HospitalInspections.org

Based on record review and interviews the facility failed to protect the patients from the unnecessary use of restraint and seclusion for falls, document and log patient holds to administer psychotropic medications, and follow physician orders in 3(#12, 10, and 21) of 20 (#1-20) charts reviewed.

Review of patient #12's chart revealed that she was a 91 year old female admitted on 3/6/2014. Review of the psychiatric evaluation dated 3/10/2014, staff #4 documented, " was sent to us due to increasing confusion, hallucinations, and agitation. The patient was agitated and combative at the nursing home. Patient made suicidal statements at the nursing home. The patient presents to the hospital with a urinary tract infection. Diagnostic impression: Axis I Delirium secondary to general medical condition, due to urinary tract infection. Rule out dementia, Alzheimer's type, with behavioral disturbances.
Review of the physician orders for admission on 3/7/14 revealed the patient was put on a level one monitoring level. Review of Policy and procedure "Patient Monitoring and Precautions Policy #: 6O51" defined the 3 monitoring levels:
"A. Level I: constant monitoring within 6 feet distance (arms reach). No more than two level I patients are assigned to an individual technician to monitor.
B. Level II: constant monitoring within 20 feet distance, line of sight.
C. Level Ill: close monitoring every 15 minutes. Within a distance of 40 feet or less."
Review of patient #12's chart revealed a physicians' order for level I monitoring. The sheet had the definition of a level one, two, and three monitoring system and columns. The columns listed where date, time, level, precaution orders/level of justification, MD signature, and RN signature.
Patient #12 was placed on a level one for "falls" from 3/14-3/18/2014. The definition on the "Physician order for monitoring" of a level one is as follows:
"LEVEL 1- patient is an extreme danger to themselves or others and requires 1:1 constant monitoring within arm's reach while awake, and from doorway of patient's room while asleep. Patient is never more than six feet away from the staff while awake at all times. Patient is accompanied by staff at all times including bathing, showering, shaving, and toileting. Order must be reviewed and changed or renewed by MD every 24 hours.
An interview with staff # 20 confirmed that she had 2 patients that she was watching on a 1:1. Staff #20 confirmed most of the patients she has on 1:1 are confused or high fall risks. Staff #20 confirmed two patients on a 1:1 was difficult. If one patient needed to go to the bathroom she would not be able to go right away until another employee could monitor the second patient. Staff #20 confirmed that the patients are awakened early in the mornings and brought to the quiet room. The quiet room had recliners and Geri chairs all along the walls. The patients stay in the quiet room unless they are in group or seeing the physician. The patients on 1:1s are not taken to their rooms to rest. If they need to rest they are laid back into the recliners or geri chairs. The patients are put back to bed after the 7:00 PM shift comes on. Staff#20 also confirmed that if a patient needed to be secluded or restrained it was always in the patients' room.
An interview was conducted on 3/18/2014 with staff #1. Staff #1 revealed she was aware that the definition of a 1:1 means 1 employee to 1 patient. However, most of the MHTs have 2 patients to care for. Staff #1 stated, "The mental health technicians (MHT) have to be aware that the patients are at a high fall risk. The patients are placed on 1:1s so the MHT will stay with the patients and be more observant. They don't get paid very much. If we don't put them on 1:1s then we ended up having too many falls."
An interview with staff#26 confirmed that the patients are leaned back in the chairs so they do not fall. A patient had asked to go lay down in his room during the interview. Staff #20 stated he could not because there was no one to watch him in his room. The patient struggled to get out of the chair but was unable to sit up. The Geri chair was laid back too far. The surveyor asked the nurse to assist the patient to his bed. Staff #20 and #26 confirmed the patients on 1:1 are not allowed in their rooms without a staff member present. The patients are kept all in one location, in laid back chairs, for the convenience of the staff.
Review of patient #12's chart revealed two "Now Order for Involuntary Emergency Administration of Psychoactive Medication" order forms. Patient #12 was administered Haldol 1 mg IM x 1 dose now on 3/8/14 at 8:05 PM and 3/13/14 at 10:30 PM for aggressive behavior.
Staff #1 was questioned on 3/18/14 about restraints. Staff #1 stated we don't do those here. Staff #1 denied any behavioral restraints were used. Staff #1 stated, "We do use chemical restraint as a last intervention. " Review of the restraint log was blank. Staff #1 confirmed that she did not enter chemical restraints in the restraint log.
Interview with staff #3 reported there had been patient holds for chemical restraints. Staff #3 stated, "to be honest we have not written the holds because we cannot get the doctors up here to do the face to face."
Review of patient #21's chart revealed the patient was an 86 year old male admitted to the facility on 3/7/14 for Dementia, Alzheimer's type, with behavioral disturbances.
Patient #21's chart revealed an admission order on 3/7/14. An order was written to place patient #21 on a Level 2 monitoring level (close observation within eyesight at all times.) Patient #21 was changed to a Level 1 (constant monitoring within 6 feet while awake, and at doorway when asleep.) Review of the Physician Order for Monitoring check sheet had the date as 3/12/14, level 1 for falls, aggression, aspirations, staff #4's initials, and an RN's signature. The order does not have an end time, date, what behaviors caused the level increase, and what behaviors patient #21 needs to exhibit to be removed from the 1:1.
Patient #21 was found in a geri chair laid back in the quiet room on 3/18/14 at 2:00pm. Staff #20 was in the room with the patient as his 1:1 along with 4 other patients. Patient #21 requested from the surveyor to help him. Patient #21 requested help to go to bed. Patient #21 made several attempts to get out of the chair but was unable to sit up.
An interview with staff#26 confirmed that the patients are leaned back in the chairs so they would not fall. Patient #21 had asked to go lay down in his room during the interview. Staff #20 stated he could not because there was no one to watch him in his room. Patient #21 struggled to get out of the chair but was unable to sit up. The Geri chair was laid back too far. The surveyor asked the nurse to assist the patient to his bed.
Staff #20 and #26 confirmed the patients on 1:1 are not allowed in their rooms without a staff member present. The patients are kept all in one location, in laid back chairs, for the convenience of the staff.
Review of patient #21's "care and observation flow sheets" revealed the patients' status, location, and Interventions every 15 minutes. The following dates revealed the hours the patient is up in a geri chair or recliner without the ability to move freely on his own.
3/6/14- admitted at 5:15 PM- to bed at 9:15 PM for a total of 4 hours in a chair.
3/7/14 up to chair at 5:45 AM- to bed at 8:45 PM. Patient back up to chair at 11:00 PM for a total of 15 hours in a chair.
3/8/14 -11:00pm on (3/7). Patient back to room at 8:30 PM for a total of 21.5 hours in a chair.
3/9/14- up at 6:00 AM- to bed at 6:00 PM for a total of 12 hours in a chair.
3/10/14- up at 2:45 AM- to bed at 8:30 PM for a total of 18.5 hours in a chair.
3/11/14 up at 6:15 AM- to bed at 8:15 PM for a total of 14 hours in a chair.
3/12/14 up at 6:30 AM- to bed at 8:45 PM for a total of 14.25 hours in a chair.
Staff #20 and #26 confirmed that this would be a normal day for the patients. If the patients were tired they could sleep in the chairs.

Review of patient #10's chart revealed the patient was an 83 year old male admitted on 3/7/14 with a diagnosis of Major Depressive Disorder. Review of Patient #10's admission physician orders revealed that the patient was placed on a level 1 monitoring level (constant monitoring within 6 feet while awake, and at doorway when asleep) for falls. Nurse's notes dated 3/7/14 at 7:00 PM states, "will continue to monitor on level 2 precautions." There was no order or nursing documentation that the physician was notified and the precaution levels were lowered.
Review of patient #10's "care and observation flow sheets" revealed the patients' status, location, and Interventions every 15 minutes. The following dates revealed the hours the patient was up in a geri chair or recliner without the ability to move freely on his own. Surveyor observed patient #10 in a geri chair and the patient was leaned back. The patient demonstrated that he was not able to get out of the chair on his own.
3/8/14 up to chair at 12:30 AM- to bed at 8:15 PM for a total of 20.45 hours.
3/9/14 up to chair at 6:15 AM- to bed at 6:15 PM for a total of 12 hours.
3/10/14 up to chair at 6:15 AM- to bed at 9:00 PM for a total of 15 hrs.
3/11/14 up to chair at 6:15 AM- to bed at 8:30 PM for a total of 14 hours.
3/12/14 up to chair at 6:15 AM- to bed at 9:45 PM for a total of 17 hours.