**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, and staff and physician interview hospital nursing staff failed to escalate observations and change in assessments for 1 of 6 Behavioral Health patients awaiting placement in the Emergency Department (Patients #5). The findings included: Review of the hospital's policy titled, Assessment and Reassessment, 1PC.ADM.0013, revised 06/28/2021 revealed ... SECTION VI: EMERGENCY DEPARTMENT... B. The priority of data collection is determined by the patient's immediate condition ... E. Reassessment ... Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition ... 2. Exceptions: Patient with a provisional psychiatric diagnosis, including patients presenting with potential harm to self or others, should have vital signs and assessment documented a minimum of once per shift or more frequently if patient experiences changes in behavior ... Review of the hospital's policy titled, Fall Prevention and Post Fall Care Guidelines 1PC.ADM.0004.01, revised 05/2021 revealed, ... High Risk Fall Prevention Algorithm High fall risk patients ... do NOT leave in bathroom unattended! ... Post Fall Care ... Documentation A. Document known details of the fall B. Patient assessment findings and any interventions ... D. Communication with LIP/AP; included orders and interventions E. Communication with family/significant other ... Review of the hospital's policy titled, Patients at Risk for Suicide in Non-Behavioral Health Settings: Identification and Monitoring 1PC.PSY.0102, revised 07/2021 revealed, ... Additional suicide interventions for moderate and high risk ... Staff member accompany the patient to the bathroom and maintains line-of-sight at all times ... Review of the hospital's policy titled, Documentation and Guidelines for Practice, 1NR.NSA.001, last revised 06/28/202 revealed, ... 3. Document significant changes in assessment findings and report them to the LIP/AP [Licensed Independent Practitioner/Advanced Practitioner] as appropriate ... Closed record review revealed Patient #5 was a [AGE]-year-old male who presented to the Emergency Department [ED] on 08/25/2021 at 2233 via Law Enforcement, under Involuntary Commitment (IVC). Review of the IVC paperwork revealed the patient was ... assaulting his care workers, headbutting the concrete, and walking into traffic. Respondent has stated that he is suicidal. Review of the Electronic Physician Orders revealed, Suicide Precautions, Camera Obs [observation] (1:1 not indicated) was ordered by Physician Assistant (PA) #1 at 2236. Review of the ER Report by PA #1, dated 08/25/2021 at 2237, revealed the patient's Problem List/Past Medical History included Pan[DIAGNOSES REDACTED] (condition in which the pituitary gland stops making most or all hormones). Review of the Physical Exam revealed ... Neurological: Alert and oriented to person, place, time, and situation, no gross motor or sensory deficit observed ... Review of the ED Triage RN assessment by RN #7, dated 08/25/2021 at 2256 revealed ...Endocrine Hx [History] ED: Diabetes, Other: [DIAGNOSES REDACTED] ... ... Morse Fall Risk History of Falling Immediate or Within Last 3 Months: No ... Score: 15 Morse Fall Risk Level: Low Risk ... Problems (Active) ... Pan[DIAGNOSES REDACTED] ... Mental Health Status ... Behavioral Health Emergency: CCSRS [Columbia Suicide Severity Scale: tool used to assess suicide risk] indicates Moderate or High Risk of Harm ... Suicide Risk Assessment ... Suicide Risk Level Score: 8 ... Suicide Risk Level: Moderate Risk... Review of the lab results at 2258 revealed: Sodium: 139, Potassium: 4.5, Chloride: 101, BUN: 14, Creatinine: 1.32 (H), Calcium: 10.2, Protein: 8.0, Albumin 4.2, ALT: 16, AST: 22, Osmolality: 276. Review of the Triage Mental Status Exam nursing assessment by RN #7, dated 08/25/2021 at 2307, revealed the patient was alert and oriented x4, with no communication deficits and cooperative. Review of the nursing assessment by RN #7, on 08/25/2021 at 2117 revealed, Patient #5 was alert and oriented x4, no communication deficits, anxious mood, appropriate thought process, cooperative and well groomed. Review of the Morse Fall Risk Scale assessment revealed Morse Fall Risk Score: 15, Morse Fall Risk Level: Low Risk. Further review of the assessment revealed at 2307, RN #7 noted Musculoskeletal WDL. Review of the Triage Mental Status Exam revealed on 08/26/2021 at 0453, the Licensed Clinical Mental Health Counselor (LCMHC) #1 noted Patient #5 was oriented x4 and Well Groomed. At 0925, RN #12 noted his mood as Anxious, Depressed, appropriate thought process, cooperative and Well Groomed, Musculoskeletal WDL. At 2117, RN #1 noted his mood as Anxious, Irritable, Tearful and Restless, Musculoskeletal WDL. Review of a provider ER Report note by MD #6, dated 08/27/2021 at 0757 revealed, ...When I went to round on him this morning, he was laying on his stomach he said he could not move his back was hurting. He could not rollover on his own. With the nurse we helped him rollover and then later he was able to sit up. He may have just had some spasm and tightness in his back. He is now sitting up and doing better. I did order some ibuprofen for him ... Review of the Electronic Physician Orders revealed Ibuprofen 800 mg by mouth now was ordered at 0755 and administered at 1132 (3 hours, 37 minutes later). Review of the nursing assessment by RN #11, dated 08/27/2021 at 1134 revealed, the patient was noted as Anxious, Elated, Irritable, Sad ... Jittery, Pacing, Restless on the Triage Mental Status Exam, Musculoskeletal WDL. At 2025, RN #11 noted Mood - Anxious, Elated, Irritable, Sad, Tearful, Thought Process ... Impaired Focus/Concentration, Obsessive, Paranoid, Racing Thoughts Behavior ... Jittery, Pacing, Restless, Attention Seeking, Disruptive, Manipulative, Paranoid ... Musculoskeletal WDL. Review of the ED provider and nursing documentation revealed no noted notification of the patient's change in behavior. Review of the medical record revealed there were no documented nursing assessments noted 08/28/2021 and 08/29/2021. Review of the ER Report note by MD #5, dated 08/29/2021 at 0028 revealed, ... Over the course of the night he did become slightly agitated and was shouting at nurses. He received oral medications with good effect and rested comfortable over the course of the night. Review of the Triage Mental Status Exam nursing assessment by RN #4, dated 08/30/2021 at 0900 revealed Patient #5 was alert and oriented x4 with no communication deficits, Musculoskeletal WDL and Moves All Extremities Well. Review of the medical record revealed there was no documented nursing assessment for the 7p-7a shift per policy. On 08/31/2021 at 0818, RN #6 noted Thought Process - Helpless ... Mood - Anxious ... Musculoskeletal WDL ... Morse Fall Risk Score: 15 ...Low Risk ... Broset Numeric Score: 0. Review of the medical record revealed there was no documented nursing assessment for the 7p-7a shift per policy. Review of the ER Report revealed on 09/01/2021 at 1006, MD #6 wrote, ... He has no complaints this morning other than his glasses seem dirty and his whole body aches ... Review of the medical record revealed no noted intervention for the patient's complaint of body aches. Review of the medical record revealed there was no documented nursing assessment noted 09/01/2021 per policy or intervention following the patient's complaint of body aches. Review of the Triage Mental Status Exam revealed on 09/02/2021 at 0840, RN #5 noted Mood - Anxious; Thought Process - Helpless; Behavior - Restless, Attention Seeking, Manipulative, Paranoid ... Musculoskeletal WDL... Broset Numeric Score: 0. Review of the Morse Fall Risk Scale assessment by RN #5 on 09/02/2021 at 0900 revealed Morse Fall Risk Score: 35... Moderate Risk. Review of the ER Report revealed at 1013, MD #1 wrote, ... This morning, the patient complains of some calf pain and blurry vision. He says he is uncomfortable when he is sleeping. We will give him Tylenol and ibuprofen. Review of the ED provider and nursing documentation revealed no noted provider notification of the patient's complaint of weakness and pain. At 1548, MD #7 noted, ...He is ambulatory, eating normally during my shift and voices no current complaints other than wanting to leave the ER as he has been here several days ... Review of the medical record revealed there was no documented nursing assessment noted for the 7p-7a shift per policy. On 09/03/2021 at 0524, MD #8 wrote ... Upon my assessment, he is resting comfortably. He is easily arousable, denies acute complaints. Remains cooperative ... At 0718, MD #9 wrote, ... He is in stable condition this morning and expresses all needs are being met. He unfortunately stumbled in the bathroom this morning and struck his face. He did not have LOC [loss of consciousness] and has not had any concussion symptoms. No cephalohematoma [accumulation of blood under the scalp], battles [sic] sign or raccoon eyes. He did have minor epistaxis [nosebleed] and sustain [sic] an upper lip hematoma [bruise]. He does not have any facial tenderness, bruising or deformity. Epistaxis was minor from b/l [bilateral] nares and easily controlled with afrin [nasal spray used to treat nasal congestion] and pressure. No septal [area between nostrils] hematoma. No dental injuries noted. No malocclusion [abnormal alignment] or trouble opening jaw. PERRL [Pupils Equal, round, Reactive to Light], EOMI [Extraocular (eyes) Movements Intact]. He is provided tylenol. Review of the Morse Fall Risk Score assessment by RN #6, at 0752 revealed Fall Risk Score: 60 ... High Risk. Review of the medical record revealed there was no noted documentation of known details of the fall, patient assessment findings and interventions, provider, guardian, and supervisor notification, Fall Risk Assessment, or evidence of a post-fall debrief meeting by nursing per policy. Review of the nursing assessment by RN #6, dated 09/03/2021 at 0832 revealed, Triage Mental Status Exam revealed on 09/03/2021 at 0832, RN #6 noted Mood - anxious; Thought Process - Helpless; General Appearance - Appropriate, Musculoskeletal WDL Yes, Except For pain all over, states he feels he is getting weak and having pain from being here so long ... Broset Numeric Score: 0... Review of a Mental Health Contact Note by the Licensed Clinical Social Worker (LCSW), at 1007 revealed, ... Patient appeared groggy and tired. He reported that he had fallen earlier for the third time since his ED admission. Patient stated that he has been feeling weak when he gets up and then falls. Patient had visible blood from his nose and in the corner of his mouth which she [sic] complains resulted from his last fall. Patient stated that because he is not active he gets tired and sluggish. It is unclear at this time patient [sic] has been medicated which is contributing to his grogginess ... Review of the ER Report revealed at 2350, MD #7 wrote, ... Patient had fallen in the bathroom earlier today. On my evaluation he is ambulatory, talking, no active bleeding from bilateral naris [sic] ... Review of the medical record revealed there was no documented nursing assessment for the 7p-7a shift per policy. Review of the ED provider and nursing documentation revealed no noted provider or nursing notification by the LCSW of the patient's report of multiple falls since admission and noted grogginess. Review of the nursing assessment by RN #10, dated 09/04/2021 at 0638 revealed, Triage Mental Status Exam Orientation - Oriented x4, Identifies self, Level of Consciousness - Alert, Awake, Communication - Delayed, Pressured, Stutters ... Musculoskeletal WDL - Yes, Except For: Pt has weak gate [sic] and often stumbles over his own [sic] ... Broset Numeric Score: 1 ... Confused Review of the ED provider and nursing documentation revealed no noted provider notification of the patient's change in speech, altered gait, change in the Broset score secondary to noted confusion or Fall Risk Assessment per policy. At 0827 on 09/04/2021, MD #9 wrote ... He is in stable condition this morning but says he feels 'weak all over' and he continues to slump onto the floor and require staff to help him back up. He is seen ambulating and performing ADLs [activities of daily living] without any difficulty at other times. Review of the nursing documentation revealed the patient's risk for violence was assessed at 0900 by RN #4, Broset Numeric Score: 1 ... Confused Review of the medical record revealed there was no additional documented nursing assessment for the 7a-7p shift or provider notification of the change in the Broset score secondary to confusion. Review of the Triage Mental Status Exam assessment by RN #10, on 09/05/2021 at 0236 revealed, Orientation - Oriented x4, Identifies self, Level of Consciousness - Alert, Awake, Communication - Slurred, Stutters ... At 0918, RN #6 also noted that Patient #5's Communication as Slurred, Stutters ... Review of the ER Report revealed at 1553 MD #9 wrote, ... He is in stable condition this morning. Review of the ED provider and nursing documentation revealed no noted notification of the patient's change in speech. On 09/06/2021 at 0123, MD #3 wrote ... Patient has been calm and cooperative with staff, no issues. Patient is sleeping on exam tonight. Review of the Triage Mental Status Exam nursing assessment by RN #10, on 09/06/2021 at 0406, revealed Orientation - Oriented x4, Identified self; Level of Consciousness - Alert, Awake; Communication - Slurred; Mood- Anxious; Thought Process - Delayed Associations, Helpless; Behavior - Intrusive, Attention Seeking, Dependent, Limit testing, Self endangering; General Appearance - Disheveled, Poor hygiene Review of the ER Report by MD #10 at 0751 revealed ... Medical Decision Making - Documents reviewed: Emergency department nurses' notes, flowsheet, emergency department records, Psychiatric consultation notes. Reexamination/Reevaluation Course: unchanged. Pain status: unchanged. Assessment: Resting, cooperative, vitals stable. Interventions: awaiting psychiatric disposition. Review of the medical record revealed there was no documented nursing assessment for the 7a-7p shift per policy. Review of the ED provider and nursing documentation revealed no noted notification of the patient's change in thought process, slurred speech, behavior and general appearance. Note: Review of an incident report dated 09/06/2021 at 1030, revealed RN #2 noted the patient was left unattended in the bathroom and fell . Review of the nursing documentation revealed there was no documented nursing assessment for the 7a-7p shift per policy, details of the fall, patient assessment findings and interventions, provider, guardian, and supervisor notification, or evidence of a post-fall debrief meeting by nursing per policy. Review of the ER Report revealed on 09/07/2021 at 0419, MD #3 wrote, ...No issues throughout the night, patient sleeping on exam. Review of the Vital Signs at 0525 revealed Temperature: 101.0, Heart Rate: 184, Respirations: 48, Blood Pressure: 152/92, SPO2: 97% on room air. Review of the Laboratory results at 0545 revealed: Sodium: >170, Chloride: 142, BUN: 49.0, Creatinine: 2.07, Protein: 8.7, ALT: 131, AST: 305, Troponin: 0.04, Osmolality: >349, Lactic Acid: 4.54. Review of Nurse Notes at 0647, revealed RN #7 wrote Staff went to check patients' blood glucose and observed pt was not talking and felt hot to touch. Upon assessment pt was found to be febrile with increased respirations. Fingertips blue and mottling to all extremities. Pt was moved to a medical room for further evaluation and treatment. At 1028, MD #3 wrote, I was alerted by nursing staff that the patient had developed a temperature here [at 0551]. Upon assessment patient is febrile and tachycardic [rapid heart rate]. He is tachypneic [rapid breathing] and breathing 40-50 times a minute. He has dry mucous membranes and mottling [blotchy, red-purplish marbling of the skin caused by the heart no longer being able to pump blood effectively] to his upper extremities and lower extremities bilaterally. He will groan occasionally but will not follow commands and will not make any purposeful movements. Febrile, tachy [tachycardic] to 180s Mottled extremities Dry mucus membranes Patient would not follow commands but will moan occasionally Abdominal TTP [Tenderness to Palpate] No leukocytosis [high white blood cell count] at this time however labs appear hemoconcentrated [thickened due to the loss of fluid] so I suspect with fluid resuscitation [correction] he will develop a leukocytosis. He does have an elevated lactate here [caused by impaired tissue oxygenation]. Elevated creatinine [signifies impaired kidney function], hypernatremia [high concentration of sodium in the blood], Transaminitis [elevated liver enzymes], No acute process on CXR [Chest Xray], Covid negative, EKG with sinus tachycardia; elevated trop [troponin: indicative a heart damage], No acute process on CT [CT Scan]. I did attempt to sedate the patient with ketamine [anesthetic] and try to proceed with an LP [lumbar puncture]. I was unable to obtain CSF [Cerebrospinal Fluid] studies [tests used measure chemicals in the spinal fluid]. My colleague pointed out that the patient has not received his DDAVP in [sic] the entire time has been [sic] in the ER which is nearly 300 hours at this time. Explained his elevated sodium and altered mental status. Patient has been covered with broad-spectrum antibiotics to cover for meningitis [inflammation of brain and spinal cord membranes, typically caused by infection] in addition to acyclovir [antibiotic]. CT abdomen is still pending. I have spoken to [Hospital B] direct to help facilitate transfer as I feel that the patient will need ICU [Intensive Care Unit] level of care. Review of the medical record revealed there was no documented nursing assessment noted during the 7a-7p shift per policy. Review revealed Patient #5 was transferred to a higher level of care on 09/21/2021 at 1814. Review of an incident report, dated 09/03/2021 at 0710, revealed RN #6 noted, Fall from bed, witnessed by staff [virtual sitter]. Mobility status at time of fall: Ambulatory - Unlimited no Assistance. Time of last fall risk assessment: >1 week. Last fall risk assessment score: Morse score 35 - Moderate Risk. Fall risk assessment score post fall: Morse score 60 - High Risk Fall safety. Precautions in place a time of fall? Yes ... Pt [Patient] states when he went to stand up this morning, his legs were wrapped up in blanket and he fell forward, Pt states he hit his face and now has a nosebleed. Pt [MD #3], made aware [sic]. Afrin spray administered to pt and nose clamp applied to his nose. Bleeding stopped after treatment. [ED Nurse Manager] and [RN #13] house supervisors made aware ... Contributing Factors: Mobility/balance/strength issues Immediate Actions: Phy [physician] Notified, Reinstruction of Family Member/visitor, tx [treatment] provided ... Notified/Witnesses: [Patient Safety Assistant: PSA #1] (Sitter watching cameras when patient fell ). [RN #14] Nurse of pt. from night shift checked on pt after fall and notified myself. [MD #9] notified. Review of an incident report, dated 09/06/2021 at 1030, revealed RN #2 noted, Fall while standing, Intentional Fall, Unwitnessed. Location: Tub/shower room [bathroom]. Amb. [Ambulatory] limited with assist. Time last fall risk assessment: 12-14 hr. [09/03/2021 at 0752 (72 hours, 38 minutes)] Last fall risk assessment score: 55 [last noted fall risk assessment score was noted as 60]- High Risk. History falls last month? Yes Fall risk assessment score post-fall .... 55 - High Risk Fall safety precautions in place at time of fall? Yes ... Patient was assisted to the bathroom in the BH [Behavioral Health] unit. I got the patient to the toilet and [sic] the patient sat down. He asked me to stop put [sic] and shut the door. As soon as I closed the door, I heard him scream 'Oh F**k and heard a loud noist [sic]. The patient was found on the floor, on his back, on the other side of the bathroom, with his head towards the wall. Contributing factors: 4 Ps not addressed (paint, potty, position, possessions) [sic], Unattended during toileting. Immediate Actions: Physician Notified. Fall Precautions in place at time of fall: High risk interventions in place. Low risk interventions in place. Other safety precautions in place at time of fall: Gripper socks and assisted to bathroom ... The patient has been doing things like for [sic] the last several days for attention. Review of the incident report revealed nursing staff left the patient unattended in the bathroom and failed to follow hospital policy. Interview on 10/15/2021 at approximately 0930, with the Interim Chief Nursing Officer (ICNO), Clinical Professional Development Educator and Director of Accreditation, revealed that following discussion of the findings in Patient #5's record review with the State Agency during the onsite investigation and ongoing improvement initiatives, an opportunity had been identified for nursing regarding escalation of concerns and change in patient assessment on 10/14/2021. Interview on 10/15/2021 at 1605 with RN #2 revealed he was Patient #5's assigned nurse during the 7a-7p shift on 09/06/2021. Interview revealed, He was still somewhat with it. I noticed some sort of decline. He could still walk but you had to stay with him. Interview revealed RN #2 assisted Patient #5 to the bathroom on 09/06/2021, stepped out and shut the door, and heard a thump. When the nurse opened the door, Patient #5 was found lying on his back in the floor. RN #2 shared that he assessed Patient #5, got him into a wheelchair, and that he was fine. It was my first time caring for psych [psychiatric] patients. Interview revealed the off-going nurse reported that Patient #5 was Kinda going the wrong way ... more lethargic. Would come out onto the hall, was attention seeking. He was sitting in the wheelchair and urinated on himself, but he was following commands. Interview revealed RN #2 got Patient #5 in the shower and helped him bathe. I made him do it. It took him a while and I helped but I made him do it. Interview revealed RN #2 verbally notified the provider of the patient's fall, He ask 'How's he look, and I said looks ok. Now, if he rounded on him and checked on him, I guess. They're supposed to check on him. Interview revealed RN #2 did not inform the provider that the patient had urinated on himself or the reported increase in lethargy. Interview revealed, Nursing assessments are supposed to be done every shift. Interview with RN #2 revealed that a post-fall assessment or physician notification was not recorded in the medical record per policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review and staff interviews, the hospital nursing staff failed to ensure a rejected medication order was reconciled and to notify the LIP/AP or pharmacy per policy resulting in drug omission errors for 1 of 2 Behavioral Health patients with rejected medication orders in the Emergency Department (Patient #5). The findings included: Review of the hospital's policy titled, Medication Orders, 1MM.MED.0012, revised 04/16/2021 revealed ... GENERAL INFORMATION ... F. All medication orders are reviewed independently for appropriateness by a pharmacist and the nurse prior to administration ... Nursing Responsibilities ... The nurse should understand the intention of each medication ... 3. Periodically check for unverified or rejected orders that require clarification and attempt to complete ... ORDER CLARIFICATION A. Nursing Responsibilities ... 1. Identify medication order which needs to be clarified, either via phone or call from Pharmacy, note on a rejected order ... 2. Contact ordering licensed independent practitioner or advance practitioner (LIP/AP) ... 4. When nursing gets a rejected order on eMAR [electronic medication administration record] ... review details for reason for rejection ... 5. Modify the rejected order ... Review of the hospital's policy titled., Medication Errors, 1IM. MED.0010, revised 02/12/2019 revealed, POLICY: A. All medication errors (as defined below) require completion of a report via [Hospital] online reporting system ... DEFINITIONS ... A. Medication Error: A medication error is any preventable event that may cause or lead to....Patient harm while the medication is in the control of the health care professional ... Closed record review revealed Patient #5 was a [AGE]-year-old male who presented to the Emergency Department [ED] on 08/25/2021 at 2233 via Law Enforcement, under Involuntary Commitment (IVC) for ... assaulting his care workers, headbutting the concrete, and walking into traffic. Respondent has stated that he is suicidal. Review of the ER Report by PA #1, dated 08/25/2021 at 2256, revealed the patient's Problem List/Past Medical History included Pan[DIAGNOSES REDACTED] (condition in which the pituitary gland stops making most or all hormones) and Home Medications (16 Active) included DDAVP (Desmopression) Nasal 10 mcg/inh nasal spray 10 mcg = 1 spray, Alternate Nostrils, BID (used to treat Diabetes Insipidus: condition that causes an imbalance of fluid in the body). Review of the 'Electronic Physician Orders, dated 08/26/2021 at 1552, revealed Desmopressin (DDAVP Nasal) 10 mcg, Nasal Spray, Alternate Nostrils, BID (twice daily) was ordered by the ED Physician Assistant (PA #2). Review of the Order Comment revealed at 1558, the order was rejected by the Pharmacist (Pharm #1) following order verification with note stating, reject reason: non-stock. Please have patient/family bring in and send to pharmacy for identification. Further review of the order history revealed at 1737, another Pharmacist (Pharm #2) modified the Order Comment and noted, reject reason: non-stock. We have injectable despopressin [sic] 4mcg/1ml. May give 1 mcg (1/10th dose of nasal formulation) subcutaneously BID. Review revealed the ordered was reviewed and acknowledged by the Registered Nurse (RN #1) on 08/26/2021 at 2117. Review of the Medication Administration Record (MAR) revealed Desmopressin (DDAVP Nasal) 10 mcg, Nasal Spray, BID was added as a routine scheduled medication on 08/26/2021 at 1552. Review revealed reject reason: non-stock. We have injectable despopressin [sic] 4mcg/ml. May give 11 mcg (1/10th dose of nasal formulation) subcutaneously BID was noted on the scheduled medication. Review of the Desmopressin Admin [Administration] Details on 08/29/2021 at 2009 RN #3 noted (Not Given) Medication Unavailable; on 08/30/2021 at 0900, RN #4 noted, (Not Given) Medication Unavailable; on 09/02/2021 at 0824, RN #5 noted, (Not Given) Medication Unavailable; and 09/05/2021 at 0913 and 1050, RN #6 noted (Not Given) Medication Unavailable. Further review of the MAR revealed no nursing notation on the scheduled Desmopressin 08/26/2021-08/28/2021 (5 scheduled doses with no nursing documentation addressing reason for omission); 08/29/2021 for the 0900 scheduled dose (1 scheduled dose with no nursing documentation addressing reason for omission); 08/30/2021 for the 2100 scheduled dose (1 scheduled dose with no nursing documentation addressing reason for omission); 09/01/2021 (2 scheduled doses with no nursing documentation addressing reason for omission); 09/02/2021 for the 2100 scheduled dose (1 scheduled dose with no nursing documentation addressing reason for omission); 09/03/2021-09/04/2021 (4 missed doses with no nursing documentation addressing reason for omission); 09/05/2021 for the 2100 dose (1 missed dose with no nursing documentation addressing reason for omission); or 09/06/2021 (2 missed doses with no nursing documentation addressing reason for omission). Review revealed 23 scheduled doses of Desmopression were not administered per physician order. Review of nursing progress notes revealed there was no documentation of provider or pharmacy notification of the missed doses or attempts to clarify the rejected order per policy. Review of provider progress notes revealed there was no documentation noting notification from nursing of the missed doses addressing the need for resolution of the rejected order per policy. Interview on 10/12/2021 at 1510, with the Division Director of Risk, Claims, and Litigation, Interim Chief Nursing Officer (ICNO) Pharmacy Director, Chief Executive Officer (CEO), Clinical Professional Development Educator, Acute Care Team Lead (ACTL) ... revealed following review of the events leading up to 09/07/2021, the ED Medical Director (MD #1) and Risk Management determined a Serious Safety Event had occurred. Interview revealed the hospital's accrediting body was notified on 09/29/2021 ... and that a Root Cause Analysis (RCA: analysis conducted to identify the root cause of a problem or event) was conducted 09/16/2021. Interview revealed when an order is rejected, an icon appears that flags in the MAR summary. The Pharmacist spoke with the patient's nurse [RN #1] and verbalized that alternative recommendations. Interview revealed Pharm #2 attempted to notify the provider first by calling the ED, went to the ED to speak with them directly but was unable to do so, and reported the recommendation to Patient #5's nurse. Interview revealed the provider was not notified of the rejected order and that it was not until 09/07/2021, following a change in condition, that providers became aware that the DDAVP had not been administered in 9 days. The provider reviewed the record and noted the patient [Patient #5] had symptoms of [DIAGNOSES REDACTED] Review of documents presented during a team meeting on 10/12/2021 at 1510, included an Administrative Timeline, education materials titled, It Happened Here, summary of the hospital's Hand off Communication (1PC.ADM.0005) policy, Importance of Event Reporting education. 1. Review of the Administrative Timeline revealed no education to nursing staff of their responsibility in reconciling rejected medications prior to the State Agency onsite investigation. 2. It Happened Here 10/1/2021 Situation: Pt required intubation and transfer to a higher level of care after home medication was rejected for continued administration while in the ED. Background: Patient was in ED waiting for placement at inpatient psychiatric facility. Medication Reconciliation was completed. However, Desmopressin (DDAVP) was rejected by pharmacy. Patient later required intubation and transfer to higher level of care due to hypernatremia and altered mental status. Assessment: * Medication Reconciliation was completed and order was placed to continue patient's Desmopressin (DDAVP) * Desmopressin (DDAVP) was rejected by pharmacy due to route ordered being unavailable ... *Nursing documentation reflected that medication was not being administered due to medication being unavailable * Nursing unfamiliar with medication and its indications for use. * Variation in review of medications when performing hand off of care to include any rejected medications Recommendation ... * Medications to be reviewed with each hand off of care (RN and MD) ... Review of the education handout, received on 10/12/2021, revealed no education related to nursing staff's role and responsibility in notifying the provider of a rejected medication order. 3. Review of Hand off Communication policy, received on 10/12/2021, revealed no education related to nursing staff's role and responsibility in notifying the provider of a rejected medication order. 4. Review of an RCA Chart, received 10/12/2021, revealed nursing's role and responsibiliy in notifying a provider of a rejected medication order was not identified. Interview on 10/15/2021 at 1100 with RN #1 revealed she was Patient #5's assigned nurse during the 7p-7a shift on 09/26/2021. Interview revealed, I remember seeing Pharmacy down there [in the ED] but it's been so long ago, I can't remember what she said. Interview revealed RN #1 could not recall if she notified Pharmacy or the provider of the rejected medication, was not aware of nursing's responsibility to contact the ordering provider of a rejected order and to clarify, if possible, per policy resulting in 23 missed doses of Desmopressin. Interview on 10/15/2021 at 1605 with RN #2 revealed he was Patient #5's assigned nurse during the 7a-7p shift on 09/06/2021. Interview revealed RN #2 saw Patient #5 had a scheduled dose of Desmopressin on the MAR and asked, Hey we got this med? RN #2 could not recall who he asked but shared they replied, 'We don't have it' so I didn't give it. During the interview, RN #2 was asked if he notified Pharmacy or the provider of the rejected Desmopressin order and number of missed doses and stated, He [Patient #5] was here 4-5 days before me. What's my reporting going to do for it? I mean, if it wasn't important enough for them [Pharmacy and ED Providers] by then, I didn't think it was a big deal. I didn't know what Desmopressin was for. Interview with RN #2 revealed he was not aware of nursing's responsibility to contact the ordering provider of a rejected order and to clarify, if possible, per policy, resulting in 23 missed doses of Desmopressin. NC 680
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of the hospital's policy and procedures, Health Care Power of Attorney (HCPOA) documentation, medical record review, and staff interviews, the hospital staff failed to notify a patient's Health Care Power of Attorney (HCPOA) of the need for restraint for 1 of 1 patient requiring the use of non-violent restraints with a designated HCPOA (Patient #2). The findings included: Review of the hospital's policy, Restraint Use - Non-Violent, Number IRI.ADM.0004, revised 12/14/2016, on 03/10/2020 revealed ...Nonviolent, non-self-destructive behavior are those behaviors resulting from confusion, disorientation.... that the patient is not responsible for safe decision-making and may cause accidental harm self or others. The patient may be interfering with medical interventions or may be compromising their safety/wellbeing. ... Documentation ... e. When appropriate, notification of family/legally responsible representative. ... Review on 03/11/2020 of Patient #2's Health Care Power of Attorney document provided by the hospital's accreditation team revealed it was signed by the patient and witnessed by a Notary Public on 05/19/2005. Closed medical record review on 03/10/2020 revealed a [AGE]-year-old presented to the hospital's emergency room (ER) via Emergency Medical Services (EMS) on 12/11/2019 at 1726 with altered mental status (Patient #2) and transferred to another hospital, per the family's request, on 12/12/2019 at 2233. Review of the ER provider note by MD #1 revealed that when upon arrival to the ER, the patient seemed to have some confusion. She also reported, ...that the left side of her head is [sic] hurt all day today ... Head CT (computed tomography) is negative. Labs reassuring. No evidence of infection on her urine ... (Family member) is here and think [sic] she is slightly confused which seems to come and go as well. ... Review revealed Continuous Cardiac Monitoring was initiated at 2206 by a Registered Nurse (RN #1), prior to the patient's transfer to the Acute Care Medical Surgical Unit. Review of the Cardiac Monitor Event Log, dated 12/12/2019 at 0129, revealed a note by the Cardiac Monitor Unit Technician (CMUT) stating, called (RN) about leads off in 213 (Patient #2's room). pt ripping leads off. Review of a nursing note by RN #2 on 12/12/2019 at 0145 revealed, pt (Patient) is agitated and won't keep gown or leads [cardiac monitor] on. needing something for anxiety. Review revealed MD #2 was notified and ordered Ativan [sedative used to treat anxiety] 0.5 mg IV push [administered in the vein] at 0145. Review of the Non-Violent Restraints note at 0200 by RN #2 revealed, the patient became agitated and attempted to hit staff. MD #2 was notified at 0200, and the patient was placed in Non-violent, bilateral soft wrist and ankle restraints at 0200. Review revealed the patient remained in Non-violent restraints until 0858, when the HCPOA arrived. Review of a Physical Therapy (PT) note by PT #1, on 12/12/2019 at 1153, revealed ... Per RN, pt's family very upset due to pt being placed in restraints overnight without family's acknowledgement. ... Review failed to reveal documented notification of the HCPOA of the need for Non-Violent Restraint per hospital's policy. Interview with the Director of Accreditation (DA), on 03/11/2020 at 1000, revealed RN #2 (RN who initiated the Non-Violent restraints) was no longer an employee of the hospital and was not available for interview. Interview with RN #3, on 03/11/2020 at 1143, revealed she was Patient #2's primary nurse on 12/12/2019 during the 7a-7p shift. Interview revealed the patient's HCPOA was very upset when she came in and found the patient in restraints without her knowledge. Interview revealed, She wanted to know what was going on, why she wasn't notified (of the need for restraints) and wanted to speak with the doctor. Interview revealed RN #3 was not aware the patient's HCPOA had not been notified of the need for Non-Violent restraint use and that according to the hospital policy, the HCPOA should have been notified. Interview with MD #3, on 03/11/2020 at 1349, revealed the HCPOA was upset because she was not aware the patient had been placed in restraints during the night and wanted to know why she had not been notified. Interview revealed the hospital staff failed to notify the patient's guardian of the need for Non-Violent restraint per policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital policy and procedure, medical record review, and staff interview, the hospital's medical staff failed to document elements of the face-to-face assessment for 2 of 2 patients (Patient #3 and #10) following initiation of violent restraints per policy. The findings included: Review on 03/12/2020 of the hospital's policy, Restrain/Seclusion, CSG.CSG.001, effective 01/29/2020, revealed ... 9. Face-to face assessment by a Physician or LIP: a. A face-to-face assessment by a physician or LIP (Licensed Independent Practitioner), RN or physician assistant with demonstrated competence, must be done within one (1) hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will: 1) Work with the staff and patient to identify ways to help the patient regain control 2) Evaluate the patient's immediate situation 3) Evaluated the patient's reaction to the intervention 4) Evaluate the patient's medical and behavioral condition 5) Evaluate the need to continue or terminate the restraint or seclusion 6) Revise the plan of care, treatment and services as needed. ... Review om 03/12/2020 of the hospital's PROVIDER RESTRAINT EDUCATION: NEW POLICY JANUARY 29, 2020 training revealed, ... FACE TO FACE EVALUATION - DOCUMENTATION A physician face to face assessment within one hour of violent behavior restraint placement must be completed and documented. An AP (Advanced Practitioner) can complete the face to face assessment in place of the physician ... The physician or AP documentation for the Face to Face Assessment occurs in the Violent Restraint Powerplan in the Face to Face phase. ... 1. Open medical record review for Patient #3, on 03/12/2020 revealed a [AGE]-year-old male who (MDS) dated [DATE] at 1349 via law enforcement (LE) under Involuntary Commitment (court order). Review of the ER Report revealed, Per per [sic] staff who talked to alone for cement [sic] (law enforcement), patient reports that he did methamphetamine today, was at a drugstore that he was banned from and was seen attempting to pleasure himself in the area. He also reportedly threatened to rob the store. Law enforcement placed him on IVC stating that he was a harm to himself or others. ... Review of the nursing notes revealed on 02/29/2020 at 1627 the patient was Agitated, Threatening to leave, Suspicious, Threatening and was ordered Haldol (antipsychotic) 10 mg IM, Benadryl (antihistamine) 50 mg IM, and Ativan (Benzodiazepine) 2mg IM and a physical hold was utilized to administer the medications. Review of the restraint documentation by RN #4, on 02/29/2020 at 1754, revealed ... Restraints Violent Face to Face - Face to Face Completed within one hour by: MD/LIP/AP Face to Face completed by: (MD #6 name). Review failed to reveal documented evaluation of the patient's immediate situation, evaluation of the patient's reaction to the intervention, and evaluation the patient's medical and behavioral condition per policy. Interview with RN #4, on 03/13/2020 at 1300, revealed that the patient became upset and wanted to leave the ER. A Behavioral Emergency Response Team (BERT) call (consists of staff members from behavioral health services who have experience in caring for patients with acute psychiatric disorders as well as competence in management of assaultive or escalating behavior) was made when the patient's behavior began to escalate. The patient was held while the medications were administered. Interview revealed, the he (MD #4) was right there, assessing the patient while we administered the meds. Interview revealed nursing staff in the ER have historically documented that the Face to Face assessment was completed by the doctor as part of the restraint documentation. Interview revealed MD #4 did not document the Face to Face assessment per policy. Interview with the ER Medical Director (MD #5), on 03/13/2020 at 1400, revealed the physician is in the ER when a violent restraint is initiated. When a manual restraint is required for the administration of medication, It is conducted under the supervision of the physician. Once the patient is safe and stabilized, the face to face evaluation should be documented in the medical record by the physician. Interview revealed on 01/23/2020, during a Medical Staff meeting, the Chief of Staff informed physicians that the one-hour face to face assessment had been built into the medical record for physicians to complete and a mandatory training module was sent out for physicians to complete. Interview revealed physician's or APs are expected to document the one-hour face to face assessment for initiation of all violent restraints. Interview with the Director of Accreditation, on 03/13/2020 at 1600, revealed nursing staff in the ED note that the one-hour face to face assessment has been completed as a safety net to assure documentation of completion. Interview revealed training was disseminated in January to all providers regarding changes to the Restraint/Seclusion policy, with the expectation that physicians would document the face to face assessment in the medical record. Interview revealed elements of the face to face assessment was not documented per policy. 2. Closed medical record review for Patient #10, on 03/13/2020, a [AGE]-year-old with a history of methamphetamine abuse who presented to the ER via EMS with law enforcement (LE) on 02/12/2020 at 1923 due to substance abuse and combative and psychotic (disconnection from reality) behavior. Review of the ER report by MD #6, on 02/12/2020 at 2000, revealed ...According to EMS who received a report from the patient's girlfriend, the patient has been combative all day long hitting his face and head on the floor, rolling around, and has not been able to be redirected. His girlfriend states he has used cocaine and methamphetamines today ... He is asleep on ED arrival due to combative behavior with EMS he was given 2.5 mg of versed (used for sedation). Review of the Restraint documentation by RN #5, on 02/12/2020 at 2147, revealed the patient was placed in bilateral lower and upper limb restraints at 1950 for Combative, Danger to self and/or others, Destructive, Physical aggression, Violent behavior. Further review of the restraint documentation by RN #5 ... Restraints Violent Face to Face - Face to Face Completed within one hour by: MD/LIP/AP Face to Face completed by: (MD #6 name). Review revealed elements of the face-to-face assessment were not documented by the physician per policy. Interview with RN #4, on 03/13/2020 at 1300, revealed nursing staff in the ER have historically documented that the Face to Face assessment was completed by the doctor as part of the restraint documentation. Interview revealed MD #4 did not document the Face to Face assessment per policy. Interview with the ER Medical Director (MD #5), on 03/13/2020 at 1400, revealed the physician is in the ER when a violent restraint is initiated. When a manual restraint is required for the administration of medication, It is conducted under the supervision of the physician. Once the patient is safe and stabilized, the face to face evaluation should be documented in the medical record by the physician. Interview revealed on 01/23/2020, during a Medical Staff meeting, the Chief of Staff informed physicians that the one-hour face to face assessment had been built into the medical record for physicians to complete and a mandatory training module was sent out for physicians to complete. Interview revealed physician's or APs are expected to document the one-hour face to face assessment for initiation of all violent restraints. Interview with the Director of Accreditation, on 03/13/2020 at 1600, revealed nursing staff in the ED note that the one-hour face to face assessment has been completed as a safety net to assure documentation of completion. Interview revealed training was disseminated in January to all providers regarding changes to the Restraint/Seclusion policy, with the expectation that physicians would document the face to face assessment in the medical record. Interview revealed elements of the face to face assessment was not documented per policy. NC 131
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