HospitalInspections.org

Based on facility policy, record review and interview, it was determined the facility failed to ensure medication was not used as a restriction to manage a patient's behavior of agitation for 1 of 20 (Patient #7) sampled patients.

The findings included:

1. Review of the facility's "Use of Restraints in Non-Psychiatric Hospital" policy documented, "...A comprehensive assessment of the patient, including a physical assessment to identify medical problems that may be causing behavior changes, must determine that the risks associated with the use of restraints are outweighed by the risk of not using the restraints...Definitions...A Drug used as a restraint is medication used as a restriction to manage the patient's behavior or restrict the patient's movement, and is not a standard treatment or dosage for the patient's medical or psychiatric condition..."

2. Medical record review revealed Patient #7 was admitted to the facility on 6/13/13 at 16:25 PM with the diagnosis of Dementia.

Review of the 6/13/13 nursing narrative note documented at 16:25 PM, "...Pt admitted...oriented x 3...19:00 [PM] pt agitated, attempting to get out of bed, yelling...19:10 [PM] pt screaming and hysterical and escalating...19:15 [PM] called [MD's name] orders for haldol 1 mg [milligram] IM [intramuscularly] now and 1 mg po [by mouth] q HS [every night] received..."

Review of the 6/13/13 physician's orders documented a telephone order at 19:15 PM for haldol 1 mg IM now and haldol 1 mg every night at time of sleep.

The 6/13/13 physician's progress note documented for the patient's status change "Haldol for agitation"

Review of the 6/14/13 physician's progress note documented at 10:41 AM, "...Agitation-Haldol..."

Review of the physician's History and Physical dictated on 6/14/13 at 20:38 PM documented, "...Positive for Dementia...Negative for anxiety and depression...medications: Includes Haldol for agitation...physical Exam...The patient is oriented to person, place and time..."

There was no documentation the facility had conducted a comprehensive patient assessment that included the identification of medical problems which could be causing the behavior changes, or determined the risks associated with the use of restraints were outweighed by the risk of not using the restraints. There was no documentation the medication was administered for a psychiatric/mental disorder.

3. During a telephone interview on 6/19/13 at 11:07 AM the patient's physician was interviewed regarding the use of haldol (an anti-psychotic medication) for the behavior of agitation and not a psychiatric disorder. The physician stated the patient "...had agitation in association with Sundowner's syndrome [associated with Dementia] seen in the elderly..." The physician was asked if "Sundowner's" Dementia was a psychiatric condition. The physician stated, "...Actually, that's a perfect drug [haldol] for her with sundowner's. The psych [psychiatric] literature indicates that 1 milligram of haldol is more than sufficient for sundowner's"

Based on record review, observation and interview, it was determined the facility failed to ensure nursing services were provided to meet the needs of all patients for 1 of 20 (Patient #10) sampled patients.

The findings included:

Medical record review revealed Patient #10 was admitted to the Rehabilitation Hospital on 6/10/13 with diagnoses of Urinary Tract Infection, Encephalopathy, Acute Renal Insufficiency, Deconditioning, Hypertension, Type 2 diabetes, Osteoarthritis, Hyperlipidemia and Neuropathy.

Observations on 6/18/13 at 8:35 AM revealed the patient to be sitting in a wheel chair in her room. The patient stated to the Licensed Practical Nurse (LPN), "Everything they've done to me since I been here hurts so bad. Just suffer awful. Pray to die sometimes"

There was no documentation the LPN addressed the patient's pain and/or psychosocial needs.

During an interview on 6/19/13 at 8:30 AM the Interim Chief Nursing Officer verified there was no documentation of any follow up to for the patient.

Based on facility protocol, medical record review and interview, it was determined the facility failed to follow physician's orders for medication administration and diabetic protocols for 2 of 20 (Patient's #6 and 8) sampled patients.

The findings included:

1. Review of the facility's "Diabetic Protocol for Insulin Dependent Diabetics" protocol documented the following, "...Accu-checks ac & hs [before meals and bedtime] with sliding scale insulin....Sliding Scale Insulin, Regular Humulin Insulin
0-200 No insulin
201-250 6 units of Regular Insulin SQ [subcutaneous]
251-300 9 units of Regular Insulin SQ
301-350 12 units of Regular Insulin SQ
351-400 15 units of Regular Insulin SQ
401- or > [greater than] 15 units of Regular Insulin SQ and call M.D. [medical doctor]...Sliding Scale insulin should only be given if pt [patient] has no other coverage (i.e. [for example] oral hypoglycemics or scheduled insulin)...Give bedtime snack at 9 PM 5. If no sliding scale insulin administered, recheck glucose in two hours. If levels remain elevated, administer sliding scale per protocol..."

2. Medical record review for Pt #6 documented an admission date of 6/5/13 with diagnoses of Trans-ischemic Attack, Infarct Right Occipital Cortex, and Insulin Dependent Diabetes Mellitus. Physician's orders dated 6/5/13 documented, "Novolog 70/30 20 units SQ in AM and 16 units q [every] PM, Diabetic Protocol with SS [Sliding Scale], Glimepiride [medication to lower blood sugar] 2 mg [milligrams] PO [by mouth] Q AM, Glimepiride 1 mg PO daily at HS."

Review of the Clinical Information Record dated 6/13/13 through 6/16/13 revealed the following accu-checks were performed with results out of range, and no sliding scale insulin was administered or a re-check of the blood sugar (BS) in 2 hours:
6/13/13 - 4: 00 PM BS 231.
6/13/13 - 9:00 PM BS 282.
6/14/13 - 7:00 AM BS 242.
6/14/13 - 11:00 AM BS 208.
6/14/13 - 4:00 PM BS 218.
6/14/13 - 9:00 PM BS 256.
6/15/13 - 4:00 PM BS 299.
6/15/13 - 9:00 PM BS 355.
6/16/13 - 11:00 AM BS 259.
6/16/13 - 4:00 PM BS 226.

During an interview in the conference room on 6/18/13 at 8:25 AM the Interim Chief Nursing Officer stated there was no documentation of blood sugars in accordance with the facility's protocol and the patient did not receive sliding scale insulin as ordered.

3. Medical record review for Pt #8 documented an admission date of 6/4/13 with diagnoses of Cerebral Vascular Accident, Right Sided Weakness with Dysphagia, Non-diabetic. On 6/12/13 at 7:00 AM a "Report to Physician about a Change in Condition" form was completed documenting, "...pt throat, R [right] ear pain caused pt not to be able to eat breakfast...RECOMMENDATIONS:...start Nystatin S&S [swish and swallow] 5 ml [milliliters] TID [three times a day]"


Review of the Medication Administration Record for 6/16/13 documented the 6:00 AM and 2:00 PM dose was circled with no explanation indicating why the medication was not administered. The 10:00 PM dose was circled and written was the word "unavailable" next to the time. On 6/17/13 at 6:00 AM the dose was circled and written was the word "unavailable".

Review of the Daily Progress/Narrative report dated 6/16/13 documented, "2200 [10:00 PM] ...Nystatin not given not available..."

During an interview in the conference room on 6/18/13 at 2:25 PM the Pharmacist stated, "The nurse is suppose to check the MedSpense [medication administration storage], if not available, we can bring it with in an hour. There is a back up pharmacy. If we can not get a med [medication], we call the physician and notify him. The Nystatin was in the MedSpense. There were other patients on it that could have borrowed a dose from"

Based on record review, observation and interview, it was determined the facility failed to ensure therapy services addressed patients' needs for 1 of 20 (Patient #10) sampled patients.

The findings included:

1. Medical record review revealed Patient #10 was admitted to the Rehabilitation Hospital on 6/10/13 with diagnoses of Urinary Tract Infection, Encephalopathy, Acute Renal Insufficiency, Deconditioning, Hypertension, Type 2 diabetes, Osteoarthritis, Hyperlipidemia and Neuropathy.

Review of the 6/17/13 Certified Occupational Therapy Assistant (COTA) Daily Therapy note documented, "...Pt [patient] stated, 'I am ready to meet the Lord' "

Review of the 6/18/13 COTA Daily Therapy note documented after standing the patient stated, "I just want to die, I have no strength. I am doing my best, I don't know why I have to be punished for this. Pt stated the above quotes [with] eyes closed as though she was praying..."

There was no documentation the COTA followed up on the patient's expressions of wanting to die or reported this to the nursing department or the physician.

2. Observations on 6/18/13 at 8:35 AM revealed the patient to be sitting in a wheel chair in her room. The patient stated, "Everything they've done to me since I been here hurts so bad. Just suffer awful...Pray to die sometimes"

3. During an interview on 6/19/13 at 8:30 AM the Interim Chief Nursing Officer verified there was no documentation of any follow up to for the patient's expressions of wanting to die.

During an interview on 6/19/13 at 10:45 AM the COTA stated, "...I don't feel she's a danger to self. She just said 'I think I'm tired'...She had her eyes closed, like having a conversation with God...Speech came back and said she [the patient] was better..."