning the grievance he filed.

Based on record review and interview, the hospital failed to ensure the license verification of all hospital nursing personnel for whom current licensure is required. This was noted in the personnel records of 3 of 7 nurses sampled for personnel record review. Findings:

The personnel record of #S3 (LPN) was reviewed on 9/28/10. This review revealed that #S3 was initially hired as a mental health technician on 8/11/09. This review revealed that #S3 was promoted to a licensed practical nurse in December of 2009 after being granted a temporary permit from the Louisiana State Board of Practical Nurse Examiners to function as a licensed practical nurse on 12/15/09 pending licensure examination. The expiration date of the temporary permit was 2/09/10. Review of the personnel record on 9/28/10 revealed no evidence to indicate that a current license verification was obtained on #S3.

The Director of Human Resources was interviewed on 9/28/10 at 1:50 p.m. The Director of Human Resources confirmed that #S3 was granted a temporary permit from the Louisiana State Board of Practical Nurse Examiners to function as a licensed practical nurse on 12/15/09 pending licensure examination. The Director of Human Resources confirmed that the expiration date of the temporary permit was 2/09/10. The Director of Human Resources reviewed the personnel record of #S3 on 9/28/10 and reported that there was no evidence to indicate that a current license verification was obtained on #S3. The Director of Human Resources indicated that she needed to go to her office to search for a license verification for #S3. The Director of Human Resources returned and presented a license verification with a report date of 9/28/10 indicating that #S3 was currently licensed to practice as a licensed practical nurse in the state of Louisiana. The Director of Human Resources was unable to provide license verification for the time frame of 2/09/10 (expiration date of temporary permit) through 9/28/10.

The personnel record of #S4 (Registered Nurse) was reviewed on 9/29/10. This review revealed that the most recent license verification indicated that #S4's license expired on 1/31/10.

The Director of Human Resources was interviewed on 9/29/10 at 9:50 a.m. The Director of Human Resources reviewed the personnel record of #S4 on 9/29/10 and reported that there was no evidence to indicate that a current license verification was obtained on #S4. The Director of Human Resources indicated that she needed to go to her office to search for a license verification for #S4. The Director of Human Resources returned and presented a license verification with a report date of 9/29/10 indicating that #S4 was currently licensed to practice as a registered nurse in the state of Louisiana. The Director of Human Resources was unable to provide license verification for the time frame of 1/31/10 through 9/29/10.

The personnel record of #S5 (Registered Nurse) was reviewed on 9/29/10. This review revealed that the most recent license verification indicated that #S5's license expired on 1/31/10.

The Director of Human Resources was interviewed on 9/29/10 at 9:50 a.m. The Director of Human Resources reviewed the personnel record of #S5 on 9/29/10 and reported that there was no evidence to indicate that a current license verification was obtained on #S5. The Director of Human Resources indicated that she needed to go to her office to search for a license verification for #S5. The Director of Human Resources returned and presented a license verification with a report date of 9/29/10 indicating that #S5 was currently licensed to practice as a registered nurse in the state of Louisiana. The Director of Human Resources was unable to provide license verification for the time frame of 1/31/10 through 9/29/10. .

Based on record review and interview the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing plan of care by failing to ensure a patient was careplanned for all medical and psychiatric conditions for 1 of 5 sampled patients (#5). Findings:

Review of patient #5's medical record reflected the patient had diagnoses to include Tourette's syndrome, Obsessive Compulsive Disorder (OCD) and Anxiety. Review of the patient's care plan reflected the patient was not careplanned for Tourette's syndrome.

During an interview with S1, DON on 9/29/10 at approximately 11:00 a.m., she confirmed the above finding.

Based on record reviews and interviews, the hospital failed to ensure that orders from the licensed practitioner were carried out regarding the administration of medications and failed to ensure that the ordering practitioner was notified of current medications and/or medication errors at the time of occurrence. This was noted for 3 of 5 sampled patients (#1, #2, and #5). Findings:

Patient #1: Medical record review revealed that the patient was admitted to the hospital on 6/29/10. Review of the record revealed orders dated 6/30/10 at 7:00 a.m. for 300mg of Trileptal to be administered at hs (hour of sleep); 300mg of Seroquel to be administered at hs (hour of sleep); 60mg of Cymbalta to be administered twice daily; and 500mg of Depakote to be administered at hs (hour of sleep). Review of the medication administration record revealed no documentation to indicate that the hs Trileptal, the hs Seroquel, the hs Depakote, or the p.m. Cymbalta were administered to the patient on 7/01/10. There was no documentation in the record to indicate that the ordering practitioner was notified of the omitted doses of medications and no documentation to indicate that a medication variance report had been completed relating to the four medication errors. In an interview on 9/27/10 at 2:30 p.m., the Director of Nursing confirmed that there was no documentation in the record to indicate that the medications were administered as ordered and no documentation to indicate that the practitioner was notified of the medication omissions.

Patient #2: Medical record review revealed that the patient was admitted to the hospital on 9/23/10. Review of the record revealed orders dated 9/23/10 at 6:00 p.m. for 1mg of Risperdal to be given twice daily with instructions to give the first dose now. Review of the medication administration record revealed that first dose of Risperdal was not administered to the patient until 9:00 p.m. on 9/23/10 which was 3 hours after the first dose now order was given. There was no documentation in the record to indicate that the ordering practitioner was notified of the delay in the first dose administration of the Risperdal and no documentation to indicate that a medication variance report had been completed relating to the delay in the administration of this medication. In an interview on 9/27/10 at 2:30 p.m., the Director of Nursing confirmed that the documentation indicated that the first dose of Risperdal was not administered until 3 hours after the first dose now order was received. The Director of Nursing indicated that medications ordered to be administered now should be administered within one hour of the order.

The hospital's policy/procedure titled Medication Management/Administration (presented as a current policy/procedure) was reviewed. The policy/procedure documents that drugs shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice.





13225

Paatient #5

Review of the medical record for Patient #5 revealed the patient was an 18 year old male admitted to Acadia Vermilion Psychiatric Hospital on 6/28/10 per Physician ' s Emergency Certificate from Hospital " A " . Review of the record reflected Patient #5 had a past history of Tourette's, Obsessive Compulsive Disorder (OCD) and Anxiety.

Review of " Acadia Vermilion Hospital Nurse to Nurse Report for Patient Accepted for Admission " form reflected S6, RN was the Staff/Nurse receiving report concerning Patient #5. Further review of the form reflected Patient #5 ' s current home medications were listed on the form signed by S6, RN and documentation reflected Patient #5 ' s home medications were stored at the hospital on the East Wing where the patient was admitted.

Further review of the medical record for Patient #5 revealed Admission Orders dated 6/28/10 at 2310 (11:10 p.m.). Review of the orders reflected S8, RN obtained a telephone order from S9, Psychiatric Nurse Practitioner to admit Patient #5 to Acadia Vermilion Psychiatric Hospital.

Interview with S8, RN on 6/29/10 at 11:40 a.m. revealed she was the RN for the 3:00 to 11:00 p.m. shift on 6/28/10. She revealed Patient#5 was admitted to the hospital on 6/28/10 at 2310 during the change of shift. S8, RN confirmed she obtained the admit orders. S8, RN further stated she did not inform S9, Psychiatric Nurse Practitioner of the patient ' s current medications.

During an interview with S9, Psychiatric Nurse Practitioner, on 6/29/10 at 11:50 a.m., S9 confirmed that she was not made aware of Patient#5 's current medications at the time of his admission. She confirmed that S8,RN did not inform her of the patient's current medications.

Interview with S6, RN revealed she worked the 11:00 p.m. to 7:00 a.m. shift. She confirmed that she (S6) completed the Nursing Assessment form and signed the Medication Reconciliation & Physician/LIP (Licensed Independent Practitioner) orders. S6, RN stated when she signed the Medication Reconciliation & Physician/LIP orders, the form was blank and there were no medications listed on the form. S6, RN stated she did not notify the physician or the Psychiatric Nurse Practitioner concerning medications for Patient #5.

Interview with S11, LPN on 9/28/10 at 2:40 p.m. revealed he was the medication nurse for the 11:00 p.m. to 7:00 a.m. shift on 6/28/10. S11, LPN stated he wrote the name of the current medications for Patient #5 on the Medication Reconciliation & Physician/LIP orders form. S11, LPN stated he placed the form in the medical record and flagged the chart so the physician could see the current medication list. #S11, LPN confirmed he did not call the physician/nurse practitioner concerning patient #5 ' s current medications.

Review of patient #5's medical record reflected the patient current medications included clonazepam 1 mg by mouth every morning, Luvox CR 100 mg 2 capsules by mouth every morning, Geodon 40 mg 1 capsule by mouth once every morning and Geodon 60 mg 1 capsule every night, Diphenhydramine 50 mg 1capsule by mouth daily at 1800 (6:00 p.m.) and Intuniv 4 mg 1 tablet by mouth every morning. Documentation further reflected the patient's home medications were stored on the East Wing.

Review of the " Medication Reconciliation & Physician/LIP order form revealed a telephone order concerning the continuation or discontinuation patient #5 ' s medications were not obtained until 6/29/10 at 12:45 p.m. per telephone order received by S12, LPN from S10, Medical Doctor.