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Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to ensure:

1. Patients received care in a safe setting :

The facility failed to:

a. develop and implement a policy regarding utilization of medical beds. These beds were identified by the facility as posing a ligature risk in November 2022.

b. fully develop their "suicide prevention policy" to include frequency of suicide risk assessment by nursing; and suggested preventative interventions for patients assessed at "moderate or high risk" for suicide.

c. identify and correct hazards with potential for harm to self or others in seclusion room C and 300 hallway.

[Refer to Tag A-0144]

2. Compliance with Restraint/Seclusion requirements:

The facility failed to identify antipsychotic and sedative medications given intramuscularly (IM) to control patient aggressive behaviors as restraints:

a. the restraint policy was unclear that IM emergency medications were chemical restraints. The policy did not address all regulatory requirements for restraint usage regarding chemical restraints;

b. nursing staff failed to verbalize that IM emergency medications used to control a patient's aggressive behaviors were restraints;

c. record review of 3 of 3 sampled patient records showed administration of IM antipsychotic / sedatives to control aggressive behaviors (Patient ID # 15,18,19 ) .There was no post-administration documentation of patient monitoring or face-to face assessments [refer to Tags A-0175 and A-0179 ].

[Refer to Tags A-0160; A-0175; A-0179]

Based on observation, interview, and record review, the facility failed to uphold all patients' right to receive care in a safe setting. The facility failed to:

a. develop and implement a policy regarding utilization of medical beds. These beds were identified by the facility as posing a ligature risk in November 2022.

b. fully develop their "suicide prevention policy" to include frequency of suicide risk assessment by nursing; and suggested preventative interventions for patients assessed at "moderate or high risk" for suicide.

c. identify and correct hazards with potential for harm to self or others in seclusion room C and 300 hallway.

Findings included:

Record review of facility policy titled "Patient Rights,"dated 8/01/2022, showed the process for informing patients of their rights and responsibilities. Review of the "Patient Bill of Rights" form given to the patients, showed: Basic Rights of All Patients:...3. You have the right to a clean and humane environment in which you are protected from harm...."

a. No policy for medical bed utilization [ ligature risk ]:

Record review of facility "2022 Risk Assessment" showed documentation of 30 medical beds identified as a "ligature risk." The beds were located in various rooms in the 100 and 200 hallways. "Prevention measure" listed on the "Risk Assessment " was : "patients will be supervised on an appropriate level throughout duration of the day." "Plan Of Action" was: "patients will be supervised on an appropriate level throughout duration of the day." Columns tabled "Assigned to /Action Date/ Status" were all marked as "N/A."

Observation rounding with Staff-B, Chief Nursing Officer [CNO] on 7/13/2023 at 2:15 PM showed patient room # 110 located on the 100 hallway. This room contained a "medical bed." This hallway was completely unoccupied at the time of observation and demonstration.

Surveyor and CNO firmly tied a bedsheet around the exposed metal frame of the medical bed and draped it over the mattress, postponing it over the side. Significant downward pressure was applied to the bedsheet on the opposite side of the tie-off point. The knot held in place. Surveyors and CNO acknowledged it was likely sufficient pressure & time to cause strangulation. CNO verified all 30 medical beds were the same as the bed in room # 110.

During an interview on 07/12/2023 at 10:30 AM with Staff-A, Quality Director, she stated the facility did not have a policy or criteria for use of the medical beds.

b. Suicide Prevention policy; not fully developed:

Record review of facility policy titled " Suicide Prevention," revised date June 14, 2023, showed the facility utilized the Columbia Suicide Severity Rating Scale (C-SSRS) to assess patient suicide risk.

1. Frequency of Suicide Risk Assessment (Nursing):

Review of Attachment A: "Suicide Screening Questions" read at the top: "The following screening questions will be asked in the Intake Assessment." The policy did not address frequency of suicide risk assessments performed by nursing after a patient was admitted. During a telephone interview with Staff-A, Quality Director on 7/19/ 2023 at 10 AM , the policy was reviewed and discussed. Staff-A stated that nursing performed a suicide risk assessment every shift ( 12 hour shifts). Staff-A acknowledged this was not documented in the "Suicide Prevention" policy. Review of facility policy titled "Nursing Documentation Standards ," dated 08/1/2022 , showed descriptions of required nursing assessments including (but not limited to) : timeframes and requirements for vital signs, weights, pain, medications, and behaviors. Suicide Risk Assessment by nursing was not addressed in this policy.

2. Lack of possible interventions: patients assessed at Moderate or High Suicide Risk:

The Suicide Prevention policy was 6 pages in length. Review of the bottom of page 5 read :"Step 4: Determine Level of Risk and Develop interventions to LOWER risk level. The page directly after this statement (page 6) was the last page of the policy. The only information on this page was a listing of the "Risk Stratification Levels": High Suicide Risk; Moderate Suicide Risk; and Low Suicide Risk. There were no suggested interventions listed for patients assessed at Moderate or High Risk for suicide. The only suicide prevention intervention listed in the policy was the admtting or attending physician would determine the level of observation.


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c. Unidentified hazards: potential to harm self or others:

Observation on 7/13/23 at 1:37 PM in seclusion room C there was a hard piece of plastic material place behind the badge reader. This plastic was able to be lifted, exposing a sharp edge that could be used for self-harm.

Observation on 7/13/23 at 2:02 PM at the end of the 300 hallway, on the floor was a hard plastic room number identification placard. This placard was accessible to all patients on 300 hallway ; it had sharp edges that could be used for self-harm.

Interview with CNO (ID #B) at the time of observations acknowledged both could be used for harm to self or others.

Based on record review and interviews, the facility failed to identify antipsychotic and sedative medications given intramuscularly (IM) to control patient aggressive behaviors as restraints:

a. the facility restraint policy was unclear that IM emergency medications were chemical restraints. The policy did not address all regulatory requirements for restraint usage regarding chemical restraints;

b. nursing staff failed to verbalize that IM emergency medications used to control a patient's aggressive behaviors were restraints;

c. record review of 3 of 3 sampled patient records showed administration of IM antipsychotic / sedatives to control aggressive behaviors (Patient ID # 15,18,19 ) .There was no post-administration documentation of patient monitoring or face-to face assessments [refer to Tags A-0175 and A-0179 ].

Findings included :

a. Facility restraint policy:

Record review of facility policy titled "Restraint Management"-VNS 1.11, undated, showed:

DEFINITIONS:

1. "Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
2. Emergency medication is the use of a medication that is not a standard treatment for the patient (sic) is new or continuing medical or behavioral condition."

The policy did not state that IM emergency medications used to control patients' aggressive behaviors were restraints. The policy did not reference the requirements for: restraint order, face-to-face assessment, required patient monitoring for emergency drugs used as restraints [*not all inclusive of requirements].


b. Nursing staff interviews:

Interviews were conducted with nursing staff on 7/12/2023. All nurses were asked: "If Haldol was given IM to control a patient's aggressive behavior , do you consider this a restraint?" The responses were as follows:


* 12:20 PM with Staff B, Chief Nursing Officer (CNO), he stated " no, emergency behavioral meds are not considered a restraint."

* 11:10 AM with Staff D, RN , she stated " When we give Haldol and Ativan for out-of-control behavior, it is not a restraint. The only restraints are when we put up side-rails or tying hands."

* 11:45 AM with Staff J, LVN, he stated " ..if a patient was hitting others or hurting self, it is not a restraint to give them these meds."


c. Lack of patient monitoring and face-to- face assessments :

[* please see TAGS A-0175 and A-0179]

Based on record review and interview, the facility failed to ensure that 3 of 3 patients who received intramuscular (IM) antipsychotic /sedative medication to control aggressive behaviors were appropriately monitored and assessed [Patient ID # 15, 18, 19].

Findings included :

Record review of facility policy titled "Restraint Management"-VNS 1.11, undated, failed to show that emergency medications IM used to control patients' aggressive behaviors were restraints. The policy did not reference the requirements for required patient monitoring post-administration of emergency drugs used as restraints.

Record review on 7/12/2023 of the clinical records of Patient ID # 15, 18, 19 showed the following:

Patient # 15:

Medication Administration Record (MAR) showed:

-06/09/2023: Ativan 2 milligrams (mg) given IM at 12:40 PM and Haldol 5 mg given IM at 1315 PM

-06/10/2023: Haldol 5 mg given IM at 1545 PM.

-06/11/2023 : Haldol 5 mg and Ativan 2 mg given IM at 1403 PM.

-07/03/2023: Haldol 5 mg given IM at 1130 AM

Ativan 2 mg given IM at 1140 AM

Ativan 2 mg given IM at 1150 AM

Ativan 2 mg given IM at 1151 AM

Ativan 2 mg given IM at 1220 PM

Haldol 5 mg given IM at 1220 PM

Record review of all the IM orders for Ativan and Haldol listed above for Patient # 15 showed they were one-time orders to "control agitation / behavior."

Patient ID # 18:

Medication Administration Record (MAR) showed:

-06/15/2023: Ativan 2 mg IM and Haldol 5 mg given IM at 1348 PM

Benadryl 50 mg IM and Haldol 5 mg given IM at 1521 PM

Record review of the IM orders for Ativan and Benadryl listed above for Patient # 18 showed they were one-time orders to "control agitation / behavior."

Patient ID # 19:

Medication Administration Record (MAR) showed:

-05/22/2023: Haldol 5 mg and Ativan 2 mg given IM at 2025 PM

Record review the IM order for Ativan and Haldol and Ativan listed above for Patient # 19 showed it was a one-time orders to "control agitation / behavior."

The clinical records for Patients # 15, 18, 19 were reviewed with Staff B, Chief Nursing Officer (CNO). During an interview with the CNO on 07/11/2023 at 11:30 AM, he said "patients are not monitored after getting emergency meds-we just check for efficacy." There was no documentation of patient monitoring or assessment following administration the IM meds to control behaviors.

Based on record review and interview, the facility failed to ensure that 3 of 3 patients who received intramuscular (IM) antipsychotic /sedative medication to control aggressive behaviors received a face-to- face assessment within one hour of adminstration of restraint [Patient ID # 15, 18, 19].

Findings included :

Record review of facility policy titled "Restraint Management"-VNS 1.11, undated, failed to show that emergency medications IM used to control patients' aggressive behaviors were restraints. The policy did not reference the requirement for "face to face " patient asessment post-administration of emergency drugs used as restraints.

Record review on 7/12/2023 of the clinical records of Patient ID # 15, 18, 19 showed the following:

Patient # 15:

Medication Administration Record (MAR) showed:

-06/09/2023: Ativan 2 milligrams (mg) given IM at 12:40 PM and Haldol 5 mg given IM at 1315 PM

-06/10/2023: Haldol 5 mg given IM at 1545 PM.

-06/11/2023 : Haldol 5 mg and Ativan 2 mg given IM at 1403 PM.

-07/03/2023: Haldol 5 mg given IM at 1130 AM.

Ativan 2 mg given IM at 1140 AM

Ativan 2 mg given IM at 1150 AM

Ativan 2 mg given IM at 1151 AM

Ativan 2 mg given IM at 1220 PM

Haldol 5 mg given IM at 1220 PM

Record review of all the IM orders for Ativan and Haldol listed above for Patient # 15 showed they were one-time orders to "control agitation / behavior."


Patient ID # 18:

Medication Administration Record (MAR) showed:

-06/15/2023: Ativan 2 mg IM and Haldol 5 mg given IM at 1348 PM

Benadryl 50 mg IM and Haldol 5 mg given IM at 1521 PM

Record review of the IM orders for Ativan and Benadryl listed above for Patient # 18 showed they were one-time orders to "control agitation / behavior."

Patient ID # 19:

Medication Administration Record (MAR) showed:

-05/22/2023: Haldol 5 mg and Ativan 2 mg given IM at 2025 PM

Record review the IM order for Ativan and Haldol and Ativan listed above for Patient # 19 showed it was a one-time orders to "control agitation / behavior."

The clinical records for Patients # 15, 18, 19 were reviewed with Staff B, Chief Nursing Officer (CNO). During an interview with the CNO on 07/11/2023 at 11:30 AM, he said "patients are not monitored after getting emergency meds-we just check for efficacy." There was no documentation of face-to- face assessments of Patients 15,18,19 within one hour of administration of emergency drugs used as restraints.

Based on observation, interview, and record review, the facility failed to ensure nursing staff :

a. provided wound care per orders and facility policy for 2 of 2 patients (Patient ID #1 and 16)

b. informed charge nurse or provider of a Change in Patient's condition per facility policy (citing Patient ID # 20)


Findings included:

a.

Record review of facility policy titled "Skin Assessment and Wound Care, "dated 06/01/2023, showed:

I. POLICY

To ensure the optimization of all wounds and to monitor high risk patients for skin breakdown, voyages behavioral health identifies and protects patients who have wounds and who are at high risk for developing wounds.

II. PROCEDURE

1. Part of the admission process, the RN will perform an initial head to toe skin assessment. If wounds are present photographs and documentation of the wound to include the size- length, width, depth, and tunneling as well as the appearance of the wound to include any drainage or odor and complete the Norton scale.
2. The nurse will obtain wound care orders per hospital protocol.
3. The nurse will complete the Norton scale anytime the patient weekly and PRN with significant change in condition.
4. Pictures and measurements of each wound will be done weekly; with significant change in the wound; and within 24 hours of discharge.

III. MEASURING GUIDELINES

1. Measure head to toe for length and left to right for width (anatomically correct).
2. Photographs should be taken with the anatomical position in mind, if unable, the documentation should provide location as well.

IV. ONGOING ASSESSMENT

1. The nurse will notify any new findings of wounds on all patients to the wound care provider or physician, as indicated.
2. Utilizing the BH skin and wound assessment (frequency), all wounds will be assessed, photographed, and measured with significant change in wound status.

V. TREATMENT TIMES

1.One care treatment should be performed per provider orders and documented in the treatment administration record


Medical record review for patient (ID#1) 3/10/23 nursing assessment showed:
Skin Assessment: Significant findings- Multiple draining wounds.
Wound Present: yes.
Wound Color: Brown.
Wound Drainage Amount: Scant.
Type of wound closure: None.
Peri-wound skin status: Excoriated.
Skin/ wound assessment comments: Multiple bilateral Lower extremities wound

Norton Pressure Injury Risk:
Risk Level for Skin Breakdown <10 very high risk
Norton Pressure injury Risk total score: 10

Review of wound care orders for patient (ID # 1) dated 3/10/23 showed:
1. ABD skin fold, and other skin fold, apply nystatin powder QD and after each shower.
2. Left posterior thigh and buttock excoriation, clean with normal saline, pat dry, apply protective barrier cream, Q shift, and after each diaper change.
3. Sacrum stage II wound, normal saline clean, pat dry, apply allevyn Border foam dressing, change Q Monday Wednesday Friday and Saturday, no diaper is suggested
4. bilateral lower leg and left lateral thigh wounds, normal saline clean, pat dry, apply Vaseline gauze to wound base then apply dura fiber AG dressing. change every Monday Wednesday Friday Saturday.
5. Right third toe ulcer, clean with normal saline, pat dry, apply calcium alginate dressing cover with 2 x 2 gauze, secure what tape.
6. Please turn and reposition Q2 hours.
7. please provide low air loss mattress for pressure redistribution and for moisture management.

During chart review with staff (ID A) on 7/12/23 at 12:45 PM she confirmed nursing documentation did not contain wound measurements and did not show wound care was provided as ordered. She also confirmed that low air loss mattress was not received for patient (ID #1).

Medical record for patient (ID#16) admission 7/6/23 skin assessment showed:
Significant findings: No significant findings.
Wound Present: yes
Wound color: pink
Wound odor: none
Wound drainage: clear
Wound drainage amount: scant
Type of wound closure: none
Peri-wound skin status: intact
Risk Level for Skin breakdown 14-18 Medium risk
Norton Pressure Injury Risk Total Score: 17

Review of wound care orders for patient (ID # 16) dated 7/6/23 showed:

Wound care treatment daily per patient home regimen, approved by her dermatologist: claim scan with normal saline gently, tap dry, use the mixture of Vaseline ointment, triple antibiotic ointment and hydrocortisone 2.5% cream to affected area daily. Monitor for signs of infection.

History and Physical for patient (ID#16) showed: history of present illness: ... upon admission assessment she has diffused skin rashes, skin open areas to her extremities and back, found large fluid filled blister to left forearm.

Integumentary: warm to touch, dry, color good. No new bruises, lacerations, or abrasions.
Abnormal findings: wound care, epidermolysis bullosa, severe

Pictures of wounds for patient (ID#16) at admission show burn like wounds on face, abdomen, extremities x 4 back and buttocks.

During chart review with staff (ID A) on 7/13/23 at 11:04 PM she confirmed nursing documentation did not contain wound measurements and did not show wound care was provided as ordered.


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b.

Record review of facility policy titled "Nursing Documentation Standards ," dated 08/1/2022 , showed : Nursing Daily Assessment:...ii. Vital signs will routinely be assessed according to or as needed with patient change in condition. Any changes in readings outside normal shall be reported to the Charge Nurse for further assessment.

Review of the medical record for current Patient # 20 showed the following:

Admission "History and Physical "exam, dated 6/22/2023 : showed current blood pressure was 148/78; documented history of hypertension; home medication included Nifedipine ER 30 milligrams ( 3 tabs to = 90 mg) at bedtime for hypertension.

Nursing documentation:

-6/28/2023: (time 1936) : blood pressure measurement : 192/83
-6/28/2023: (time 2100) : blood pressure measurement : 192/83

Further review of nursing notes dated 6/28/2023 failed to show that the charge nurse or provider was informed of either of these elevated blood pressure measurements.

During an interview on 07/11/2023 at 12 NOON with Staff A, Quality Director, she verified the findings and stated the charge nurse or provider should have been notified of the elevated blood pressure readings.