HospitalInspections.org

Based upon reviews of medical records (#3), and the hospital's grievance process, Administrative and staff interviews revealed the hospital failed to ensure staff followed the Grievance procedure/plan as evidenced by Registered Nurse (RN S9) did not initiate an occurrence report per policy/procedure/plan when patient #3's family complained about the lack of patient care. Findings:

Review of patient #3's medical record revealed RN S9 documented, 08/20/10, 5pm, "Pt (patient) discharged @ (at) family's request. States pt not being taken care of. Verbalizes intent to take pt to (name of local acute care hospital's) ER (emergency room)".

Review of the hospital's Concern/Complaint/Grievance Process, (policy # PI. 1.10, 2.10, 2.20, 2.30, 3.10; RI. 2.120) revealed investigations of any complaints/grievances that involved quality or appropriateness of patient care would occur in a timely manner (investigation within 7days and final findings reported to complainant/s no later than 30 days). "Procedure: Each staff member is empowered to manage patient complaint within 24 hours and to use good judgement regarding the reporting of such to their Department Manager/Supervisor. Complaints are documented on an 'Occurrence Report' and follow the occurrence management process...Grievances are documented on a 'Grievance Report' by the employee as soon as the grievance is received and the report is immediately forwarded to the Department Manager/Supervisor. At a minimum, this must be completed by the end of the working shift...A 'follow-up' response is provided to the patient within 7 working days of the event. Concerns/complaints and grievances are logged for data management and filed by the facility Risk Manager...Upon admission to the facility, patient and/or family are provided information regarding the concern/complaint/grievance process...Acknowledgement of the patient having received information regarding the concern/complaint/grievance process is noted via patient or patient representative signature."

Review of patient #3's medical record revealed the patient's daughter (who had patient's Power of Attorney) had placed her signature as evidence of receipt of information relative to patient rights/responsibilities and the hospital's grievance process.

Interview, 09/29/2010, 1:15pm, with Quality/Risk Manager RN S4, confirmed RN S9 should have recorded the family's complaint on an Occurrence Report and reported the incident to her supervisor, Director of Psychiatric Units RN S3.

Based upon reviews of the Nurse Staffing Patterns and hospital policies and procedures, Administrative and staff interviews the hospital and Director of Nursing failed to ensure a Registered Nurse (RN) was scheduled and available to perform patient assessments, on the 3rd Floor Adult Psychiatric Unit; and on 2-East Medical Psychiatric Unit. Findings:

Review of the Nurse Staffing Pattern for coverage on the Adult Psychiatric Unit (dated 08/01/10 through 08/14/10), revealed there failed to be an RN scheduled on the following shifts: 08/01/10 no RN for 24 hours; 08/02/10 7pm-7am; 08/05/10 7pm-7am; 08/06/10 7pm-7am; 08/07/10 7pm-7am; 08/08/10 7pm-7am; 08/09/10 7pm-7am; 08/10/10 7pm-7am; and 08/14/10 no RN for 24 hours.

Review of a Nurse Staffing Pattern, dated 08/15/2010 through 08/21/2010, revealed there failed to be an RN scheduled on the Adult Psychiatric Unit on the following shifts: 08/15/10 7am-7pm; 08/17/10 7pm-7am; 08/18/10 7pm-7am; and 08/19/10 7pm-7am.

Review of the Nurse Staffing Pattern, dated 08/15/10 through 08/21/10, revealed there failed to be an RN scheduled on 2-East Medical Psychiatric Unit on 08/20/10 during the 7am-7pm shift.

Interviews, on 09/30/10 at 10:00AM, with Chief Clinical Officer (CCO) S1, Director of Nursing (DON) S2, and Director of Psychiatric Units, RN S3 confirmed the hospital's administrative personnel were aware of a lack of RN coverage on the Adult Psychiatric and Medical Psychiatric Units during the above documented dates and shifts.

CCO S1, DON S2, and RN S3 confirmed there should have been an RN scheduled and present on these units to provide/supervise patient care.

Based upon reviews of 2 of 12 medical records (#1, #3), review of hospital policies/procedures, Administrative and staff interviews, the hospital failed to ensure each patient received an initial nursing assessment performed/supervised and documented by a Registered Nurse (RN). Findings:

Review of patient #1's medical record revealed a form titled "Nursing Admission Assessment", dated 09/17/10, 3:40pm. Licensed Practical Nurse (LPN) S5 documented patient #1's initial (admission) assessment on this form; however, there lacked documented evidence that the assessment completed by the LPN was supervised by an RN as evidenced by a lack of an RN signature.

Continued review of patient #1's medical record and the Nursing Admission Assessment forms revealed a form titled "Suicide Risk Assessment". Listed next to "instructions" was "To be completed by the RN at the first part of...admission assessment and whenever necessary throughout patients stay..." There failed to be documented evidence an RN performed/documented/supervised this assessment as the only signature documented on the Nursing Admission Assessment and the Suicide Risk Assessment was that of LPN S5.

Review of patient #3's medical record revealed a "Nursing Admission Assessment" form that indicated LPN S5 documented and completed the findings (contained on the nursing assessment form). LPN S5 documented (by her signature) that she completed the admission assessment, 08/11/10, at 5PM.

Review of hospital policy # IM. 6.10 revealed, "...2. The nursing process is used in the delivery of patient care and is evidenced in the following documentation: a. Initial assessment and evaluation, performed by an RN...3. Data collected within the defined scope of responsibility/duties of each care giver may be documented by that individual. The evaluation of the data for identifying patient care needs/problems and planning of care must be documented by the RN."

There failed to be documented evidence an RN had reviewed and agreed with the findings made by LPN S5.

Interviews, 09/29/10, with Chief Clinical Officer S1, Director of Psychiatric Units, RN S3, and LPN S5 confirmed an RN had not re-assessed the patient, nor reviewed the findings documented by LPN S5.

Based upon reviews of physician's verbal orders (for #3), Medication Administration Records (#3), pharmacy policies/procedures, Administrative and staff interviews, the hospital failed to ensure the physician's verbal order for non-formulary medications (#3) was verified by the Licensed Practical Nurse (LPN) (#S5) as evidenced by an incomplete medication order; and that pharmacy policies/procedures for medications brought from home were followed. Findings:

Review of a Physician's Order, dated 08/12/10, 3pm, revealed LPN S5 documented "Metanx & Lunesta may be brought from home since Rx (prescription) not on formulary T.O.R B (telephone order read back) name of physician/S12/LPN S5 name". Review of the order indicated it was incomplete as there lacked a dose amounts, routes of administration, and how often to administer either medication.

Review of patient #3's Medication Administration Records (MARs), dated 08/11/10 through 08/20/10, revealed: 08/11/10 Metanx and Lunesta "not available"; 08/12/10 Metanx "not available"; 08/12/10 Registered Nurse (RN) S11 documented Lunesta administered at 9pm; 08/13/10 LPN S6 documented he administered Metanx at 9am; RN S11 documented patient #3 declined her Lunesta at 9pm; 08/14 through 08/19 revealed Metanx and Lunesta were administered per MAR documentation; patient #3's family requested she be discharged, 08/20/10, 5pm. There failed to be documented evidence patient #3's home medications were returned to her or a family member upon discharge on 08/20/10.

Review of a pharmacy policy/procedure, # MM.2.40, titled "Medications Brought By Patient" revealed "Policy: Patient's own medications shall not be used unless there is a physician's order stating that the patient may take his/her own medications...The order will be reviewed by the pharmacist...if it is felt that the order is justified, the following should be done. Procedure: The medications will be sent to the Pharmacy Department for proper identification and labeling to insure proper dispensing and administration...9. After normal hours of operation, in the absence of a pharmacist, the physician will be responsible for identifying the patient's home medications..."

Interview, 09/30/10, 8:45am, with the Director of Pharmacy, Registered Pharmacist (RPh) S10, revealed the pharmacy had a policy for the administration of home medications provided by the patient. (Note that Pharmacy policy/procedure #MM.2.40 as listed above was the policy RPh S10 referred to.) When RPh S10 reviewed patient #3's physician's order, dated 08/12/10 and documented by LPN S5, he agreed the verbal order was not complete as LPN S5 did not document the routes of administration, frequency of administration, nor the doses to be administered. RPh S10 further stated the medications should have been visually identified by either patient #3's physician or by a pharmacist prior to either of the medications being administered. RPh S10 confirmed LPN S5 did not follow the approved pharmacy policy relative to the use of patients home medications.

Interview, 09/30/10, 9:50am, with LPN S5 revealed, when questioned in regard to patient #3's medication orders, she stated she had written the verbal medication order. She further stated patient #3's family member brought the Lunesta (a controlled drug substance for sleep), on 08/13/10 in the afternoon. LPN S5 stated she could not remember for certain, but she did not think the family had brought the Metanx (a vitamin). LPN S5 was questioned in regard to the hospital's policy on medications brought from home. LPN S5 stated, home medications were sent to the pharmacy, but if they were to be used, they bypassed the pharmacy. LPN S5 was questioned what she did with the Lunesta once the family brought it in, she replied, "I think I put it in (patient #3's name) medication drawer". The surveyor then questioned LPN S5 in regard to the verbal order she had documented and was it a complete order, she replied "no".

Interviews, 09/30/10, 10:15am, with Chief Clinical Officer S1, Director of Nursing S2, Director of Psychiatric Units RN S3, and the Director of Pharmacy, RPh S10, confirmed LPN S5 did not follow the hospital's policy relative to the use of home medications. RN S3 further confirmed he was not aware all nurses, assigned to the psychiatric units, were not following hospital policies until the surveyor brought this to his attention.

Based upon reviews of medical records (#3), pharmacy policies/procedures, Administrative and staff interviews, the hospital failed to ensure pharmacy policies/procedures were followed relative to the use of patient (#3) home medications. Findings:

Review of a Physician's Order, dated 08/12/10, 3pm, revealed LPN S5 documented "Metanx & Lunesta may be brought from home since Rx (prescription) not on formulary T.O.R B (telephone order read back) name of physician/S12/LPN S5 name".

Interview, 09/28/10, with LPN S5 revealed, (after she reviewed the order), she agreed it was incomplete as there lacked a dose amounts, routes of administration, and how often to administer either medication.

Review of a pharmacy policy/procedure, # MM.2.40, titled "Medications Brought By Patient" revealed "Policy: Patient's own medications shall not be used unless there is a physician's order stating that the patient may take his/her own medications...The order will be reviewed by the pharmacist...if it is felt that the order is justified, the following should be done. Procedure: The medications will be sent to the Pharmacy Department for proper identification and labeling to insure proper dispensing and administration...9. After normal hours of operation, in the absence of a pharmacist, the physician will be responsible for identifying the patient's home medications..."

Interview, 09/30/10, 8:45am, with the Director of Pharmacy, Registered Pharmacist (RPh) S10, revealed the pharmacy had a policy for the administration of home medications provided by the patient. (Note that Pharmacy policy/procedure #MM.2.40 as listed above was the policy RPh S10 referred to.) When RPh S10 reviewed patient #3's physician's order, dated 08/12/10 and documented by LPN S5, he agreed the verbal order was not complete as LPN S5 did not document the routes of administration, frequency of administration, nor the doses to be administered. RPh S10 further stated the medications should have been visually identified by either patient #3's physician or by a pharmacist prior to either of the medications being administered.

There failed to be documented evidence patient #3's home medications were returned to her or a family member upon discharge on 08/20/10.

RPh S10 confirmed pharmacy personnel and LPN S5 did not follow the approved pharmacy policy relative to the use of patients home medications.