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Based on policy review and record review, the Hospital failed to notify the guardian/parent of a restraint/seclusion event for 1 of 2 sampled closed records of patients restrained or secluded (Patient #11). Failure to notify the guardian/parent of restraint/seclusion limits the patient's/representative's right to make informed decisions regarding his care.

Findings include:

Review of the hospital's "Restraint and Seclusion" policy occurred on 02/12/13. The policy, dated 01/14/12, stated, ". . . Seclusion or restraint are allowed to be used in an emergency situation in which there is imminent danger to the patient causing injury to self or others and after non-restrictive measures have been proven to [sic] ineffective or assessed to be inappropriate. . . . Patient care staff takes the following steps: . . . c. . . . Patient's guardian/parent needs to be notified of the event and intervention used. . . ."

- Review of Patient #11's medical record occurred on February 12-14, 2013. Patient #11, an adolescent, received inpatient care from August 3, 2012 to August 18, 2012. The physician's orders showed Patient #11 restrained or secluded the following days: 08/12/12, 08/13/12, 08/15/12, 08/17/12, and 08/18/12.

A restraint flow sheet, dated 08/17/12, lacked evidence staff notified the patient's guardian/parent of the restraint/seclusion event and interventions used.

Based on record review, review of information provided to patients, policy review, and staff interview, the Hospital failed to provide education to the community about health care directives for 1 of 1 year (February 2012-January 2013) and failed to ensure a social worker provided additional information for 1 of 1 closed record (Patient #19) of a patient who requested additional information regarding formulating an advance directive. Failure to provide education and information limited the patients' and community members' abilities to make informed decisions regarding advance directives.

Findings include:

Review of the hospital's "Advance Health Care Directive Information Guide" (information provided to patients upon admission) occurred on February 12-14, 2013. This guide, revised 02/28/07, stated, ". . . National Law: The Patient Self-Determination Act, a federal law passed in 1991, requires health care providers to educate their patients and the community on issues related to advance health care directives so that patients have the opportunity to express their wishes regarding the use or refusal of medical care. . . . North Dakota Law: . . . You can request to meet with a social worker, who will provide you with additional information. . . ."
Review of the hospital's policy "Advance Health Care Directives" occurred on February 12-14, 2013. This policy, revised 07/15/11, stated, ". . . 7. If the patient does not have an advance health care directive, but is interested in more information, a. Staff informs the patient that he/she will need to visit with a social worker, and that staff will notify the social worker to meet with him/her within two business days. . . . The Medical Records Department will monitor that advance health care directive information is provided to adult inpatients and that adult patients requesting more information . . . met with a social worker promptly."

- During an interview on 02/13/13 at 2:15 p.m., a Licensed Social Worker (#3) stated the hospital does not provide community education regarding advance directives. The social worker stated the hospital did not have documentation regarding its efforts to provide community education.

- Review of Patient #19's medical record occurred on 02/12/13. The record contained an "Advance Health Care Directive Acknowledgement." On this form, Patient #19 identified he had not executed an Advance Health Care Directive, and the patient indicated, ". . . I'd like to meet with a social worker to receive more information. . . ." The form and the Social Work progress notes lacked evidence a social worker met with Patient #19.

During interview on 02/14/13 at 9:45 a.m., a Licensed Social Worker (#3) stated if a patient asked to visit with a social worker regarding advance directives, the hospital unit coordinator would inform the social work department by e-mail and the department would visit with the patient the next business day. The social worker stated staff would document the visit in the patient's record.

Based on observation and staff interview, the Hospital failed to ensure inpatients received care in a safe setting when Hospital staff removed 1 of 1 crash cart containing the equipment, supplies, and drugs and biologicals commonly used in life-saving procedures from the inpatient nursing unit for use in the outpatient department. Failure to have a crash cart readily available at the inpatient nursing unit limited the staff's ability to immediately treat inpatients in life-threatening situations.

Findings include:

During an interview on 02/13/13 at 10:00 a.m., an administrative nurse (#1) stated staff brought the crash cart from the inpatient nursing unit to the outpatient department during Electroconvulsive Therapy (ECT) treatments on Monday, Wednesday, and Friday afternoons. The nurse (#1) stated the outpatient department is in use on those days from about 1:00 p.m. to 5:00 p.m.

Observation of the outpatient department on 02/13/13 at 1:40 p.m. (during ECT treatments) showed a crash cart located in the procedure room. A staff nurse (#6) identified the crash cart as the cart from the inpatient nursing unit and confirmed staff brought the cart to the outpatient department for the ECT treatments that day.

Observation of the crash cart with a staff nurse (#9) on the morning of 02/14/13 showed the cart contained various equipment (AED - Automated External Defibrillator, portable oxygen tank, suction machine), supplies (ambu-bag, different types of airways), and medications used in life-saving procedures. The staff nurse (#9) confirmed this was the only crash cart on the inpatient nursing unit and stated staff would not have immediate access to the crash cart for use with inpatients when the crash cart was in the outpatient department.

During an interview on 02/14/13 at 11:05 a.m., an administrative nurse (#1) stated she did not realize the crash cart would not immediately be available to the patients on the inpatient nursing unit when the cart was in the outpatient department and confirmed the practice as unsafe.

Based on record review and review of policies and procedures, the Hospital failed to ensure a written modification to the plan of care/treatment plan occurred with the use of restraints or seclusion for 2 of 2 sampled closed records of patients restrained or secluded (Patients #11 and #16). Failure to modify plans of care/treatment plans for use of restraint/seclusion limits the staff's ability to manage patients' behavioral issues.

Findings include:

Review of the "Restraint and Seclusion" policy occurred on 02/12/13. The policy, dated 01/14/12, stated,
". . . The use of seclusion or restraint
Is in accordance with a written modification to the patient's plan of care . . ."

- Review of Patient #11's medical record occurred on February 12-14, 2013. Patient #11, an adolescent, received inpatient care from August 3, 2012 to August 18, 2012. The physician's orders showed Patient #11 restrained or secluded the following days: 08/12/12, 08/13/12, 08/15/12, 08/17/12, and 08/18/12.

Patient #11's record lacked evidence of modification of the care plan/treatment plan for use of the restraints/seclusions.

- Review of Patient #16's record occurred on February 12-14, 2013. Patient #16's admission occurred on 12/17/12 and diagnoses included anxiety with depression and Alzheimer's dementia. The record indicated on 01/02/13 at 12:40 a.m. nursing staff implemented a Geri chair with tray as "Pt kept trying to get up and was being aggressive with the CNAs [certified nursing assistants] when they tried to get him to sit so that he wouldn't fall and hurt himself."

Patient #16's Master Treatment Plan narrative, dated 01/03/13, did not include modifications for the use of the Geri chair restraint.

Based on record review, policy and procedure review, and staff interview, the hospital failed to ensure the development of a treatment plan/plan of care for 2 of 10 active records reviewed (Patients #7 and #8) and 4 of 12 closed records reviewed (Patients #11, #12, #16, and #17) of patients receiving treatment at the hospital. The failure to assess patient's specific behaviors, develop an individualized plan of care, evaluate the plan on a periodic basis, and revise or update the patient's care in response to those assessments resulted in the hospital not meeting the behavioral needs of patients.

Findings include:

Review of the following policies occurred on all days of survey. These policies included:

* "Scope of Services and Plan for Provision Care," dated 01/14/12, stated,
". . . 3.0 Policy: The [hospital] treatment program consists of an evaluation process, diagnosis and identification of treatment needs, followed by intensive individual and/or group work. . . .
Care Planning
Based on initial assessment, an initial treatment plan is developed upon admission for each patient, followed by a Master Treatment Plan developed within three days of admission. Treatment goals and therapeutic interventions are recommended. . . . Integration and coordination of care among departments and disciplines is carried out through daily multidisciplinary treatment planning sessions, as well as documentation in the medical record and unit or departmental meetings. Length of stay is determined by a patient's condition and level of functioning. . . .
4.0 . . . Multidisciplinary team approach includes evaluations and ongoing services from the Psychiatrist, Registered Nurse, Social Worker, Occupational Therapist, . . . The treatment is driven by the needs and abilities of the individual patient and planning is on-going process. . . ."

* "Patient Assessment, Monitoring and Treatment Planning Related to Psychiatric Acuity Level and Precautions," dated 01/14/12, stated,
"1.0 Purpose: To accurately, thoroughly and consistently assess and monitor high-risk behaviors and the psychiatric acuity level of all patients on a continuous basis.
2.0 Areas/Persons Affected: All inpatients at [the hospital]
3.0 Policy: It is the policy of [the hospital] to accurately, thoroughly, and consistently assess and monitor high-risk behaviors . . . of all patients on a continuous basis, and to provide effective supervision, intervention, and treatment planning for each patient to assure their physical safety as well as their optimum psychosocial and emotional recovery. . . .
6.0 Procedures: . . . 8. When a medication-based or other intervention is required . . . document the intervention in the patient medical record . . . 11. The SBAR [Situation, Background, Assessment, Recommendation] communication tool will be implemented and used as possible to efficiently and effectively standardize the communication of patient status and high-risk behaviors . . . Staff will provide . . .
a. S - Situation (What is happening now, chief complaints, acute changes)
b. B - Background (What led up to the event, pertinent history)
c. A - Assessment (What do you see, what do you think is going on)
d. R - Recommendation (What action do you propose) . . ."

* "Restraint and Seclusion," dated 01/14/12, stated, ". . . The multidisciplinary team incorporates into the patient's treatment plan the potential risks of dangerous patient behavior and interventions to deescalate the patient. . . . Patient care staff takes the following steps: a. Assess the patient's behavior, thoughts, and emotional state and the context in which the behavior occurred. The purpose of the assessment is to determine appropriate interventions that will most quickly resolve the situation with the least intrusive and restrictive measures. b. Follow the treatment plan . . . for early interventions and prevention strategies to avoid use of restrictive interventions. c. When possible, attempt to modify the patient's behavior by non-restrictive interventions . . .

- Review of Patient #16's record occurred on February 12-14, 2013. The hospital admitted Patient #16 on 12/17/12 with diagnoses including anxiety with depression and Alzheimer's dementia. An incident report from 01/02/13 at 12:40 a.m. stated, "Pt [patient] kept trying to get up and was being aggressive with the CNAs [certified nursing assistants] when they tried to get him to sit so that he wouldn't fall and hurt himself." The report identified the immediate treatment provided was a Geriatric chair with a tray, and the physician "recommended" a Geriatric chair with tray for 24 hours.

The medication record showed nursing staff administered a PRN (as needed) dose of Klonopin, an anti-anxiety medication, for "anxiety, restlessness" at 12:10 a.m., one half hour before requesting the Geri chair order. The record identified the "effect" of the anti-anxiety drug as the patient "sleeping" at 1:45 a.m. Staff failed to develop interventions to address Patient #16's behaviors prior to utilizing the Klonopin and failed to determine the effectiveness of the Klonopin prior to utilizing the Geri chair with tray.

Patient #16's "Behavior Log" identified nursing staff placed Patient #16 in a Geri chair with tray on 01/02/13 due to restlessness for safety and positioning; an entry on 12/22/12 stated the patient displayed physical aggression with staff during toileting and cares; and an entry on 12/30/12 indicated the patient pushed and kicked staff during cares. The entries lacked documentation of what led up to the event and what interventions staff attempted.

Patient #16's Master Treatment Plan narrative, dated 01/03/13, did not include changes as a result of the use of the Geri chair restraint.

A treatment plan, completed on admission on 12/17/12, included a goal of speaking loudly as the patient did not have hearing aids available due to dead batteries. The treatment plan, dated 12/27/12, stated, "Speak loudly as patient does not have hearing aids available on unit at this time due to dead batteries." The nursing progress notes lacked awareness of the hearing problem and what measures staff would use to obtain new batteries for the patient's hearing aids.

Patient #16's treatment plan failed to include interventions regarding aggressive behaviors, restlessness, and anxiety and the medical record lacked evidence of individualized approaches for staff to utilize.

- Review of Patient #11's medical record occurred on February 12-14, 2013. The hospital admitted Patient #11, an adolescent, in August 2012 with diagnoses including mood disorder, oppositional defiant disorder, and attention deficit disorder. The physician's orders showed Patient #11 restrained or secluded on 08/12/12, 08/13/12, 08/15/12, 08/17/12, and 08/18/12. A behavior log identified 11 entries between 08/04/12 and 08/15/12. The entries lacked documentation of what led up to the event and what interventions staff attempted.

Review of Nursing Progress Notes identified Patient #11 exhibited aggressive behavior toward female staff on three or more occasions including threatening, hitting, grabbing, and reaching down their shirts. The progress notes identified Patient #11 threatened other patients. On two occasions, male staff had to intervene and hold Patient #11 while a female staff member got away from the patient.

Patient #11's treatment plan failed to include interventions regarding aggressive behaviors.

- Review of Patient #17's medical record occurred on February 12-14, 2013. The hospital admitted Patient #17, a geriatric patient on 01/14/13 with diagnoses including schizoaffective disorder and bipolar type. Patient #17's behavior log showed one incident of the patient swearing at staff and lacked documentation of what led up to the event and what interventions staff attempted.

Patient #17's Master Treatment Plans, dated 01/17/13 and 01/24/13, showed the patient had self-harm and aggressive behaviors. The treatment plans failed to identify causative factors for the behavior, an assessment of the behaviors, and patient specific interventions.

- Review of Patient #12's medical record occurred on February 12-14, 2013. The hospital admitted Patient #12, a geriatric patient, on 11/16/12 with diagnoses including mood disorder and dementia.

A behavior log identified two behaviors: on 11/18/12 at 6:25 a.m. of hitting and kicking at staff and throwing all bedding on the floor, and on 11/22/12 at 6:25 a.m., the patient hit out at staff and "Pt talked about ending her life. Pt threw body on floor and refused to get up." Both entries lacked within the progress note, immediate staff action, patient's response and plan to alter the behavior.

Review of other nursing progress notes, dated between November 16 and November 23 included 12 entries which lacked how staff attempted to de-escalate the behaviors i.e. immediate staff action, (including non-pharmacological interventions), patient's response and plan to alter the behavior.

Patient #12's treatment plan/plan of care failed to address these behaviors and lacked evidence of individualized approaches for staff to utilize.



19410

- Review of Patient #7's medical record occurred on February 11-13, 2013. The Hospital admitted Patient #7 on 10/31/12 with medical diagnoses including Alzheimer's dementia with reactive confusion and behavioral disturbances.

Review of Patient #7's Nursing Progress Notes identified the following:
*02/03/13 at 6:50 a.m. - "Pt [patient] was combative [with] hs [evening] cares hitting out, punching and kicking . . ."
*01/27/13 at 6:45 p.m. - ". . . Pt hitting, kicking and pushing to the staff and pulling hair of other peers . . . entering into the other pt rooms . . ."
*01/23/13 at 5:30 p.m. - "Pt become aggressive at supper. Pt took female peer ice cream [and] hit pt on L [left] side of face. . . Pt given PRN [as needed] Risperdal . . ."
* 01/05/13 at 6:50 a.m. - "pt was combative . . . kicks out, punches out [and] attempts to slap [at] staff. . . ."
*01/03/13 at 7:35 p.m. - ". . . extremely agitated about everything. She was hitting and kicking staff and even clawed another patient. . . ."
*01/04/13 at 6:30 a.m. - "Pt had other staff by wrists upon arrival. Pt very aggressive, going in peers rooms, boundary intrusive, hitting pinching. . . ."

Nursing Progress notes and the Behavior Log identified episodes of Patient #7 exhibiting aggressive behaviors - hitting, kicking, pinching, pushing, wandering, yelling, biting, etc. The nursing progress notes and behavior log did not identify interventions implemented by staff to manage Patient #7's behavior. The Medication Administration Record (MAR) identified staff administered PRN antipsychotic medication to Patient #7 for behaviors two times in February 2013, eight times in January 2013, eleven times in December 2012, and 17 times in November 2012. The record did not identify non-pharmacologic interventions implemented prior to giving the antipsychotic medication.

Patient #7's Nursing Care Plan did not address behaviors and did not address non-pharmacologic interventions for staff to try during periods of agitation and aggression. The Master Multidisciplinary Treatment Plan for Patient #7 did not identify individualized non-pharmacologic treatment interventions for nursing staff to implement when the patient exhibited behaviors.

- Review of Patient #8's medical record occurred on February 11-13, 2013. The Hospital admitted Patient #8 on 01/22/13 with medical diagnoses including Alzheimer's dementia with psychosis.

Patient #8's Nursing Progress Notes identified the following:
*02/12/13 - ". . . Pt has been restless this shift. . . . Pt given Seroquel (antipsychotic medication) gel . . . due to [increased] agitation with [no] relief. Pt began hitting out at staff when redirected for unsteady gait. Pt was given Haldol (antipsychotic medication) . . . Pt continued to hit out at staff. Pt unredirectable for attempting to ambulate alone. At 1600 [4:00 p.m.] pt give Seroquel . . . due to yelling at staff [and] grabbing. Pt continues to have agitation/irritability at this time. . . ."
*02/11/13 - " Pt was being very aggressive [with] staff, hitting, yelling, trying to get up. Pt had already received 5 mg [milligrams] PO [per mouth] Haldol, 10 mg IM [intramuscular] Haldol earlier in the day with very little effect. . . ."
*02/10/13 - "Pt is punching and pinching staff. IM given by RN [registered nurse]."
*02/09/13 - "Pt is hitting and attempting to punch staff . . ."
*02/08/13 - "Pt became [increased] in agitation [and] aggression. Pt given Seroquel PRN at this time."

Nursing Progress notes and the Behavior Log identified episodes of Patient #8 exhibiting aggressive behaviors such as hitting, kicking, punching, and pinching. The nursing progress notes and behavior log did not identify interventions implemented by the staff to manage Patient #8's behavior. The Medication Administration Record (MAR) identified staff administered PRN antipsychotic medications to Patient #8 for behaviors 19 times in February 2013 and 9 times in January 2013. The record did not identify non-pharmacologic interventions implemented prior to giving the antipsychotic medication.

Patient #8's Nursing Care Plan did not address behaviors and did not address non-pharmacologic interventions for staff to try during periods of agitation and aggression. The Master Multidisciplinary Treatment Plan for Patient #8 did not identify individualized non-pharmacologic treatment interventions for nursing staff to implement when the patient exhibited behaviors.

The failure to assess patient behaviors on an ongoing basis, develop patient specific interventions and plans of care, and evaluate the effectiveness of the interventions limits the staff's ability to provide consistent care for patients.

Based on observation, record review, and staff interview, the Hospital failed to ensure the use of verbal and telephone orders occurred infrequently for 4 of 10 active patient (Patients #1, #2, #6, and #8) records reviewed. The use of verbal and or telephone orders poses an increased risk of miscommunication that could contribute to an error, resulting in an adverse patient event.

Findings include:

Observation at a nurse station on 02/12/13 at 9:35 a.m. revealed a conversation between a random nursing staff member and a medical provider (#1). Observation showed the nursing staff member taking verbal orders from the physician and recording the orders in a patient's medical record.

- Review of Patients #1, #2, #6 and #8's active medical records occurred on February 11-13, 2013 and identified the following telephone and verbal orders:
*Patient #1's record identified the Hospital admitted the patient on 02/10/13 at 10:10 p.m. to the child unit. The record included one verbal order written on 02/11/13 at an unknown time and one telephone order written on 02/12/13 at 9:30 a.m. for medication changes/additions.
*Patient #2's record identified the Hospital admitted the patient on 02/06/13 to the adolescent unit. The record included two separate verbal orders written on 02/07/13 at 10:50 a.m. for medication changes/additions; two separate telephone orders written on 02/08/13 at 10:20 a.m. and 12:30 p.m. for medication changes/additions; one verbal order written on 02/09/13 at 10:08 a.m. for a treatment therapy; and two separate verbal orders written on 02/10/13 at 10:35 a.m. for a medication change and sensory evaluation.
* Patient #6's record identified the Hospital admitted the patient on 01/30/13 at 3:30 p.m. The record included the following verbal orders: 01/30/13 at 3:30 p.m. for admission orders; 02/02/13 at 8:20 a.m. for discontinuing one-to-one supervision; 02/05/13 at 10:56 a.m. for medication; and 02/06/13 at 10:56 a.m. for geriatric chair with tray restraint.
* Patient # 8's record identified the Hospital admitted the patient on 10/31/12 at 10:45 a.m. to the geriatric unit. The record included the following verbal orders: 10/31/12 at 1:25 p.m. for medication and physical therapy evaluation; 9:00 p.m. for geriatric chair with tray restraint; 11/01/12 at 9:00 p.m. for geriatric chair with tray; 11/02/12 at 6:00 a.m. for medication clarification; 11/23/12 at 11:00 a.m. for straight catheterization for a urinalysis; and 01/24/13 at 9:00 a.m. for medication increase.

During an interview on 02/14/13 at 10:40 a.m., an administrative nurse (#1) stated staff must limit the routine use of verbal and/or telephone orders and confirmed the practice as a problem within the Hospital.


19410

Based on record review, review of medical staff rules and regulations, and staff interview, the hospital failed to ensure the person responsible for providing or evaluating the services provided performed accurate documentation, completed, signed, dated and authenticated entries within the medical record for 3 of 3 active outpatient (Patients #5, #7, and #8) records reviewed and 10 of 12 closed records (Patients #9, #11, #12, #13, #14, #16, #17, #18, #19, and #20) reviewed. Failure to complete the medical record has the potential to affect the care, treatment, and services for patient's behavioral problems. Failure to provide an accurate and completed medical record can limit tracking of occurrences, behaviors, seclusion and restraint procedures and patient care.

Findings include:

Review of the Medical Staff Rules and Regulations occurred on 02/11/13. The rules and regulations, dated 12/09/11, stated ". . . 7. All clinical entries in the patient's medical record shall be accurately dated and authenticated with signature and credentials. . . ."

Review of the following records occurred on all days of survey:

- Review of Patient #5's active outpatient medical record showed the patient received electroconvulsive therapy (ECT) on 06/01/12, 06/04/12, 06/06/12, 06/08/12, 06/11/12, 06/13/12, 06/15/12, 06/18/12, 06/20/12, 06/22/12, 06/25/12, 06/29/12, 07/0/212, 07/11/12, 07/16/12, 07/18/12, 07/30/12, 08/13/12, 08/29/12, 09/19/12, 10/17/12, and 11/28/12. Review of Patient #5's pre and post ECT orders for the above dates showed the provider timed and signed the post procedure orders before the procedure occurred.

- Patient #7's medical record included 11 occasions when staff did not identify the time of the nursing progress note for the time period of 01/22/13 through 02/13/13.

Review of Patient #7's pre and post ECT orders for 10/31/12, 11/07/12, 11/14/12, 11/23/12, 12/03/12, 12/12/12, 12/21/12, 12/31/12, 01/23/13, 01/28/13, 01/3013, and 02/01/13 showed the provider timed and signed the post procedure orders before the procedure occurred.

- Patient #8's medical record included 54 occasions when staff did not identify the time of the nursing progress note for the time period of 10/31/12 through 02/12/13.

- Patient #9's record contained 9 occasions when staff did not identify the time of the nursing progress notes for the time period between 11/16/12 through 11/26/12.

- Patient #11's record contained nursing progress notes, dated between 08/03/12 through 08/20/12, entered without timing on nine occasions. The record contained several undated and untimed seclusion/restraint worksheets. A debriefing form (review with the patient and staff regarding a restraint or seclusion incident) lacked timing and dating on two occasions.

- Patient #12's record contained a provider's progress note, dated 11/17/12, not authenticated or timed.

- Patient #13's record contained a discharge summary not signed, dated, or timed by the provider.

- Patient #14's record contained a discharge summary not signed, dated, or timed by the provider.

- Patient #16's record contained 14 nursing progress notes, dated between 12/13/12 and 01/04/13, entered without timing.

- Patient #17's record contained an untimed "Intake Assessment and Admission Treatment Plan", dated 01/14/13.

- Patient #18's record contained two psychiatric evaluations, dated 11/15/12 and 11/16/12, not timed and authenticated.

- Patient #19's record contained a discharge summary completed on 09/01/12, signed and timed on 01/10/13.

- Patient # 20's record included two psych progress notes, dated 12/11/12 and 12/12/12, not authenticated and a discharge summary, dated 12/13/12, lacked authentication by the provider within 30 days.

During an interview on 02/13/13 at 10:05 a.m., an administrative nurse (#1) stated she expected providers to document post procedure orders upon completion of the procedure. The nurse (#1) stated all staff must document accurate information in the patient's medical record at the time of service/treatment or upon completion of the service/treatment.

During interview on the morning of 02/14/13, an administrative nursing staff member (#1) stated she expected nursing staff to time all their entries in the medical record.


28086





19410

Based on record review, review of medical staff rules and regulations, and staff interview, the hospital failed to ensure the timing and authentication of orders promptly by the ordering practitioner for 7 of 10 active patient (Patient #1, #2, #3, #4, #6, #7, and #8) records and 4 of 12 closed patient (Patient #11, #13, #16, and #17) records reviewed. Failure to time and authenticate orders has the potential to cause medical errors to go unnoticed and may be a potential hazard/risk to the patient.

Findings include:

Review of the Medical Staff Rules and Regulations, dated 12/09/11, stated ". . . All clinical entries in the patient's medical record shall be accurately . . . authenticated with signature and credentials. . . . discharge diagnosis shall be recorded . . . dated and signed by the responsible practitioner . . . verbal orders are authenticated within 48 hours by the practitioner responsible for the patient. . . . It is recognized that all verbal orders may be associated with a potential hazard/risk to the patient; therefore verbal orders are to be signed within 48 hours by the practitioner responsible for the patient. . . "

Review of the medical records occurred on all days of survey and identified:

- Patient #1's record showed a nurse wrote a verbal order on 02/11/13 for two different medication changes/additions and failed to include the time of the order.

- Patient #2's record showed a nurse wrote a telephone order for admission on 02/06/13 and failed to include the time of the order.

- Patient #3's record showed a provider wrote an order for Electro-Convulsive Therapy (ECT) treatment clearance and failed to include the time of the order.

- Patient #4's record showed provider orders which included the following:
*On 02/06/13 the provider ordered two different medication changes/additions and failed to include the time of the order.
*On 02/07/13 the provider ordered four different medication changes/additions/discontinuations and clearance for ECT treatment and failed to include the time of the order. An additional provider order written on this day for pre-procedure ECT orders also failed to identify the time of the order.
*On 02/08/13 the provider ordered two different medication changes and failed to include the time of the order. The same day, a nurse wrote a telephone order for a medication change and family practice consult and failed to identify the time of the order.

- Patient #6's record showed the physician wrote orders on 01/31/13 and 02/05/13 and failed to include the time of the order. The record included verbal orders on 01/30/13, 02/02/13, 02/05/13, 2/06/13 and telephone orders on 01/31/13 the provider did not authenticate.

- Patient #7's record showed the physician wrote orders on 01/28/13, 02/04/13, 02/05/13, 02/06/13, and 02/11/13 and failed to include the time of the order.

- Patient #8's record showed the physician wrote orders on 11/12/12, 11/19/12, 11/21/12, 11/27/12, 12/03/12, 12/05/12, 12/07/12, 01/07/13, and 01/22/13 and failed to include the time of the order.

- Patient #11's record showed physicians' orders, dated 08/13/12, 08/15/12, 08/16/12, 08/18/12, and 08/23/12 authenticated on 12/31/12. An order, dated 08/17/12, lacked a physician's signature to authenticate the verbal order.

- Patient #13's record contained provider orders dated 01/08/13, 01/09/13, and 01/13/13 not timed.

- Patient #16's record contained a physician's order, dated 01/02/13, for a Geriatric chair with tray for 24 hours. The provider failed to authenticate the order. The record also contained three verbal orders, all dated 01/16/13, not authenticated by the provider.

- Patient #17's record contained physician orders, dated 11/17/12, 11/19/12, 11/20/12, 11/21/12, and 11/23/12, not timed.


19410




28086

During interview on the afternoon of 02/13/13, a medical records staff member (#4) stated the hospital does not do quality assurance/quality improvement monitoring of authenticating verbal orders, including the authentication of verbal orders within a timely manner.

Based on policy and procedure review, record review, and staff interview, the Hospital failed to ensure the medical record included all reports of treatment and information necessary to monitor the patient's condition for 1 of 1 active outpatient (Patient #5) record reviewed. Failure to keep a complete medical record limited staff involved with the patient's care access to the information necessary to monitor the patient's condition and the ability to provide appropriate care.

Findings include:

Review of the policy "Electroconvulsive Therapy (ECT)" occurred on 02/13/13. This policy, revised 02/07/12, stated, ". . . Due to the nature of the treatment and potential risks involved it is of great importance that certain procedures be understood and implemented so safety is ensured and consent is documented. . . . 1. The psychiatrist has documented in the patient's record that other alternative, less invasive treatment modalities have been discussed and ECT may represent the most effective therapy for the patient. . . ."

Review of the policy "Electroconvulsive Therapy (ECT): Conditions and Consent" occurred on 02/13/13. This policy, revised 02/07/12, stated, ". . . A. Informed consent must be obtained from the patient by the treating psychiatrist and documented in the progress notes. . . ."

Review of the "Pre-ECT Orders" form occurred on 02/13/13. This pre-printed form, undated, stated, ". . . 7. When starting on initial ECT treatment obtain a consult for a second psychiatrist to review risks vs. [verses] benefits, education and evaluation of ECT treatments. . . ."

Review of Patient #5's active outpatient medical record occurred on 02/13/13 and identified the Hospital admitted the patient for initial ECT treatment on 05/30/12. The record showed the patient received further treatments on 06/01/12, 06/04/12, 06/06/12, 06/08/12, 06/11/12, 06/13/12, 06/15/12, 06/18/12, 06/20/12, 06/22/12, 06/25/12, 06/29/12, 07/02/12, 07/07/12, 07/11/12, 07/16/12, 07/18/12, 07/30/12, 08/13/12, 08/29/12, 09/19/12, 10/17/12, and 11/28/12. The record failed to include documentation from the psychiatrist recommending ECT treatment, consultation from the second psychiatrist to review risks/benefits/education/evaluation prior to initial treatment, informed consent from the treating psychiatrist, and progress notes.

During an interview on 02/13/13 at 4:40 p.m., an ECT treatment nurse (#8) confirmed Patient #5 and other outpatient ECT medical records did not include documentation from the psychiatrist recommending ECT treatment, consultation from the second psychiatrist to review risks/benefits/education/evaluation prior to initial treatment, informed consent from the treating psychiatrist, and progress notes.

Based on observation, record review, and staff interview, the Hospital failed to document the removal of all medications from the storage area or after-hours supply and ensure a pharmacist reviewed medication removal activity for 1 of 1 after-hours medication storage area. These failures have the potential to create an insufficient distribution, control, and accountability of medications and allowed an opportunity for unsafe and unauthorized use of medications.

Findings include:

During an interview on 02/13/13 at 3:40 p.m., a staff nurse (#11) stated during the time the pharmacist is unavailable (after hours, weekends, and holidays) and providers ordered new medications, medication changes, one time medications, and as needed medications for patients, nursing staff removed medications from the contingency medication carts for administration to patients.

Observation of the medication storage area on the geriatric nursing unit occurred on 02/14/13 at 8:35 a.m. with a staff nurse (#9). Observation showed a large medication cart, located in the locked medication room, which the nurse (#9) identified as the contingency medications (after-hours supply). The cart contained multiple medications packaged in different doses in bottles and cassettes, including benzodiazepines, antipsychotics, and antibiotics. The nurse (#9) stated nursing staff logged removal of the contingency medications on a "pharmacist review" form.

Review of the pharmacy review form occurred on 02/14/13 at 8:50 a.m. The form stated, "The policy of the Stadter Center is that the consulting pharmacist is to review medication administered after hours to patients to ensure of no contraindications or interactions with other medications. Review of medication needs to be completed within 48 hours of order written."

Review of completed pharmacist review forms from January to February 2013 occurred on 02/14/13 at 8:50 a.m. and showed the following:
*A nurse removed a 0.1 milligram (mg) clonidine (used for attention deficit hyperactivity disorder or as adjunctive therapy to stimulant medications) tablet for a patient. The form lacked the date and time of the pharmacist's review and the date and time of medication removal. Another form (titled contingency record - contained the name and a running count of a particular medication, filed separately within the binder, not included with the pharmacist review form) revealed a nurse removed the medication on 01/19/13.
*A nurse removed Seroquel (an antipsychotic) and trazadone (an antidepressant) for a patient. The form lacked the date and time of medication removal. The contingency record revealed a nurse removed two 25 mg tablets of Seroquel on 01/26/13 and 01/27/13; removed two 50 mg tablets of trazadone on 01/26/13 and 01/27/13; and removed three 50 mg tablets of trazadone on 01/28/13, 01/29/13, and 01/31/13. The form lacked a pharmacists' review of the medication removal.
*A nurse removed ibuprofen and other medications for a patient. The nurse failed to specify the other medications on the form. The form lacked a pharmacists' review of the medication removal.

Review of contingency record forms from January to February 2013 occurred on 02/14/13 at 9:00 a.m. and identified nursing staff removed several other types of medications for patients including Haldol (an antipsychotic), Risperdal (an antipsychotic), tramadol (an analgesic), Vistaril (used for anxiety), Zyprexa (an antipsychotic), and Abilify (an antipsychotic). The nursing staff did not log removal of these medications on the pharmacist review form.

During an interview on 02/12/13 at 5:15 p.m., a pharmacist (#12) stated he could not recall reviewing any records from the contingency medication cart, and stated his main responsibility pertained to filling and distributing medications to the patients within the Hospital and attending monthly pharmacy and therapeutic meetings.

During an interview on 02/14/13 at 11:10 a.m., an administrative nurse (#1) stated nursing staff must log removal of medications from the contingency medication cart and did not realize nursing staff failed to document removal of all medications from the cart. The nurse (#1) stated the night nurse staff faxed the pharmacist review forms to the pharmacist every night and stated she did not realize the pharmacist had not reviewed the forms.

Based on observation, review of manufacturer's instructions, and staff interview, the Hospital failed to maintain medical equipment to ensure an acceptable level of safety and quality for 1 of 1 automated external defibrillator (AED) on the inpatient nursing unit. Failure to maintain equipment critical to patient health and safety, such as an AED, could result in serious injury or death if the equipment failed to function properly.

Findings include:

Observation of the crash cart on the inpatient nursing unit occurred on 02/14/13 at 9:10 a.m. with a staff nurse (#9) and showed the cart contained a portable AED. Observation of the AED showed a sticker attached to the side of the machine which identified completed maintenance on 02/07/08 from another facility's biomedical department. The nurse (#9) confirmed the machine as the only AED within the Hospital and on the inpatient nursing unit.

During an interview on 02/14/13 at 10:15 a.m., a maintenance staff member (#10) stated he had not checked the AED's manufacturer's instructions for routine maintenance requirements and had not placed the AED on a routine maintenance schedule.

Review of the "MRL [company name] Automated External Defibrillator", Part Number 990020 - Revision B, users manual occurred on 02/14/13. The manual, undated, pages 4-2 and 4-3, stated, ". . . To ensure the readiness and optimum working condition of the MRL AED, the unit should be inspected and tested according to the inspection schedule outlined below. The goal is to maintain the unit in an operation ready state. In addition to the daily check, authorized personnel must complete performance and calibration testing at regularly scheduled intervals, which should not exceed one year. . . . Each MRL AED should be inspected on a regular basis to ensure that the unit is ready for service when needed. The following table presents guidelines for determining an appropriate inspection schedule for your MRL AED units. Frequency of Use . . . infrequently, such as once a year . . . Inspection Schedule . . . monthly . . ."

The Hospital failed to review the AED's manufacturers' instructions and establish a maintenance strategy to determine the appropriate frequency for maintenance, inspection, and testing of the AED based upon acceptable risk to patient health and safety.

Based on record review, review of policies and procedures, and staff interview, the hospital failed to implement its written protocols to ensure the Organ Procurement (OPO) organization received notification of 1 of 2 patient death records (Patient #13) reviewed. The facility's failure did not allow the patient's family an opportunity to provide a tissue or eye donation.

Findings include:

Review of the hospital's "Organ Procurement" policy occurred on 02/13/13. The policy, dated 12/09/11, stated, "Purpose: Hospitals must contact their organ procurement organization (OPO) in a timely manner about individuals whose death is imminent or who die in the hospital. . . . Policy: The [hospital] will work with a designated OPO to ensure that the family of each potential donor is informed of its options to donate organs, tissues, or eyes or to decline to donate. . . ."

Review of the hospital's policy "Patient Death" occurred on 02/13/13. The policy, dated 05/12/08, stated the purpose as establishing "guidelines for interventions in the event of a patient death. . . . The RN [Registered Nurse] Charge Nurse will notify [OPO] regarding the patient's death. (Refer to the [OPO] policy book and follow directions indicated) . . ."

Review of Patient #13's closed medical record occurred on 02/13/13. The record lacked documentation regarding notification of the OPO upon the patient's death.

During an interview on 02/13/13 at 5:00 p.m., an administrative staff member (#1) stated the hospital had not notified the OPO of Patient #13's death.

Based on record review, review of policy and procedure, and staff interview, the hospital failed to ensure annual education to staff on Organ Procurement in collaboration with the Organ Procurement Organization (OPO) for 1 of 1 year (February 2012-January 2013). Failure to provide staff education regarding donation issues may have contributed to the hospital staff failing to notify the OPO of one patient death.

Findings include:

Review of Patient #13's closed medical record occurred on 02/13/13. The record lacked documentation regarding notification of the OPO upon the patient's death.

Staff education records, reviewed on 02/14/13, lacked evidence the hospital provided staff with education regarding donation issues.

During an interview on 02/13/13 at 5:00 p.m., an administrative staff member (#1) indicated the hospital had not provided OPO training to the staff in the past year.

Based on review of policy and procedure, record review, and staff interview, the Hospital failed to ensure patients received a complete medical history and physical (H&P) examination no more than 30 days prior to a procedure requiring anesthesia services for 1 of 1 active outpatient (Patient #5) record reviewed. Failure to complete an H&P within 30 days prior to a procedure limits the hospital's ability to ensure the patient's condition is acceptable for the procedure.

Findings include:

Review of the policy "Electroconvulsive Therapy (ECT)" occurred on 02/13/12. This policy, revised 02/07/12, stated, ". . . Due to the nature of the treatment and potential risks involved it is of great importance that certain procedures be understood and implemented so safety is ensured . . . It is the policy . . . to provide safe and effective ECT treatment . . . 7. History/Physical exam has been performed in the past 30 days, or updated from the past three months . . ."

Review of the "Pre-ECT Orders" form occurred on 02/13/13. This pre-printed form, undated, stated, ". . . 2. History and Physical within 90 days. . . ."

Review of Patient #5's active outpatient record occurred on 02/13/13 and identified a completed H&P on 05/24/12 and another completed H&P on 09/05/12. The record showed the patient started ECT treatments on 05/30/12 and received further treatments on 06/01/12, 06/04/12, 06/06/12, 06/08/12, 06/11/12, 06/13/12, 06/15/12, 06/18/12, 06/20/12, 06/22/12,06/25/12, 06/29/12, 07/02/12, 07/06/12, 07/11/12, 07/16/12, 07/18/12, 07/30/12, 8/13/12, 08/29/12, 09/19/12, 10/17/12, and 11/28/12. Given the initial H&P completion date of 05/24/12 and the ongoing treatments, the Hospital failed to complete an H&P on 06/23/12, 07/23/12, and 08/22/12. Given the second H&P completion date of 09/05/12 and the ongoing treatments, the Hospital failed to complete an H&P on 10/05/12 and 11/04/12.

During an interview on 02/13/13 at 2:15 p.m., a staff nurse (#8) stated the Hospital required a completed H&P for ECT treatments every 90 days and stated all patients undergo general anesthesia for the procedures.

During an interview on 02/14/13 at 10:40 a.m., an administrative nurse (#1) stated the Hospital required a completed H&P for ECT treatments every 90 days and did not realize the requirement for completion every 30 days.