HospitalInspections.org

Based on a review of medical records, policy and procedures, Physician Call Schedule, Provider Services Agreement, Medical Staff By-Laws / Rules and Regulations, Patient Rights and Responsibilities, Glucometer Instruction Manual and interviews, the hospital failed to ensure Patient Identifier (PI) # 1, a patient who required inpatient hospitalization in the Geriatric Psychiatric Unit due to severe, multiple psychiatric and medical conditions was:

- assessed and evaluated daily by the attending psychiatrist and/or medical physician;

- provided oversight and coordination of care by the attending psychiatrist;

- ensured information sharing / communication between the attending psychiatrist and/or medical physicians and the patient's family;

- provided and/or documented coordination of patient care between the psychiatrist and the medical physicians; and

- obtained a endocrinology consultation in a timely manner.

This affected PI # 1, one of five sampled medical records.


Findings Include:

Medical Record Review Includes:

Psychiatric History and Physical Dated 12/22/15:

Author: Attending Psychiatrist

Admission Date: 12/21/15

Patient Profile: Patient (PI # 1) admitted from the Dementia Unit. Information gathered by interviewing the patient (PI # 1) who is quite disorganized, not reliable, and unable to give detailed history due to his advanced memory deficits and increased confusion. Further details obtained by reviewing the patient's medical chart, review of record from the dementia unit and reports from staff. (No documentation of interview with patient's family was found in the medical record review.)

Chief Complaint: The patient could not give details. Quite demented, argumentative and "noncooperative."

History of Present Illness: This is the first admission to (name of geriatric psychiatric unit) at (name of general hospital) for this 81 year old male (PI # 1) with prior diagnosis of dementia with behavioral disturbances. The patient was living with with his family until about two weeks ago. While he was in the dementia unit, PI # 1 started becoming more and more aggressive, trying to hit staff members and was difficult to redirect. Hence the family requested PI # 1 be admitted here for further evaluation and management of his behaviors.

Throughout the interview, PI # 1 was disorganized. Most of his answers made no sense. He appears to be somewhat delirious (disorder characterized by confusion, inattentiveness, disorientation and agitation, www.onlinemedicaldictionary.org) related to his medical condition.

While in the emergency Room last night, PI # 1 was found to have dehydration and was given a liter of IV fluids. He received Ativan (medication) to control his agitation. Since his admission to the unit, his blood sugar is fluctuating and has required medical attention.

Past Medical History:
Diabetes Type 1
Hypertension
Parkinson's Disease

Past Psychiatric History:
PI # 1 has been diagnosed with Dementia and it has recently gotten worse. He has been treated by his primary physician with Aricept and Namenda.
PI # 1 has been treated with Seroquel for psychotic symptoms (a symptom of serious mental disorders characterized by an impaired relationship with reality,www.healthline.com).

Social History: PI # 1 used to live with his wife, but was recently admitted to an Assisted Living Facility.

Mental Status Examination:
Speech disorganized, non-goal directed with significant thought blocking and looseness of association (patient's responses do not relate to the interviewer's questions, www.google.com). PI # 1 was irritable, demanding and could not tell why he is here, his age, date of birth and today's date and month. Insight and judgement poor. He is responding to internal stimuli thus exhibiting psychotic symptoms. He is dangerous to himself due to his agitated behavior. Cognition and memory significantly impaired.

Review of Systems: Uncontrolled Diabetes and Dehydration.

Physical Examination: Deferred to medical staff.

Identified Problems:

1. Memory deficits.
2. Psychotic Symptoms to include hallucinations (apparent perception of something not present, www.google.com) and delusions (belief that is firmly maintained despite being contradicted by what is generally accepted as reality, www.google.com).
3. Behavioral Disturbance including agitation, irritability, resisting care.
4. Dehydration and Uncontrolled Diabetes.

Diagnostic Impression:

Axis I: Dementia...with significant behavioral disturbance, delirium secondary to medical condition.
Axis II: No diagnosis.
Axis III: Hypertension, Diabetes Type 1, Parkinson's Disease.
Axis IV: Severe.
Axis V: Current GAF (Global Assessment of Functioning) around 30.

Treatment Plan:
...3. Consult medical staff for physical examination and medical management.
4. Continue making adjustments with his psychotropic medications and mood stabilizers....memory deficits are far advanced...The patient (PI # 1) is not capable of making rational and informed decisions regarding use of psychotropic medications and mood stabilizers...

Psychiatric Progress Notes: Documented by Attending Psychiatrist,
Employee Identifier (EI) # 1.

Dates of Service:

12/24/15: Mental Status Examination (MSE): Speech limited with significant thought blocking. Psychotic...

12/26/15: MSE: Cognition and memory impaired. Responding to internal stimuli...
Treatment Plan: If medical condition worsens, may discharge from the psychiatric unit either to the medical floor or possibly (name of another hospital) for further evaluation of his medical condition.

12/28/15: MSE: Limited interaction. Responds to internal stimuli...

12/30/15: Lying in bed in room. Limited interaction. Cognition and memory impaired...

12/31/15: Lying in bed in room. Limited interaction. Cognition and memory impaired...Waiting for nursing home placement.

Treatment Plan: Social service will try to place him in a nursing home as soon as possible. The patient has more medical issues than the psychiatric condition.

1/2/16: Note documented by EI # 2, Psychiatrist responsible for patient rounds per January 2016 call schedule for Geriatric Psychiatric Unit.

The patient (PI # 1) was seen, records review and discussed with staff...Following his admission, his medications were titrated (adjusted) and he became less combative. Observed lying in a geri chair (specialized recliner with wheels which are not self-propelled, www.google.com). High blood sugar, elevated BUN (Blood Urea Nitrogen - forms when protein breaks down, www.google.com) and possible Renal Failure.

The patient's speech is disorganized and he was disoriented to person, place, time and date. He is incontinent, has to be fed and helped with activities of daily living. The patient's wife visited yesterday and felt PI # 1 was somewhat too sedated. The attending psychiatrist, EI # 1, discontinued all psychiatric medications except for prn (as needed). His wife called today and said the patient was accepted by a nursing home. The nursing home wants to admit the patient on Monday. He (PI # 1) will be seen by EI # 1 and staff to determine his discharge.


Psychiatric Discharge Summary
Date: 1/4/16
Documented by EI # 1, Attending Psychiatrist Includes:

Date of Admission: 12/22/15

Date of Discharge: 1/4/16

Discharge Diagnoses:

Axis I: Dementia...with significant behavioral disturbance, delirium secondary to medical condition, resolving.
Axis II: No diagnosis.
Axis III: Hypertension, Diabetes Type 1, Parkinson's Disease.
Axis IV: Severe.
Axis V: Current GAF (Global Assessment of Functioning) "around 30" at admission and "around 35" at discharge.

Discharge Medications:
1. Vitamin D3 2000 international units daily.
2. Levemir (long acting insulin) 20 units every AM.
3. Regular insulin 4 units at 11:30 AM and 4 units at 4:30 PM.
4. Lisinopril 10 mg. (milligrams) daily.
5. Metoprolol 25 mg. twice daily.

Discharge Instructions:
The patient discharged to the Nursing Home on 1/4/16.

Reason for this hospitalization: At the time of admission, the patient was on an unknown dose of Seroquel...

MSE: Patient sitting in a wheelchair with IV (intravenous fluids infusing). His speech is disorganized, non-goal directed with significant thought blocking. Cognition and memory significantly impaired.

Hospital Course: ...The patient was advised to participate in therapeutic activities. The patient had significant medical conditions including dehydration and unstable diabetes and required constant attention from the medical doctor.

Since the patient's (PI#1's) diabetes was "uncontrollable," the Seroquel (medication used to treat certain psychiatric conditions, www.webmd.com) was discontinued. A low dose of Depakote (mood stabilizer) 250 mg. twice daily and Haldol (antipsychotic medication) 1 mg. twice daily. Due to his medical condition, PI # 1 was unable to participate much in therapeutic activities.

In spite of his medications, PI # 1's condition got worse, especially his diabetes. He required IV (intravenous) fluids. He was found to be experiencing excessive sedation. Hence, family did not want PI # 1 to be on Haldol or Depakote. On 1/1/16, Haldol and Depakote were discontinued.

Due to PI # 1's multiple medical problems, the treatment team felt the patient was not stable or able to participate in therapeutic activities on the psychiatric unit and recommended discharge to the nursing home.

Condition at the time of Discharge:
PI # 1 was less agitated. However, he required a significant amount of redirection. The patient was not on any antipsychotic medications or mood stabilizers...


Medical Progress Notes:

12/22/15 - time not documented: Blood sugar is 33 by renal profile this AM. Patient (PI # 1) is "somulent" but "arousable"... (Blood Glucose Range per hospital: 70 - 105 milligrams per Deciliter)...


- 12/23/15 - 11:30 AM: Patient blood sugar dropped again...Received Ampule D50 (Dextrose 50 %, a solution to restore blood glucose levels, www.drugs.com)...

Diabetes Mellitus. Will discontinue PM insulin. Continue PBS (patterned blood sugars) and SSI (Sliding Scale Insulin). Documented by EI # 5, Medical Physician.


12/24/15 - 8:40 AM: Blood sugar dropped to 40 again...Discontinue SSI and continue AM insulin only. Documented by EI # 5, Medical Physician.


12/30/15 - (time not documented): Patient has gone down mentally. Blood sugars still erratic. (Medical Physician)


12/31/15 (time not documented): "Dr... (EI # 5) discussed diabetes with (name of PI # 1's endocrinologist - not on hospital staff) yesterday
and insulin regiment was changed yesterday. Pt. (patient) will need to have pattern blood sugars checked next 3 - 4 days and see (name of endocrinologist) in 3 4 days for follow up ...Ok for discharge from medical standpoint." Documented by EI # 6, Medical Physician.

The note above (dated 12/31/15) was the only documentation related to the endocrinology consultation found in a review of the progress notes from 12/22/15 through 1/4/16. The note was documented by a medical physician (EI # 6). According to the note documented by EI #6, EI # 5 (also a staff medical physician) had contact with the endocrinologist. However, there was no documentation by EI # 5 related to the consultation in PI # 1's medical record.

On 5/27/16 at 9:55 AM the Geriatric Psychiatric Unit Director/
EI # 4, was asked about the medical physician's documentation of his discussion with PI # 1's endocrinologist not on hospital staff ( (physician who treats diabetes mellitus, www.google.com). EI # 4 said, "I did not see (name of hospital medical physician / EI # 5's) documentation with (name of endocrinologist). See progress note
above dated 12/31/15 and written by EI # 6.


1/3/16 - 9:00 AM: Called to see for reduced level of consciousness.
103/79, 81, 18, 97.6. Unresponsive...skin with decreased turgor...
Impression: Urinary Tract Infection (UTI) with Lethargy.


1/4/16 - 4:30 PM: Patient "somulent" but "arousable"...Dehydration- "Give 500 NS (Normal Saline) bolus IVF (intravenous fluids). Treat UTI with Levaquin (antibiotic)...

A review of the Physician Progress Notes from 12/22/15 through
1/4/16 revealed no documentation of communication between the psychiatrists and/or medical physicians about PI # 1's psychiatric and/or medical conditions and collaboration of care for the patient.


A review of PI # 1's Glucose Levels (Blood Sugars) Documented by Nursing Staff (Blood Glucose Range per hospital laboratory guidelines: 70 - 105 milligrams per Deciliter):


12/22/15:

10:30 AM: 278

4:30 PM: 239


12/23/15:

5:45 AM: 37

6:21 AM: 201

12:00 PM: 460

4:30 PM: 223

10:00 PM: 21

10:08 PM: 147

11:33 PM: 83


12/24/15:

12:33 AM: 40

1:20 AM: 160

5:29 AM: 180

6:47 AM: 215

11:15 AM: 294

4:15 PM: 256

11:12 PM: 411


12/25/15:

6:25 AM: 447

11:00 AM: 452

5:32 PM: 452

5:33 PM: "HHH" per glucometer, a medical device for determining the approximate concentration of glucose in the blood, www.wikipedia.org. (According to the glucometer's manufacturer's instructions, "HI" means the blood glucose level is higher than 500 mg/dL or there may be a problem with the test strip. Monitor the blood glucose again with a new test strip. If HI displays again, contact your healthcare professional immediately. "HHH" was not seen in the instruction manual.)

7:00 PM: 499

7:30 PM: 470 (level per laboratory)

9:00 PM: 430


12/26/15:

6:05 AM: 387

11: 00 AM: "HI"

1:21 PM: "Hi"

4:52 PM: 647

8:00 PM: 361

3:00 AM: 53


12/27/15:

6:27 AM: 244

11:26 AM: 413

1:01 PM: "HHH"

2:00 PM: 314

4:00 PM: 119

6:00 PM: 266

8:10 PM: 231


12/28/15:

3:00 AM: 181

6:15 AM: 109

11:00 AM: 303

4:30 PM: 484

9:00 PM: 418


12/29/15

6:00 AM: 56

6:30 AM: 127

10:53 AM: 409

9:00 PM: 481


12/30/15

5:32 AM: 241

11:15 AM: 443

6:24 PM: 384

9:00 PM: 120


12/31/15

6:46 AM: 292

11:40 AM: 458

8:57 PM: 105


1/1/16

6:37 AM: 185

10:45 AM: 195

4:32 PM: 376

9:00 PM: 267


1/2/16

6:00 AM: 239

11:38 AM: 337

9:00 PM: 79

11:25 PM: 124


1/3/16:

6:09 AM: 125

11:20 AM: 362

4:00 PM: 380

9:00 PM: 273


1/4/16:

5:19 AM: 318


Policy and Procedure Review:

1). Confidentiality of Patient Information (revised 1/6/13):

II. Release of Patient Condition Information to Relatives and Friends:

1. Routine daily calls asking the condition of patients will be handled by the charge nurse. Inquiries for "unusual" professional and clinical information of hospitalized patients will be referred to the physician in charge of the patient.


Physician Call Schedule for Geriatric Psychiatric Unit:

December 2015:

12/22/15 - 12/31/15: A review of the schedule for these dates revealed PI # 1's Attending Psychiatrist / EI # 1 was the "On - Call" psychiatrist everyday, except 12/29/15.

On 12/23/15 a line was drawn through the word (rounds).

On 12/25, 12/27 and 12/29 the word "Rounds" was not documented on the schedule.

January 2016:

On 1/1/16 and 1/3/16 the word "Rounds" was not documented
on the schedule.


Provider Services Agreement between hospital and the Attending Psychiatrist (Effective date 11/13/07):

Article 1: Physician's Duties

1.1 Professional Medical Services: ...Physician shall provide professional medical services...to program patients in accordance with
the terms and conditions of this Agreement. Physician shall be responsible for the quality of such professional medical services...Physician services shall include:

...1.1.2.1 Visits with Program inpatients as medically necessary and/or dictated by hospital bylaws...


Medical Staff By-Laws Reviewed and Revised: 9/2015

"...it is recognized that the medical staff is responsible for the quality of medical care in the hospital and must accept and discharge this responsibility subject to the ultimate authority of the hospital governing body, and that the cooperative efforts of the medical staff, the administrator and the governing body are necessary to fulfill the hospital's obligations to its patients.

...the physicians...practicing in this hospital hereby organize themselves into a medical staff in conformity with these by-laws."

Definition:

...2. The term medical staff means all medical physicians...holding unlimited licenses...who are privileged to attend patients in the hospital...

3. The term governing body means the Board of Directors of the hospital. The governing body is a professional review body as defined in paragraph 431 (11) of the Health Care Quality Improvement
Act of 1986.

Article I: Name
The name of this organization shall be (name of the Hospital) Medical Staff.

Article II: Purposes

2.1 The purposes of this organization are to:

2.1.1 Insure that all patients admitted to or treated in any of the facilities or services shall receive the best possible care."


Medical Staff Rules and Regulations:
Initial Review/Approval: 1996
Subsequent Review and Revision: 9/2015

1.3: " A member of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital...and for transmitting reports of the condition of the patient to the referring practitioner and to relatives of the patient. Whenever these responsibilities are transferred to another staff member, a note covering the transfer shall be entered on the order sheet of the medical record...


2.3: ...Progress notes shall be written at least daily on critically ill patients, and those where there is difficulty in diagnosis or management of the clinical problem."


Patient Rights and Responsibilities (contained in the Geriatric Psychiatric Unit Patient Handbook):

...6. Receive information from your physician about your illness, course of treatment, outcome of care (including unanticipated outcomes), and your prospects for recovery in terms that you can understand.

...9. The patient has a right to consult with a specialist...

26. Receive a response to any reasonable request for service...

28. Have all of your patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on your behalf.


Interviews:

On 5/25/16 at 1:10 PM, the Administrator/CEO (Chief Executive Officer, Employee Identifier, EI # 3), was asked if he was aware of any concerns about the care of PI # 1 during his hospitalization in December 2015. EI # 3 stated, "We completed the investigation and I signed off on the letter (from PI # 1's family to the hospital related to concerns about his care) yesterday." Because the letter contained multiple concerns about two of the physicians who treated PI # 1, the Administrator was asked if he spoke to the physician. EI # 3 said, " I did not speak to the physician (PI # 1's attending psychiatrist)."


During an interview on 5/27/16 at 9:39, the Geriatric Psychiatric Unit Director, EI # 4, was asked if the staff nurses should have documented conversations with PI # 1's family in the medical record. EI # 4 said, "Yes. There should have been documentation in the progress and/or patient notes or in a narrative form."

During an interview on 5/27/16 at10:15 AM, Administrator/CEO, stated he did not know if the psychiatrists are required to see hospitalized patients on a daily basis.


During an interview on 5/27/16 at 10:30, The Geriatric Psychiatric Unit Director, EI # 4, confirmed psychiatric patients are not seen daily by the psychiatrists.

*Note: Staff reported PI # 1's Attending Psychiatrist was out of town during the dates of the complaint investigation. The state surveyor requested time to speak with the psychiatrist, but staff failed to provide a means of contact.


During a telephone interview on 6/9/16 at 2:30 PM, (Family Identifier / FI # 1) stated neither the psychiatrist or the physician managing PI # 1's diabetes, returned her repeated telephone calls regarding PI # 1. According to FI # 1 the nurses on the Geriatric Psychiatric Unit, "insisted the physicians not returning calls was the way things were done." FI # 1 said she called the attending psychiatrist multiple times, but the psychiatrist never returned her calls.

At the beginning of PI # 1's hospitalization, FI # 1 said she was able to communicate with the patient on the telephone. FI # 1 reports she called the unit two times per day and was always assured the patient was being cared for and was resting by nursing staff if PI # 1 was not available to talk on the telephone. FI # 1 did not recall the names of the nurses. According to FI # 1, the patient became less communicative, but she was never informed by any staff member that PI # 1's medical and or psychiatric conditions were deteriorating.

FI # 1 was asked if any geriatric staff member including the attending psychiatrist contacted her or requested her input at any time during PI # 1's hospitalization and she said no.

FI # 1 said she visited PI # 1 in 1/1/16 and found him sitting in a wheelchair. FI # 1 described PI # 1 as "catatonic" and his posture was stiff. FI # 1 said the patient was non-communicative and had to be fed by staff. Approximately ten days prior, PI # 1 was able to feed himself and ambulate to a limited degree. FI # 1 said she told the nursing staff, "I want him off the psychiatric drugs because he was a zombie." When FI # 1 returned home after visiting PI # 1, she had a message from the hospital indicating he (PI # 1) was being released and the psychiatric medications were discontinued. According to FI # 1, the message included instructions for her to pick up PI # 1 because there was, "No reason to keep him." FI # 1 stated she was unable to talk with the social wordier and get a copy of PI # 1's records because staff was out due to the holiday. FI # 1 said this resulted in a three day delay of PI # 1's discharge.

According to FI # 1, she discussed these concerns with the patient's (PI # 1's) primary physician (not on hospital staff). Reportedly, the physician advised FI # 1 that none of her calls to the attending psychiatrist had been returned. FI # 1 said she wanted the hospital physicians to consult with PI # 1's endocrinologist about managing the patient's diabetes. According to FI # 1, she and PI # 1 managed his blood sugars at home using insulin and blood sugar results based on a sliding scale. FI # 1 stated in the 35 years that PI # 1 had diabetes, his blood sugars had ranged from 80 to 235. PI # 1's blood sugars were never as unstable at home as they were during his hospitalization on the psychiatric unit. FI # 1 wanted the hospital physician(s) to consult with PI # 1's endocrinologist to help manage his diabetes, but she was unable to communicate with the hospital physicians because they did not return her telephone calls.


In conclusion, PI # 1's blood sugars were very erratic. The patient required D50 (Dextrose 50%, a solution of dextrose in water for intravenous injection that restores blood glucose levels in hypoglycemia, www.drugs.com) on two occasions due to very low blood sugar levels. PI # 1 was confused and unable to make independent decisions. At times, PI # 1 was dehydrated. PI # 1 also developed a UTI (may increase blood sugar levels, www.webmd.com). Eight days elapsed before a medical physician consulted P I# 1's endocrinologist. Based on a review of the Physicians Progress Notes dated 12/22/15 through 1/4/16, PI # 1 was not seen daily by a psychiatrist and / or a medical physician and there was no documentation regarding communication between the psychiatrist(s) and/or medical physicians about PI # 1's medical and or psychiatric illnesses. Eight days after admission, PI # 1's endocrinologist was consulted by a medical physician on the hospital staff. Following the consultation and subsequent change in diabetic medication, PI # 1's blood sugars were less erratic.