HospitalInspections.org

Based on observation, document review and interview, it was determined that for 1 of 11 patients (Pt. #1), the Facility failed to ensure the physician's orders were followed to help promote patient safety. This practice potentially affected 11 patients currently on census.

Findings include:

1. On 2/14/13 at approximately 9:50 AM an observational tour was conducted on unit C North, a closed psychiatric unit. In Room C 6, a plastic knife on Pt. #1's bedside table, was identified by an RN (E# 11) and MHT(E#12) staff as contraband.

2. The clinical record for Pt. #1 was reviewed on 2/14/13 at approximately 11:00AM. Pt. # 1, a 62 year old female, was admitted to unit C 6 on 10/13/12 with a diagnosis of Bipolar Disorder. A physician's order dated 10/31/12 at 2:30PM included, "Remove utensils from each tray after meals." The order remained in effect.

3. Hospital policy #PC-SEC-06-40-08.00 titled,"Contraband and Restricted use Item Identification and Control." revised 5/25/10 included," Contraband shall include but not be limited to:...knives."

4. On 2/14/13 at approximately 11:30AM, the Nurse Manager (E#2) was informed by E#10 and E#11 that a plastic knife was discovered in Pt. #1's room. E#2 stated that the plastic knife is considered contraband and should be removed.

Based on review of documents and interview, it was determined that for 1 of 1 (Pt. #1) patient who required medication for emergency management, the Hospital failed to inform the patient of a restriction of rights.

Findings include:

1. Hospital Policy entitled, "Restriction of Patient Rights( reviewed 8/09) required Procedure 1. When restricting a patient rights the charge nurse shall: a. Insure that a clear and complete description of the necessity for restricting patient's rights is in the progress notes and any other applicable document(e.g. the Restraint/Seclusion Record, DMHHDD-123) and... The charge nurse or designee will complete the Restriction of Rights ( MHDD-4) form and insure that the original is placed in the chart and that a copy goes to the patient, to the Clinical Nurse Manager, to the office of the Hospital Administrator for notification to the Facility Director, to the guardian (if any) and anyone else the patient may designate. The forms must be so distributed within one regularly scheduled working day of an emergency restriction of rights."

2. The clinical record of Pt. #1 was reviewed with a Unit Staff Registered Nurse (E#1) and Unit Manager (E#2) at approximately 12:30 PM on 2/13/13. Pt. #1's Physician Orders, Medical Administration Record and Restriction of Rights forms were reviewed. The physician ordered Haldol 10mg, Lorazepam 2mg and Benadryl 50mg IM for aggressive behavior toward another patient and a homicidal threat toward a physician on 11/9/12 at 11:00 AM. The medication was administered however, the restriction of rights form was not completed.

3. The Clinical Nurse Manager (E#2) and Quality Manager (E#6) was interviewed on 2/14/13 at approximately 11:00 AM. E#2 and E#6, both stated that the facility did not complete a Restriction of Rights form for Pt. #1 on 11/9/12 at 11:00 AM.