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Based on a review of policy, and 4 open and 1 closed patient record, it is revealed that the Medicare Important Message was not given, or was given outside of time requirements for patients #1, #3, #4, #6, and #8.

The facility has a policy for the Important Message which addresses the financial aspects of the notification, but not the time requirements for notification. Deficits in notification are as follows:

Patient #1, an 85-year-old, admitted on 4/17/13, received no IM as of the time of survey on 4/23/13.

Patient #3, a 79-year-old, admitted on 4/12/2013, received no IM notification until 4/17/2013.

Patient #4, a 70-year-old, admitted 4/11/13, received no IM notification until 4/17/10.

Patient #6, an 82-year-old, admitted 3/26/2013, received no IM notification as of time of survey 4/23/13.

Patient #8 closed record, an 86-year-old admitted 2/28/2013 received one IM on 3/1/2013 for an admission greater than 5 days.

On observation, review of patient medical records, and interview with hospital licensed staff specifically, nursing, social work, and psychiatry on 04/25/13-04/26/13, it was determined that the medical records of 4 mentally impaired patients on the Meisel Ground Unit lacked appropriate information important in the provision of care and in accordance with patients ' rights. Information included the following: 1) current clarity of the patient's ability to make their own health care decisions, 2) documentation in the patient medical record pertaining to the status of the patient's Durable Medical Power Of Attorney (DMPOA) and 3) general consents for treatment and administrative functions. This was evident in 4 of 4 patient medical record reviews.
Patient # 20 is a 60 year old, admitted to the MG Unit on 02/22/13 for schizophrenia, agitation, and anorexia. Review of the patient's medical record on 04/24/13 revealed that on 02/25/13 the patient signed: Receipt of Privacy Practices, Communicating Your Concerns, Consent for Medical Treatment and Admission, and a Document Checklist . A Decision Making Capacity and Treatment Limitations Form completed by the attending physician on 02/23/13 assessed the patient as " not capable of making and communicating decisions " regarding medical care and financial affairs, but in contrast as capable of making and communicating decisions regarding code status. A second Decision Making Capacity and Treatment Limitations Assessment was conducted by the psychiatrist on 03/04/13 and confirmed that the patient was incapable of making and communicating decisions regarding health care.
On further review of the medical record, specifically, a "Maryland Medical Orders for Life-Sustaining Treatment" "MOLST" form completed and signed by the attending physician on 02/23/13 indicated that Patient #20 was to have attempted cardiopulmonary resuscitation (CPR) in the event of a cardiac or pulmonary arrest. The orders for the MOLST Form were entered as the result of a discussion with the patient's surrogate decision maker (brother).
On 04/25/13 interview of the charge nurse, psychiatrist, and social worker confirmed on joint observation and review of Patient #20's medical record that the patient lacked capacity to make decisions on all matters at this time and that there was no DMPOA document located on the patient's record designating who staff could speak with regarding the patient's medical status or other presenting concerns.
During further interview with the psychiatrist it was determined that on admission Patient #20 had capacity to make decisions; however, since admission the patient's condition had deteriorated requiring the patient's sibling be consulted on all medical matters concerning the patient. Further review of Patient #20's Admission Form (demographic sheet) identified the sibling as the Health Care Decision Maker". The social worker was able to obtain a copy of the patients substitute guardian document which was located in the accounting office. The form indicates that the sibling of Patient #20 is the appointed guardian by Baltimore City Circuit Court as of 08/02/06 and able to make medical decisions on Patient #20's behalf. A copy of the document was subsequently placed in Patient #20's medical record by the social worker on 04/25/13 at 11:13 AM only after the surveyor inquiry had been made.

Patient #21 is a 66 years old, admitted to the unit on 04/23/13 for alcohol intoxication , depression, and diabetes. The patient's Admission Form (demographic patient information sheet) indicated that the patient had a friend who was identified on the form as the patient's " Health Care Decision Maker". On 04/23/13 at 18:33 a nursing progress note (interdisciplinary note) assessed the patient as alert and oriented times three and able to follow direction. On 04/24/13 at 9:47 a nurse noted that the patient was "able to give good information about self " . Further medical record review revealed that there was no DMPOA document and consent for treatment on the patient chart. Interview of the Charge Nurse on 04/24/13 at 2:30 PM revealed that the consent to treat for the patient was not in the medical record and staff were trying to locate it.

Patient #23 is a 57 years old, admitted to the facility from another hospital system on 04/10/13 with a diagnosis of Episodic Mood Disorder. Review of Patient #23's medical record revealed that there was no consent for treatment found in the medical record.

Patient #24 is a 74 year old, admitted to the facility on 04/05/13 with a diagnosis of Dementia. Observation and review of Patient #24's medical record indicates that the patient's daughter is the Power Of Attorney. However, the medical record did not contain a copy of the DMPOA document.
Failure by the hospital staff to maintain consistent and clear information about the: 1) patient ' s capability in the decision making process, 2) having DMPOA documents on the patients ' medical records, and 3) obtaining general patient treatment consents, potentially places a patient at risk for not receiving appropriate care as related to their condition and for having protected health care information or health care decisions discussed with unauthorized individuals.

Based on hospital policy " Restraint Use " allows nursing to assess patients once per shift for necessity of the intervention.

Hospital policy " Restraint Use " revised 3/13 states in part under Assessment and Reassessment, (for non-violent restraints) " b. Nurse assesses patient behaviors every shift that necessitate need for a restraint. " In practice, patients were being assessed every two hours by facility nursing as documented in the restraint record despite the policy.

Review of the facility "Restraint Use " policy reveals that the patient's attending physician may be notified of a restraint episode within 72 hours of the initiation of restraint.

The facility policy for " Restraint Use " revised 3/13, reveals in part, " Restraint Orders ... If the restraint is not ordered by the patient ' s attending physician, the nurse notifies him/her as soon as possible [within 72-hours]. This notification is documented. "

Notification time of the attending within 72 hours does not meet the regulatory requirements of " as soon as possible. "

Based on review of the medical record and hospital investigation, it was determined that the hospital failed to monitor patient #13 while in one-point soft wrist restraints.

Patient #13 is a 48 year old female admitted to the chronic hospital on the high intensity care unit on October 19, 2012. Patient#13 was placed in a right soft wrist restraint with mittens to protect her dialysis catheter from dislodgment. An order was written on 4/1/13 at 1300 and there is a note written by the physician. However, there were no monitoring forms found in the medical record regarding the patient's observation and care while in the restraint.

Based on policy and interview, the hospital does not keep a log for restraint deaths while in 2-point soft wrist restraints per CMS 482.13 (g) (2).

Interview with the hospital educator reveals that the hospital does keep a log for patients who die in restraint, although no patient has died while in restraint, within 24-hours of restraint, or where it is reasonable to assume that the use of restraint contributed directly or indirectly to a patient ' s death. However, staff was not aware of the need for a separate log for patients who die with the latter associations related to 2-point soft wrist restraint.

Hospital policy for " Restraint Use " outlines Death Reporting Requirements, but does not document requirements for documenting deaths related to 2-point soft wrist restraints.

Based on observation and staff interview, it was determined that the hospital failed to keep drugs secure when the crash cart was found unlocked during the unit tour.

On 4/24/13 at 10:00 am during unit tour with the charge nurse on Meisel 1, the crash cart was found to be open. When the surveyor checked by slightly pulling on the top drawer of the cart, the side bar moved and the red plastic lock #8559412 was broken. The top drawer of the cart contained injectable medications and therefore was not secure. The charge nurse stated the cart had not been used in the past several days and she did not know when the cart was opened. The cart was being signed off as checked every shift and was signed off up through 4/24/13. The Director of pharmacy was interviewed regarding the crash cart and felt that the lock could have been broken accidentally or that staff are not checking to be sure the lock is secure and maybe eyeballing to make sure the lock is there. The cart was sent back to pharmacy Central Supply and pharmacy and new cart sent to the unit.

During tour of the hospital's Meisel Ground Unit on 04/24/13, while interviewing the Charge Nurse regarding narcotic management and drug diversion, the Charge Nurse confirmed that there had been concerns related to drug diversions. The concerns had been reported to the nursing supervisor and an investigation had been completed by pharmacy personnel and the unit mangers; but, at the time of the interview the charge nurse was not aware of the outcome of the investigation but did indicate that the suspected diversion was related to Oxycontin.

04/25/13 further follow-up to the previous findings of 04/24/13 were completed by the surveyor. At that time interviews were conducted with the Director of Risk Management, the Pharmacist, and Performance Improvement Coordinator. At that time the surveyor was made aware that an agency staff nurse was suspected of having been involved in the alleged diversion. The personnel file of the individual was subsequently reviewed by the surveyor.

At the time of the personnel file review, it was determined that the agency nurse had been hired to work at Levindale on 12/29/12 from a Staffing Agency. The file revealed that the staffing agency had completed a criminal background check but initially it was unclear if the facility had thoroughly reviewed the background check or requested additional information related to some of the findings in the background check prior to hiring the individual.

However, on further interview and review of the file it was determined that on 03/31/13 and 04/01/13, while there should have been Oxycodone floor stock available on Meisel ground, the unit nurses had notified the pharmacy that there was no Oxycodone floor stock available. As a result the pharmacy completed audits and search of medication on all three Chronic Hospital Units; however, the medication and control sheet were not found. Therefore, it could not be determined when the narcotic medication and control sheet went missing.

On further interview and review of documentation it was determined that on 04/07/13 during evening shift change and narcotic count two RN(s) discovered a discrepancy in the narcotic count for OxyIR 10 mg (narcotic sheet missing ) and 8 tablets from the Oxycontin bubble pack; unaccounted for.

The unit Lead Nurse, supervisor, unit nursing manager and security staff were all made aware of the discrepancy and unit staff were all required to remain on the unit while an initial investigation was completed. However, despite the agency employee having been instructed not to not leave the MG Unit until the narcotic discrepancy had been resolved, the nurse left the unit and had to be overhead paged three times before returning to the unit while attempt was made to resolve the narcotic discrepancy. On 04/07/13 the hospital notified the nurse staffing agency that the nurse was instructed to not return to the hospital because of behavior described as erratic and non-compliant on this day.

Interview conducted with the Director of Risk Management, Director of Pharmacy, and Performance Improvement Coordinator on 04/25/13 revealed that: 1) they were unaware of the employee ' s background check prior to the drug diversion incident, 2) that there have been no further incidents since the employee was terminated from working at the facility, 3)the Maryland Board of Nursing had not been notified about the nurse and suspicion of drug diversion, 4) a claim of missing controlled substance on form 106 had not been filed with the DEA. In addition, review of the hospital's Drug Diversion Policy and Procedure specifically, steps #8 and #11, indicate that an assessment to report on form 106 to the DEA would be done and a completed report sent to the Maryland Board of Nursing.

Based on observation of the hospital on April 24, 2013, it was determined that the patient environment was not maintained in a manner that was free of accident hazards as was possible.
The findings included:
On April 24, 2013, an environmental health survey was conducted at this hospital center. Based on observation of the Meisel G - Level occupational therapy area, it was revealed that there was an electric stove and range that was connected to electrical power at all times. This surveyor determined that, if unobserved, a resident may activate the stove top and this could result in a patient or staff person burn injury. Upon discovering the concern, this surveyor intervened to the director for therapy and they were alerted to the potential for accidental injury.

This regulation is not met as evidenced by:

Based on review of the medical record it was determined that the hospital failed to document the discussion of the discharge evaluation results and discharge plans for patient #13.

Patient #13 is a 48 year old female admitted to the chronic hospital on the high intensity care unit on October 19, 2012. During day one of survey, April 24, 2013 while reviewing the patient ' s medical record there was no indication that the patient ' s son (the identified surrogate decision maker) was involved in the patient ' s discharge planning. The case manager during record review on the unit on 4/24/13 at 12:20PM stated that the patient is a difficult placement and there is only one possible placement. There is no documentation on the weekly care planning sheets or in the progress notes of communication with the son.

This regulation is not met as evidenced by:

Based on a review of onsite outpatient rehabilitation and outpatient partial hospitalization services, is revealed that paper record documentation is not integrated into the hospital record.

The hospital has onsite, out-patient services which include rehabilitation and partial hospitalization. While some of the patients served come from outside referrals, many of the patients served, are referred through the hospital discharge process. In the case of the partial hospitalization service, that number is approximately 50%.

The hospital has an electronic and a paper record. However, the paper portion of the record is not scanned into the electronic portion of the record. Therefore, for these outpatient areas, the record is not fully integrated into the patient ' s inpatient record which does not meet the regulatory requirement for integration of outpatient records with inpatient records of individuals.

Based on interview and a review of the facility Medical Records practices, it is revealed that multiple Supervisors and Unit Manager's have keys to the Medical Record Department, and frequently do not sign out records resulting in frequent irretrievable records.

Interview with the Manager of Medical Records revealed that multiple staff inclusive of all unit managers and hospital supervisors have keys to the Medical Records Department (MRD). The facility has both an electronic and paper sign out for records, which is frequently not documented when records are taken from the MRD. Consequently, the MRD Manager and staff frequently have to search for patient records, which does not meet regulatory requirements for the security of medical records.