HospitalInspections.org

Based on review of patient records, policies and procedures and interview with staff , the hospital failed to protect the patient's rights as evidenced by the following deficiencies:
1. A117 due to the failure to provide the court appointed guardian for the patient the information about the patient's rights;
2. A131 due to the failure to obtain informed consent from the guardian after being appointed by the court;
3. A160 due to the failure to provide the least restrictive alternative for medications to control a patient's behavior ;
4. A 173 due to failure to provide clinical justification for a restraint; and
5. A 196 for failure to training to staff in the performance of the face to face evaluation.

Based on review of 7 open medical records and 6 closed medical records, it was determined that 1 out of 7 open records lacked documentation of appropriate acquired informed consent from the patient's court ordered guardian through the Department of Social Services, which did not meet the requirement of this regulation or the hospital's policy.

Patient # 7 is a 54 year old female admitted to the hospital's psychiatric unit, Meisel 2 on 11/09/12. During the admission process it was determined that the patient's health care agent was confused and not able to give informed consent. The hospital social worker and legal department became involved and guardian of person and a law firm guardian of property by the court for Patient #7. The social worker is responsible for notifying the admission department regarding the guardian appointment and documenting the date of appointment on the patient's face sheet. Once the admission department was notified of the court appointed guardians, the admission agreement, patient rights and responsibilities, privacy, and Medicare Important Message should have been provided to the guardians and signed forms placed in the patient's medical record.

During the medical record review for Patient #7 on 12/18/12, none of the admission paperwork could be found. The admission department was contacted during the survey and stated that they had received notification of the court appointed guardians but the information had not been sent therefore, the guardians had not received the necessary paperwork nor been informed of the patient's rights including the "Important Message from Medicare."

Based on the review of (7) open medical records, it was determined that 1 out of 7 open records lack documentation of appropriate acquired informed consent from the patient's court appointed guardian through the Department of Social Services.

Patient # 7 is a 54 year old female admitted to the hospital's Meisel 2 psychiatric unit, on 11/09/12. During the admission process it was determined that the patient's health care agent was confused and not able to give informed consent. As a result the hospital's social worker and legal department became involved and guardianship was pursued through the Department of Social Services (DSS). However, no important message could be found in the medical record and the admission department verified that the guardians had not received the admission packet.

The hospital's failure to notify the guardian of Patient #7's rights, including the patient's rights as a Medicare recipient failed to meet the standard.

Patient #1 is an 83 year old male who was admitted to the Levindale Household Unit on March 13, 2012. Prior to admission Patient #1 had been living at home mainly independent. Patient #1 had also been diagnosed with Severe Alzheimer's Dementia with Cognitive Impairment and Visual Spatial decline.

Review of the medical record indicates that while on the Household Unit, Patient #1 had great difficulty adjusting to the unit. He was observed wandering in and out of other patient ' s rooms and was unable to comprehend boundaries. Documentation also indicates that Patient #1 had multiple periods of aggressive and combative behaviors and could not be redirected by care staff. Medication adjustments were made but Patient #1 continued to exhibit combative and aggressive behaviors. He was considered a danger to other patient's on the unit and was assessed as needing a more structured setting with supervision.

As a result, on April 12, 2013 Patient #1 was transferred to the Chronic Hospital's Behavioral Health Unit for continued monitoring of his aggressive behaviors and medication management. However, documentation indicates that Patient #1 continued to wander into other patient's rooms, required maximal staff assistance with prompting for him to eat and drink. He also was unable to comprehend and maintain standard safety measures.

Documentation indicates that staff continued to monitor and redirect Patient #1; however, on the evening of May 5, 2012 Patient #1 became very disoriented and aggressive with staff members. Subsequently at 8:13 PM, Patient #1 was administered 25 milligrams of Seroquel orally and 0.5 milligrams of Ativan IM. Documentation indicates that staff subsequently assisted Patient #1 into a wheelchair and placed him into his room.

On further review of the medical record, specifically, a nursing progress note dated 05/05/12 at 10:15 PM the note states that Patient #1 was found lying face down on his left shoulder after falling from the wheelchair. According to the nurse's note, at the time Patient #1 was found, a head to toe assessment was completed. Patient #1 was observed to be guarding his left shoulder. The nurse documented that Patient #1 was subsequently assisted to bed and the nurse practitioner was notified.

There was some conflicting documentation in the nurse practitioner's progress note dated 05/05/12 at 11:05 PM, which stated that Patient #1's fall occurred when he got out of bed by himself, fell onto a chair, and was found lying across the chair with his left arm and shoulder as the area that appeared to have struck the chair first. The documentation by the nurse practitioner also indicates that an assessment was completed and at that time the nurse practitioner found that Patient #1 had a swollen, tender area to the left mid-supraclavicular region (above the clavicle) and was also unable to elevate his left arm without wincing.

Orders were written and Patient #1 was administered 800 milligrams of Motrin. An ice pack was applied to the left shoulder and patient #1 was transported to the emergency department for a stat X-ray of the left shoulder. Results were positive for a left comminuted fracture of the mid portion of the clavicle.

However, there is no documentation or indication that prior to being found on the floor, staff had attempted to assist Patient #1 into bed or had come back to check on him between the time he was placed into his room and later found injured on the floor of his room.

Based on review of 2 of 7 open medical records, it was determined that Patient #8 and 10 were prescribed and administered PRN psychotropic medication to manage their behavior. However, the orders were incomplete as they did not start with the offer of the medication in oral form and did not identify the number of doses within twenty four hours.

1. Patient #9 is an 87 year old female who was admitted to the Meisel 2 psychiatric unit on 12/13/12. On 10/14/12 at 8:35 am the patient was placed in a Lap Buddy while in chair for restlessness, confusion, and agitation. At 9:05 am, an order was obtained for Haldol 1 mg IM every 4 hours PRN (as needed) for agitation. There is no indication that the patient was offered the medication in oral form before use of the intramuscular (IM) form.

2. Patient # 11 is a 70 year old male who was admitted to the Meisel 2 psychiatric unit on 10/10/12. Review of the medical record indicates that the patient was placed on a PRN dose of Haldol 10 mg twice a day as well as several mood stabilizers and PRN Haldol 2 mg IM ( intramuscular) every 4 hours for agitation. There is no indication that the patient was offered the medication in the oral form before use of the IM form.

In each case there is no documenatation that the patient was offered the oral form of the medication, which would been less restrictive.

Based on review of the medical record and hospital policy and procedure, it was determined that the hospital failed to provide an order to ensure clinical justification for the restraint use for patient #10.

Patient #10 is an 87 year old male admitted to the psychiatric unit, Meisel 2 on 12/10/12. The patient required the use of a Lap Buddy restraint while up in a chair to protect him from harm. Review of patient #10's medical record revealed that there was no order for the Lap Buddy usage on 12/15/12, although the monitoring form revealed the restraint was used from 12 midnight to 3:00 pm.

Based on review of the medical record and hospital investigation, it was determined that the hospital failed to provide an order to ensure clinical justification for the restraint use for patient #10.

Based on review of policies and procedures, medical record review, and documented staff education and training, it was determined that the hospital lacked evidence of training for the Nurse practitioner and Physician Assistant to conduct the 1-hour face-to-face training.

The hospital provides the staff with training and requires demonstration of competency in the application of restraints, monitoring, assessment, and providing direct care for a patient in restraints. Review of the training program revealed that the licensed and non-licensed staff received basic training but no training regarding training on how to conduct the 1-hour face-to-face evaluation. The surveyor reviewed the competency and personnel files for the Nurse Practitioner, Physician Assistant and Physician, which included their basic training in seclusion and restraints through Healthstream and CPI training.

Based on review of the medical records and interview with staff it was determined that the hospital failed to assess a patient for two hours after administering mediactions for his behavior.

Patient #1 is an 83 year old male who was admitted to the Levindale Household Unit on March 13, 2012. Prior to admission Patient #1 had been living at home mainly independent. Patient #1 had also been diagnosed with Severe Alzheimer's Dementia with Cognitive Impairment and Visual Spatial decline.

Review of the medical record indicates that while on the Household Unit, Patient #1 had great difficulty adjusting to the unit. He was observed wandering in and out of other patient ' s rooms and was unable to comprehend boundaries. Documentation also indicates that Patient #1 had multiple periods of aggressive and combative behaviors and could not be redirected by care staff. Medication adjustments were made but Patient #1 continued to exhibit combative and aggressive behaviors. He was considered a danger to other patient's on the unit and was assessed as needing a more structured setting with supervision.

As a result, on April 12, 2013 Patient #1 was transferred to the Chronic Hospital's Behavioral Health Unit for continued monitoring of his aggressive behaviors and medication management. However, documentation indicates that Patient #1 continued to wander into other patient's rooms, required maximal staff assistance with prompting for him to eat and drink. He also was unable to comprehend and maintain standard safety measures.

Documentation indicates that staff continued to monitor and redirect Patient #1; however, on the evening of May 5, 2012 Patient #1 became very disoriented and aggressive with staff members. Subsequently at 8:13 PM, Patient #1 was administered 25 milligrams of Seroquel orally and 0.5 milligrams of Ativan IM. Documentation indicates that staff subsequently assisted Patient #1 into a wheelchair and placed him into his room.

On further review of the medical record, specifically, a nursing progress note dated 05/05/12 at 10:15 PM the note states that Patient #1 was found lying face down on his left shoulder after falling from the wheelchair. According to the nurse's note, at the time Patient #1 was found, a head to toe assessment was completed. Patient #1 was observed to be guarding his left shoulder. The nurse documented that Patient #1 was subsequently assisted to bed and the nurse practitioner was notified.

There was some conflicting documentation in the nurse practitioner's progress note dated 05/05/12 at 11:05 PM, which stated that Patient #1's fall occurred when he got out of bed by himself, fell onto a chair, and was found lying across the chair with his left arm and shoulder as the area that appeared to have struck the chair first. The documentation by the nurse practitioner also indicates that an assessment was completed and at that time the nurse practitioner found that Patient #1 had a swollen, tender area to the left mid-supraclavicular region (above the clavicle) and was also unable to elevate his left arm without wincing.

Orders were written and Patient #1 was administered 800 milligrams of Motrin. An ice pack was applied to the left shoulder and patient #1 was transported to the emergency department for a stat X-ray of the left shoulder. Results were positive for a left comminuted fracture of the mid portion of the clavicle.

However, there is no documentation or indication that prior to being found on the floor, staff had attempted to assist Patient #1 into bed or had come back to check on him between the time he was placed into his room and later found injured on the floor of his room.

Based on review of 1 out of 7 open medical records and hospital policy and procedure, it was determined that the physician failed to authenticate a telephone order promptly.

Patient #7 is a 54 year old female admitted to the hospital psychiatric unit, Meisel 2 on 11/9/12. During the admission process, it was determined that the patient's health care agent was confused and not able to give informed consent. The hospital social worker and legal department became involved and guardianship was pursued through the Department of Social Services (DSS).

Based on 11/21/12, a telephone order was written at 2055 (8:55pm) for Haldol 5 mg IM now for severe agitation and Ativan 1mg IM now for severe agitation. The order was read back, transcribed, faxed and signed off by the nurse accepting the order. As of the survey 12/18/12, the order had not been authenticated by the physician.

Based on a tour and observation of the Meisel 2 psychiatric unit, it was determined that the facility failed to maintain and store equipment for patient use in a manner that would maintain the safety and quality of the equipment for patient use.

During the unit tour, the surveyors inspected the equipment storage room. On entering the room, the surveyors noted a strong smell of urine and multiple stains on the carpet. Several pieces of paper and other debris were noted on the carpeted floor. Multiple wheelchairs and wheelchair parts (foot-rest) had been placed in the room with very little room for entry making it hazardous for staff to retrieve wheelchairs and other equipment for patient use.
On further observation the surveyors also noted a stand- on hospital scale that had broken, torn and missing pieces of safety molding around the base where the patient would stand. There was also a broken rolling blood pressure cuff that had not been tagged for repair.

On further observation of the unit and the equipment, the surveyors noted a chair scale that had a missing screw at the base of right rear leg. Further observation revealed that the original screw had been replaced with a larger screw that was not holding the leg in place and the surveyors were able to lift the leg up from the holding bracket making the chair unstable for patient use. The base of the scale was also in disrepair with gray peeling plastic.
In addition, the surveyors also noted broken and cracked safety molding around the following patient room doors 290, 292, 294, 296, and 298.