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Based on staff interview, review of policies and procedures and review of medical records, it was determined the facility failed to ensure advance directives were accurately followed for 1 of 3 patients (#6) whose medical records contained advance directives. The lack of clarity had the potential to result in patients not having their advance directives honored. Findings include:

Patient #6 was an 84 year old female admitted to the facility on 8/15/12 for care related to a psychiatric disturbance. Her medical record contained an 11 page notarized document titled "LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE," dated 11/17/06. The document was marked and initialed by Patient #6 beside the statement "I direct that all medical treatment, care and procedures, including artificial life sustaining procedures, be withheld or withdrawn, except that nutrition and hydration, whether artificial or nonartificial shall not be withheld or withdrawn."

Admission orders to Behavioral Health Services, dated 8/15/12 at 11:00 PM, included an order that Patient #6 was to be a "Full Code," meaning a full resuscitation would be performed, which was not in alignment with her notarized document.

An "INPATIENT GERIATRIC PSYCHIATY (sic) EVALUATION," dictated on 8/16/12 at 5:04 PM, included documentation that Patient #6 was to be a Full Code.

In an interview on 11/01/12 beginning at 2:50 PM, the Director of Behavioral Health reviewed Patient #6's medical record and confirmed the Advance Directive indicated she did not wish to be a Full Code, although the physician had ordered "Full Code." The Director of Behavioral Health was not able to find documentation in Patient #6's record to indicate her code status had been questioned or clarified to include her wishes.

The facility failed to ensure Patient #6's record clearly and accurately reflected her code status.

Based on medical record reivew, staff interview and review of hospital policies, it was determined the hospital failed to provide a safe environment for 2 of 17 patients (#5 and #10) whose records were reviewed. This failed practice had the potential to result in negative patient outcomes and interfere with the safety of all patients. Findings include:

1. Patient #5:

a. Patient #5 was a 62 year old male who had presented to the ED on 9/25/12 at 12:07 PM with a painful mass in his left groin area. He was in the ED approximately eight hours before transfer to the Medical Surgical patient care unit. Patient #5's medical record documented he was an insulin dependent diabetic.

A nursing note at 12:30 PM stated the ED attending physician was notified of a POC glucose test of 326 mg/dl. The lab reported his glucose to be 325 mg/dl at 12:38 PM. An entry in the ED record documented Patient #5 was admitted to a medical-surgical unit on 9/25/12 at 7:55 PM. There was no further documentation in Patient #5's record during his eight hours in the ED of a re-assessment of his glucose level or of medication ordered to treat his hyperglycemia.

The American Diabetes Association suggests a target range of 70-130 mg/dl for most adults with diabetes. Additionally, hyperglycemia (high blood sugar) can be an indicator of infection somewhere in the body.

At 7:15 PM the ED physician initiated orders on a preprinted order sheet titled "EMERGENCY DEPARTMENT ADMISSION HOLDING ORDERS." The preprinted sheet included instructions which read: "Check off desired orders. If not checked it won't be done." The preprinted order sheet contained a box that was left unchecked for "See Diabetes Management order set." The order sheet did not contain diagnosis of diabetes, diabetic medication, or orders for monitoring Patient #5's blood sugar.

An admission assessment for Patient #5 was completed by an RN on the medical surgical unit on 9/25/12 at 9:25 PM. Admission orders were written by a physician at 10:00 PM. Included in the admission orders was a preprinted form titled: "ADULT DIABETES MANAGEMENT," dated 9/25/12 at 10:00 PM. The form contained instructions to monitor Patient #5's glucose before meals and at bedtime.

A POC glucose level was taken on 9/25/12 at 11:18 PM, with results of "critical high," which indicated the level was over 500 mg/dl. The POC glucose was repeated at 11:45 PM, which also read "critical high." The nurse documented the lab was contacted to draw a blood specimen to confirm the glucose. On 9/26/12 at 12:53 AM the nurse documented the lab result of Patient #5's glucose was 682 mg/dl. The nurse documented she contacted the physician and orders were received for insulin on 9/26/12 at 1:00 AM.

During an interview on 11/02/12 at 11:20 AM, the ED Physician stated he had been aware of Patient #5's elevated glucose result of 326 mg/dl. He stated the patient had told him he had high glucose readings at home as well. The ED Physician stated he "should have rechecked the glucose, but the patient had gone to ultrasound, CT scan, and radiology for tests, and it had not been done."

A consultation by the facility Hospitalist, dictated 9/26/12 at 9:14 PM, stated Patient #5 had complained of chills, but otherwise his review of systems was negative.

The "Admission Assessment Record," completed by an RN on 9/25/12 at 9:39 PM, documented Patient #5 did not exhibit signs or symptoms of hyperglycemia, and stated he was steady on his feet and appropriate with conversation.

Patient #5's blood glucose levels were not reassessed between 12:30 PM and 11:18 PM on 9/25/12.

b. An RN entry in Patient #5's record dated 9/26/12 at 8:15 AM, indicated he was allergic to iodine. The RN documented a wrist band was placed, his profile and chart were updated as well as pharmacy and the consulting physician were notified.

The attending physician dictated a "HISTORY AND PHYSICAL," on 9/26/12 at 2:31 PM. The H&P included Patient #5's allergy to iodine.

The Medication Profile was printed daily, and from 9/26/12 until his discharge on 10/02/12 documented Patient #5's allergy to iodine resulted in hives with a severity reaction as "Severe."

On 9/27/12 Patient #5 had a surgical procedure to remove the mass in his left groin. An "OPERATIVE REPORT," dictated by the attending physician on 9/27/12 at 3:44 PM, he dictated he had placed a Telfa soaked in Betadine into the pocket of the tissue created by the removal of the mass. Betadine is the brand name of an iodine based antiseptic. The physician did not include documentation in the report that he was aware of Patient #6's allergy to iodine and his decision to use Betadine despite the documented allergy.

During an interview on 11/01/12 beginning at 5:10 PM, the Director of the Medical Surgical unit reviewed Patient #5's record and confirmed the allergy to iodine which was documented as producing hives. The Director was unable to find documentation by the surgeon that acknowledged his use of Betadine despite the allergy to iodine.

The record did not contain evidence of a local or systemic reaction after the use of Betadine during the surgical procedure.

The facility administered a medication to a patient with a known allergy to that medication.

2. Patient #10's medical record documented an 87 year old female who was admitted to the facility on 2/23/12 for nausea and vomiting related to a possible small bowel obstruction. Other diagnoses included congestive heart failure, atrial fibrilation (irregular heart rate associated with palpitations, fainting, chest pain and/or congestive heart failure,) type 2 diabetes, acute kidney failure and severe osteoporosis (disease of the bones that leads to increased risk of fracture.) The "Discharge Instructions," dated 2/28/12 at 11:32 AM, indicated Patient #10 was discharged on 2/28/12, at 11:32 AM, to a skilled nursing facility.

The nursing "Admission Assessment Report," dated 2/23/12 at 8:40 AM, documented Patient #10 required assistance to get in and out of bed and was experiencing short term memory loss at the time of the assessment. Additionally, the assessment included Patient #10 had a history of falling, and documented her mental status as "Overestimates/Forgets Limitations." Patient #10 was documented to be at high risk for falls.

The nursing "Daily Focus Assessment Report" included documentation as follows:

- 2/23/12 at 7:51 AM - "...History of Falling, ...Overestimates/Forgets Limitations, ...Bed or Safety Alarm Placed, ...Must Be Accompanied to Tests and Procedures, ...Fall Risk Care Plan Implemented."
- 2/23/12 at 9:30 AM - "...Pt. found getting up OOB fall alarm triggered. Pt. put back in bed and fall alarm reset."
- 2/23/12 at 10:28 AM - "...Pt. found sitting on floor. Bed alarm went off but unable to reach pt before she [got] out of bed. Pt. doesn't have and (sic) cuts or bruizes (sic). Notified [PA] of pt. a fall. To get a one to one order."

Patient #10 was documented to have been at exhibiting high risk behavior with a potential for falls, but 1:1 patient supervision was not implemented to ensure her safety until after she experienced a fall.

The Chief Quality/Risk Officer was interviewed on 10/31/12, beginning at 3:15 PM. She stated 1:1 staff were utilized for fall risk patients as a last resort. She said the hospital did not employ enough sitters. Additionally, the Chief Quality/Risk Officer said patients who were at risk for suicide were the first priority related to the need for 1:1 staff. She stated there were 5 to 6 sitters the facility used for patient supervision and all were in use most of the time. The Chief Quality/Risk Officer stated the facility's practice was to initially ask for assistance from patients' families before providing a sitter for patient supervision.

The policy "Fall Prevention," last revised 7/2011, documented a list of several interventions that could be used once a patient was identified as a fall risk. The interventions included "...Provide sitters as needed (family or volunteers)" and "...Provide 1:1 staffing..." The policy also indicated interventions did not require a physician's order.

The facility failed to implement interventions sufficient to safeguard Patient #10 from falls.