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Based on observation, interview, and record review the facility:
- failed to provide a safe environment for 54 of 54 patients by allowing non-suicide- resistant shower water control knobs in 39 of 55 patient bathrooms on the adult and children/adolescent units. The configuration of these water control knobs create a looping hazard (material or a device could be looped around the knobs to be used for choking or strangulation) for all patients in the facility.
- failed to protect patients by having accessible electrical cords in seven of 15 patient rooms on the Module C (Senior Adult Unit).The configuration of the electrical cords create a potential hanging hazard for all patients in the facility.
- failed to provide a safe environment for seven of seven patients on the Module C by not restricting their access to storage areas where potential hazards exist;
- failed to secure heavy furniture in two of 15 patient rooms, which could cause potential harm if pulled on or tipped over by patients or staff.
-failed to provide written notice to patients or their representatives regarding the steps taken to investigate a grievance, the results of the grievance process and the date of completion
-failed to ensure patient privacy for all patients on Module C
- failed to document restraint use in patient care plans
-failed to ensure the restraint orders are signed by the physician

Due to the severity of the situation and the potential harm to all patients in the facility, this resulted in overall noncompliance with the Condition of Participation: Patient Rights CFR 482.13 and demonstrates an unsafe patient care environment. This situation constituted a condition of Immediate Jeopardy.

At the time of the exit conference at 4:00 PM on 12/01/10, the facility implemented actions to abate this immediate jeopardy situation. The facility had a census of 54.

Based on interview and record review the facility failed to provide written notice to patients or their representatives regarding the steps taken to investigate a grievance, the results of the grievance process and the date of completion for three patients (#22, #36, and #32) of four grievance files reviewed. The facility had a census of 54.

Findings included:

Review of the facility policy, "Grievances: Patient and Family; The Role of the Patient Advocate" defines a grievance as "an allegation involving a violation of patient's rights, premature discharge, or any complaint that cannot be properly resolved by staff present". The facility policy also includes criteria for the written response to the complainant that the facility Patient Advocate or designated authority will send to a complainant within seven days of receiving the initial complaint. "The response will include:
-The name of the contact person,
-The steps taken to investigate the grievance on behalf of the patient,
-The results of the grievance process, how the grievance was resolved,
-The date of completion of the investigation,
-The process to follow if the patient is not satisfied with the response."

1. Review of a complaint filed with the Patient Advocate, Staff N showed a response letter to Patient #22 dated 11/05/10, regarding alleged inappropriate verbal comment(s) and inappropriate physical contact by a staff member was vague and unclear regarding the steps taken by the facility to investigate on the complainant's behalf. The response letter failed to provide the complainant patient with any indication of outcome, indicate whether disciplinary action was taken or not, or what steps were taken to mitigate and prevent future recurrences of patient sexual harassment by facility staff. The letter did not address the complainant's right to appeal the facility's final decision or indicate the date the investigation was completed.

2. Review of a complaint filed with Staff N showed a response letter to Patient #36 dated 11/05/10, regarding alleged inappropriate patient to patient physical contact failed to address what steps were taken to investigate on the complainant's behalf, did not address the outcome, and did not address to the complainant how the complaint was resolved or if any steps were taken to mitigate and prevent future recurrences of patient to patient hazing or sexual harassment. The letter did not address the complainant's right to appeal the facility's final decision or indicate the date the investigation was completed.

3. Review of a complaint filed with Staff N showed a response letter to Patient #32 dated 11/05/10, regarding alleged patient to patient misconduct failed to indicate what steps were taken to investigate on the complainant's behalf, did not address the outcome, and did not address to the complainant how the complaint was resolved or what would be done to mitigate and prevent future recurrences of patient to patient hazing or sexual harassment. The letter did not address the complainant's right to appeal the facility's final decision or indicate the date the investigation was completed.

During an interview on 11/30/10 at 2:50 PM, Staff N stated the letters were usually the final contact with the complainant and the alleged perpetrator unless the final decision was appealed or complaint reinitiated. He/she stated that if the letter is undeliverable or if the facility lacks a forwarding address of a discharged patient, they do not send a letter. He/she stated due to concerns about violation of HIPPA, the absence of a positive contact or valid mailing address, the facility makes no attempt or secondary attempt to contact a complainant through family members or friends so an appropriate letter of closure can be sent. He/she stated that a letter was not mailed to patient #32 because the patient gave no forwarding address, was homeless and left the facility AMA (Against Medical Advice) and left the facility without being formally assessed and discharged by a physician. When asked if the facility attempted to contact or inquire of the patient's whereabouts through patient #32's mother, Staff N stated no because he/she wanted to protect the patient's confidentiality.

Based on observation and interview, the facility failed to ensure all opportunities for privacy are afforded to seven of seven patients who reside in a 16 bed module. The facility census was 54 patients.

Findings included:

1. Observation on 11/30/10 at 10:50 AM, through 12/01/10 at 1:30 PM, showed no privacy curtains in 16 of 16 rooms shared by a current census of seven patients in Module C. Two of the rooms were shared by patients.

During an interview on 11/30/10 at 11:15 AM, Staff E stated if a physician wished to examine or interview a patient privately, the roommate would be asked to leave, or the doctor and his/her patient would go to an unoccupied room. During an interview on 12/01/10 at 1:15 PM, Staff K also stated that the roommate would be asked to leave. When asked about potentially violating patient rights, he/she stated the rooms did have privacy curtains in them. He/she stated that the curtains had been removed several months ago, when another module adolescent population was temporarily relocated to Module C while renovation on their module had been completed. He/she stated that the geriatric patients in Module C had the lowest census, so they were temporarily moved next door into an adjacent vacant section. He/she stated that everybody moved back into place several weeks ago. He/she stated that the curtains could be placed back up again, but maintenance just hadn't gotten to it yet. he/she placed a call to maintenance staff, which arrived with curtains in hand and began to put them into patient rooms at 1:30 PM.

Based on observation, interview, and record review the facility:
- failed to provide a safe environment for 54 of 54 patients by allowing non-suicide- resistant shower water control knobs in 39 of 55 patient bathrooms on the adult and children/adolescent units. The configuration of these water control knobs create a looping hazard (material or a device could be looped around the knobs to be used for choking or strangulation) for all patients in the facility.
- failed to protect patients by having accessible electrical cords in seven of 15 patient rooms on the Module C (Senior Adult Unit).The configuration of the electrical cords create a potential hanging hazard for all patients in the facility.
- failed to provide a safe environment for seven of seven patients on the Module C by not restricting their access to storage areas where potential hazards exist;
- failed to secure heavy furniture in two of 15 patient rooms, which could cause potential harm if pulled on or tipped over by patients or staff.

The facility admits patients with diagnoses of suicidal ideation, history of suicidal ideations, attempts at self harm, seizure precautions, assault precautions and fall precautions. The facility had a census of 54 at the start of the survey.

Findings included:

1. Observation on 11/30/10 at 10:00 AM, on Module B acute adult unit, accompanied by the assistant director of nursing, Staff E showed 13 patient bathrooms (rooms 200, 201, 202,203, 204, 205, 206, 207, 208, 209, 210, 211 and 212) with shower stalls with a central water control knob. The water control knobs in every shower protruded from the wall approximately three inches and were approximately four feet off the floor.

2. Observation on 11/30/10 at 10:20 AM, on Module B dual diagnosis unit, accompanied by the assistant director of nursing, staff E showed seven patient bathrooms (rooms 213, 214, 215, 216, 217, 218 and 219) with shower stalls with a central water control knob. The water control knobs in every shower protruded from the wall approximately three inches and were approximately four feet off the floor.

3. Observation on 11/30/10 at 3:30 PM, on Module A the adult trauma unit, accompanied by the director of social services, staff D showed nine patient bathrooms (rooms 100, 101, 102, 103, 104, 105, 106, 107 and 108) with shower stalls with a central water control knob. The water control knobs in every shower protruded from the wall approximately three inches and were approximately four feet off the floor.

4. Observation on 11/30/10 at 3:50 PM, on Module A the child and adolescent unit, accompanied by the director of social services, staff D showed eleven patient bathrooms (rooms 109, 110, 111, 112, 113, 114, 115, 116, 117, 118 and 119) with shower stalls with a central water control knob. The water control knobs in every shower protruded from the wall approximately three inches and were approximately four feet off the floor.

The configuration of these water control knobs expose a plumbing object that material or a device could be looped around for strangulation, which places all patients at risk.

5. During an interview on 11/30/10 at 10:05 AM, the assistant director of plant operations, Staff H stated that the facility replaced and/or covered plumbing in all the patient bathrooms to make the bathrooms safe except for the shower water control knobs. Staff H stated that the shower water control knobs are on back order from the supplier. Staff H stated that the shower water control knobs will be replaced as soon as the replacement parts are received from the supplier, which is estimated to be within the next two weeks.

6. During an interview on 11/30/10 at 10:00 AM, Staff D stated that the facility admits patients with diagnoses of suicidal ideation, history of suicidal ideations or attempts at self harm.
Review of admitting diagnosis for patients on Module B showed of the current census of 21 patients, 15 are, or have been sometime during their admission, on suicide precautions.
Review of admitting diagnosis for patients on Module A adult trauma unit showed of the current census of 11 patients, 11 are, or have been sometime during their admission, on suicide precautions.
Review of admitting diagnosis for patients on Module A child and adolescent unit showed of the current census of eight patients, six are or have been sometime during their admission, on suicide precautions or self harm precautions.


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7. Observation of patient rooms and common areas in Module C on 11/30/10 at 10:50 AM, showed all eight patient rooms were unlocked and patients had access to their rooms without constant monitoring by staff. Five of the eight rooms were occupied by seven patients who had age or disease related memory problems. Of the five occupied rooms, beds in three rooms (534, 535, and 537) had cords for bed alarm pads hanging below the mattresses. Two air mattresses in two occupied rooms (537 and 539) had electrical cords from air pumps that extended more than three feet in length to a maximum of seven feet.
8. Observation of Module C on 11/30/10 at 10:50 AM, showed furniture stored in an unsecured storage closet that was located in a group meeting room. A large round table with fixed legs was stacked inverted on the back of several stacked chairs. Approximately half of the table was not supported by the chairs and could be easily tipped by leaning against the edge or pushing down on the free hanging corner. A wood block under the door to the group meeting room held the door open against an automatic door closer (pneumatic device to keep the door closed).
During an interview on 11/30/10 at 10:55 AM, Staff E stated that the door should be closed and the storage closet is secured when not being accessed by staff. He/she stated that staff probably had the sensory cart (sensory stimulation) out and had not locked the doors.
9. Observation during a tour of Module C on 11/30/10 at 11:00 AM, showed unsecured furniture (a desk and two wardrobe closets) in rooms 534 and 535. A desk on the south wall of room 534 was not secured, and two free standing open-front wardrobe closets were not secured. Note: With seven of seven patients on assault precautions, and seven of seven patients on fall precautions and three of seven on seizure precautions, any unstable or unsecured furniture could cause potential harm if pulled on or tipped over by patients during an altercation.
10. Observation on 12/01/10 at 1:00 PM, showed the cords for pressure alarms had been secured to bed frames with plastic zip ties, however, the two electrical cords from the air pumps in rooms 537 and 539 lay unsecured on the floor.

Based on policy review and record review, the facility failed to address restraint use in the care plan for three patients (#14, #15, and #21) of six restraint records reviewed. The facility had a census of 54.

Findings included:

1. Review of facility policy PC-660, Restraint; Seclusion; Protective Holds dated 11/16/2010 documents on page eight, item #14, "Treatment plan revision following the episode of seclusion/restraints. The Master Treatment Plan (MTP) MUST BE REVIEWED and/or REVISED after EACH (facility punctuation) seclusion/restraint occurrence (physical or mechanical). The documentation shall be written on the MTP either as a new problem or added to an existing problem. Documentation should address current interventions that are viable options and discontinue interventions that are not viable to decrease the likelihood of another episode of seclusion or restraint."

2. Record review showed discharged Patient #14 entered the facility 11/11/10 for treatment of depression and suicidal ideations. Review of the physician orders dated 11/12/10 at 10:00 PM, showed a telephone order for a protective hold (the application of physical force, restricting free movement of the whole body or a portion of the body in order to control physical activity) due to the patient's physical aggression. Review of the Master Treatment Plan showed no documentation addressing the physical aggression of the patient and no documentation of a protective hold intervention related to the behavior of the patient.

3. Record review showed discharged Patient #15 entered the facility on 11/08/10 due to anger problems and aggressive behavior. Review of the physician orders dated 11/08/10 at 5:25 PM, showed a telephone order for a protective hold due to the patient's physical aggression. Review of the Master Treatment Plan showed no documentation addressing the physical aggression of the patient and no documentation of a protective hold intervention related to the behavior of the patient.







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4. Record review of Patient #21's current medical record showed he/she was admitted to the facility on 11/17/10 for treatment of aggression. On 11/21/10, the patient was placed in a protective hold (a physical restraint), after the patient began throwing things and hitting and kicking staff. There is no documentation of the protective hold in the patient's Master Treatment Plan, also known as a care plan.
During an interview on 12/1/10 at 9:30 AM, Staff E, Assistant Chief Nursing Officer stated he/she was not able to find Patient #21's Master Treatment Plan updated with the protective hold from 11/21/10.

Based on policy review and record review, the facility failed to ensure the physician signed an order for a restraint for two patient's (#14, and #19) of six restraint records reviewed. The facility had a census of 54.

Findings included:

Review of facility policy PC-660, Restraint; Seclusion; Protective Holds dated 11/16/2010 documents in part on page four, item #5: that restraint/seclusion is used only in an emergency and requires a physician's order. In an emergency and in the absence of a physician, the registered nurse (RN) may authorize initiation of restraint/seclusion. The physician must be contacted immediately - within a few minutes, to obtain an order. Telephone/verbal orders for restraint/seclusion may be received and recorded by an RN. The physician shall authenticate the telephone/verbal order within 24 hours.

Record review showed discharged Patient #14 entered the facility 11/11/10 for treatment of depression and suicidal ideations. Review on 11/30/10 of a physician's order form dated 11/12/10 at 10:00 PM, showed a telephone order for a protective hold (the application of physical force, restricting free movement of the whole body or a portion of the body in order to control physical activity) due to the patient's physical aggression. Further review of the restraint order showed the physician failed to sign the telephone order.


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Review of Patient #19's current medical record on 12/01/10 at 1:30 PM, showed
Protective Hold/Seclusion Mechanical Restraint order dated 11/30/10 at 1900 (9:00 PM), was not signed, dated or timed by the physician.

Based on review of the medical staff rules and regulations and record review the facility failed to consistently implement a system that ensured physician's telephone and verbal orders were dated, timed and signed for six patient's (#16, #18, #19, #21, #25, and #28) of eight records reviewed for telephone and verbal orders. The facility had a census of 54.

Findings included:

Review of the medical staff rules and regulations last revised 11/16/10 showed on page three section G, item #8: "All orders, including verbal orders, must be dated, timed and authenticated (signed) by a practitioner responsible for the care of the patient within 24 hours."

Current record review on 11/30/10 showed Patient #16 entered the facility 11/20/10 for treatment of anxiety and panic attacks. Review of the physician order form showed the following orders:

Orders dated 11/25/10 at 6:35 PM:
- Coumadin (medication used to prevent blood clots) 13 mg (milligrams, a unit of measure) po (by mouth) today
- DC (discontinue) Lovenox (medication to prevent blood clots), INR (International Normalized Ratio, a standard unit used to measure how quickly blood clots) 2.3

Order dated 11/26/10 at 10:50 AM:
- Lower Coumadin to 10 mg po today

The above telephone orders were not signed by the physician.






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Review of Patient #18's current medical record on 11/30/10 at 2:25 PM, showed physician orders for admission on 11/26/10 at 1356 (1:56 PM), not signed, dated or timed by a physician.

Review of Patient #19's current medical record on 11/30/10 at 2:25 PM, showed the following information:
- Verbal order dated 11/14/10 for Seroquel (drug used for depression) 12.5 mg po now - anxiety/agitation was not signed, dated or timed by physician.
-Telephone order dated 11/18/10 at 12:30 PM, for Geodon (drug used for bipolar disorder [severe mood swings]) 10 mg IM (Intramuscular) now x (times) 1, Ativan (drug used to treat anxiety) 0.5 mg IM now x 1, was not signed, dated or timed by physician.
-Telephone order dated 11/24/10 at 12:00 PM, for CXR (chest x-ray) today, CBC (complete blood count [blood test for blood disorders]), BMP (basic metabolic profile [blood test for system disorders]), medical doctor to evaluate for UTI (urinary tract infection), and difficulty swallowing, was not signed, dated or timed by physician.
-Written order dated 11/24/10 at 1:00 PM, for Robitussin (cough medication) two teaspoons QID (four times a day) regarding congestion, was not timed and dated by the physician.
- Telephone order dated 11/24/10 at 4:18 PM, for Remeron (drug used to treat depression) 15 mg half in AM, 5 PM before meal, was not timed and dated by physician.
-Telephone order dated 11/27/10 at 1630 (4:30 PM), for mobile x-ray for assessment left knee, 3 views, was not signed, dated or timed by physician.
-Telephone order dated 11/28/10 at 0720 (7:20 AM), to continue Ativan anxiety) 0.5 mg po q (every) 4 hrs (hours) PRN (as needed) agitation, was not signed, dated or timed by physician.







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Current record review of Patient #21's medical record showed he/she was admitted to the facility on 11/17/10 for treatment of aggression. A physician's telephone order was written on 11/19/10 at 12:30 AM, for Benadryl (medication to calm patient) 50 mg po, x 1 for anxiety/sleep. The order was signed by the physician on 11/21/10 at 11:30 AM, 59 hours after the order was written.

Current record review of Patient #25's medical record showed he/she was admitted to the facility on 11/25/10 for treatment of aggression. A physician's telephone order was written on 11/27/10 at 3:50 PM, for the following:
-Discontinue Amoxicillin (antibiotic);
-Start Zithromax (antibiotic) as Z-Pack;
-Zithromax 250 mg po two on day 1, give with food, give now;
-Zithromax 250 mg po, one daily days 2-5 (with food).
The order was not signed by the physician until 11/29/10 at 8:00 AM, 39 hours after the order was written.


Current record review on 11/29/10 of Patient #28's medical record showed he/she was admitted to the facility on 11/09/10 for depression and suicidal ideation. On 11/23/10 a physician's illegible telephone order was written to discontinue ortho BP (set of blood pressures taken while laying, sitting, and standing), BID (two times a day). This order was not signed by the physician.




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Record review on 12/01/10 of Patient #31's open medical record showed a telephone order dated 11/27/10 and timed 20:00 (8:00 PM), to discontinue Lisinopril 20 mg po daily and start Lisinopril 10 mg po daily. The order had not been signed by the physician, four days later.
Record review of the same patient's open medical record showed a telephone order dated 11/29/10 and timed 8:30 PM to decrease Aricept to 5 mg po daily and increase Namda to 10 mg po daily. This order had not been signed by the physician, 48 hours later.