HospitalInspections.org

Based on a review of a hospital policy, a review of SECURITY/SAFETY ROUNDS CHECK forms for a ten day period, a review of one of three medical records, and interview with administrative staff, it was determined that patients did not receive care in a safe setting.

Findings include:

Reference #1: The PURPOSE section of Behavioral Health Services policy and procedure titled 'Safety and Security Precautions' indicated: "To provide patients with a safe and protected environment." The PROTOCOLS section of the policy indicated: "Routine Checks (q [every] 15 minutes) All patients shall minimally be placed on every 15 minute checks upon admission and through out [sic] their in-patient hospital stay to ensure their safety. This level of precaution shall be documented on the security check sheet. The GENERAL INFORMATION section of the policy indicated: ".....
C. The staff member assigned to the patient security check will document the location of the patient on the check sheet every 15 minutes. The staff member will assess each patient for changes in behavior or physical status; a change in behavior or physical status will be documented in the medical record.
....."

1. Review of 'One South Annex Unit SECURITY/SAFETY ROUNDS CHECK' forms dated 3/10/12 did not indicate that any of the 20 patients identified as being on routine 15 minute checks were checked between 1:45am and 3:00am.

2. Review of 'One South Annex Unit SECURITY/SAFETY ROUNDS CHECK' forms dated 3/15/12 - 3/16/12 did not indicate that any of the 18 patients identified as being on routine 15 minute checks were checked between 6:45am and 7:15am.

3. Review of a 'One South Annex Unit SECURITY/SAFETY ROUNDS CHECK' form dated 3/17/12 - 3/18/12 did not indicate that any of the 8 patients identified as being on routine 15 minute checks were checked between 2:15am and 2:45am.

4. Administrators #4 and #5 agreed with the findings on the afternoon of March 20, 2012.


Reference #2: The POLICY section of Behavioral Health Services policy and procedure titled 'Safety and Security Precautions' indicated: "All patients shall be assessed for their potential for suicide, elopement, assault, and injurious behavior and be placed on appropriate precaution." The PROCEDURE section of the policy indicated: "....
5. Any staff member who has information suggesting that the patient is a safety risk must inform the Charge RN immediately. The patient's physician and treatment team members shall be informed by the Charge RN of these changes as soon as possible. This shall be documented in the medical record.

1. Review of the 'Assessment Summary' section of a PSYCHIATRIC EVALUATION H (HISTORY) AND P (PHYSICAL) form dated 3/16/12 in the medical record of Patient #12 indicated the entry: "+ s/ideations" (positive suicidal ideations). There was no evidence in the medical record that the psychiatrist who performed the evaluation informed the Charge RN.

2. Administrators #4 and #5 agreed with the findings on the afternoon of March 20, 2012.

Based on document review and staff interview, it was determined that the facility failed to ensure that respiratory treatments orders were implemented.

Findings include:

Reference: The facility's Respiratory Policy, titled, "Treatment Times and Documentation"stated, 'Policy: 1. All routine treatments on Telemetry and Medical Floors will be administered between 7:00 am and 11:00 pm.
2. All treatments on Telemetry and Medical floors ordered with a frequency of (Q4 hours, Q6 and Q8) will be administered on a PRN basis during 11pm to 7am...
4. Treatments will be administered "while awake" between the hours of 10 pm - 8 am unless specifically written as around the clock (ATC).
5. The respiratory care department will consult with the physician and obtain a change in order or reschedule treatment if clinical indication is present...
7. All STAT treatments will be administered within 15 minutes of notification to (sic) the order.
8. Initial orders will be initiated with (sic) 4 hours of receipt of the order from the SMS system. "

1. In Medical Record #2 the following was evident:

a. The physician telephone order dated 3/12/12 at "12:10" stated, "Albuterol 2.5 mg (milligram)/3cc (centicubic) via nebulizer 4 x [times] daily." The respiratory care department progress notes indicated that the patient received one respiratory treatment on 3/12/12 at 21:15.

i.The initial Respiratory treatment was not initiated within 4 hours of receipt of order, as per policy. The patient should have received 2 treatments on 3/12/12 instead of one.

b. The physician order dated 3/13/12 at 1:30 pm stated, "Albuterol 2.5 mg. + 3cc NS (normal saline), Atrovent .5mg + 3cc NS } 4 times daily." The respiratory care department progress notes indicated that the patient continued to receive Albuterol treatments at 415 PM and 845 PM and on 3/14/12 at 730 AM despite the change in medication. Although there was an entry at 1130 AM on 3/14/12, there was no medication documented as given;

i. The treatments were administered three times per day and not four times, as ordered.

c. The physician telephone order dated 3/14/12 at 12:15 stated, "D/C [discontinue] current neb [nebulizer] tx [treatment], Xopenex 1.25 one unit dose Q8 circle [hour] ..." The respiratory care department progress notes indicated that the patient received Xopenex treatments on 3/14/12 at 1945, on 3/15/12 at 7:20 AM and 1940. Thereafter, the patient received Xopenex treatments twice a day on 3/16, 3/17, 3/18, and 3/19/12.

i. The treatments were administered two times and not three times. Although the respiratory policy indicated that treatments ordered every 8 hours should be given twice during the day and as needed at night, there was no evidence that the respiratory therapist clarified the order for this patient who was admitted for COPD exacerbation.

2. The above was confirmed with Staff #2.

3. Review of Medical Record #3 on 3/20/11 at approximately 1:00 PM revealed:

a. The physician order dated 3/19/12 untimed stated, "Proventil 2.5 mg. in 3cc (cubic centimeter) NS Q6 hours x7 days first dose now ... " The order was signed off by the nurse on 3/19 /12 at 3 PM. The respiratory care department progress notes indicated that the STAT order was given at 2000 on 3/19/12. This was not in accordance with the policy. There were no further respiratory treatments administered since.

4. The above referenced policy indicated that treatments Q4 hours, Q6 and Q8 would be administered on a PRN basis during 11 pm and 7 am. The policy did not include the indication, or indications, for PRN (as needed) use.

5. The above was confirmed with Staff #3.