HospitalInspections.org

Based on observation, interview and document review, the facility failed to ensure an emotionally safe setting was provided with the patients dignity maintained for 1 of 10 patients (patient #3).

Findings include;

1. Review of policy/procedure "PATIENT RIGHTS AND RESPONSIBILITIES" last revised 7/16, indicated the following on page 1 of 5 and 4 of 5: "You have the right to:............30. Wear the individuals own clothes subject to any safety hazards....."

2. Review of policy/procedure "BED BUG (CIMEX LECTULARIUS) PREVENTION AND MANAGEMENT" last revised 5/15, indicated the following on page 2 and 3 of 4 under procedure: "A. If there is suspicion/confirmation of bed bugs: 1. The patient's clothing should be removed and double bagged in a soiled linen bag. If family or a significant other is present, give them the bag and instruct them to place the clothing in a dryer on high heat for 30 minutes prior to washing. Then launder in hot water and detergent, and machine dry. If the clothing cannot be taken home, it should remain in the room until the presence of bed bugs is confirmed or ruled out. If confirmed, launder the clothing onsite or dispose of it by incineration."

3. Review of policy/procedure "PERSONAL HYGIENE" issued on 5/15, indicated the following on page 2 of 2: A unit stock of clean clothing is available for patient use. When the patient has no proper clothing available, please supply appropriate items from supply closet."

4. Review of patient #3 medical record indicated the following:
(A) He/she was admitted on 4/12/17 from an acute care hospital in another state.
(B) The record indicated that there was a bedbug issue at his/her home. The personal inventory sheet on admission indicated that the patient had a black trash bag and a purse.
(C) The patient was documented as alert and oriented x 3.

5. During tour of the units beginning at 10:55 a.m. on 4/18/17 patient #3 was observed sitting in the doorway of his/her room in a wheelchair with a hospital gown on.

6. Patient #3 indicated in interview at 11:10 a.m. on 4/18/17 that he/she has asked for their clothing and could not obtain any clothing. He/she has been at the facility for one (1) week and in a hospital gown. He/she indicated that they only had one set of clothing brought with them and that family could not visit due to the distance.

7. Staff member #2 (Director of Nursing) indicated in interview beginning at 11:15 a.m. on 4/18/17 that patient #3 was not given his/her clothes because of a bedbug issue at his/her home and it was an infection control issue.

8. Staff member #6 (Assistant Director of Nursing) indicated in interview at 5:30 p.m. on 4/18/17 that the clothing/personal belongings of patient #3 came to facility in a sealed bag which remained sealed due to bed bug issue that the patient had.

Based on document review and interview, the facility failed to ensure a registered nurse supervised the care being provided to 2 of 10 patients (patients #1 and 4).

Findings include;

1. Review of patient #1 medical record indicated the following:
(A) The patient had an order for Cardizem CD (blood pressure medication) to be given daily for hypertension and to hold if the systolic blood pressure is <100 or the diastolic blood pressure is <60.
(B) The narrative nurses notes indicated that on 4/5/17 at 0800 hours, the patients blood pressure was 83/39.
(C) The medication administration record (MAR) indicated that the patient received the Cardizem at 0900 hours on 4/5/17.

2. Review of patient #4 medical record from facility #1 indicated the following:
(A) The patient was admitted on 2/23/17 from an acute care hospital with delusions and cognitive impairment after shooting a gun in his/her home. His/her diagnoses included, but were not limited to, major neurocognitive disorder related to Alzheimers with delusions and behavior disturbances, seizure disorder, and hypertension.
(B) Narrative notes at 10:00 a.m. on 4/10/17 documented by staff member #11 (Registered Nurse [RN]) indicated that the patient appeared to be confused and was hard to redirect. The note states "Patient was found by the NP on the floor. Patient was assessed and noted to be weaker then normal. Patient was placed on 1:1 for safety. Patient wouldn't remain in w/c. Later patient became more lethargic. Patient was sent to hospital and currently admitted......" The nurses notes lacked actual time of events such as orders received/carried out, EKG obtained, and what time the patient was sent out from the facility. The above note had a time of 10:00, however orders were written for care/treatment at 10:00 a.m. and 10:20 a.m. and the 15 minute monitoring sheet indicated the patient was still at the facility at 12:00 p.m. The nurses notes lacked detailed assessment/reassessment of the patient. Vital signs were written to the side of the narrative note and listed blood pressure as 124/60, pulse 68, temperature 96.3 and 98.1. There was no time by the vital sign entry.
(C) Orders were written at 9:30 a.m. on 4/10/17 including, but not limited to, vital signs and neuro checks every 30 minutes x 2 hours and then every hour for 4 hours due to altered mental status. An order was written at 10:20 a.m. for stat EKG (electrocardiogram). The medical record lacked documentation that the vital signs and neuro checks were conducted per order or the time the EKG was performed, therefore unable to determine if it was obtained stat.
(D) The EKG sheet had a stamped date of 8/14/18 and time of 12:15 a.m. The NP had signed off on the document at 1300 hours on 4/10/17. The interpretation listed idioventricular rhythm, right bundle branch block, left anterior fascicular block, bifascicular block, and possible inferior infarct. Unable to determine the actual time of the EKG. The heart rate (HR) beats per minute (bpm) was 28 per the results of the EKG.
(E) Per document titled "PATIENT OBSERVATION MONITOR", the patient was in the facility at 12:00 p.m. and the entry for 12:15 p.m. indicated "hospital 12:12 p.m.". There was no further documentation by nursing staff member #11 after the 10:00 a.m. entry.

3. Review of policy/procedure "INCIDENT REPORTS" last revised 1/16, indicated the following on page 1 under purpose: "... An incident is defined as : any event which is not consistent with the routine operation of Neuropsychiatric Hospital of Indianapolis and that adversely affects or threatens to affect the well-being of the Patients, employees....." and "2. An Incident Report should be completed by the end of the shift that the incident occurs by the employee who witnessed or was informed of the incident;"

4. Review of policy/procedure "TRANSFER AND TRANSPORT OF A PATIENT" last revised 1/17, indicated the following on page 2 of 4: "9. Prior to transfer, the Registered Nurse will document the patient's assessment, condition, and time of transfer on the Continuing Care Transfer Information form. The copy is sent with the patient and the original is maintained in the patient's medical record."

5. Review of policy/procedure "CHANGE OF CONDITION" issued on 5/15, indicated the following on page 1 of 2: "3. The assessments, physician notification, and any interventions and/or orders received and carried out will be documented in the nursing notes of the patient's medical record along with the patient's response. The change of condition will continue to be monitored and documented until resolved or a clinical decision has been determined by a physician....."

6. Review of policy/procedure "ASSESSMENT/REASSESSMENT" issued 5/15, indicated the following on page 1 of 1: "7. Nursing will re-assess each patient every shift and as warranted by the patient's medical condition and documented in the patient record."

7. Staff member #9 (Nurse Practitioner [NP]) indicated in interview at 3:30 p.m. on 4/18/17 that he/she found patient #4 on the floor on 4/10/17 when entering room.

8. Staff member #7 (Chief Nursing Officer) verified in interviews beginning at 3:40 p.m. on 4/18/17 that the medical record for patient #4 lacked documentation of vital signs and neuro checks per order on 4/10/17 and it was not charted in the nurses notes the complete events of the morning of 4/10/17 and when the patient was sent to the hospital. He/she verified there was no incident report completed for 4/10/17 when patient #4 was found on the floor per the N.P. He/she indicated that they were aware that the date/time stamp on the EKG sheets is incorrect and the practice is for the nurse to write the date and time at the top of the sheet to indicate what time the EKG was obtained. He/she verified that the MAR (medication administration record) for patient #1 indicated that the patient received their blood pressure medication on 4/5/17 when the blood pressure was too low per physician order to give.

9. Staff member #2 (Director of Nursing) verified in interview at 4:10 p.m. on 4/18/17 that the "Continuing Care Transfer Information form" was not completed for the transfer of patient #4 on 4/10/17.

10. Review of incident reports indicated there was no incident report completed for patient #4's fall on 4/10/17.

Based on document review and interview, the facility failed to ensure competencies were completed prior to assigning patient care for 2 of 2 Registered Nurse (RN) personnel files reviewed (staff members #11 and 12).

Findings include;

1. Review of patient #4 medical record indicated that complete assessments/reassessments were not documented for events (confusion, increased lethargy, increased weakness, low blood pressure, low heart rate, a fall) that occurred on 4/10/17.

2. Review of incident reports indicated there was no incident report completed for a fall involving patient #4 on 4/10/17.

3. Review of staff member #11 personnel file indicated he/she was hired 3/6/17. His/her file lacked evidence of the job specific/competency/preceptor form which included medical record documentation requirements as well as completing an incident report.

4. Review of staff member #12 personnel file indicated he/she was hired 2/6/17. His/her file lacked evidence of the job specific/competency/preceptor form.

5. Staff member #4, CNA (Certified Nursing Assistant) indicated in interview at 3:00 p.m. on 4/18/17 that both staff members #11 and 12 (both Registered Nurses [RN]) came into room to check patient #4 on 4/10/17 after a change in condition was noted.

6. Staff member #1 (Chief Executive Officer) indicated in interview at 5:00 p.m. on 4/18/17 that staff member #11 and 12 had not turned in their completed job specific competency preceptor forms.