Based on review of hospital policies and procedures, medical record reviews, observations and staff and physician interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to receive care in a safe setting and to ensure an effective nursing service to provide supervision and evaluation of patient care. Findings include: 1. The hospital failed to provide care in a safe setting by failing to secure the patient environment to prevent patient access to unattended saline flushes, failing to follow a physician order for liquid pain medicine, and failing to escalate observations and assessments to the physician. ~cross refer to 482.13 Patient Rights: Tag 0144 2. Hospital nursing staff failed to prevent access to unattended saline flushes, to provide a timely admission assessment to communicate the change in a patient's mood, and to escalate observations and assessments for 1 of 1 medical/surgical patients with a substance abuse history for 1 of 1 medical/surgical patients with a substance abuse history sampled. (Patient #6). ~cross refer to 482.23 Nursing Services: Tag 0395 3. The hospital failed to have an effective quality assessment and performance improvement program to analyze, track, and make improvement for patient safety by failing to monitor pharmacy modifications to physician orders to determine if they met approved parameters, and failing to evaluate actions and to implement a facility-wide response plan after a patient safety event. ~cross refer to 482.21 Quality Assessment and Performance Improvement: Tag 0286
Based on policy and procedure review, observations, medical record review, and staff and physician interviews, the hospital failed to promote and protect a patient's rights by failing to provide a safe environment for a medical/ surgical patient with a known history of substance abuse. Findings include: The facilty failed to provide care in a safe setting by failing to prevent unattended access to saline flushes, failing to follow a physician order for liquid pain medicine, and failing to escalate observations and assessments for 1 of 1 medical/surgical patients with a substance abuse history (Patient #6) ~cross refer to 482.13 Patient Rights' Standard: Tag 0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, and staff interview, the facility staff failed to provide care in a safe setting by failing to prevent patient access to unattended saline flushes, failing to follow a physician order for liquid pain medicine, and failing to escalate observations and assessments for 1 of 1 medical/surgical patients with a substance abuse history sampled (Patient #6). The findings included: Review of facility policy, Safety Precautions for the Patient with Behavioral Health Needs - All facilities revised 02/26/2018, revealed, ...B. All inpatients will receive routine assessments of mental status including assessment of safety. Patients should also be screened for safety issues after a potentially distressing event occurs such as, but not limited to ...bad news form a healthcare provider ... C. When a patient is identified as having serious safety concerns, immediate action must be taken to ensure the safety of that patient ... D. A high level of safety will be maintained in the patient's environment ... staff must be aware of hazard potential associated with such items and the patient will be monitored closely for unsafe behaviors. To make the care environment as safe as possible, the following precautions will be initiated: ... 2. To enhance safety of the environment, the patient room/environment should be checked at least once per shift and after the patient has had visitors: .... e. ... IV supplies must be removed from room .... Review of facility policy, Pharmacist Clinical Expectations and Guidelines revised 04/01/2013, ...I. Clinical Expectations A. Pharmacist Daily Clinical Responsibilities. 1. Verify medication orders i. During verification, pharmacist reviews medications and monitoring and intervenes as needed... III...A. Mechanism: 1. When a clinical intervention is identified, the Pharmacist may use three methods of intervention according to their clinical judgement: a. Direct contact with prescriber (preferred)... Review of facility policy, Facility Event and Close Call Reporting revised 08/2019, revealed, ...These should be completed as soon as possible after the event, but no later than the end of the shift ... PROCEDURE: ... 1. Patient notifications include events or close calls that involve, impact, or in any way may be connected to a patient under the care of the facility at the time of the event or close call .... DEFINITIONS: Event: A discrete, auditable and clearly defined occurrence ... Close Call: Events or situations that could have resulted in an adverse event (Accident, injury, or illness), but did not, whether by change or through timely intervention... Closed medical record review of Patient #6 revealed the patient was admitted to a medical/surgical floor at the facility on 01/26/2021 at 1302 with chief complaints of intractable nausea and vomiting and abdominal pain. Review of the History and Physical revealed Patient #6 was alert and oriented x4 and had a history of illicit (illegal) drug use - Suboxone (buprenorphine and naloxone - used to treat opioid addiction), and remote history of IVDA (intravenous drug abuse). Review of toxicology report collected 01/26/2021 at 1310 revealed the Urine Drug Screen (UDS) for Patient #6 was positive for buprenorphine (compound found in Suboxone-medication used for opiate addiction) and cannabinoid (compound found in cannabis/marijuana). Review revealed Patient #6 was subsequently diagnosed with [DIAGNOSES REDACTED]). Medical record review revealed Addiction Medicine consulted on 02/11/2021 at 0829 for Suboxone and pain management recommendations prior to the Whipple procedure (pancreaticoduodenectomy - operation to remove the head of the pancreas, the first part of the small intestine, gallbladder, and bile duct) for Patient #6. Review of Addition Medicine Note dated 02/11/2021 at revealed, Psychiatric History: reports one psychiatric hospitalization but numerous diagnoses including bipolar, DID (Dissociative Identity Disorder), PTSD (Post Traumatic Stress Disorder), depression and anxiety. She does not accept the dx (diagnosis) of biolar (sic) stating that prior manic behavior was due to stimulant abuse. Does report ongoing PTSD symptoms including nightmares, flashbacks and hypervigilance. She does report OD (overdose) attempts in the past during which I kind of hoped I wouldn't make it but denies SI (suicidal ideation) for many years ... Family History: her sister also has opiate use disorder, her maternal grandmother reportedly did as well ... Review of Admission assessment dated [DATE] 0515 revealed, Mental Health History: Anxiety, Depression, Other: hx(history) of opiate abuse. Review revealed Patient #6 was moved to a general surgery unit on 02/18/2021 at 2150. Review of Addiction Medicine Progress Note dated 02/18/2021 at 0958 revealed, Interval History. Now increasingly concerned about the gravity of planned procedure, worried about pain control. Would prefer to taper off buprenorphine now ... Impression and Plan ...Opiate use disorder - severe Stimulant use disorder - moderate - on low dose suboxone, now preferring to taper off prior to surgery 2/24 - plan decrease by 2mg/day(milligrams per day) with prn (as needed) Oxycodone (medication for moderate to severe pain) for pain or withdrawal symptoms ... Review of Addiction Medicine Progress Note dated 02/22/2021 at 1022 revealed, tapered down to 2mg buprenorphine with minimal withdrawal sx(symptoms) except some worsening of her chronic back pain and other aches and pains. Has been using oxycodone with good relief ... will sign off for now, however please call if new issues should arise... Review of Surgical Oncology Progress Note dated 02/22/2021 at 1208 revealed, Overnight she had a bad episode of anxiety ... This morning although she feels well, she reports severe anxiety ... Review of Surgical Oncology Progress Note Addendum dated 02/23/2021 at 1927 revealed, Addendum ... New onset tachycardia w/fevers today .... Suspect PICC (peripherally inserted central catheter) line infection, blood cultures drawn and d/c'ing (discontinuing) PICC ... Review revealed the surgical procedure for Patient #6 was rescheduled from 02/24/2021 to 03/03/2021. Review of Nursing Assessment for Mental Status dated 02/24/2021 at 2100 revealed, depressed. Review of Nursing Annotations dated 02/25/2021 at 0152 revealed, patient found down in bathroom sitting up. IV (intravenous) flushes found near patient on the floor. Patient states she was flushing her ear out. IV tubing was found disconnected from patient. MD paged. Record review revealed on 02/25/2021 at 0219 the provider was notified and ordered a UDS. Review revealed an order restricting personal belonging access was ordered 02/25/2021 at 0754. Review of Safety Monitoring Flowsheet revealed a patient safety attendant (sitter) was initiated on 02/25/2021 at 0845. Review of Surgical Oncology Progress Note Addendum dated 02/25/2021 at 0958 revealed, Patient clinically looks normal and no further fevers overnight. Tachycardia persists and had some soft pressures which have normalized this morning ...This is probably because she apparently either fell or passed out in her bathroom with several saline flushes. It is unclear how she got these but there is obvious concern for IV drug abuse given her history. This would further explain the PICC line infection that she clearly had preoperatively. I spoke with Dr. (named Addiction Medicine physician) who will see her and ordered a sitter this morning .... Review of Addition Medicine Progress Note dated 02/25/2021 at 0945 revealed, Impression and Plan ... Gastric outlet obstruction, possible pancreatic CA (cancer) - Whipple planned 2/24, postponed due to tachycardia and fevers, tentatively rescheduled for 3/3. Opiate use disorder - severe. Stimulant use disorder - moderate - did well on low dose suboxone, tapered off prior to surgery per her request and started on moderate dose opiate agonists - suspicious incident with saline flushes yesterday - pt (patient) claims cleaning out her ears. Denies cravings or illicit behavior. While this is plausible, patients with IVDU (intravenous drug use) have been known to use saline flushes to recreate process/feeling of illicit IV use. - very upset about having a sitter again. Readily agrees to liquid oxycodone for decreased diversion risk and to have belongings searched if sitter can be dc'ed (discontinued). Patients with intent to divert meds are often reluctant to agree to these measures. - repeat UDS pending, while this obviously would not reveal any diversion of oxycodone it would allow us to rule out use of illicit substance brought from outside ... Review of the Medication Administration Record revealed the Addiction Medicine physician ordered Oxycodone in liquid form on 02/25/2021 at 0933. Review of the Medication Administration Record - Order History revealed the Pharmacist modified the Oxycodone order to pill form at 0937. Review of the toxicology report collected 02/25/2021 at 1530 revealed the UDS for Patient #6 was positive for methamphetamine, benzodiazepine, buprenorphine, cannabinoid, opiates, and oxycodone. Review of Surgical Oncology Progress Note dated 02/26/2021 at 0827 revealed, Impression and Plan ... Urine drug screen positive for methamphetamines; addiction medicine following and will have social work search patient's belongings, restrict visitors, may no longer need sitter after these 2 interventions ... Review of Surgical Oncology Progress Note Addendum dated 02/26/2021 at 0939 revealed, blood growing out oral flora, U tox (urine toxicology) demonstrating amphetamines, cannabinoids among other things. Working with addiction medicine for plan. Currently continue sitter ... Review of CM-Inpatient SBIRT (Substance Brief Intervention and Referral to Treatment - team for early intervention and treatment approach for substance use disorders) Note dated 02/26/2021 at 1215 revealed, ...LCSW (Licensed Clinical Social Worker) met with patient for HRSU(High Risk Substance Use) rounding and to discuss events of the last 48 hours which resulted in the patient's UDS being tested ...and came back positive .... PRESENTATION: Patient was seen awake, alert, oriented x4 and presents with angry mood and congruent affect often yelling, cursing and raising her voice throughout this meeting ....She adamantly denies any substance use and reports she finds it insulting and offensive that she is accused of this. She insists the UDS is wrong and that the tester is wrong and demands a new UDS ... INTERVENTION: ...communicated multiple times with Dr. (named Addiction Medicine physician) .... VISITATION STATUS: No visitors as per Dr. (named Addiction Medicine physician) Patient may have access to her personal belongings once they have been searched by security. PLAN: Patient's belongings/room to be searched by security. Sitter can be discontinued after the search has been performed. Patient is to have no visitors. A confirmatory test has been ordered for the UDS sent yesterday to determine it the methamphetamine was a false positive ... Record review revealed a personal search order entered at 1242 and signed by Addiction Medicine physician. Review of Safety Monitoring Flowsheet revealed the sitter was removed at 02/26/2021 at 1315. Review of Surgical Oncology Progress Note dated 02/27/2021 at 1220 revealed, Drug screen positive for methamphetamine. Report drinking a lot of fluids... Review of Surgical Oncology Progress Note Addendum dated 02/27/2021 at 1422 revealed, In light of multiple substances found on tox screens, could potentially be substance-withdrawal related as well. Review of GMED Progress Note dated 02/27/2021 at 1519 revealed ... Impression and Plan ... Fever: ...The patient may have been using her IV access for injection .... History of IV drug abuse: Suspicious activity in the hospital concerning for further drug abuse. I agree with high risk substance abuse protocol in the presence of a sitter ... Review of GMED Progress Note dated 02/28/2021 at 1904 revealed ... Impression and Plan ... History of IV drug abuse: ... I agree with high risk substance abuse protocol in the presence of a sitter ... Review of annotations dated 03/01/2021 at 0750 revealed, patient found unresponsive. No pulse agonal breathing. CPR started. Review revealed Patient #6 died on [DATE] at 0835. Review of Surgical Oncology Brief Progress Note dated 03/01/2021 at 0838 revealed, Patient was seen this morning and was doing overall well however a little tearful about the delays with surgery ... Patient was talking to us, coherent and was doing overall okay ...the patient did have some suspicious activity around Wednesday/Thursday last week where her IV was disconnected anther were flushes on the floor and she lost consciousness in the bathroom for which the patient had a sitter for several days. She did have positive UDS for methamphetamine which was negative on admission. Addiction medicine was involved and recommended that the patient's room be searched, to restrict visitors, and that the sitter could be discontinued. Patient did not have a sitter this morning. There is concern that etiology may be related to further in-hospital drug abuse. Review of Death Summary dated 03/01/2021 at 1339 revealed, Cause of Death - Preliminary - Cardiac Arrest Due to suspicion for in hospital IV drug use overdose although etiology is not known at this time .... CODE BLUE was called over intercom at 8 AM on this patient. Nurse reported that patient's IV was beeping and that she went in to fix it and noticed that the patient was breathing agonally, IV disconnected, with a flush nearby the bed ... Medical record review failed to reveal notification of a provider and implementation of mental health interventions after mental status changes, failed to reveal notification to the ordering provider regarding changing the medication from liquid to pill form and failed to reveal an order for the High Risk Substance Use (HRSU/IVDA) plan even though there was provider documentation of supporting the plan. Review of (named hospital) Security Department Search Authorization Form dated 02/26/2021 at 1305 revealed a search was completed of Patient #6's room, Subject: room search for illegal substances ... Reason for Search: suspected illegal substances ...Physician notified: yes (named) ... Subject Response: cooperative ... List of items removed. Where are they stored? Who secured them? Knives locked up with security ... Request for incident reports related to events on 02/25/2021 at 0152 where Patient #6 was found on the floor or 02/25/2021 at 1900 to 02/26/2021 at 0030 when an unknown white substance was found in the room of Patient #6 revealed there were no incidents reported. Observation on 05/25/2021 at 1200, during tour of Unit A in room 457, revealed a supply cart in the patient room with two (2), 10 milliliter (ml) pre-filled, 0.9% Sodium Chloride (normal saline) flushes (flush #1 and #2) lying, unsecured, on top of the supply cart. Observation revealed flush #1 was unopened and labeled 0.9% Sodium Chloride. Flush #2 was open and labeled 0.9% Sodium Chloride and contained 7 mls of solution. Observation revealed both flushes were disposed of in the sharps container by the Nurse Manager (NM) upon discovery. Observation on 05/28/2021 at 0934, during tour of Unit B in room 402, revealed an unopened 10 ml pre-filled, 0.9% Sodium Chloride (normal saline) flush lying, unsecured on the counter beside the sink in the patient ' s room. Observation revealed the flush was disposed of in the sharps container by the (Carrie) prior to leaving the patient ' s room. Interview on 05/25/2021 at 1200, with Nurse Manager #2, during tour of Unit A, revealed Extra supplies should not be left in the patient ' s rooms. Interview on 05/26/2021 at 0920 with RN #1 revealed she provided nursing care for Patient #6 on the night shift (1900 - 0700) of 02/25/2021. Interview revealed Patient #6 was assessed as depressed and no additional interventions were started because a sitter was in place. Interview revealed Patient #6 was focused on sitter removal and asked, when she could get rid of her sitter. Interview revealed white powder was found on the back of the pants of a sitter and a chair in the room of Patient #6 on night shift of 02/25/2021. Interview revealed the charge nurse was notified of the unknown substance and RN #1 received instructions from the Charge Nurse to clean the area up and wash her hands. Interview revealed no incident report was completed. Interview revealed RN #1 kept the door to Patient #6 opened and checked in frequently due to concerns for the safety of the sitter. Interview revealed RN #1 did not recall leaving saline flushes in the patient's room. Interview revealed the High Risk Substance Use (IVDA) plan was not implemented during night shift of 02/25/2021. Interview on 05/26/2021 at 0935 with Nurse Manager #1 revealed the admission assessment identified suicide risk at the time of admission. Interview revealed if a staff member had concerns about changes in the mental status of a patient at any point during the hospitalization , then the physician should be notified. Interview on 05/26/2021 at 0945 with Pharmacist #1 revealed the pharmacist changed the physician order for Oxycodone from liquid to pill form. Interview revealed the ordering provider was not contacted prior to the modification of the Oxycodone order. Interview revealed an error was made when the pharmacist manually selected pills instead of liquid. Interview on 05/26/2021 at 1005 with the Pharmacy Manager #1 revealed a pharmacist should not modify a physician order unless it met specific criteria outlined in the clinical guidelines. Interview revealed the medication for Patient #6 did not meet the specific criteria. Interview acknowledged an error was made and a systems problem. Interview revealed the systems problem related to the way the physician order displayed for pharmacist verification. Interview revealed the pharmacist should have called the provider. Interview on 05/26/2021 at 1035 with RN #2 revealed she provided nursing care for Patient #6 on the day shifts (0700 - 1900) of 02/25/2021 and 02/26/2021. Interview revealed Patient #6 had two different moods based on sitter situation. Interview revealed on 02/25/2021, Patient #6 was observed as depressed, didn't say much, didn't get out of bed. Interview revealed the changes in mood and mental status of Patient #6 were not shared with the medical team. Interview revealed Patient #6 refused to urinate for the UDS for majority of the shift. Interview revealed could have gotten them (saline flushes) from the room or out in the hallway. Interview revealed Patient #6 liked to stroll the halls. Interview revealed RN #2 was present during the Code Blue response on 03/01/2021 for Patient #6. Interview revealed the IV tubing was disconnected and flushes were found in the bed of Patient #6. Interview revealed a more thorough room search should have been conducted on Patient #6. Interview on 05/26/2021 at 1125 with LCSW #1 revealed she provided support through the SBIRT(Substance Brief Intervention and Referral to Treatment - team for early intervention and treatment approach for substance use disorders) team. Interview revealed Patient #6 was anxious about the upcoming procedure. Interview revealed the High Risk Substance use plan was never fully implemented. Interview revealed LCSW#1 had red flags related to Patient #6 defensiveness about positive UDS and PICC line infection. Interview revealed LCSW #1 discussed the 2/25/2021 event and Patient #6 was upset because her sister was on the way to visit her. Interview revealed the full High Risk Substance Use (IVDA) plan (no visitors, no access to cell phone/tablet, landline only phone calls, etc.) should have been implemented for Patient #6. Interview revealed Patient #6 had been on the IVDA plan/SBIRT rounding list on a previous admission 01/04/2021 - 01/21/2021. Interview revealed the previous visit should have triggered awareness of Patient #6 substance use and proper safety measures implemented. Interview on 05/26/2021 at 1225 with CNA #1 revealed she assisted Patient #6 after the 02/25/2021 bathroom incident and was a sitter on 02/26/2021. Interview revealed Patient #6 was on the bathroom floor with a saline flush and puddle of fluid from the disconnected IV tubing. Interview revealed after the incident, Patient#6 was weird, her talking was not at baseline, and she appeared confused. Interview revealed Patient #6 was able to walk after the bathroom incident and was guided back to bed by staff. Interview revealed staff continued routine care and more frequent checks were not implemented. Interview revealed Patient #6 was very irritated with having sitters. Interview on 05/26/2021 at 1620 with Security Officer #1 revealed he performed the room search for Patient #6. Interview revealed no illicit substances were found in the room search. Interview revealed the room search did not include a search of the patient. Interview revealed security found and confiscated knives from Patient #6. Interview on 05/26/2021 at 1635 with Security Officer #2 revealed he performed the room search for Patient #6. Interview revealed Patient #6 had several stuffed animals with unstitched seams and security searched the items as well as possible. Interview revealed no illicit substances or flushes were found in the room search. Interview revealed the security confiscated knives from Patient #6 after the room search. Interview on 05/27/2021 at 1133 with MD #1, revealed she consulted on Suboxone and pain management for Patient #6. Interview revealed Addiction Medicine does not implement the High Risk Substance Use plan and deferred to the attending physician to order the plan. Interview revealed on the 02/25/2021 visit after the incident, Patient #6 appeared anxious and destabilized. Interview revealed Patient #6 felt worse due to the presence of sitters and Patient #6 didn't like being watched. Interview revealed the safety contract (liquid Oxycodone, room search) with Patient #6 was created to preserve the therapeutic relationship and minimize patient-staff conflict. Interview revealed Pharmacy did not contact MD #1 to discuss medication form changes. Interview revealed MD #1 was unaware that the order was changed from liquid to pill form until the root cause analysis. Interview revealed MD #1 felt Pharmacy should have called about the medication order. Interview revealed more frequent visits, targeted questions about Patient #6 suicidal ideation and mental health history, thorough room search, and restricting patient access to flushes should have been implemented. Follow up Interview on 05/27/2021 at 1315 with the Nurse Manager #1 revealed saline flushes should not be left in patient rooms or accessible to patients. Interview revealed Nurse Manager #1 expected staff to keep saline flushes in the medication rooms or in their(staff) pockets. Interview revealed the expectation of staff to report patient observations and concerns to the provider team. Interview revealed the events from finding Patient #6 on the floor and the unknown substance found in the room of Patient #6 should have been reported as incidents. Interview on 05/27/2021 at 1402 with the House Supervisor #1 revealed she responded to the Code Blue on 03/01/2021. Interview revealed the House Supervisor was informed that a syringe was in the bed with Patient #6 and her IV was disconnected. Interview revealed the medical examiner and police were notified due to the unexpected nature of Patient #6's death. Interview revealed the items found (syringe/flush) were not isolated and tested . Interview on 05/27/2021 at 1515 with MD #2, who assumed care for Patient #6 on 02/15/2021, revealed he assumed medical care for Patient #6 and transferred her to the general surgery floor. Interview revealed Addition Medicine was involved from the beginning. Interview revealed Patient #6 was emotional and distraught about the procedure being rescheduled. Interview revealed providers suspected that Patient #6 had used substances in-hospital. Interview revealed MD #2 felt Patient #6 had been tampering with her line after the culture results returned positive for oral flora. Interview revealed Patient #6 did not have visitor restrictions for the majority of her stay and items could have been brought by visitors. Interview revealed the sitter for Patient #6 should have remained in place and the full implementation of the High Risk Substance Use (IVDA) plan. Interview on 05/27/2021 at 1624 with RN #3 revealed she provided care for Patient #6 on the night shift (1900 - 0700) of 02/28/2021. Interview revealed Patient #6 was laughing and cutting up with staff the morning of 03/01/2021. Interview revealed bedside shift report was performed at approximately 0715 and Patient #6 requested pain medication. Interview revealed RN #3 returned to administer the Oxycodone at approximately 0730. Interview revealed RN #3 was leaving the unit when the Code Blue was called overhead. Interview revealed she responded and was shell shocked at the scene in Patient #6 room. Interview revealed Patient #6 seemed fine the last time she saw her. Interview revealed staff could have been more observant and consistent in the care of patients with history of substance abuse. Interview on 05/27/2021 at 1658 with RN #4 revealed he performed the Admission Assessment on Patient #6. Interview revealed the Admission Assessment was performed late. Interview revealed RN#4 worked on a different unit than the unit where Patient #6 expired. Interview revealed RN #4 had not received any education on patients with a history of substance abuse. Interview on 05/28/2021 at 0910 with RN #5 revealed she provided nursing care for Patient #6 on the day shift (0700 - 1900) of 03/01/2021. Interview revealed Patient #6 was awake and talking during bedside shift report. Interview revealed RN #5 and another staff RN heard beeping coming from the room of Patient #6. Interview revealed after entering the room, Patient #6 had agonal breathing and did not respond to a sternal rub. Interview revealed the Code Blue was initiated and RN #5 went to retrieve the code cart. Interview revealed RN #5 recalled conversations about the IV being disconnected, flushes in the bed, and a vape pen being discussed. Interview revealed Patient #6 did not have a sitter at the time and the High Risk Substance Use plan was not implemented. Interview revealed staff could have been tighter with the saline flushes being left unattended. Interview on 05/28/2021 at 0934, with Quality Leader #1, during tour of Unit B, revealed That should not be left in the patient ' s room. Interview on 05/28/2021 at 0950 with Accreditation Leader #1 revealed incidents should have been reported related to finding powder on the pants of a sitter and a chair in Patient #6's room and also when Patient #6 was found on the floor. Interview revealed education was not disseminated to other units that provide care for patients with a history of substance use. Interview on 05/28/2021 at 1520 with RN #6 revealed she functioned as a sitter the night of 02/25/2021. Interview revealed she found a weird, white powder on her pants and a chair in the room of Patient #6. Interview revealed the Charge RN was notified of the findings. Interview revealed no testing of the substance was performed. Interview on 05/28/2021 at 1640 with Charge RN #1 revealed she was informed of the white powder found in the room of Patient #6 on the night shift (1900-0700) of 02/25/2021.Interview revealed the substance was reported at the beginning half of the shift. Interview revealed the substance was not collected nor tested . Interview revealed no incident report was created. Interview revealed the information was not communicated to the rest of the multidisciplinary team. In summary, Patient #6 was admitted to a medical/surgery unit with a history of substance abuse on 01/26/2021. Patient #6 was assessed as depressed on 02/24/2021 at 2100 and no communication or escalation of change in mental status was relayed to the physician. On 02/25/2021 at 0152 (approximately 5 hours later) Patient#6 was found on the bathroom floor with saline flushes and a disconnected IV. On 02/25/2021, an unknown powder substance was found in her room and no communication or further escalation to a physician was noted. The two events were not reported via the incident reporting system. On 02/25/2021, a pharmacist modified the physician order for liquid Oxycodone (component of a safety plan) to pill form without communication. The sitter was removed on 02/26/2021 at 1310 and the High Risk Substance Use (IVDA) plan was never fully implemented. Patient #6 expired on [DATE] at 0835 with her IV disconnected and flushes found in her bed. The culmination of the above created a setting that was not safe for Patient #6, or any patient with a history of substance use. Observations on unit tours revealed 2 of 9 units with unattended saline flushes and interview revealed the action plan items were not implemented facility-wide.
Based on policy review, medical record review, incident report review and staff interviews the hospital failed to provide an effective data-driven quality assessment and performance improvement (QAPI) program. Findings include: The hospital staff failed to ensure an effective QAPI program to analyze, track and make improvements for patient safety by failing to monitor pharmacy modifications to physician orders to determine if the modifications met approved parameters and to evaluate if education provided was effective, and by failing to implement a facility-wide response plan to an adverse outcome and root cause analysis. ~cross refer to 482.21 QAPI Patient Safety Standard: Tag 0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
The hospital failed to ensure an effective QAPI program to analyze, track, and make improvements for patient safety by failing to monitor if pharmacy modifications met approved physician parameters, failing to ensure reporting of events and close calls (an event that could have caused an adverse outcome but did not), and by failing to implement a facility-wide response plan to an adverse event. The findings included: Review of facility policy, Facility Event and Close Call Reporting revised 08/2019, revealed, ...These should be completed as soon as possible after the event, but no later than the end of the shift ... PROCEDURE: ... 1. Patient notifications include events or close calls that involve, impact, or in any way may be connected to a patient under the care of the facility at the time of the event or close call ... IV. Process for Investigation and Analysis of Incident Trends... B. These reports are utilized for risk identification, performance improvement, and committee reporting as appropriate. C. Data should be utilized to assist with the development of facility educational and improvement initiatives ... DEFINITIONS: Event: A discrete, auditable and clearly defined occurrence ... Close Call: Events or situations that could have resulted in an adverse event (Accident, injury, or illness), but did not, whether by chance or through timely intervention ... Closed medical record review of Patient #6 revealed the patient was admitted to a medical/surgical floor at the facility on 01/26/2021 at 1302 with chief complaints of intractable nausea and vomiting and abdominal pain. Review of the History and Physical revealed Patient #6 was alert and oriented x4 and had a history of illicit (illegal) drug use - Suboxone (Buprenorphine and naloxone - used to treat opioid addiction), and remote history of IVDA (intravenous drug abuse). Review of Nursing Annotations dated 02/25/2021 at 0152 revealed, patient found down in bathroom sitting up. IV (intravenous) flushes found near patient on the floor. Patient states she was flushing her ear out. IV tubing was found disconnected from patient. MD paged. Review of annotations dated 03/01/2021 at 0750 revealed, patient found unresponsive. No pulse agonal breathing. CPR started. Review revealed Patient #6 expired on [DATE] at 0835. Review of Incident Reports related to Patient #6 on 05/26/2021 revealed no events on 02/25/2021 at 0152 where Patient #6 was found on the floor or 02/26/2021 from 1900 to 0000 when an unknown white substance was found in the room. Incident Reports did reveal reports related to the Code Blue of Patient #6. Review of Follow Up Facility Actions from a Serious Event Analysis on 05/27/2021, revealed a Serious Event Analysis meeting was performed on 03/04/2021 at 0730. Review of Immediate Abatement on the Affected Unit (name of Patient #6's unit) with a 03/02/2021 implementation due date revealed, Immediate debrief with the team, established that no flushes in patient rooms, Shared path of escalation. Any concerns initiate chain of command, and immediate notification to provider of positive UDS (urine drug screen) during admission without cause. IVDA (High Risk Substance Use/IVDA plan) protocol to be implemented. Review of Action Items revealed, Root Cause - Pharmacist changed form of medication without consulting provider, Mitigation Strategy - Audit of 30 charts per month to ensure medication dosage forms are appropriate for high risk patients, Implementation Due Date - (no date). Review of Follow Up Facility Actions failed to reveal Action Items that analyzed other units need for education related to unattended saline flushes, chain of command, and High Risk Substance Use (IVDA) plan. Review failed to reveal Action Items were implemented on other units that provide care for patients with a history of substance abuse. Review failed to reveal monitoring of pharmacy audits related to dosage form changes. Review failed to reveal a facility-wide approach to the findings of the Root Cause Analysis. Interview on 05/26/2021 at 0920 with RN #1 revealed she provided nursing care for Patient #6 on the night shift (1900 - 0700) of 02/25/2021. Interview revealed white powder was found on the back of the pants of a sitter and a chair in the room of Patient #6 on night shift of 02/25/2021. Interview revealed the charge nurse was notified of the substance and RN #1 received instructions to clean the area up and wash her hands. Interview revealed no incident report was completed. Interview on 05/26/2021 at 1005 with the Pharmacy Manager acknowledged an error was made with Patient #6 medication form selection and the error identified a systems problem. Follow-up Interview on 05/26/2021 at 1545 with the Pharmacy Manager revealed no reports or metrics were reviewed related to the selection of Pharmacy product selections or form changes. Interview revealed the inability to determine how many medication form changes were performed by Pharmacy. Interview revealed monitoring and audits had not been initiated as of 05/26/2021. Interview on 05/27/2021 at 1315 with the Nurse Manager #1 revealed the expectation is for staff to report patient observations and concerns to the provider team. Interview revealed the events from finding Patient #6 on the floor and the unknown substance found in the room of Patient #6 should have been reported as incidents. Interview on 05/27/2021 at 1427 with Quality Leader #1 revealed Action Items from the Root Cause Analysis impacted multiple disciplines. Interview revealed inconsistent practices on saline flushes throughout the facility. Interview revealed Patient #6 was cared for on three different nursing units (one of three units is currently closed). Interview revealed only one unit received targeted education identified through the root cause analysis. Interview on 05/28/2021 at 0950 with Accreditation Leader #1 revealed units that commonly care for patients with substance abuse history were not assessed for deficits related to action items identified in the Root Cause Analysis. Interview revealed an incident should have been reported related to the finding of powder in the room of Patient #6. Interview revealed facility-wide implementation of the education was not included in the action plan. Interview revealed education was not disseminated to other units that provide care for patients with a history of substance use. Interview on 05/28/2021 at 1640 with Charge RN #1 revealed she was informed of the white powder found in the room of Patient #6 on the night shift (1900-0700) of 02/25/2021. Interview revealed the substance was reported at the beginning half of the shift. Interview revealed the substance was not collected nor tested . Interview revealed no incident report was created.
Based on policy and procedure review, observations, medical record review and staff and physician interviews the hospital's nursing staff failed to have an effective nursing service to ensure oversight of day to day operations by failing to secure a patient's environment and to assess, notify and escalate observations and care concerns. Findings include: Hospital nursing staff failed to prevent patient access to unattended saline flushes, to provide a timely admission assessment, and to communicate and escalate observations and change in assessments for 1 of 1 medical/surgical patients with a substance abuse history sampled (Patient #6). ~cross refer to 482.23 Nursing Services Standard Tag 0395
**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 prevent patient access to unattended saline flushes, to provide a timely admission assessment, and to communicate and escalate observations and change in assessments for 1 of 1 medical/surgical patients with a substance abuse history sampled (Patient #6). Findings include: Review of facility policy, Assessment and Reassessment revised 09/21/2018, revealed, ...Section I: Inpatient Scope of Assessment/Reassessment. Admission History - within 24 hours ... Focused Assessment - every 12 hours or more frequently based on nursing judgement ... D. Focused Assessments will be performed by the RN ... A focused assessment is based upon, but not limited to the following: status related to diagnosis, patient care needs or nursing diagnosis/problems identified in the Individualized Plan of Care (IPOC), response to treatment, or change in condition .... C. The RN assesses, observes, interprets the information to determine abnormalities, conducts further observations to clarify information and then identifies the patient problems to address in the individualized plan of care plan ... Review of facility policy, Safety Precautions for the Patient with Behavioral Health Needs - All facilities revised 02/26/2018, revealed, ...B. All inpatients will receive routine assessments of mental status including assessment of safety. Patients should also be screened for safety issues after a potentially distressing event occurs such as, but not limited to ...bad news form a healthcare provider ... C. When a patient is identified as having serious safety concerns, immediate action must be taken to ensure the safety of that patient ... D. A high level of safety will be maintained in the patient's environment ... staff must be aware of hazard potential associated with such items and the patient will be monitored closely for unsafe behaviors. To make the care environment as safe as possible, the following precautions will be initiated: ... 2. To enhance safety of the environment, the patient room/environment should be checked at least once per shift and after the patient has had visitors: .... e. ... IV supplies must be removed from room .... Review of facility policy, Facility Event and Close Call Reporting revised 08/2019, revealed, ...These should be completed as soon as possible after the event, but no later than the end of the shift ... PROCEDURE: ... 1. Patient notifications include events or close calls that involve, impact, or in any way may be connected to a patient under the care of the facility at the time of the event or close call .... DEFINITIONS: Event: A discrete, auditable and clearly defined occurrence ... Close Call: Events or situations that could have resulted in an adverse event (Accident, injury, or illness), but did not, whether by change or through timely intervention ... Closed medical record review of Patient #6 revealed the patient was admitted to a medical/surgical floor at the facility on 01/26/2021 at 1302 with chief complaints of intractable nausea and vomiting and abdominal pain. Review of the History and Physical revealed Patient #6 was alert and oriented x4 and had a history of illicit (illegal) drug use - Suboxone (buprenorphine and naloxone - used to treat opioid addiction), and remote history of IVDA (intravenous drug abuse). Review of toxicology report collected 01/26/2021 at 1310 revealed the Urine Drug Screen (UDS) for Patient #6 was positive for buprenorphine (compound found in Suboxone-medication used for opiate addiction) and cannabinoid (compound found in cannabis/marijuana). Review revealed Patient #6 was subsequently diagnosed with [DIAGNOSES REDACTED]). Medical record review revealed Addiction Medicine consulted on 02/11/2021 at 0829 for Suboxone and pain management recommendations prior to the Whipple procedure (pancreaticoduodenectomy - operation to remove the head of the pancreas, the first part of the small intestine, gallbladder, and bile duct) for Patient #6. Review of Addition Medicine Note dated 02/11/2021 at revealed, Psychiatric History: reports one psychiatric hospitalization but numerous diagnoses including bipolar, DID (Dissociative Identity Disorder), PTSD (Post Traumatic Stress Disorder), depression and anxiety. She does not accept the dx (diagnosis) of biolar (sic) stating that prior manic behavior was due to stimulant abuse. Does report ongoing PTSD symptoms including nightmares, flashbacks and hypervigilance. She does report OD (overdose) attempts in the past during which I kind of hoped I wouldn't make it but denies SI (suicidal ideation) for many years ... Family History: her sister also has opiate use disorder, her maternal grandmother reportedly did as well ... Review of Admission assessment dated [DATE] 0515 revealed, Mental Health History: Anxiety, Depression, Other: hx(history) of opiate abuse (19 days after admission). Review revealed Patient #6 was moved to a general surgery unit on 02/18/2021 at 2150. Review of Addiction Medicine Progress Note dated 02/18/2021 at 0958 revealed, Interval History. Now increasingly concerned about the gravity of planned procedure, worried about pain control. Would prefer to taper off buprenorphine now ... Impression and Plan ...Opiate use disorder - severe Stimulant use disorder - moderate - on low dose suboxone, now preferring to taper off prior to surgery 2/24 - plan decrease by 2mg/day(milligrams per day) with prn (as needed) Oxycodone (medication for moderate to severe pain) for pain or withdrawal symptoms ... Review of Addiction Medicine Progress Note dated 02/22/2021 at 1022 revealed, tapered down to 2mg buprenorphine with minimal withdrawal sx(symptoms) except some worsening of her chronic back pain and other aches and pains. Has been using oxycodone with good relief ... will sign off for now, however please call if new issues should arise... Review of Surgical Oncology Progress Note dated 02/22/2021 at 1208 revealed, Overnight she had a bad episode of anxiety ... This morning although she feels well, she reports severe anxiety ... Review of Surgical Oncology Progress Note Addendum dated 02/23/2021 at 1927 revealed, Addendum ... New onset tachycardia w/fevers today .... Suspect PICC (peripherally inserted central catheter) line infection, blood cultures drawn and d/c'ing (discontinuing) PICC ... Review revealed the surgical procedure for Patient #6 was rescheduled from 02/24/2021 to 03/03/2021. Review of Nursing Assessment for Mental Status dated 02/24/2021 at 2100 revealed, depressed. Review of Nursing Annotations dated 02/25/2021 at 0152 revealed, patient found down in bathroom sitting up. IV (intravenous) flushes found near patient on the floor. Patient states she was flushing her ear out. IV tubing was found disconnected from patient. MD paged. Record review revealed on 02/25/2021 at 0219 the provider was notified and ordered a UDS. Review revealed an order restricting personal belonging access was ordered 02/25/2021 at 0754. Review of Safety Monitoring Flowsheet revealed a patient safety attendant (sitter) was initiated on 02/25/2021 at 0845. Review of Surgical Oncology Progress Note Addendum dated 02/25/2021 at 0958 revealed, Patient clinically looks normal and no further fevers overnight. Tachycardia persists and had some soft pressures which have normalized this morning ...This is probably because she apparently either fell or passed out in her bathroom with several saline flushes. It is unclear how she got these but there is obvious concern for IV drug abuse given her history. This would further explain the PICC line infection that she clearly had preoperatively. I spoke with Dr. (named Addiction Medicine physician) who will see her and ordered a sitter this morning .... Review of Addition Medicine Progress Note dated 02/25/2021 at 0945 revealed, Impression and Plan ... Gastric outlet obstruction, possible pancreatic CA (cancer) - Whipple planned 2/24, postponed due to tachycardia and fevers, tentatively rescheduled for 3/3. Opiate use disorder - severe. Stimulant use disorder - moderate - did well on low dose suboxone, tapered off prior to surgery per her request and started on moderate dose opiate agonists - suspicious incident with saline flushes yesterday - pt (patient) claims cleaning out her ears. Denies cravings or illicit behavior. While this is plausible, patients with IVDU (intravenous drug use) have been known to use saline flushes to recreate process/feeling of illicit IV use. - very upset about having a sitter again. Readily agrees to liquid oxycodone for decreased diversion risk and to have belongings searched if sitter can be dc'ed (discontinued). Patients with intent to divert meds are often reluctant to agree to these measures. - repeat UDS pending, while this obviously would not reveal any diversion of oxycodone it would allow us to rule out use of illicit substance brought from outside ... Review of the toxicology report collected 02/25/2021 at 1530 revealed the UDS for Patient #6 was positive for methamphetamine, benzodiazepine, buprenorphine, cannabinoid, opiates, and oxycodone. Review of Surgical Oncology Progress Note dated 02/26/2021 at 0827 revealed, Impression and Plan ... Urine drug screen positive for methamphetamines; addiction medicine following and will have social work search patient's belongings, restrict visitors, may no longer need sitter after these 2 interventions ... Review of Surgical Oncology Progress Note Addendum dated 02/26/2021 at 0939 revealed, blood growing out oral flora, U tox (urine toxicology) demonstrating amphetamines, cannabinoids among other things. Working with addiction medicine for plan. Currently continue sitter ... Review of CM-Inpatient SBIRT (Substance Brief Intervention and Referral to Treatment - team for early intervention and treatment approach for substance use disorders) Note dated 02/26/2021 at 1215 revealed, ...LCSW (Licensed Clinical Social Worker) met with patient for HRSU(High Risk Substance Use) rounding and to discuss events of the last 48 hours which resulted in the patient's UDS being tested ...and came back positive .... PRESENTATION: Patient was seen awake, alert, oriented x4 and presents with angry mood and congruent affect often yelling, cursing and raising her voice throughout this meeting ....She adamantly denies any substance use and reports she finds it insulting and offensive that she is accused of this. She insists the UDS is wrong and that the tester is wrong and demands a new UDS ... INTERVENTION: ...communicated multiple times with Dr. (named Addiction Medicine physician) .... VISITATION STATUS: No visitors as per Dr. (named Addiction Medicine physician) Patient may have access to her personal belongings once they have been searched by security. PLAN: Patient's belongings/room to be searched by security. Sitter can be discontinued after the search has been performed. Patient is to have no visitors. A confirmatory test has been ordered for the UDS sent yesterday to determine it the methamphetamine was a false positive ... Record review revealed a personal search order entered at 1242 and signed by Addiction Medicine physician. Review of Safety Monitoring Flowsheet revealed the sitter was removed at 02/26/2021 at 1315. Review of Surgical Oncology Progress Note dated 02/27/2021 at 1220 revealed, Drug screen positive for methamphetamine. Report drinking a lot of fluids... Review of Surgical Oncology Progress Note Addendum dated 02/27/2021 at 1422 revealed, In light of multiple substances found on tox screens, could potentially be substance-withdrawal related as well. Review of GMED Progress Note dated 02/27/2021 at 1519 revealed ... Impression and Plan ... Fever: ...The patient may have been using her IV access for injection .... History of IV drug abuse: Suspicious activity in the hospital concerning for further drug abuse. I agree with high risk substance abuse protocol in the presence of a sitter ... Review of GMED Progress Note dated 02/28/2021 at 1904 revealed ... Impression and Plan ... History of IV drug abuse: ... I agree with high risk substance abuse protocol in the presence of a sitter ... Review of annotations dated 03/01/2021 at 0750 revealed, patient found unresponsive. No pulse agonal breathing. CPR started. Review revealed Patient #6 died on [DATE] at 0835. Review of Surgical Oncology Brief Progress Note dated 03/01/2021 at 0838 revealed, Patient was seen this morning and was doing overall well however a little tearful about the delays with surgery ... Patient was talking to us, coherent and was doing overall okay ...the patient did have some suspicious activity around Wednesday/Thursday last week where her IV was disconnected anther were flushes on the floor and she lost consciousness in the bathroom for which the patient had a sitter for several days. She did have positive UDS for methamphetamine which was negative on admission. Addiction medicine was involved and recommended that the patient's room be searched, to restrict visitors, and that the sitter could be discontinued. Patient did not have a sitter this morning. There is concern that etiology may be related to further in-hospital drug abuse. Review of Death Summary dated 03/01/2021 at 1339 revealed, Cause of Death - Preliminary - Cardiac Arrest Due to suspicion for in hospital IV drug use overdose although etiology is not known at this time .... CODE BLUE was called over intercom at 8 AM on this patient. Nurse reported that patient's IV was beeping and that she went in to fix it and noticed that the patient was breathing agonally, IV disconnected, with a flush nearby the bed ... Medical record review failed to reveal notification of provider and implementation of mental health interventions after mental status changes, failed to complete a timely Admission Assessment, and failed to reveal documentation related to an unknown powder substance in the room of Patient #6. Request for incident reports related to events on 02/25/2021 at 0152 where Patient #6 was found on the floor or 02/25/2021 at 1900 to 02/26/2021 at 0030 when an unknown white substance was found in the room of Patient #6 revealed there were no incidents reported. Observation on 05/25/2021 at 1200, during tour of Unit A in room 457, revealed a supply cart in the patient room with two (2), 10 milliliter (ml) pre-filled, 0.9% Sodium Chloride (normal saline) flushes (flush #1 and #2) lying, unsecured, on top of the supply cart. Observation revealed flush #1 was unopened and labeled 0.9% Sodium Chloride. Flush #2 was open and labeled 0.9% Sodium Chloride and contained 7 mls of solution. Observation revealed both flushes were disposed of in the sharps container by the Nurse Manager (NM) upon discovery. Observation on 05/28/2021 at 0934, during tour of Unit B in room 402, revealed an unopened 10 ml pre-filled, 0.9% Sodium Chloride (normal saline) flush lying, unsecured on the counter beside the sink in the patient ' s room. Observation revealed the flush was disposed of in the sharps container by the (Carrie) prior to leaving the patient ' s room. Interview on 05/25/2021 at 1200, with Nurse Manager #2, during tour of Unit A, revealed Extra supplies should not be left in the patient ' s rooms. Interview on 05/26/2021 at 0920 with RN #1 revealed she provided nursing care for Patient #6 on the night shift (1900 - 0700) of 02/25/2021. Interview revealed Patient #6 was assessed as depressed and no additional interventions were started because a sitter was in place. Interview revealed Patient #6 was focused on sitter removal and asked, when she could get rid of her sitter. Interview revealed white powder was found on the back of the pants of a sitter and a chair in the room of Patient #6 on night shift of 02/25/2021. Interview revealed the charge nurse was notified of the substance and RN #1 received instructions to clean the area up and wash her hands. Interview revealed no incident report was completed. Interview revealed RN #1 was unsure if observations were reported to the the provider team. Interview revealed she did not recall leaving flushes in the patient's room. Interview on 05/26/2021 at 0935 with Nurse Manager #1 revealed the admission assessment identified suicide risk at the time of admission. Interview revealed if a staff member had concerns about changes in the mental status of a patient at any point during the hospitalization , then the physician should be notified. Interview on 05/26/2021 at 1035 with RN #2 revealed she provided nursing care for Patient #6 on the day shifts (0700 - 1900) of 02/25/2021 and 02/26/2021. Interview revealed Patient #6 had two different moods based on sitter situation. Interview revealed on 02/25/2021, Patient #6 was observed as depressed, didn't say much, didn't get out of bed. Interview revealed the changes in mood and mental status of Patient #6 were not shared with the medical team. Interview revealed Patient #6 refused to urinate for the UDS for majority of the shift. Interview revealed could have gotten them (saline flushes) from the room or out in the hallway. Interview revealed Patient #6 liked to stroll the halls. Interview revealed RN #2 was present during the Code Blue response on 03/01/2021 for Patient #6. Interview revealed the IV tubing was disconnected and flushes were found in the bed of Patient #6. Interview revealed a more thorough room search should have been conducted on Patient #6. Interview on 05/26/2021 at 1225 with CNA #1 revealed she assisted Patient #6 after the 02/25/2021 bathroom incident and was a sitter on 02/26/2021. Interview revealed Patient #6 was on the bathroom floor with a saline flush and puddle from the disconnected IV tubing. Interview revealed after the incident, Patient#6 was weird, her talking was not at baseline, and she appeared confused. Interview revealed Patient #6 was able to walk after the bathroom incident and was guided back to bed by staff. Interview revealed staff continued routine care and more frequent checks were not implemented. Interview revealed Patient #6 was very irritated with having sitters. Interview on 05/27/2021 at 1133 with MD #1 revealed she consulted on Patient #6 Suboxone and pain management. Interview revealed Addiction Medicine does not implement the High Risk Substance Use plan and deferred to the attending physician for ordering the plan. Interview revealed on the 02/25/2021 visit after the incident, Patient #6 appeared anxious and destabilized. Interview revealed Patient #6 felt worse due to the presence of sitters and Patient #6 didn't like being watched. Interview revealed the safety contract (liquid Oxycodone, room search) with Patient #6 was created to preserve the therapeutic relationship and minimize patient-staff conflict. Interview revealed more frequent visits, targeted questions about Patient #6 suicidal ideation and mental health history, thorough room search, and restricting patient access to flushes should have been implemented. Follow up Interview on 05/27/2021 at 1315 with the Nurse Manager #1 revealed saline flushes should not be left in patient rooms or accessible to patients. Interview revealed Nurse Manager #1 expected staff to keep saline flushes in the medication rooms or in their(staff) pockets. Interview revealed the expectation of staff to report patient observations and concerns to the provider team. Interview revealed the events from finding Patient #6 on the floor and the unknown substance found in the room of Patient #6 should have been reported as incidents. Interview on 05/27/2021 at 1402 with the House Supervisor #1 revealed she responded to the Code Blue on 03/01/2021. Interview revealed the House Supervisor was informed that a syringe was in the bed with Patient #6 and her IV was disconnected. Interview revealed the medical examiner and police were notified due to the unexpected nature of Patient #6's death. Interview revealed the items found (syringe/flush) were not isolated and tested . Interview on 05/27/2021 at 1624 with RN #3 revealed she provided care for Patient #6 on the night shifts (1900 - 0700) of 02/28/2021. Interview revealed Patient #6 was laughing and cutting up with staff the morning of 03/01/2021. Interview revealed bedside shift report was performed at approximately 0715 and Patient #6 requested pain medication. Interview revealed RN #3 returned to administer the Oxycodone at approximately 0730. Interview revealed RN#3 was leaving the unit when the Code Blue was called overhead. Interview revealed she responded and was shell shocked at the scene in Patient #6 room. Interview revealed Patient #6 seemed fine the last time she saw her. Interview revealed staff could have been more observant and consistent in the care of patients with history of substance abuse. Interview on 05/27/2021 at 1658 with RN #4 revealed he performed the Admission Assessment on Patient #6. Interview revealed the Admission Assessment was performed late. Interview revealed RN#4 worked on a different unit than the unit where Patient #6 expired. Interview revealed he had not received any education on patients with a history of substance abuse. Interview on 05/28/2021 at 0910 with RN #5 revealed she provided nursing care for Patient #6 on the day shift (0700 - 1900) of 03/01/2021. Interview revealed Patient #6 was awake and talking during bedside shift report. Interview revealed RN #5 and another staff RN heard beeping coming from the room of Patient #6. Interview revealed after entering the room, Patient #6 had agonal breathing and did not respond to a sternal rub. Interview revealed the Code Blue was initiated and RN #5 went to retrieve the code cart. Interview revealed RN #5 recalled conversations about the IV being disconnected, flushes in the bed, and a vape pen being discussed. Interview revealed Patient #6 did not have a sitter and the High Risk Substance Use plan was not implemented. Interview revealed staff could have been tighter with the saline flushes being left unattended. Interview on 05/28/2021 at 0934, with Quality Leader #1, during tour of Unit B, revealed That should not be left in the patient ' s room. Interview on 05/28/2021 at 0950 with Accreditation Leader #1 revealed incidents should have been reported related to the finding of powder in the room of Patient #6 and Patient #6 on the floor. Interview revealed education was not disseminated to other units that provide care for patients with a history of substance use. Interview on 05/28/2021 at 1520 with RN #6 revealed she worked as a sitter the night of 02/25/2021. Interview revealed she found a weird, white powder on her pants and a chair in the room of Patient #6. Interview revealed the Charge RN was notified of the findings. Interview revealed no testing of the substance was performed. Interview on 05/28/2021 at 1640 with Charge RN #1 revealed she was informed of the white powder found in the room of Patient #6 on the night shift (1900-0700) of 02/25/2021. Interview revealed the substance was not collected nor tested . Interview revealed no incident report was created. Interview revealed the information was not communicated to the rest of the multidisciplinary team. In summary, Patient #6 was admitted to a medical/surgery unit with a history of substance abuse on 01/26/2021. The Admission Assessment was completed on 02/14/2021; 19 days after admission to the facility. Patient #6 was assessed as depressed on 02/24/2021 at 2100 and no communication or escalation of change in mental status was relayed to the physician. On 02/25/2021 at 0152 (approximately 5 hours later) Patient#6 was found on the bathroom floor with saline flushes and a disconnected IV. On 02/26/2021, an unknown powder substance was found in her room and no communication or further escalation to a physician was noted. The two events were not reported via the incident reporting system. Patient #6 expired on [DATE] at 0835 with her IV disconnected and flushes found in her bed. Observations on unit tours revealed 2 of 9 units with unattended saline flushes and interview revealed the action plan items were not implemented facility-wide. The culmination of the above displayed a failure of nursing staff to supervise and evaluate nursing care to patients with a history of substance abuse.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy review, medical record review and staff interview, the hospital nursing staff failed to obtain vital signs for 2 of 2 patients who received a blood transfusion per hospital policy (Patient #8 and #9). Findings include: Review on 05/25/2021 of the hospital's Blood and Blood Component Administration (Blood Transfusion) ... policy, last revised 05/19/2020, revealed, ... 5. Obtain baseline vital signs (temperature, pulse, respiration, and blood pressure). ... Febrile patients may receive blood, but fever documented before transfusion should not be considered as a transfusion reaction unless a temperature rise of > 1.8 [degrees] F and of at least 100.4 [degrees] F is noted. ... c. Check complete set of vital signs 15 minutes into the transfusion. ... f. Check complete set of vital signs every hour during infusion and at completion and document ... 3. Febrile Non[DIAGNOSES REDACTED] Reactions: Febrile non[DIAGNOSES REDACTED] reactions are indicated by the presence of at least one of the below criteria: a. A fever > 38 [degrees] or 100.4 [degrees] F orally and a change of at least a temperature rise > 1.8 [degree] F or 1 [degree] C occurring in association with transfusion and without other explanation. ... 5. Implementation: If a [DIAGNOSES REDACTED] or febrile non[DIAGNOSES REDACTED] transfusion reaction....is suspected: a. STOP the transfusion immediately. ... 1. Medical record review on 05/26/2021, revealed Patient #8 was admitted [DATE] at 1323 anemia, hemoglobin of 6.3, hyponatremia, and sepsis due to a urinary tract infection. Record review revealed an order to transfuse 2 units of blood on 05/11/2021 at 1101. Review of the blood transfusion and vital signs nursing documentation revealed the second unit of blood was started at 2304. Vital signs at 2304 were recorded as T 99.4, P 114, R 17 and BP 133/60. Vital signs at 2324 (20 minutes later) were recorded as T 101.8, P 115, T 17 and BP 127/60. Review of a nursing progress note by the RN administering the blood at 2347 revealed , MD notified, continue transfusion. Vital signs at 0000 (13 minutes after MD notification) were P 109 (no T, R or BP were recorded). Vital signs at 0207 (2 hours, 43 minutes after last full set of recorded vital signs) were recorded as T 102.1, P 114, R 18 and BP 124/69. The transfusion was noted to end at 0210. Review failed to reveal the nurse stopped the blood transfusion prior to calling the MD and vital signs per policy. Request for interview revealed the registered nurse (RN #12) who administered the blood was not available for interview. Interview with a Nurse Supervisor (NS) #2 on 05/27/2021 at 1403 revealed a complete set of vital signs, including temperature, pulse, respirations and blood pressure, should be taken every hour during the blood transfusion and when the transfusion is completed. 2. Medical record review on 05/26/2021, revealed Patient #9 was admitted [DATE] at 1915 for electrolyte abnormalities, anemia and failure to thrive secondary to endometrial cancer. Review of the History and Physical, dated 05/13/2020 at 1654, revealed that on arrival to the hospital, the patient had an episode of bloody diarrhea with frank, bright red bleeding. Record review revealed an order to transfuse 2 units of blood on 05/14/2021 at 1212. Review of the blood transfusion and vital signs nursing documentation revealed the second unit of blood was started at 1751. Vital signs were recorded at 1856 and not recorded again until 2042 (1 hour, 46 minutes later). Vital signs were recorded as T 98.5, P 110, no respirations recorded and BP 133/64. Review failed to reveal vital signs per policy. Telephone interview with the RN #11 (Registered Nurse) who administered the blood, on 05/27/2021 at 1003, revealed vital signs should be done 15 minutes after a blood transfusion is started and should include temperature, pulse, respirations and blood pressure, to assess how the patient is tolerating it [transfusion], hourly during the transfusion and obtain another set of vital signs after the blood is complete. Interview revealed the second unit of blood was transfusing at shift change, which a rough time for us. It's not an excuse, but it's the only thing I can think of that may have caused the oversight. Interview with a Nurse Supervisor (NS) #2 on 05/27/2021 at 1403 revealed a complete set of vital signs, including temperature, pulse, respirations and blood pressure, should be taken every hour during the blood transfusion and when the transfusion is completed. NC 543, NC 297, NC 369, NC 693, NC 548
Based on facility policies and PPE guidance review, contract review, observations, and staff interviews, the facility staff failed to follow infection control policies and PPE guidance on 3 of 11 units toured (3W, Neuro Trauma ICU, and J6). The findings include: Review on 02/16/2021 of the facility procedure titled PPE Guidance Outside of OR and Procedural Areas For HCA Facilities During the COVID-19 National Public Health Emergency with an amendment date of 12/11/2020 revealed ... Due to increased COVID activity in the community, and our commitment to the safety of our team members, we are moving to eye protection for all patient care ... Review on 02/16/2021 of the facility policy title Isolation: Transmission-Based Precautions with a revision date 10/23/2020 revealed ... B. Personal Protective Equipment (PPE) 1. PPE refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents ... Table 1: Overview of Appropriate PPE for Transmission-Based Isolation Precautions Transmission-Based Isolation Precautions Type: ... Contact Precautions ... Personal Protective Equipment (PPE) appropriate to task including ... *Gown *Gloves *Additional PPE appropriate to task *Additional PPE appropriate to organism ... Droplet Precautions .... *Mask *Additional PPE appropriate to task *Additional PPE appropriate to organism ... D. Contact Isolation Precautions 1. Contact isolation precautions are designed to reduce the risk of transmission of epidemiologically (study of the causes, distribution, and control of disease) important pathogens that can be transmitted by direct contact or indirect contact. a. Direct contact: skin-to-skin contact that occurs when performing patient care activities. b. Indirect contact: contact with environmental surfaces or patient care items ... Review of School Affiliation Agreement effective 01/21/2020 revealed, NOW, THEREFORE, in consideration of the mutual promises contained herein, the Parties (Trustees of [college name]) and (Facility name) Hospital Manager, LLC (Facility name) hereby agree as follows: 1.RESPONSIBILITIES OF SCHOOL ...(v) require Program Participants to comply with applicable laws and (Facility name) policies and procedures when onsite at the Facility. 1. Observation on 02/16/2021 at 1118 on a 3 West unit revealed Certified Nursing Assistant (CNA) #8 walked into Patient #21's room with gloves and a surgical mask on. Observation revealed a sign on the outside of the room for Contact and Droplet isolation. Observation revealed the Contact sign read ... Wear gown and gloves when entering room ... Observation revealed CNA #8 did not have a gown on when entering the room. Observation revealed CNA #8 did not have goggles or a face shield on when entering Patient #21's room. Interview on 02/16/2021 at 1121 with CNA #8 revealed she had forgotten the patient was on isolation and that she was not aware that she should be wearing goggles or a face shield when performing patient care. Interview revealed CNA #8 went into Patient #21's room to provide assistance with toileting. Interview on 02/16/2021 at 1123 with Nurse Manager (NM) #9 confirmed the patient was on contact and droplet precautions. Interview confirmed CNA #8 should have had on a gown and gloves prior to entering the room. Interview confirmed CNA #8 should be wearing a face shield/goggles when performing patient care. Interview on 02/16/2021 at 1127 with Infection Preventionist (IP) #27 revealed the procedure was that all staff wear eye protection when performing patient care. Interview revealed eye protection would be either goggles or a face shield. Interview revealed personal eye glasses for vision is not considered eye protection. 2. Observation on 02/16/2021 at 1120 on a 3W unit revealed Registered Nurse (RN) #10 entered Patient #22's room and administered oral Ditropan (medication for bladder and urinary conditions). Observation revealed RN #10 had a surgical mask and gloves on while in the patient room. Observation revealed RN #10 did not have on goggles or a face shield while in the patient room. Continued observation revealed a PA (Physician Assistant) was in Patient #22's room performing an evaluation without goggles or a facemask on. Interview on 02/16/2021 at 1125 with RN #10 revealed she was not aware the procedure was to wear goggles or a face shield with all patient care. Interview on 02/16/2021 at 1125 with NM #9 confirmed RN #10 should have had on either goggles or a face shield while in the patient room administering the medication. Interview on 02/16/2021 at 1127 with Infection Preventionist (IP) #27 revealed the procedure was that all staff wear eye protection when performing patient care. Interview revealed eye protection would be either goggles or a face shield. Interview revealed personal eye glasses for vision is not considered eye protection. 3. Observation on 02/16/2021 at 1618 on a Neuro Trauma ICU (intensive care unit) revealed RN #11 was in Patient #23's room that had a sign on the door that read CAUTION!!! N95 Required Aerosol generating procedure in progress *Other equipment (such as face shield or goggles) may also be required. KEEP DOOR CLOSED. Observation revealed RN#11 had on a surgical mask. Interview on 02/16/2021 at 1618 with RN #1 (Director of the ICU) confirmed RN #11 should have on a N95 mask while in the patient room. Interview on 02/16/2021 at 1625 with RN #11 revealed she knew she was supposed to wear an N95 mask. Interview revealed RN #11 had the N95 on all day and had taken it off for a break from it on her face. Interview revealed RN #11 confirmed she went in the patient room with a surgical mask on to get the numbers off the CRT (cardiac resynchronization therapy) machine (machine to help heart beat). 4. Observation on 02/16/2021 at 1620 on an Neuro Trauma ICU (intensive care unit) revealed RN #12 in Patient #24's room at the beside with the IV (intravenous) pump with no goggles or face shield on. Interview on 02/16/2021 at 1621 with RN #12 confirmed she did not wear goggles or face shield while in the patient room. Interview revealed RN #12 was in the patient room giving medications to the patient. Interview on 02/16/2021 at 1621 with RN #1 confirmed RN #12 should have on goggles or a face shield on while in the patient room performing care.
5. Observation on 02/16/2021 at 1420 during a tour of an orthopedic unit (J6) revealed three nursing students without goggles or face shields at the bedside. Observation revealed two students entered one patient room while the third student entered another patient room located near the rear nursing station. Observation revealed the students exited the two patient rooms after a few minutes without goggles or face shields. Interview on 02/16/2021 at 1440 with NM #20 revealed it was the expectation that nursing students observe the facility's infection prevention practices. NM #20 confirmed the nursing students did not have on goggles or face shields during the unit tour. Interview confirmed the nursing students should wear goggles or face shield when at the bedside. 6. Observation on 02/16/2021 at 1435 during a tour of an orthopedic unit (J6) revealed APP (Advanced Practice Provider) #19 entered a patient room #620 with no goggles or face shield and performed a face to face patient visit. Interview on 02/16/2021 at 1440 with NM #20 revealed it was the expectation that all staff members observe the hospital's infection prevention practices. Interview confirmed the staff should wear goggles or face shield when at the bedside. Interview revealed leadership does on the spot coaching when staff were observed without goggles or face shield when at the bedside.
7. Observation on 02/19/2021 at 0950 during tour of an orthopedic surgery unit revealed a patient being transported on a bed through the hallway. Observation revealed the patient was wearing a face shield and the staff member transporting the patient was wearing a face mask but not a face shield or goggles. Interview with the Nurse Manager, RN #7 providing the tour confirmed staff transporting patients were expected to wear a face shield or goggles and a mask during patient transport. and the staff member had not followed hospital PPE guidance.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, and staff interviews, the hospital Interventional Radiology (IR) staff failed to provide care in a safe setting by failing to prevent a fall resulting in a patient injury for 1 of 2 patients (Patient #1) undergoing a procedure. The findings include: Review of policy Facility Event and Close Call Reporting Policy, review/revised date 08/20/2019, revealed ...Policy: This policy is intended to minimize risk to patients ....through the development and implementation of an event and close call reporting system ... These should be completed as soon as possible after the event, but no later than the end of the shift ... Facility managers .... have 15 business days to complete and document their review and actions. The manager responsible for completion and documentation of final investigation .... Has 60 calendar days to complete and document their final review, actions, and disposition. ... Review of policy Fall Prevention, Risk Screening and Intervention, reviewed/revised date 05/09/2019, revealed ...Policy: (Hospital) will screen patients as appropriate to identify those most at risk for falls and should implement interventions to reduce the risk of injury from falling .... General Information: .... B. When the patient is transported to another area of the hospital, the unit initiating the transport will communicate the patient's fall risk .... Closed medical record review for Patient #1 on 07/29/2020, revealed a [AGE]-year-old male admitted on [DATE] with lower extremity weakness and shortness of breath. His medical history was significant for respiratory failure, [DIAGNOSES REDACTED] (brain disease), diabetes, oxygen dependency and overall poor health. Record review revealed the patient's height was 5 foot, 5 inches and weight, 284 pounds. Review of the fall risk assessment revealed a score of 50, indicating the patient was a Moderate/High fall risk. The patient's condition deteriorated, requiring intubation (artificial airway) and dialysis. On 12/31/2019, the patient was transported to IR for placement of a vascular catheter (central line used specifically for dialysis), accompanied by an Intensive Care Unit (ICU) nurse at 0830. Review of a nursing progress note by RN #7, on 12/31/2019 at 0900, revealed, Patient was on IR table for about 20 minutes, I was at bedside, IR staff started procedure, was told to go into control room [anteroom adjoining the procedure room], I hear a loud crash about 2 minutes later. Paged provider [PA] and she came down to IR. Review of a Rapid Response note by RN #9, on 12/31/2019 at 1316 revealed, ...received call at approx. [approximately] 0900 that pt [patient] had fallen from IR tale [sic] - pt in supine [face up] position cervical collar placed and pt placed on backboard transported to CT and then back to ICU - Provider aware and present. Review of the nursing note by RN #7 at 1000 revealed the patient was transferred back to ICU at 1000 and a skin tear to the left arm was noted. Review of the PA progress note at 1015 revealed, Patient fell from IR table to the ground. Unclear as to if there was head trauma. CT head and neck without fracture or bleed. On exam of the patient he appeared to have pain in the left should [sic] which improved with ROM [range of motion] examination which raised the question of slight subluxation [dislocation]. Imaging pending. Review of the physician's (MD #1) progress note at 1729 revealed, Spoke to RN. Patient fell from the IR table to the ground. Imaging of the head and neck were unremarkable for fracture or bleeding. He had ecchymosis (bruising) over his left arm and left shoulder pain. There was a question of possible dislocation. [Left] Shoulder and humerus [long bone of the arm] imaging are unremarkable. Interview on 07/28/2020 at 1407 with the Assistant Vice President of Cardiovascular Services, Director of IR, Radiology Nurse Manager, and Manager of IR revealed Patient #1 was transferred to the procedure table and arm cradles, used to keep the arms from falling off the table, were placed on both sides of the patient, for comfort. Interview revealed a safety strap was available but was not used because the staff did not feel the patient was at risk of rolling off the table. Interview revealed the IR scrub technician (SPT #3) had her back turned to the patient, preparing the surgical instruments, the ICU nurse and SPT #1left the procedure room and went into the control room, and the Respiratory Therapist was at the head of the procedure table, turned away from the patient when he fell off the table (approximately 3-4 feet) onto his left shoulder at 0900. Review of an action plan, developed following analysis of the patient's fall on 12/31/2019, presented by the Manager of IR on 07/31/2020 (213 days post-fall), revealed Key Issue to Address ... Ensure appropriate safety mechanisms are in place for appropriate patient condition, Have one person within arm's reach of patient at all times while in the procedure room, IR staff unaware of fall risk. Review revealed Recommendations included, Educate all technologists to use straps for patients unable to understand and follow instructions and/or when needed for positioning assistance, IR RN (registered nurse) will be assigned to all invasive procedures in IR, Have IR Navigator (unit coordinator) note falls risk on IR tracking Board for all staff to view ... Further review of the plan revealed metrics for monitoring and evaluation of the Recommendations included, Appropriate fall precautions will be implemented 95% of the time, Falls risk will present on the tracking board for 95% of patients ... Interview on 07/29/2020 at 0930 with the Director of Accreditation Services revealed the ICU nurse (RN #7) who cared for the patient on 12/31/2019 was not available for interview. Interview on 07/29/2020 at 1000 with the Manager of IR revealed the patient was accompanied by an ICU nurse and RT to IR. The patient was transferred to the procedure table and his arms were placed in the arm cradles. Interview revealed, He was an extremely large man and those tables are small, but staff thought he was sedated. The Manager of IR shared that safety straps were available but were not used, The staff does not routinely use the [safety] strap on the patient if the patient is not moving much. Interview revealed, This patient initially was not moving. When staff stepped away from the table, the patient suddenly tried to get up and they were unable to reach him before he fell off the table. Interview on 07/29/2020 at 1110 with Special Procedures Technician (SPT) #1 revealed he was in the control room, with the ICU nurse, when Patient #1 fell from the procedure table in IR on 12/31/2019. The patient was escorted from ICU, with a nurse and respiratory therapist, unconscious and non-verbal and transferred onto the procedure table. As standard practice, arm cradles were placed on both sides of the patient, for comfort. Interview revealed a safety strap was available but He was sedated to the point of unconsciousness and made no motion until the point of rolling off the table, he said. Interview revealed SPT #1 and the ICU nurse left the procedure room, walked to the control room and heard the patient fall to the floor. Interview revealed the safety strap was typically used for obese patient's and he [Patient #1] was not large enough to consider using it. SPT #1 shared patient fall risk status is not routinely shared with IR staff and that he was not aware that Patient #1 was a Moderate/High falls risk. Interview on 07/29/2020 at 1130 with the Respiratory Therapist (RT) revealed he accompanied the patient and ICU nurse to IR on 12/31/2019. He [Patient #1] had been extubated the day prior (12/29/2019), was morbidly obese and required intermittent BiPAP. We go down to assist in the event the BiPAP is needed for supplemental oxygen when the patient lies flat. He was a big guy and I remember it was difficult getting him onto the table. His arm kept falling off and I walked over and laid his arm back up on him. As I stepped away, moving the BiPAP, I turned and saw him starting to fall and before I could get to him, he was on the floor. Interview revealed that due to the patient's size, the arm cradles were not effective and that the safety strap was not used. Interview on 07/29/2020 at 1150 with SPT #2 revealed he was in the procedure room when Patient #1 fell on [DATE]. He was unconscious, non-verbal and I thought sedated. We transferred him to the table and prepped for the case. Interview revealed the patient regained consciousness, picked his torso up, threw his knee over and off he went. (SPT #3) was scrubbing [preparing instruments for the procedure] with her back to the patient. He was a large man and those tables are so small. SPT #2 shared the safety strap was used to prevent patient's from rolling off the table but was not used because the patient was sedated to the point of unconsciousness. SPT #2 shared patient fall risk status is not routinely shared with IR staff and that he was not aware that Patient #1 was a Moderate/High falls risk. Interview on 07/29/2020 at 1225 with SPT #3 revealed she was the scrubbing technician and that she was in the procedure room when the patient fell on [DATE]. The unit nurse and RT arrived with the patient, who was fairly unresponsive and on a BiPAP. We moved him onto the table, and I walked over to prepare the surgical tray. My back was to the table and I heard (SPT #2) yell, 'Oh my God!', when I turned around, he had fallen onto the floor. Interview revealed, We were busy preparing for the procedure, we thought he was sedated, and turned our backs to him. SPT #3 shared patient fall risk status is not routinely shared with IR staff and that she was not aware that Patient #1 was a Moderate/High falls risk. Interview on 07/31/2020 at 1115 with the Director of IR and the Director of Quality and Patient Safety revealed a post-fall analysis was conducted on 01/02/2020, with immediate actions taken to prevent patient falls during procedures. Additional opportunities for improvement in communicating patient fall risk status were also identified. Interview revealed no audits had been conducted to monitor and analyze effectiveness of the implemented safety measures outlined in the action plan. We have not conducted any audits to date.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of policy and procedures, medical records, and staff interviews, facility staff failed to monitor the condition of a patient in four-point restraints for violent behaviors per policy in 1of 4 sampled emergency department patients prior to final disposition (Patient #7). The findings include: Review of the policy Patient Restraint/Seclusion effective 01/29/2020 revealed, PURPOSE: 1. To protect the dignity and safety of inpatients, outpatients, staff and visitors through safe restraint processes. 2. To identify patients at risk for restraint or seclusion and provide alternatives to restraint use ...4. T define the procedure to be followed when all alternatives have been exhausted ...7. Monitoring the Patient in Restraints or Seclusion ...d. A trained staff member monitors each patient in restraint or seclusion at least three (3) times an hour for safety ...This check will be documented in either electronic record or on paper ...f. Monitoring is based on the individual needs of the patient. Variables of the patient's condition, cognitive status, and risks associated with the intervention may require more frequent evaluations ... 12. Documentation Requirements: ...i. Assessment of the patient in restraint or seclusion j. Monitoring of the patient in restraint or seclusion ... Review of the medical record revealed Patient #7 was a [AGE]-year-old female who arrived in the emergency department (ED) on 06/14/2020 escorted by law enforcement officers (LEO) under involuntary commitment (IVC) orders after threatening family members. Review of Patient #7's medical record revealed a history of multiple hospital admissions for schizoaffective disorder, Hepatitis C, and illicit substance abuse. On admission, her drug screen indicated recent use of amphetamine, methamphetamine, cannabis, and fentanyl. Review of the medical record revealed, after receiving intramuscular injections of haloperidol (medication used to treat inability to discern real from un-real things) and lorazepam (medication used to reduce feelings of anxiety), Patient #7 was placed in bilateral ankle and wrist restraints for ongoing violent behavior on 06/14/2020 at 1831 per Restraint Flowsheet documentation by RN #1. Further review of Restraint Flowsheet documentation by RN #1 revealed restraints were discontinued on 06/14/2020 at 1940 (59 minutes later). Further review revealed a Safety Monitoring Flowsheet was initiated for Patient #7 on 06/14/2020 at 2214 and continued until an inpatient behavioral health admission on 06/15/2020 at 1758. Record review revealed no restraint monitoring documentation between 1831 and 1940 on 06/14/2020. Telephone interview on 07/31/2020 at 1545 with RN #1 revealed she had no access to the medical record system and did not recall the events of 06/14/2020 or Patient #7. Interview on 07/31/2020 at 1310 with RN #2 revealed he recalled Patient #7 and had reviewed the record. Interview revealed Patient #7 had arrived shortly before the end of his day shift and described her as one of the most ecstatic and violent patients I've seen in a long time. Interview revealed Patient #7 had been escorted into the ED by three instead of typically one LEO, she had been placed in a room across from the nursing station because of agitation, had been medicated, and in bilateral ankle and wrist restraints soon after her arrival. Interview revealed Patient #7 remained in restraints at the time he reported off to the on-coming nurse, RN #1. Interview on 07/31/2020 at 1210 with RN #3 revealed he had administered haloperidol and lorazepam to Patient #7 and had limited interaction with the patient beyond administering the medication. RN #3 recalled Patient #7 was using word salad and was not making sense. She would not let us even touch her and would thrash around on the bed if we got near her. RN #3 revealed once restraints are on it triggers (sends a reminder through the electronic medical record, EMR) for Q1 hour checks ... someone is not required to be in the room. When Doctor (named) put in the order, he put no 1:1 sitter needed. Interview on 07/31/2020 at 1225 with RN #4 revealed when patients are in bilateral ankle and wrist restraints for violent behavior, monitoring was required at least three times an hour per policy. Interview revealed EMR attestation indicated three times an hour monitoring was done but there was no documentation of Patient #7's condition at the time of the monitoring. NC 521, NC 901, NC 930
Based on review of hospital policy and procedure, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR º489.20 and º489.24. The findings included: 1. The hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled DED patients who presented to the hospital for evaluation and treatment. (Patient #3) ~ Cross refer to º489.24(a) and º489.24(c) Medical Screening Examination - Tag A 2406.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy and procedure review, medical record review, and physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 30 sampled DED patients who presented to the hospital for evaluation and treatment. (Patient # 3) The findings included: Review of the Emergency Medical Treatment and Labor Act - EMTALA policy, revised 09/05/2018 revealed ...DEFINITIONS: ... D. 'Emergency Medical Condition' 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual....in serious jeopardy.... G. 'Medical Screening Examination (MSE): The screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist.... PROCEDURE: MEDICAL SCREENING EXAMINATION: A. Any individual who presents to the Emergency Department (ED) or other locations .... meeting the definition of a DED and requests examination or treatment (request is made by or on behalf of the individual) will undergo a MSE to determine whether such individual is experiencing an EMC [Emergency Medical Condition]. ... Medical record review of a Pre-Arrival Summary for Patient #3, dated 06/22/2019 at 0551, revealed ...SI, Axillary [under the arm] temp 97.0. Been in and out of river all night. Abrasions on arms. ... Review of EMS (Emergency Medical Services) Notes, assessment date and time 06/22/2019 at 0514, revealed ... Primary Impression Hypothermia [cold temperature] Secondary Impression Suicide attempt.... Signs & Symptoms Behavior/Emotional State - Suicidal ideations Generalized Symptoms - Hypothermia.... Alcohol/Drugs Patient Admits to Drug Use....EMS called ref [as written] possible animal attack. Upon our arrival male subject was awake in fetal position on porch. Subject was wet he states he had been in the river, he states he was attempting to commit suicide. He states he just walked into the river he could not bring himself to jump off the bridge. The patient was moved via stretcher to EMS unit, unable to acquire oral temp. Axillary Temp is 97, EMS placed patient on stretcher and moved without incident to EMS unit. En route EMS began passive rewarming with hot packs and cabin temp. The patient admits to walking into the river with intention of committing suicide, and the abuse of Meth [methamphetamine, an addictive stimulant] and barbiturates [drugs that act as central nervous system depressants] this evening. He states he passed out on the porch was unsure how long he had been there....full report to rec [receiving] RN (Registered Nurse) and pt turned over to same... . Review of ED Triage Full Note, entered 06/22/2019 at 0611, revealed ...Stated Reason for Visit: .... EMS and pt [patient] stated he was in the river for an extended period of time. Pt stated he did meth at 2200 last night and takes barbituates [sic] prescribed for panic attacks. Denies HI/SI [homicidal ideations, suicidal ideations], was thinking about jumping off bridge r/t [related to] disappointed for doing meth again ....Thoughts of Harming Self/Others or BH [Behavioral Health] Complaint: Yes. ... Vital signs at triage were Temperature [T] 98 orally, Heart Rate [HR] 83, Respiratory Rate [RR] 18, Blood Pressure [BP] 149/82, Oxygen Saturation 98% on room air, and a pain score of 4 [on a scale from 0-10 where 10 is worst pain]. Review of a home medication list revealed the following medications: Escitalopram [Lexapro - drug that can treat depression and anxiety], Lorazepam [drug used to treat anxiety], and melatonin [used to help with sleep]. Review of Medical History - ED Triage Hx2 revealed ... Mental Health History ED : Bipolar [mental health condition], Substance abuse. ... Further review of Triage revealed Mental Health Status - ED Triage v5....Scale for Suicide Risk Assessment : CSSRS [Columbia Suicide Severity Rating Scale] - Adult Assess CSSRS Adult? Yes Behavioral Health Emergency : CSSRS indicates Low Risk of Harm, required BH OP [behavioral health outpatient] Appointment.... CSSRS Screener - Adult 1. Have you wished you were dead or wished you could go to sleep and not wake up? : Past month, no 2. Have you had any actual thoughts of killing yourself? : Past month, no 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? No CSSRS Calculation : 0 ED CSSRS Screen : Low Risk. ... Review of the CMP [Comprehensive Metabolic Panel], collected at 0611, revealed normal results except for elevated total bilirubin of 1.90 [reference range {RR} 0.20 - 1.20] and elevated AST of 56 [RR 5-34]. Review of Hematology results, collected at 0611, revealed an elevated WBC [White Blood Count] of 13.5 [RR 3.2-11.5] and Hemoglobin of 17.5 [RR 14.0-17.0], along with some abnormal differential results. Review of Toxicology results revealed an Acetaminophen Level that was less than 3.0 [RR 1-.0-30.0], a positive Urine Drug Screen for Amphetamines, Methamphetamines, Benzodiazepines, Cannabinoid, and Fentanyl. Lab result review revealed an Ethanol level below 10 [RR 0-10] and a Salicylate level below 5 [RR 0-30.0]. Review of Behavioral Health Referral/Triage note, service date and time 06/22/2019 at 0737, revealed Behavioral Health Referral Type of Referral (BH) : Triage Referral Assess CSSRS Adult? : Yes Patient has Outpatient ACTT [Assertive Community Treatment Team] Services : No OP ACTT Provder [sic] contacted to assist with coordination of care : No BH 30 Day Return (BH) : No Reason for Referral : BHIC [Behavioral Health Intake Clinician] met with pt ....to complete risk assessment and he scored as low risk on the CSSRS. No safety precautions were recommended at this time. Per RN Triage note: [Initials] EMS and pt stated he was in the river for an extended period of time. Pt stated he did meth at 2200 last night and takes barbituates [sic] prescribed for panic attacks. Denies HI/SI, was thinking of jumping off bridge r/t disappointed [sic] for doing meth again..'Pt arrived to the ED as a voluntary admission via LEO [law enforcement officer]/ EMS. BAL [blood alcohol] and toxicology results consistent. Pt alert and O x 4 [oriented to person, place, time, situation] today. Pt denies SI/HI/auditory/visual hallucinations. Patient admits to using methamphetamine on occasion and experiencing similar results each time. He has been reluctant to use community supports or outpatient therapy but admits that he is feeling like this time he needs to go to outpatient therapy at after [sic] the hospital. Patient is a veteran and has used the VA for certain things but would like to use his private insurance for outpatient. He shouldn't is [sic] provided several resources to find an outpatient therapist that would take his insurance on this depart. She [sic] is not experiencing any overt cognitive impairment, nor is he experiencing any perceptual disturbances. His thinking is goal oriented and his speech is linear and coherent. Patient will be contacting his parents for transportation. BHIC consults with ED M.D. [last name] who recommends who rescinds psychiatric evaluation request at this time. Behavioral Health Triage Behavioral Health Triage Screening : No 2. Is the patient currently experiencing auditory or visual hallucinations? : No 3. The patient is showing signs and behaviors consistent with moderate to severe agitation and/or aggression : No 4. The pt is showing signs and behaviors that would indicate a flight risk and/or a significant elopement history : No Recommendation : No Safety Precautions Recommended CSSRS Screener - Adult 1. Have you wished you were dead or wished you could go to sleep and not wake up? : Past month, no 2. Have your had any actual thoughts of killing yourself? : Past month, no 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? : No CSSRS Calculation: 0 ED CSSRS Screen: Low risk. Review of the ER [emergency room ] Report by MD #2, service time 0742, revealed ...Chief Complaint HARMSELFOTHERS History of Present Illness [AGE]-year-old male reported history of anxiety and previous substance abuse presented through the night after jumping into the river secondary to poor judgment in the setting of methamphetamine use which he confesses to. On interview the patient is clinically sober at this time and has no intent for self-harm or harming other people. Patient denies any hallucinations. He does reveal some abrasions to his anterior abdominal wall as well as his left foot that he sustained during the events of the night but has no other concern. He has been up and ambulatory in the department and feels stable. Review of Systems Per history of present illness otherwise a 10 point review is negative. Social History Alcohol Details Denies .... Substance Abuse Details Current, Methamphetamine .... Physical Exam ....General: Alert, no acute distress HEENT [Head eye ears nose throat] Normocephalic, atraumatic ....Cardiovascular Exam: Regular rate and rhythm ....good pulses throughout Pulmonary Exam: Normal work of breathing, clear breath sounds throughout ....Abdomen: Normal bowel sounds, nondistended, no tenderness to palpation .... Musculoskeletal: Full range of motion ....Skin: Warm and dry without rash, superficial linear abrasions overlying the epigastric area ....left foot also has abrasion without appreciable underlying foreign body Neurologic: No appreciable motor or sensory deficit, a and O [alert and oriented] x 3 [person, place, time] Psych: Appropriate, linear Assessment/Plan [AGE]-year-old male presenting during the [sic] slightly hypothermic in the setting of jumping into a local river while intoxicated with methamphetamines which he confesses to. Diagnostic studies were initiated from triage which I have reviewed. No concerning findings other than obviously pan positive UDS [urine drug screen]. Patient clinically sober at this time with no other physical exam findings or concerns. He is now normothermic [normal temperature]. He can assure me that he is not suicidal or homicidal or hallucinating. Patient stable for discharge with anticipated outpatient mental health follow-up ....Disposition: Discharge Diagnosis/Disposition Amphetamine-type substance use disorder, mild, abuse ....Depart ED Discharge Instructions: Per our discussion your diagnostic testing was generally reassuring at this time. You have assured me that you are not concerned about self-harm or harming other people. Please refrain from continued substance use. Follow-up as an outpatient with your mental health providers. Record review revealed a RARF - Discharge Disposition form, time 0813, which stated Discharge Disposition: Referral Rescinded Legal Status at Disposition : Voluntary .... Referral Rescinded : Non-Psych Discharge Disposition Comments : ED MD [Name] rescinds. ... At 1010 review revealed a pain score of 0 and at 1018, vital signs were noted as HR 92, RR 17, BP 146/80, Oxygen saturation of 99% on room air. At 1020, review revealed a Discharge Comment that mom is driving patient home. Record review did not reveal any evidence that Patient #3 was involuntarily committed [IVC] and did not reveal any IVC paperwork. Record review did not reveal any evidence a psychiatrist was requested or examined Patient #3. Review of the Death Certificate for Patient #3, on 07/30-31/2020, revealed the initial date signed was 06/26/2019. Review revealed a Medical Examiner Section where DATE PRONOUNCED was written as 06/26/2019, DATE OF INJURY was documented as 06/23/2019, PLACE OF INJURY was listed as RIVER, [name] and the description stated missing-Found in River. The immediate cause of death was initially written in as Pending, but there was a circle [appearance of a stamp] which noted CAUSE AMENDED [DATE] SUPPLEMENT ON REVERSE SIDE. Review of the SUPPLEMENTAL REPORT OF CAUSE OF DEATH, documented the immediate cause of death as Drowning and stated ...Other significant conditions contributing to death .... Methamphetamine toxicity ... The MANNER OF DEATH section revealed a box filled in beside the word Suicide and under DESCRIBE HOW INJURY OCCURRED was documented intentionally entered body of water. Further review of the Supplemental Report revealed the DATE PRONOUNCED was listed as 06/26/2019 and the DATE OF INJURY was documented as Unknown. Review revealed the SUPPLEMENTAL REPORT OF CAUSE OF DEATH was signed on 12/20/2019. Review on 07/31/2020 of a document provided by the hospital, titled REPORT OF INVESTIGATION BY MEDICAL EXAMINER, dated 06/30/2019, revealed DECEDENT (Name of Patient #3) ....DEATH .... 06/26/2019 ....1400 ....ME [Medical Examiner] NOTIFIED ....06/26/2019 ....1745 ....LAST KNOWN TO BE ALIVE .... 06/23/2019 ....1900 ....MEANS OF DEATH ....Reportedly fishing from riverbank 6/23. Then missing. Found in river 6/26 ....MEDICAL EXAMINER PRELIMINARY SUMMARY OF CIRCUMSTANCES SURROUNDING DEATH The decedent is a [AGE] year old white male. He was found dead in the [River Name] in [County name] ....He was reported missing by his family on Monday June 24. He wast [sic] last known alive on the previous evening (Sunday) around 1900 when he reportedly called his mother and stated he was fishing and would not be home for dinner. He did not return and the missing person's report was filed as mentioned. Officers responded to the area he was known to fish and discovered his wallet, a chair, and his car keys. His vehicle was reported to be present at the site according to the EMS crew I spoke with. A search ensued both on land and in the river. He was discovered on Wednesday June 26 in the [Name of River] and removed from the river. It was reported to me his body was near the location of his effects on the opposite shoreline. He was pronounced dead at 1400 ....Officers were able to identify the decedent by allowing his Uncle to view the body. He stated that he was able to positively identify the decedent. I spoke with one of the officers present and he was able to relate some facts that were not immediately apparent. The Officer told me that the decedent had been fishing in the same river ....on the previous Thursday. He suddenly arrived at a nearby home and stated he was chased by other individuals and jumped in the river. He requested that 911 be called. EMS and the [County name] Sheriff responded. According to the ....Officer the decedent was transported by [Name] EMS. The Sheriff's Office investigated the claims and found them unfounded. At some point the decedent told EMS that he had planned on harming himself. He was also described as a known substance abuser. Again according to the ....Officer, the decedent was involuntarily committed and was released on Sunday, the day he disappeared. I have requested Medical Records from this admission but thus far they have not been produced. Law Enforcement is under the opinion that the fatal event was most likely suicide. Some family members share this opinion according to the .... Officer. I examined the decedent on the evening he was discovered. This will be an Autopsy case since the event was unwitnessed.... He was dressed in shorts and a T Shirt. He was bearded. I found it reasonable that a family member could identify the decedent visually and he had numerous Sleeve Tattoos and a visible Tattoo on his L [left] leg. There was no obvious signs of trauma noted during my cursory pre Autopsy exam. Active case volume precluded completing the RIME prior to Autopsy so I contacted [location] and relayed by Phone to [name] as many details as possible about the case. I will supplement the RIME if additional pertinent information is noted after reviewing the Medical Records when they are produced. ... Review on 07/31/2020 of the Autopsy Report, titled MEDICOLEGAL AUTOPSY REPORT, reported 12/20/2019, revealed FINAL AUTOPSY DIAGNOSIS I. Drowning A. Bilateral pleural effusions B. Fluid in sphenoid sinus II. Methamphetamine toxicity III. Decomposition, moderate .... Summary of Findings The cause of death is drowning. A contributing factor is methamphetamine toxicity ....According to the .... Medical Examiner, the decedent had gone missing after reportedly going fishing. Prior to leaving he told his mother that he would not be home for supper. A couple days prior he had intentionally walked into the river. At that time he had told emergency medical services (EMS) that he was attempting to commit suicide by walking into the river because he could not bring himself to jump off the bridge. He reportedly could swim. ... Requests for interview of the Triage Nurse and the Nurse who documented the pre-arrival information revealed they no longer were at the hospital and, thus, were not available for interview. Interview with the DED Medical Director, MD #1, on 07/20/2020 at 1500, revealed patients who come into the ED are screened for suicide risk by the CSSRS. Interview revealed patients do not necessarily get evaluated by a psychiatrist. Interview revealed MD #1 reviewed the medical record. Interview revealed the treating physician had noted the patient was clinically sober and had no intent of harming self or others. Interview revealed there was consultation with psych intake and they felt the patient was safe for discharge. Interview revealed that taking a patient's rights away was a big deal and was taken very seriously. Interview revealed MD #2, the physician on duty in the ED when Patient #3 came in, was conservative in care and for him to discharge the patient meant he felt safe to do so. Further interview revealed that according to the documentation Patient #3 was interested in outpatient treatment. Interview, on 07/29/2020 at 1530, with BHIC #3 [Behavioral Health Intake Clinician] revealed the role was a triage clinician for the ED. Interview revealed BHIC #3 could not recall Patient #3's face. Interview revealed BHIC #3 did the intake assessment for Patient #3 and stated intake staff assessed patients in the ED to determine the best course of treatment and the level of risk in general. Interview revealed an order started the triage, which continued to a full psych assessment unless it is stopped at some point. Interview revealed BHIC #3 consulted with the ED doctor, and the doctor made the decision. Rescind, she stated, was the language that stopped the process. Interview revealed if a patient was involuntarily committed [IVC] law enforcement would bring paperwork from the magistrate which would be a part of the medical record. Interview revealed this patient was not IVC, that BHIC #3 documented the patient was voluntary and stated that meant she validated the information. If the patient was IVC, BHIC #3 stated, it would have been documented as such in the record and the paperwork would be in the record as well. Interview revealed patients who come via EMS may be more intoxicated initially and once they get into the ED and rest they become more lucid, calmer, and may recant what they said previously. BHIC #3 stated they were fairly conservative, that if there was any doubt the patient may be playing good patient they would play it safe. Interview revealed if a patient was lucid, had linear thought and there was no reason to question their stability, then it may not be necessary to get anyone else, such as family, involved. Interview revealed that BHIC #3 felt secure in the knowledge that both she and the MD were conservative and if there had been any questions about safety they would have addressed them. Telephone interview, on 07/29/2020 at 1615, revealed RN #4 recalled Patient #3. Interview revealed the patient came in on Meth and was disappointed in himself because he had relapsed. Interview revealed he was trying to get clean for his son. Interview revealed the patient stated he had not tried to kill himself, that he had been taking meth and accidentally ended up in the river. Interview revealed RN #4 had questioned with the provider whether they wanted to discharge the patient because he had a flat affect, was solemn and quiet. Interview revealed the only time the patient perked up was when they talked about the patient's child. RN #4 stated they thought the behavior was attributed to having just come down from a massive meth high and stated the patient scored low on the CSSRS. Interview revealed RN #4 felt okay with discharging the patient after the discussion. Further interview revealed the patient's family member came to take the patient home. Interview revealed the family member did not express any concerns to the RN about taking the patient home and Patient #3 stated he was ready to go home. At discharge, interview revealed, Patient #3 was provided a sheet of local detox resources, local outpatient resources to keep and use. Interview, on 07/20/2020 at 0905, with MD #2, revealed only a vague recollection of Patient #3. Interview revealed MD #2 reviewed the medical record. Interview revealed cases such as this one were unique cases to navigate - sobriety vs. ability to make judgments. MD #2 stated that based on his notes Patient #3 presented as clinically sober at the time of his MSE and adamantly denied suicidal or homicidal ideations. Interview revealed the patient was observed, had sobered up, hypothermia had normalized, and the patient continued to state he had no suicidal ideation. Interview revealed a judgment was made that the patient was reliable, had the judgment to make decisions, and insisted he was safe. MD #2 stated they generally had the ambulance run sheet and tried to get corroborating information when possible. MD #2 did not recall specifics but stated in looking at the medical record he could see discrepancy between the EMS report and the CSSRS. Interview revealed he leaned towards being conservative. In response to when a full psych evaluation by psychiatry or tele-psychiatry was obtained, MD #2 stated when patients were blatantly psychotic or continued SI /HI after sobriety. Interview revealed disposition was the ED physician's decision in consult with psych intake. Interview revealed after spending time with patients they sometimes got a different, clearer picture over time. In summary, review of EMS report revealed Patient #3 stated he had walked into the river attempting to commit suicide. Patient #3 was brought to the Emergency Department on 06/22/2019. The Triage Note stated the patient denied HI/SI but also stated the patient was thinking about jumping off bridge. In the Emergency Department two CSSRS evaluations indicated the patient had not considered killing himself in the past month and had never done or started or prepared to do anything to end his life. The DED physician stated the patient adamantly denied suicidal or homicidal ideations. No psychiatrist or Tele-psychiatrist was consulted to evaluate Patient #3. Patient #3 was discharged home on 06/22/2019 and was subsequently found dead in a river on 06/26/2019 after last being seen alive on 06/23/2019.
Based on review of hospital policy, food temperature logs, and interviews with staff, the hospital's dietary staff failed to monitor and record food temperatures according to policy for 2 of 2 hospital campuses (Campus A and Campus B). The findings include: Review of policy titled, PATIENT FOOD SERVICES: TRAYLINE/TASTE/TEMPERATURE RECORD, with revision date of 01/20, revealed POLICIES: All items intended for patient food service are listed on the Taste/Temperature Record. Completed forms are kept on file for one year .... Daily Preparation of Forms: Supervisor or Office: Run the Taste and Temperature Report form Webtrition (Electronic form) for each meal. Supervisor: ...TEMPERATURES: logs temperatures at all points indicated on the form in conjunction with appropriate maintenance ... Two temperatures must be noted on the form, a beginning and either a midpoint or an ending temperature. Takes immediate action if temperatures indicate a violation ... 1. Review of food temperature logs from Hospital Campus B revealed incomplete January 2020 food temperature logs. Review revealed no documentation of food temperatures on 01/08/2020, 01/09/2020, 01/11/2020, 01/12/2020, 01/13/2020, 01/18/2020, 01/21/2020, 01/22/2020, 01/24/2020, 01/25/2020, 01/28/2020, 01/29/2020 or 01/30/2020 (missing 13 of 31 days). 2. Review of food temperature logs from Hospital Campus A revealed incomplete December 2019 food temperature logs. Review revealed no food temperatures were found for 12/15/2019, 12/25/2019, 12/28/2019, 12/29/2019, 12/30/2019, or 12/31/2019 (missing 6 of 31 days). Review of February 2020 food temperatures between February 1, 2020 and February 21, 2020 revealed incomplete temperature logs. Review revealed no temperature logs were found for 02/01/2020, 02/05/2020, 02/10/2020, or 02/12/2020 (missing 4 of 21 days). Interview on 02/20/2020 at 1455 with AS #1 (Director of Food and Nutrition) revealed the staff member could not locate the missing food temperatures for December 2019, and January and February 2020. Interview revealed the policy to obtain and document food temperatures for each meal was not followed. NC 479; NC 887; NC 272; NC 736; NC 784; NC 050; NC 025; NC 019; NC 069; NC 066; and NC 120
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record reviews and staff interviews, the facility staff failed to manage pain in 1 of 8 Emergency Department (ED) records reviewed (Patient #4). The findings included: Review on 09/17/2019 of a policy titled Pain Assessment and Management, last revised on April 22, 2019, revealed PURPOSE: The purpose of this policy is to provide guidelines for assessment and management of pain patients served by HCA Mission Health. ...POLICY: A. Each patient is screened for the presence of pain in all settings where treatment is provided...B...The frequency of pain assessment is based on patient symptoms, interventions, and progress towards goals...D...Prevention of severe pain has been shown to improve healing. Therefore proactive pain management may be preferred to reactive pain treatment, particularly in patients experiencing severe and/or predictable pain... The policy did not address any requirements for the frequency of pain assessments or documentation of a patients pain before medication administration.. Emergency Department (ED) record review for Patient #4, on 09/17/2019, revealed the [AGE] year old male arrived to the ED via private vehicle on 08/07/2019 at 0701. Review of the ED record revealed Patient #4 was triaged by RN #1 at 0702 and self reported a pain score of 1 out of 10. Review revealed RN #2 performed a Nursing Assessment at 0720 and did not reassess Patient #4's pain at that time. Review of Patient #4's MSE (Medical Screening Exam) revealed it was initiated at 0833 (1 hour and 32 minutes after Patient #4's arrival to the ED) by Family Nurse Practitioner (FNP) #1. Review of the ER Report revealed Patient #4 had a history of tortuous left ureter and was found to have intrarenal stones in the past. The review revealed Patient #4 had a ureteoscopy a few months prior and the stones could not pass through the ureter due to the tortuosity of the ureter. Review further revealed Patient #4 had developed some severe left flank pain overnight and thought he was constipated. Patient #4's Physical Exam revealed General: Initially the patient appeared to be quite uncomfortable...Gastrointestinal: ...The patient is very tender in the left lower quadrant/flank region...Psychiatric: As mentioned the patient was quite uncomfortable initially. This actually created some agitation in him. The FNP note revealed Hydromorphone (pain medication) 0.5 mg IV push and Ondansetron (nausea medication) 4 mg IV push were both ordered at 0820. Review of the MAR (Medication Administration Record) revealed, RN #2 administered the ordered medications at 0838. Record review revealed Patient #4 reported a pain score of 10 at the time of the medication administration Review of the Staffing Sheets for 08/07/2019, revealed two medical doctors were available to evaluate patients prior to 0800 when FNP #1 arrived. Interview with the ED Director on 09/18/2019 at 1610 revealed the ED had at least 2 Pods (areas in the ED) with an MD available 24 hours per day. Interview revealed if a patient was roomed in a pod (area) without a medical provider until 0800 and started having pain they could be seen by a provider in another pod. The nurse, interview revealed, could just walk right over to the other pod and request orders be placed until the provider in that pod arrived. Interview with RN #2 on 09/19/2019 at 1020 revealed she was the Primary RN for Patient #4. Interview revealed He thought he was constipated, but also had a history of left sided kidney stones. Interview revealed, If it's the patient I'm thinking of, he was in pain. Interview further revealed the provider in the adjacent pod typically sees the patients in that pod until their provider arrives. A lot of the time they know who's waiting to be seen by looking at the tracking board. RN #2 revealed that on this morning, her co-worker, RN #3, actually walked over to notify the provider that Patient #4 was in pain and requesting pain medicine. I did not follow-up or attempt to notify the provider myself. Interview revealed RN #2 remembered Patient #4 asked to go to another facility because he was in pain and there was no provider in that pod, RN #2 stated, I tried to discourage him. I recall the patient wanted to go to Urgent Care, but I knew he would just end up getting sent back here. RN #2 stated that she would normally notify the provider if pain was an issue and acknowledged that she did not in this case. Review revealed RN #2 documented pain assessments on admission and again only if there is a change or after an intervention. RN #2 recalled charting a pain assessment at the time of medication administration. Interview revealed Patient #4 did not have pain medicine ordered until after FNP #1 arrived. RN #2 was unable to recall if Patient #4 ever communicated he was in pain to anyone else later that afternoon. RN #2 stated the nurses do carry phones, but if the staff answering the call bell did not see the nurse right away, and were busy with other tasks, there could be a delay in communication. Interview revealed it is common to hear the pain score directly from the patient, not from the person answering the call bell. Interview with RN #3 on 09/19/2019 at 1127, revealed RN #3 remembered Patient #4 and assisted RN #2 by walking over to the Pod to notify the doctor of Patient #4's pain. I don't recall exactly the situation, but I feel like the provider was caught up in a situation. RN #3 stated she did not follow-up because she was not the primary nurse and was just helping out. Interview with RN #4 on 09/20/2019 at 1013, revealed I've been in (Patient #4's Pod) with no provider before and and I've gone over to the provider in (Pod name) because the providers in (adjacent Pod name) are usually pretty busy. Interview with the ED Nurse Manager on 09/20/2019 at 1132, revealed there is no policy on documenting at the time a patient requests pain medicine or makes the nurse aware they have pain. Interview revealed it is usually documented at the time of medication administration. Interview revealed, there is place in the EMR (Electronic Medical Record) where staff should be documenting when a provider is notified about any patient condition or change. It is my expectation that nurses follow the policy around pain assessments and reassessments. I do not remember the exact wording in the policy because it's been changed several times. Interview requested on 09/19/2019 and 09/20/2019 revealed MD #1 was not available. NC 712, NC 000, NC 498, NC 145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy review, medical record review and staff interview, the hospital staff failed to obtain a physician order for a violent restraint for 1 of 2 violent restraint patient records reviewed (Patient #9). The findings included: Review on 06/05/2019 of a policy titled Restraint Use - Violent last revised 06/2017 revealed ...3. Orders a. When alternative methods are unsuccessful in managing violent behavior, an order for restraint, seclusion and/or therapeutic hold should be obtained from the LIP (licensed independent practitioner)... Closed medical record review of Patient #9 on 06/05/2019 revealed a [AGE] year old female who arrived to the emergency department (ED) via law enforcement involuntarily committed for violent behavior and self-harm. Review of the violent restraint flowsheet documentation dated 04/26/2019 at 2201 revealed Patient #9 was placed in a therapeutic hold for 13 minutes due to violent behaviors towards staff members after restraint alternatives were attempted. Review revealed on 04/26/2019 at 2216 Patient #9 was placed in a therapeutic hold for 5 minutes and bilateral ankle and wrists restraints for harm to self and others after restraint alternatives were attempted. Review revealed an order for bilateral ankle and wrists restraints on 04/26/2019 at 2225. Review of the physician orders failed to reveal an order for both therapeutic holds. Review revealed Patient #9 was transferred to an inpatient psychiatric facility on 05/14/2019. Interview on 06/06/2019 at 1100 with the ED Medical Director revealed MD #1 (Medical Doctor) was not available. Interview revealed physicians are the only providers who can put in an order for restraints. Interview revealed physicians can give a verbal order for restraints but if the patient was having a crisis, the ED physician would go to the patient's bedside. Interview on 06/05/2019 at 1510 with RN #1 (Registered Nurse) revealed Patient #9 was in the behavioral health holding area (BHU) when she was restrained. Interview revealed if staff had to restrain a patient the RN normally would call the emergency department physician to get a verbal order or the physician would come over to the BHU. Interview revealed nurses did have to get an order for a therapeutic hold and RN #1 did not know why Patient #9 did not have an order for the two therapeutic holds on 04/26/2019. Interview on 06/05/2019 at 1530 with Nurse Manager #1 revealed there was no available documentation in the record for Patient #9 of a physician's order for both restraints. Interview confirmed the findings. NC 417, NC 875
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy and procedure review, open and closed medical record review and staff and physician interview, the nursing staff failed to follow a physician's order for 1 of 2 patients with an alcohol assessment (Patient #1) and failed to obtain vital signs per hospital policy for 2 of 4 patient receiving a blood transfusion (Patient #8, #7). Findings included: A. Review on 09/06/2018 of the hospital policy titled Medication Administration origination date June 29, 2017, revealed Policy: ...A. Medications are administered only upon the order of a member of the medical/dental staff or other individuals who have privileges to write such orders. Review on 09/05/2018 of the closed medical record for Patient #1 revealed a [AGE] year-old female admitted on [DATE] at 1433 with a diagnosis of Left buttock wound. Record review revealed Patient #1 was discharged to a Skilled Nursing Facility (SNF) on 08/13/2018 at 1712. Review of the physician orders revealed a CIWA (alcohol withdrawal assessment) Scale order dated 08/04/2018 at 1629 with instructions to assess alcohol withdrawal signs/symptoms every six (6) hours and as needed. Review of the nursing flowsheet revealed the first (1st) alcohol withdrawal assessment was completed on 08/04/2018 at 2000. Further review of the nursing flowsheet revealed the next available documentation of an alcohol withdrawal assessment was completed on 08/05/2018 at 0900 (13 hours later). Review of the nursing flowsheet revealed the alcohol withdrawal assessment were completed every 12 hours from 08/05/2018 at 0900 through 08/07/2018 at 0745. Review of the nursing flowsheet revealed alcohol withdrawal assessments were completed on 08/07/2018 at 1253, at 2122 (9 hours and 15 minutes later), on 08/08/2018 at 0202, at 0504, at 0754 and at 2107 (13 hours and 13 minutes later). Further review of nursing flowsheets revealed documentation of alcohol withdrawal assessment completed on 08/09/2018 at 0011, at 0330, at 0835, at 2016 (11 hours and 31 minutes later) and at 2342, on 08/10/2018 at 0423 (41 minutes later) and at 1945 (15 hours and 22 minutes later), on 08/11/2018 at 0715 (11 hours and 30 minutes later), and at 2016 (13 hours and 1 minute later), on 08/12/2018 at 0730 (11 hours and 14 minutes later), and at 1957 (12 hours and 27 minutes later) and on 08/13/2018 at 0730 (11 hours and 33 minutes later) and at 1200. Review of the medical record revealed the nursing staff did not follow the physician order to assess the alcohol withdrawal signs/symptoms every six (6) hours. Interview on 09/06/2018 at 1000 with nursing management revealed staff were expected to follow the physician's orders as written. Interview revealed the nursing staff failed to assess the alcohol withdrawal signs/symptoms every six (6) hours as ordered by the physician. B. Review on 09/05/2018 of the hospital policy titled Blood and Blood component Administration (blood transfusion) revised July 6, 2017 revealed Appendix C: summary Chart of Blood Components ...Red Blood Cells Leuko-reduced ...Vital Signs: *Baseline prior to standard infusion *15 minutes into infusion *Every hours during infusion *At completion of infusion. 1. Review on 09/06/2018 of the open medical record for Patient #8 revealed an [AGE] year-old female admitted on [DATE] at 0358 with a diagnosis of blood sugar problems. Review of the physician orders dated 08/30/2018 at 0300 revealed an order to transfuse two (2) units of PRBC's (packed red blood cells). Review of the blood administration nursing flowsheet revealed the second unit of blood was started on 08/30/2018 at 1709. Review of nursing notes revealed vital signs to include a temperature, heart rate, respiratory rate, blood pressure and oxygen saturations were completed on 08/30/2018 at 1709, 1728, and 1830. Review of the nursing notes revealed documentation of a heart rate, respiratory rate, blood pressure and oxygen saturation were completed at 1930. Review of the nursing notes revealed documentation that the transfusion was completed at 2046 with documentation of temperature, heart rate, respiratory rate, blood pressure and oxygen saturation completed at 2047. Review of the physician orders dated 08/31/2018 at 0402 revealed an order to transfuse one (1) unit of blood. Review of the blood administration nursing flowsheet revealed the blood transfusion was started on 08/31/2018 at 0436. Review of nursing notes revealed vital signs to include a temperature, heart rate, respiratory rate, blood pressure and oxygen saturations were completed on 08/30/2018 at 0436, 0446, and 0556. Review of the nursing notes revealed documentation of a heart rate, respiratory rate, blood pressure and oxygen saturation were completed at 0700 and 0800. Review of the nursing notes revealed documentation that the transfusion was completed at 0859 with documentation of temperature, heart rate, respiratory rate, blood pressure and oxygen saturation completed at 0900. Review of the medical record revealed no available documentation of a temperature obtained at 0700 and 0800. Review of the medical record revealed nursing staff failed to obtain vital signs per the hospital blood transfusion policy. Interview on 09/06/2018 at 1000 with nursing management revealed staff were expected to obtain vital signs per the blood transfusion hospital policy. Interview revealed vital signs should include a temperature, blood pressure, heart rate, respiratory rate and oxygen saturation. Interview revealed the nursing staff failed to obtain a complete set of vital signs per hospital policy for Patient #8. 2. Review on 09/05/2018 of the closed medical record for Patient #7 revealed a [AGE] year-old female admitted on [DATE] at 0613 with a diagnosis of lethargy, decreased hemoglobin and red knee. Record review revealed Patient #7 was discharged on [DATE] at 1039. Review of the physician orders dated 07/24/2018 at 2203 revealed an order to transfuse two (2) units of PRBC's (packed red blood cells). Review of the blood administration nursing flowsheet revealed the first unit of blood was started on 07/25/2018 at 0127. Review of nursing notes revealed vital signs to include a temperature, heart rate, respiratory rate, blood pressure and oxygen saturations were completed on 07/25/2018 at 0126 and 0141. Review of the nursing notes revealed documentation of a heart rate, respiratory rate and oxygen saturation were completed at 0315 and 0354. Further review revealed documentation of a heart rate, respiratory rate, blood pressure and oxygen saturation were completed at 0407. Review of the nursing notes revealed documentation that transfusion was completed at 0417 with documentation of temperature, heart rate, respiratory rate, blood pressure and oxygen saturation completed at 0418. Review of the medical record revealed a transfusion reaction was identified at 0300 and no documentation of the discontinuance of the blood transfusion. Review of the medical record revealed no available documentation of vital signs obtained at 0241 and no documentation of a temperature or blood pressure obtained at 0315 and 0354. Review of the medical record revealed nursing staff failed to obtain vital signs per the hospital blood transfusion policy. Interview on 09/06/2018 at 1000 with nursing management revealed staff were expected to obtain vital signs per the blood transfusion hospital policy. Interview revealed vital signs should include a temperature, blood pressure, heart rate, respiratory rate and oxygen saturation. Interview revealed the nursing staff failed to obtain a complete set of vital signs per hospital policy for Patient #7. NC 216
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy and procedure review, medical record review, and staff interview hospital staff failed to identify an allegation of abuse as a grievance and follow the investigation process for 1 of 1 patients alleging abuse (Patient #1). The findings include: Review of policy titled Patient and Family Complaint/Grievance Reporting, origination date 10/25/2017, revealed ...DEFINITIONS: (as defined by Centers for Medicare & Medicaid Services - CMS): A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse, or neglect....1. When a patient or the patient's representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is to be treated as a grievance....Responding to the patient/family: All patient grievances must be responded to in writing as soon as possible. At a minimum, a written response will be provided within 7 days from the first date that the Grievance was received by anyone in the organization which includes the required elements set forth by CMS....Most grievances can be resolved and the resolution communicated in writing within the 7--day timeframe when that is not possible, the patient/patient's legal representative will be notified. 3. The written response must include the substance of the grievance, the steps taken to investigate the grievance, the results of the investigation, the date of completion and the hospital contact person. The response must include the respondent's name and telephone number as well as the name and phone number of the responding authority. ... Review of policy titled Identification and Management of Suspected Abuse Victims, revision date 06/16/2015, revealed PROCEDURE - [Hospital Name] INPATIENT: ....Additionally, the Care Management Staff will focus on cases of suspected patient-to-patient and staff-to-patient abuse with the health care team and with Administration as appropriate. .. Review did not reveal any other information specific to investigation of alleged staff-to-patient abuse/neglect. emergency room (ER) Record review for Patient #1, on 02/27-28/2018, revealed the [AGE]-year-old (yo) arrived to the ER [DATE] at 0414. Review of ER (emergency room ) Report note, at 0549, revealed Patient #1 ...stated she needed to be admitted to (psychiatric unit name) because her medications are 'messed up.' ....Physical Exam ....Psychiatry: Agitated, aggressive, demanding, inappropriate, reports desire for harm of the staff. Passive claims that she wants to harm herself without plan. She does not appear to be responding to any internal stimulus Assessment/Plan ....She has been slamming doors and screaming at people in the emergency department. ... Review of an ER Report note, service date and time 01/01/2018 at 0832, revealed ...Patient was repeatedly verbally assaultive towards myself and staff without any provocation....I've called security and behavioral health has called law enforcement. Patient is discharged with law enforcement to jail. Review of an ER Report note, on 01/01/2018 at 1105, revealed Patient....presents to the department today via law enforcement. She was just discharged from the Emergency Department and they found that she had an IVC order and was brought back. Record review revealed Patient #1 was placed in Violent Restraints on 01/01/2018 at 1049. Review of Violent Restraint Flowsheet, dated 01/01/2018 at 1323, revealed the restraints were discontinued at 1310 and the patient was moved to a Psychiatric Evaluation Unit in the same hospital. Review of a Progress Note by a FNP (Family Nurse Practitioner) on 01/01/2018 at 1605 revealed ...Asked by nursing to evaluate this patient for c/o right wrist pain s/p (status post) restraints. Review of a Physician Progress Note, on 01/02/2018 at 0854, revealed ...(Patient #1)....wanted to talk about the abuses she feels she suffered in the ED. She states she was abused by security for 3 hours. ... Further medical record review revealed scanned in handwritten documents. One document, dated 01/01/2018 revealed Attn (Attention) Risk Management Office of patient experience Today at approximately 5:00pm, I asked for an ADA (Americans with Disabilities Act) accomidation (sic) for my HOH (hard of hearing). Instead of assisting me, Nurse (name) laughed at me, said my ears were fine, and he didn't feel like playing games. Then he slammed the door of the nursing station on my broken arm.... Please investigate this crime by notifying law enforcement as well as conducting an internal investigation ....Please follow up w/ (with) me in person & via email. Pt's hand is injured transcribed by Nurse ... Record review revealed another scanned handwritten document, no date. Review revealed Att (Attention): Patient exp (experience): Grievance...Re: (name) I am being targeted by the female named (name) she harrasses (sic) me (Name) regularly & systematically is passive and negligent....she targets and bullies me... . Interview with Manager #1, on 02/17/2018 at 1525, revealed Patient #1 called the facility on 01/03/2018 to complain that she thought she had been abused by security. Interview revealed these were the same concerns that were brought forward while Patient #1 was still a patient in the hospital and they had already been investigated. Because the evaluation was already completed, it was decided that was sufficient as well as in the best interest of the Patient. Interview revealed the concern was considered a complaint, not a grievance because it was investigated and closed prior to the Patient's transfer out of the facility. Interview with RN #4, on 03/01/2018 at 1100, revealed RN #4 was filling in for another Tech. Patient #1 was very aggressive with Tech #3, so RN #4 switched units with Tech #3. Interview revealed RN #4 worked with Patient #1. RN #4 stated Patient #1 was pretty manic and had a lot of requests and she was working with her to calm her. Interview revealed Patient #1 claimed her arm was broken while in the ED, so RN #4 contacted a Nurse Practitioner. Further interview revealed she wrote the letter for Patient #1 stating she was abused because the Patient said her arm was injured again by another nurse. Interview revealed I wrote word for word what she said as if she wrote it. RN #4 discussed the circumstances around the letter. The RN stated she was in the hallway when Patient #1 came and asked if she saw what another nurse just did. Interview revealed RN #4 did not see what happened, but Patient #1 said (Name) just slammed my arm in the window. Interview revealed RN #4 looked at the arm and it did not look any different than it had before, there were no marks. RN #4 stated that at the time she did not think of this as an allegation of abuse, that Patient # 1 was not in reality at the time. Interview with Administrative Staff (AS) #2, on 03/02/2018 at 1315 revealed the initial allegation of abuse occurred while Patient #1 was in the hospital and the investigation concluded no abuse took place. When Patient #1 called in after discharge, the department had already reviewed the complaint and therefore took no further action. Interview revealed it was considered a complaint by the Department of Patient Experience because it was investigated at the time and the grievance policy defined care issues which were resolved at the time as complaints. AS #2 stated the way the policy was worded may have created confusion for staff. Further interview revealed Risk Management nor the Department of Patient Experience were aware of the scanned letters in Patient #1's medical record until this week. Interview revealed no investigation had been done on the information in the letters. Interview revealed the Grievance policy related to allegations of abuse/neglect was not followed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review and interview, the facility staff failed to document in the patient's medical record the date and time the death was recorded in the internal log, for 2 of 2 sampled patient records (Patients' # 2 and #3) of a death that occurred within 24 hours after the patient was removed from soft wrist restraints. The findings included: Review on 03/02/2018 revealed the hospital restraint policies did not include staff documenting in the medical record the time and date a death was recorded in the internal log. 1. Review on 03/02/2018 of Patient #2's medical record, revealed a [AGE] year old male transferred directly to the ICU (Intensive Care Unit) on 02/26/2018 at , from an outside ED (Emergency Department). The patient's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (diseases of the heart muscle), volume depletion (a reduction of fluid outside the cells), reported hematemesis (vomiting blood), and severe metabolic acidosis (when a problem in your cells throws off the chemical balance in your blood, making it more acidic). The patient was intubated (a tube inserted into the trachea for ventilation) at 1127 for acute respiratory failure and airway protection. Review revealed a physician's orders on 02/26/2018 at 1108 for non-violent limb restraints due to compromised safety and well being and interference with medical interventions. Nursing documentation by the patient's RN at 1130 revealed bilateral wrist restraints. Pt [patient] confused and resisting nursing and respiratory interventions, interfering with care. Re-assessment of the bilateral wrist restraints was documented at 1200 and they were discontinued at 1330. Review revealed a CODE BLUE (a hospital code used to indicate a patient requiring immediate resuscitation), was started at 1328, and the patient was pronounced dead on 02/26/2018 at 1400. Review revealed the date and time the death was recorded in the internal log, was not documented in the patient's medical record. Interview with Administrative Staff #2, revealed staff document in the medical record the date and time reportable deaths are reported, but the hospital did not have a policy or system in place for staff to document the date and time the death was recorded in the internal death log. Interview revealed, going forward, they will expand their process to have nursing staff document the date and time the death information was placed on the internal log, and Risk Management (RM) will track the policy to match the expanded process. 2. Review on 03/02/2018 of Patient #3's medical record, revealed a [AGE] year old male found unresponsive by a family member, arrived to the hospital ED via ambulance on 12/15/2017 at 1012. The patient was found to have a subacute right occipital and right parietal infarct (a stroke - when blood supply to the brain is blocked) and hypertensive crises (severe increase in blood pressure that can lead to a stroke). Review revealed a physician's order written on 12/15/2017 at 1830 for non-violent limb restraints due to compromised safety and well being and interference with medical interventions. RN documentation on 12/15/2017 at 1830 revealed bilateral wrist restraints started due to pt being intubated and sedated, unsure of neuro status. Concern for pt safety if he wakes up confused. Documentation revealed the bilateral soft, wrist restraints were discontinued on 12/16/2017 at 0200. Review revealed on the morning of 12/6/2017, the patient had blown, non reactive pupils (a fixed, dialted pupil, often a symptom of intracranial pressure), was sent for an MRI (Magnetic Resonance Imaging) which showed extensive infarction. The patient's family member made the decision to withdraw care, and the patient died shortly thereafter on 12/16/2017 at 1531. Review revealed the date and time the death was recorded in the internal log, was not documented in the patient's medical record. Interview with Administrative Staff #2 on 03/02/2018, revealed staff document in the medical record the date and time reportable deaths are reported, but the hospital did not have a policy or system in place for staff to document the date and time the death was recorded in the internal death log. Interview revealed, going forward, they will expand their process to have nursing staff document the date and time the death information was placed on the internal log, and RM will track the policy to match the expanded process.
Based on review of ([Brand name of] Nursing Practice guidelines used by the facility, observation and interview, the nursing staff failed to follow appropriate infection control techniques in 1 of 2 observations of drawing up injections (RN [Registered Nurse] #2). The findings included: Review of the [Brand Name of Nursing practice guidelines] procedures - Intramuscular Injection, revised August 18, 2017, revealed ... DRAWING UP MEDICATION FOR INJECTION... For single-dose or multidose vials: ... Wipe the stopper of the medication vial with an alcohol pad and allow it to dry completely. Draw up the prescribed amount of medication... Observation on 03/01/2018 at 0935 of RN #2 performing a medication pass for Patient #4 on the Orthopedic Unit, revealed the medication pass included administering a pneumococcal vaccine (pneumonia vaccine). Observation revealed the RN popped the top off the 0.5 ml, single dose vial of medication, inserted the needle into the rubber stopper, withdrew the medication and administered the vaccination. Observation revealed the RN failed to wipe the rubber stopper with alcohol prior to inserting the needle to withdraw the medication. Interview on 03/01/2018 at 1000, after the observation, revealed if the vial has a popped top it was sterile and the RN did not wipe the rubber septum with alcohol prior to inserting the needle. Interview revealed if the vial was a multi-dose vial without the top, it needs to be wiped [with alcohol]. Interview on 03/02/2018 at 1145 with the Director of the Orthopedic Unit, revealed the rubber stopper on new vials with tops, was considered clean, not sterile and should be wiped with alcohol prior to inserting the needle. Interview revealed the hospital followed the Lippincott Procedures as a guideline for drawing up medication for injection. Interview revealed We are re-educating our teams.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of policy, medical records, Current Summary Medication/Fluid Event Log, Response Timeline, and staff interview, the facility failed to provide and accurately reconciled medication list to the receiving facility upon discharge for 1 of 4 discharged patients (Patient #11). The findings included: Review on 04/27/2017 of the facility policy Medication Management (Policy: IMM.ADM.0002, Origination Date: 01/17/2017), revealed ...PROCEDURE: C. Discharge Reconciliation Process - INPATIENT SETTING: 1. Role of Provider - a. Review and reconcile home medications with therapies provided during hospitalization to ensure home list is accurate and updated with no duplications, omissions, incomplete instructions, or unintended prescriptions ... Review on 04/26/2017 of Patient #11's medical record revealed a [AGE] year old female was a direct admit to the facility on [DATE], after presenting to the ED (Emergency Department) at an outlying facility. Review of the History and Physical (H & P) upon admission revealed the patient's history of diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and [DIAGNOSES REDACTED] (high cholesterol/lipids). Review of the patient's admission history dated 01/10/2017 at 2344, revealed a medication list with the following home medications: acetaminophen (Tylenol)-oxycodone every six hours PRN (as needed) for severe pain, amantadine (for Parkinson disease), desvenlafaxine (antidepressant), diclofenac topical (non-steroidal anti-inflammatory), fluticasone nasal, PRN ( for allergies levothyroxine (for [DIAGNOSES REDACTED]), lorazepam, PRN (for anxiety), modafinil (reduces sleepiness), ondansetron PRN (for nausea and vomiting), pregabalin (for nerve and muscle pain), ranitidine (for heartburn and reflux), senna (laxative), and simvastatin (treats high cholesterol). Review of the patients Depart Discharge Summary dated 01/27/2017, revealed the medications to be taken at home included all of the above medications as well as the following 11 medications: Tylenol (an analgesic for minor aches and pains) PRN (as needed), amitriptyline (for nerve pain and depression), flexeril (a muscle relaxant), Lasix (a diuretic), loratadine (an antihistamine), meclizine PRN (treats motion sickness and vertigo), lopressor (can be used to treat blood pressure, angina and heart failure), biofreeze PRN (a pain relieving gel), a multivitamin, oxycodone (a narcotic for moderate to severe pain), and potassium chloride. Review on 04/26/2017 of the Current Summary Medication/Fluid Event Log, initiated by the manager of the neuroscience Unit on 02/02/2017, revealed the patient's family member phoned the unit on 02/02/2017 stating multiple medications were on [Patient #11's] d/c [discharge] instructions that she was no longer taking. Meds were carried over from a 2010 admission. The family member stated the patient had to be admitted to a hospital. Documentation during the facility's investigation, revealed the 11 additional medications on the patient's discharge summary were from the patient's 2010 discharge instructions. Review revealed the family member inquired about the status of the investigation on 02/17/2017. Explained that we would like to get information from IT about a possible chart merge prior to sending letter of resolution. The family member says she appreciates that however, did not think the patient should have to pay for her subsequent admission to [outlying facility] due to the nursing home giving her incorrect meds that were on our discharge orders. The family member asked which department she should speak to about this matter and was given the number for Risk Management. Documentation revealed this event will remain risk file as family's resolution request was reimbursement/compensation. Review on 04/26/2017 of the Response Timeline revealed on 02/03/2017, the Medication safety team was made aware of the event and on 02/06/2017 the Medication Safety Pharmacist reviewed the event and indicated there appeared to be a potential profile merge and requested informatics help audit the chart. On 02/07/2017, Informatics confirmed this was a profile merge. Informatics, nursing, and pharmacy aware and pulled in Medical Records to map process for merge. A meeting to map and discuss process and potential interventions occurred on 02/15/2017. Director of HIM (Health Information Management) requested a few weeks to look into this. On 02/20/2017, Neuroscience Unit was made aware of 'glitch' and as a result of the finding during daily huddles story of merging of records and medication list shared with RNs to be cautious upon discharge. During the month of March, 2017, Meetings and research completed within HIM conducted by Director to determine and identify best practice with the merging of records/based on open encounters or closed encounter ... On 04/18/2017, HIM (Health Information Management) requested until May 1 week to finish data collection, meeting set for May 2. The Medication Safety Team, Registration, Medical Records, and Clinical Informatics met on 04/26/2017, and resulted in the following steps being put into place: Bed control would contact the patient's primary nurse or any NUS (Nursing Unit Supervisor) following a file merger to redo medication history; An SBAR (Situation, Background, Assessment, Recommendation. A tool used to facilitate prompt and appropriate communication), was sent out addressing the role of the primary nurse; and a meeting was scheduled for May 2nd to develop long term automated solution. Interview on 04/27/2017 at 1022 with the physician who discharged the patient, revealed he didn't realize he was re-stating meds the patient had not previously been on and was not aware how the med rec discharge system worked in the electronic medical record program the hospital used. The physician stated he rarely discharged patients ... At the end of the day, it comes down to me not personally identifying the meds with the patient ... our practice is to make sure the list is correct before sending them out of the hospital. The physician stated he had assumed the meds that populated in the chart were a working list of patient's actual meds ... Interview on 04/27/2017 at 1037 with a Patient Registration Representative from Bed Control, revealed when a chart merged, we always call the floor, and most of the time would speak with the HUC (Health Unit Coordinator) or the RN (Registered Nurse) who has the patient. We are trying to make sure the patient's nurse or nursing supervisor is aware ... We've been doing that for at least a year ... I know to do that, and I'm the trainer for the group ... We had an email sent just this week to re-confirm we do that process ... The interview revealed Bed Control would speak with the patient's nurse or Unit Supervisor and specifically remind about med rec. Interview on 04/26/2017 at 1630 with the Neurosciences Unit Supervisor, revealed staff brought this up in daily huddles, the potential for an EMR (electronic medical record) merge and staff to have extra awareness ... It may appear nothing has been done, however, we have determined this is a very complicated process involving numerous departments. I think this is what contributes to the time frame. HIM has done the same thing instructing them to wait for merge if you can and also did work with registration people on exhausting several options before creating a new account... We haven't just been sitting on this, it's been a thoughtful process. Interview on 04/27/2017 at 1050 with the Chief Quality Officer, the VP (Vice President for Quality and Safety, the Director of Accreditation, and the Chief Medical Information Officer, revealed they have found there are between 2 and 7 mergers per day, which include trauma patients and newborns. The interview revealed the facility had a very careful merge overlay process within the universe of merged records. The facility also had team based care units with huddles every shift and the RLs are reviewed during the huddles. Interview revealed the Medication Safety Team was working on the med rec and then realized this was bigger than the med rec - it was part of the merger. The administration and teams were trying to discover the best practice and as the team re-approached this week, we put a new level of awareness with bed control. The administration is looking at both sides, merging vs not merging, before making a decision on the right thing to do ... We don't want to inadvertently harm someone ... We've looked at tradeoffs and are trying to find the safest approach. Interview revealed the administration emphasize the importance of med rec all of the time. The interview revealed the facility has not educated broadly among the medical staff because it would be difficult to say what to do next until we come up with a system... Interview revealed implementation of change would be when a broad communication would go out ... the RLs [grievance files] get reviewed every day and this was part of a complex, crazy process we are trying to get right. The administration revealed they knew this was a pharmacy/IT issue ... We have our process on the front line, then a process for bringing things back to us after review. For some reason, this didn't make it back to us ...
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital policies and procedures, medical record review, observation, and interviews, the hospital nursing staff failed to implement measures to prevent skin breakdown for 3 of 3 sampled patients at risk for skin breakdown (#2, 6, and 9). The findings include: Review on 12/02/2015 of the hospital's policy titled Nursing Management of Simple Wounds initial policy dated 07/18/2014 revealed General Information ...B. The Wound Ostomy Continence (WOC) RN (registered nurse) or the Wound Resource Nurse (WRN) is consulted for assistance in the management of pressure ulcers and wounds as needed in addition to collaborating with the attending ...Procedure: E. Implement interventions per the Prevention Guidelines for Pressure Ulcers policy ...for patients with a Braden Score of 18 or less is skin/wound issues are identified. 1. RN may place an order for a specialty bed or mattress if criteria are met per the Specialty Bed policy ...Wound Type and Interventions: ...H. Shallow open wound(s) with drainage, stool contamination possible: ...4. Evaluate for specialty bed, per policy ..., and order if appropriate ... Review on 12/02/2015 of the hospital's policy titled Specialty Beds / Low Air Loss Mattresses initial policy dated 03/05/2014 revealed Policy: ...This policy is implemented when the patient meets the defined criteria for implementation ...Procedure: ...B. Specialty Bed/Low Air Loss Mattress Types and Selection Criteria 1. Low Air Loss Surface Criteria: a. Initial Assessment: Indications for placement on appropriate Low Air Loss Surface ...4) Patient meets at least three of the following criteria: a) Braden Scale of 18 or less; b) Patient unable to independently reposition or turn self due to physical and/or mental disability; ... f) Nutritional status of at risk to poor as evidenced by taking < 50 % intake PO (eating less than 50% of meals by mouth), NPO (nothing by mouth), and/or maintained on clear liquids or IV fluids for more than five days; g) Need for moisture management due to incontinence (inability to control bowel or bladder) or excessive perspiration ... Review of the hospital's policy titled, Pressure Ulcer Prevention Guidelines initial policy effective November 14, 2013 revealed Policy: All healthcare providers plat a role in pressure ulcer prevention. Each patient will be assessed by the RN at admission and at least once every 12-hour shift for individual risk and/or actual pressure related skin breakdown. The nursing staff will implement the prevention protocol for any patient who scores 18 or less on the Braden Risk Assessment Scale ... Procedure: B. 1. All patients are on pressure redistributing mattresses. Staff should refer to the policy on specialty beds to determine if patient meets criteria for low air mattress or replacement bed ...3. Provide pressure redistributing foam chair cushion for at-risk patients ...D. Implement Interventions to Manage Moisture/Incontinence as appropriate: ... 5. Avoid use of diapers except for when incontinent patients are ambulating or going off unit for a procedure ... 1. Closed record review on 12/01/2015 of the History and Physical (H&P) completed by medical doctor (MD) #2 dated and timed 05/21/2015 at 0502 revealed a [AGE] year old (y.o.) female (Patient #2) presented to the hospital's Emergency Department (ED) on 05/21/2015 from a Skilled Nursing Facility (SNF) with complaints of shortness of breath (SOB), fever, a productive cough, hypoxemia (low oxygen levels in the blood) with an oxygen saturation (O2 sat: measures the amount of oxygen in the blood. Normal values 95-100% with anything below 90% considered low. For COPD patients O2 sat of 88-92% is the goal range) of 80% on room air. Review revealed Patient #2 had a history of Chronic Obstructive Pulmonary Disease (COPD: Chronic lung disease). Review revealed Patient #2 was treated for Pneumonia the week prior to presentation to the ED and completed treatment with Levaquin (medication used to treat infection) on 05/14/2015. Continued review revealed Patient #1 received Zosyn and Quinolone (used to treat infection) while in the ED. Review revealed Patient #2 reported no stomach pain and no nausea or vomiting. Further review revealed Patient #1 was admitted to unit A with the following diagnoses[DIAGNOSES REDACTED][DIAGNOSES REDACTED] (high levels of fat in the blood). Review on 12/01/2015 of Patient #2's progress notes by MD #3 dated 05/22/2015 through 05/25/2015 revealed Patient #2 was experiencing No nausea, No vomiting, No diarrhea or complaints of pain and discomfort noted. Review of MD #3's progress note dated and timed 05/25/2015 at 0944 revealed She feels better but has a lot of anal itching which is irritating her... Review revealed Yeast infection (fungal infection that causes irritation, discharge and intense itchiness) sx (symptoms). Review of MD #3's progress note dated and timed 05/26/2015 at 0759 revealed Patient seen at bedside...Has some [DIAGNOSES REDACTED] (reddening of the skin cause by injury or irritation) around anus as incontinent (inability to control bowel or bladder). Review revealed ...Yeast infection sx. Record review of MD #4's progress note dated 05/27/2015 through 05/28/2015 revealed ... No diarrhea... Review on 12/01/2015 of Patient #2's physician orders and Medication Administration Record (MAR) revealed Patient #2 received 38 doses of antibiotics, all of which can cause diarrhea, throughout the course of hospitalization . Review revealed an orders by MD #3 on 05/21/2015 for Vancomycin (used to treat infection) 1500 mg IVPB (intravenous piggy back: method used to administer medications directly in the blood stream) every 24 hours and Cipro (used to treat infection) 400 mg IVPB every 8 hours. Continued review revealed an order by MD #3 on 05/26/2015 at 0807 for Augmentin (antibiotic used to treat infection) 875 mg by mouth twice daily. Review revealed an order from MD #6 on 05/21/2015 at 0044 for a one time dose of Zosyn (antibiotic used to treat infection) 3.375 g (grams: unit of measurement) IVPB and a one time dose of Levaquin (antibiotic used to treat infection) 750 mg IVPB. Further review revealed another order for Zosyn 3.375 g IVPB every 8 hours by MD #2 on 05/21/2015 at 0419. Review on 12/01/2015 of Patient #2's nursing assessment of the bladder function revealed that on admission, Patient #2 had no bowel or bladder difficulties. Review revealed on 05/22/2015 at 2015, Patient #2 was assessed as having problems with urgency (a sudden, strong urge to urinate). Review on 05/23/2015 at 0521 revealed Patient #2 was placed in an adult brief secondary to difficulties urinating and Incontinent. Review revealed Patient #2 remained in an adult brief until discharge on 05/28/2015. Review on 12/01/2015 of Patient #2's nursing assessment of the bowel function revealed no evidence of diarrhea or incontinence prior to admission. Review revealed Patient #2 began to have incontinent diarrhea (4 episodes documented) on 05/22/2015 through 05/24/2015. Continued review revealed on 05/24/2105 at 2108, 4 episodes of diarrhea were documented through 05/26/2015. Further review revealed 2 episodes of incontinent diarrhea on 05/27/2015 and 2 on 05/28/2015. Review on 12/01/2015 of Patient #2's documented activity status over the course of hospitalization revealed the required assistance with turning and repositioning and walking to the bedside commode; recliner; and bathroom. Review revealed Patient #2 had generalized weakness, SOB (shortness of breath), and was unsteady through 05/25/2015. Review revealed on 05/26/2015 Patient #2 required total assistance with toileting with periodic use of bedpan throughout the remainder of hospitalization . Record review revealed Patient #2 received antibiotics prior to admission with no diarrhea or incontinence problems noted until 05/22/2015 and was placed in an adult brief on 05/23/2015. Review revealed over the course of hospitalization , 38 additional doses of antibiotics were administered and assistance with repositioning was required. Review revealed Patient #2 developed a number of risks for skin breakdown and the facility did not implement preventive measures outlined in hospital polices resulting in skin breakdown. Review on 12/01/2015 of Patient #2's Braden Skin Assessment (tool used to determine an individual's risk of developing a pressure ulcer by examining six criteria: ... 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice versa) by registered nurse (RN) #2 dated and timed 05/21/2015 at 1333 by RN #3 revealed a score of 18 and occasionally moist, limited mobility, no apparent problem with friction (rubbing) or shearing (torn), and limited awareness of sensation. Review revealed no change in the Patient #2's Braden score until 05/25/2015 at 0436, which was 16 per RN #4. Continued review revealed the change in assessment was from occasionally moist to very moist and no apparent problem with friction and shearing to potential problem creating a higher risk of skin breakdown. Review revealed the score was raised to 17 on 05/26/2015 at 2039 by RN #5 with occasionally moist driving the score back up. Further review revealed 05/27/2015 at 2050, the Braden score returned to 16 per RN #6 with Problem noted for friction and shearing, indicating skin breakdown, and remained 16 until discharge on 05/28/2015. Review revealed an order by MD #3 on 05/26/2015 at 0758 for a Wound Care Nurse consultation to Evaluate and treat, Incontinence Care. Review on 12/01/2015 of Patient #2's progress notes revealed notation by the Wound, Ostomy, and Continence Nurse (WOCN) #2 on 05/26/2015 at 1043 stating that Patient #2 met criteria for a specialty low air loss mattress (used to decrease the risk of skin breakdown) according to hospital guidelines and the recommendation was made that one be ordered, if the patient is still here tomorrow. Continued review revealed Patient #2 was discharged on [DATE] at 1826 with no evidence of an order for a specialty low air loss mattress determined as necessary to prevent further skin breakdown by the WCON #2 and in accordance with the hospital's Nursing Management of Simple Wounds and Specialty Beds/Low Air Loss Mattresses policies. Review on 12/01/2015 of Patient #2's nursing Plan of Care (POC) implemented for Risk of Pressure Ulcer revealed Preventive Skin Care Measures (measures taken to prevent skin breakdown or other issues) performed each shift dated 15/21/2015 - 05/28/2015 revealed Avoid Pressure Over Bony Prominences...Avoid Pressure Points from Lines (IV), Tubes (NC), and sheets ...Time in Chair Limited to 2 Hours or Less at a Time; Chair Foam Provided ... measures were put into place to avoid skin breakdown or damage due to pressure. Review revealed no evidence of a providing Patient #2 with a specialty bed/low air loss mattress as indicated in B. 4. of the hospital's Specialty Beds/Low Air Loss Mattresses policy. Interview on 12/02/2015 at 1010 with WCON #2 revealed the superficial ulcer was not considered a pressure ulcer because it was not caused by pressure. Interview revealed the superficial ulcer wound be treated as a wound and staff would follow the hospital's Nursing Management of Simple Wounds policy, which outlines measures to be taken when a patient's Braden Score is 18 or less or if skin/wound issues are identified. Interview revealed WCON #1 was not aware adult briefs were being used for Patient #2's stool and urinary incontinence. Interview revealed I would not recommend it (use of adult briefs). Typically we don't like to place any patient in them (adult briefs) unless they are ambulating (walking) on the hall or going somewhere for a procedure. Interview revealed I don't think (Patient #2) had one on. If she did, I would've addressed it at that time. Interview revealed WCON #1 an order for a Wound Care Consultation was written by MD #3 on 05/26/2015 and that Patient #2 was evaluated for skin/wound issues on 05/26/2015 at 1043. Interview revealed a specialty bed/low air loss mattress keeps air flowing through the mattress maintaining it in a floating state to avoid any pressure in vulnerable areas. Interview revealed the specialty bed was indicated for Patient #2 and was to be ordered if the patient is not discharged today. Interview revealed the patient was not discharged on [DATE] and should have been placed in a specialty bed because (Patient #2) met the criteria. Interview revealed, If the bed was not ordered, I would have to say our policy (Nursing Management of Simple Wounds) was not followed. Interview on 12/02/2015 at 1010 with WCON #1 revealed specialty bed mattress are indicated for patients with multiple risk factors (for skin/pressure issues). Interview revealed patient's requiring the specialty bed mattress are at greater risk for skin breakdown. Interview revealed any patient with a Braden Score is 18 less or if skin/wound issues are identified should be placed receive a specialty bed mattress as a preventive measure to help reduce the risks of the development of a pressure ulcer or other skin/wound issues. Interview revealed I would have to agree with (WCON #2) indicating that if an order for a specialty bed was not implemented for Patient #2, the hospital did not follow the Nursing Management of Simple Wounds policy. Interview revealed education addressing preventive measures for skin/wound issues is provided in orientation, via the hospital's Learning Management System (LMS: electronic learning), and one-to-one during the WCON's daily unit rounds, as needed but is not part of the hospital's annual hospital wide training. Interview revealed This is an area we can certainly improve on. Interview on 12/03/2015 at 1315 with WCON Director revealed education addressing skin or wound issues and preventive measures is provided during hospital orientation and use to be done every year during our Blitz (a time that all required annual education is provided). Interview revealed annual training was removed from the hospital's Blitz because it (annual training) just got so big, some trainings had to be trimmed. Interview revealed annual education addressing skin or wound issues and preventive measures had not been provided since 2013. Interview revealed education on skin or wound issues and preventive measures was indicated and would be added back to the annual Blitz. Interview revealed This is an area we can certainly improve on. 2. Record review on 12/03/2015 of the H&P completed by MD #4 dated and timed 11/27/2015 at 2201 revealed a 73 y.o. female (Patient #6) presented to the hospital's Emergency Department on 11/27/2015 with a complaint of worsening shortness of breath (SOB).) Review revealed Patient #6 has a history of chronic respiratory failure and is on 4 L (liters: unit of measurement). Review revealed diagnoses including Chronic Obstructive Pulmonary Disease (COPD: Chronic lung disease); possible pneumonia (inflammation of the lungs caused by infection); signs of heart failure; and suspected chronic peripheral artery disease (PAD: reduced blood flow to the legs and arms). Review revealed MD #4 was unable to palpate (feel) pulses in Patient #6's feet, indicating poor blood flow. Review revealed Patient #6's weight was 85 pounds. Review on 12/03/ of the nursing Braden Skin Assessments revealed a score of 17 on 11/27/2015 at 2250 by RN #8; 16 on 11/28/2015 at 2256 by RN #4; and 15 on 11/29/2015 at 0715 by RN #9. Review revealed the score was assessed as a 17 on 11/29/2015 at 1943 by RN #4. Review on 12/03/2015 of Patient #6's Adult Activity assessments revealed assistance was required with walking, which has primarily consisted of ambulation to the bedside commode and back to bed per documentation. Review revealed Patient #6 was on continuous supplemental O2 (oxygen) administered by nasal cannula (NC: O2 delivery device) and required the head of the bed to be up to assist with breathing. Review revealed Patient #6 presented to the hospital with a number of risks for skin breakdown with a Braden Skin Assessment score of 18 or less. Review revealed the facility did not implement preventive measures outlined in hospital polices. Review on 12/03/2015 of Patient #6's physician orders and nursing notes revealed no evidence of a request for a WCON consultation for a Braden Skin Assessment of 18 or less in addition to other at risk criteria as indicated in hospital policy. Review of Patient #6's Preventive Skin Care Measures performed each shift dated 11/07/2015 - 12/03/2015 revealed Avoid Pressure Over Bony Prominences...Avoid Pressure Points from Lines (IV), Tubes (NC), and sheets was put into place to avoid skin breakdown or damage due to pressure. Review revealed no evidence of a providing Patient #6 with a pressure redistributing foam chair cushion as indicated hospital policy. Observation on 12/02/2015 revealed Patient #6 did not have a pressure redistributing foam cushion or a specialty bed/low air mattress. Observation revealed Patient #6 was sitting upright in bed with the head of the bed elevated to help with breathing. Observation revealed Patient #6's weight was below 100 pounds with multiple purple and reddened areas on the arms and legs. Interviews on 12/02/2015 at 1430 with Patient #6 revealed I have to stay on my back with my head up to help me breathe. Interview revealed that while staff had assisted with ambulation to the bedside commode, they had not turned and repositioned Patient #6 during her hospitalization . Interview revealed It's hard for me to turn or reposition myself because of all the tubes (IV and NC) and equipment (heart monitor: device used to monitor electrical activity of the heart) I have hooked to me. Interview revealed My bottom is getting tender and if I had to stay longer, I would have to have them look at it but I am supposed to go home today. Interview on 12/02/2015 at 1451 with Nurse Manager #1 revealed that once the Braden Skin Assessment has been completed and a real or potential risk for skin breakdown/damage has been identified, a specialty bed and foam chair cushion should be provided. Interview revealed a consultation with a WCON should also be considered for additional alternative treatment measures, assessment, and continued evaluation. Interview revealed patients at risk for skin breakdown or damage should not be placed in adult briefs except during periods of ambulation or off-unit procedures and removed immediately following return to his or her room. Interview revealed repositioning, protective cream, and skin assessments are used as preventive measures to aid in avoiding skin breakdown or damage. Interview revealed Nurse Manager #1 did not know Patient #6 and had not personally performed a nursing assessment of her but given her difficulty in repositioning due to medical monitoring devices, IV tubing, O2 tubing, and poor nutrition, she would be considered high risk for skin breakdown and that the hospital's policies were not followed. Interview on 12/02/2015 at 1010 with WCON #1 revealed specialty bed mattress are indicated for patients with multiple risk factors (for skin/pressure issues). Interview revealed patient's requiring the specialty bed mattress are at greater risk for skin breakdown. Interview revealed any patient with a Braden Score is 18 less or if skin/wound issues are identified should receive a specialty bed mattress as a preventive measure to help reduce the risks of the development of a pressure ulcer or other skin/wound issues. Interview revealed that following review of Patient #6's condition, limited mobility, limited activity tolerance, multiple medical devices, and Braden Skin Assessment scores indicated she would be considered high risk for potential skin breakdown and preventive measures should have been implemented as outlined in the hospital's policies. Interview revealed This is an area we can certainly improve on. Interview on 12/03/2015 at 1315 with WCON Director revealed education addressing skin or wound issues and preventive measures is provided during hospital orientation and use to be done every year during our Blitz (a time that all required annual education is provided). Interview revealed annual training was removed from the hospital's Blitz because it (annual training) just got so big, some trainings had to be trimmed. Interview revealed annual education addressing skin or wound issues and preventive measures had not been provided since 2013. Interview revealed education on skin or wound issues and preventive measures was indicated and would be added back to the annual Blitz. Interview revealed This is an area we can certainly improve on. 3. Record review on 12/03/2015 of the H&P documented by MD #5 on 11/24/2015 at 0120 revealed an 84 y.o. male (Patient #9) who presented to the hospital's ED on 11/24/2015 after falling and hitting his head with complaints of neck pain. Review revealed Patient #9 had a CT (computed tomography: scan of internal organs) scan of the head on 11/24/2015 at 0024 that revealed a subdural hematoma (SDH: collection of blood on the brain). Review revealed a CT scan of the cervical spine (bones in the neck area) was also performed with notable bruising of the neck. Review on 12/03/2015 of the Braden Skin Assessment on the nursing POC for Patient #9 on 11/24/2015 at 0315 by RN #11 revealed a score of 15 with Avoid Pressure Points from Lines, Tubes, and Sheets; Avoid Pressure Over Bony Prominences, Turn Patient as measures indicated for the prevention of skin breakdown or damage. Review revealed a score of 16 on 11/24/1025 at 2000 by RN #12 and remained unchanged until 11/26/2015 at 0758, which was assessed as a score of 17 by RN #13. Review revealed Patient #9's Braden Scale Assessment included slightly limited perception (awareness of surroundings), rare incontinence, slightly limited mobility, adequate nutrition, and a potential for skin damage from friction or shearing. Continued review revealed Patient #9's medical condition became unstable and required transfer to Unit B. Review revealed a Braden Skin Assessment score of 7 and included completely limited perception, total incontinence, no mobility (became confined to the bed), completely unable to move independently, very poor nutrition, and remained a potential for skin damage from friction or shearing on 11/26/2015 at 2200 by RN #15. Review revealed Patient #9's Braden Skin Assessment ranged between 7- 9 during continued treatment on Unit B. Review revealed Patient #9 was transferred back to Unit A on 11/29/2015 at 1635 with no change in the assessed score of 9 at that time or evidence of documented continued Braden Skin Assessments through 12/01/2015 at 1314. Review revealed no evidence of a WCON consultation, provision of a pressure redistributing foam cushion, or of a specialty bed/low air loss mattress outlined in the hospital's policies. Review revealed Patient #9 presented to the hospital risks for skin breakdown with a Braden Skin Assessment score of 18 or less. Review revealed Patient #9's condition progressively worsened and the skin assessment scores indicated higher risks for developing skin breakdown. Review revealed the facility did not implement preventive measures outlined in hospital polices. Interview on 12/02/2015 at 1010 with WCON #1 revealed specialty bed mattress are indicated for patients with multiple risk factors (for skin/pressure issues). Interview revealed patient's requiring the specialty bed mattress are at greater risk for skin breakdown. Interview revealed any patient with a Braden Score is 18 less or if skin/wound issues are identified should be placed receive a specialty bed mattress as a preventive measure to help reduce the risks of the development of a pressure ulcer or other skin/wound issues. Interview revealed a specialty bed would have been contraindicated for Patient #9 if the neck fracture had remained unstable; however, since it was stabilized prior to admission to Unit A, preventive measures should have been implemented as outlined in the hospital's Specialty Bed/Low Air Loss Mattresses and Pressure Ulcer Prevention Guidelines policies. Interview revealed the need for a specialty bed would not be indicated for any patient receiving care on Unit B since all beds in that area have low air loss mattresses; however, interview revealed that according to hospital policy, once Patient #9 was admitted to Unit A, pressure ulcer prevention guidelines should have been implemented, including provision of a foam chair cushion and a specialty bed/low air loss mattress ordered, with consideration for a WCON consultation should have been implemented and certainly upon his transfer back (to Unit A). Interview revealed the hospital did not follow the hospital's policies. Interview revealed This is an area we can certainly improve on. Interview on 12/03/2015 at 1315 with WCON Director revealed education addressing skin or wound issues and preventive measures is provided during hospital orientation and use to be done every year during our Blitz (a time that all required annual education is provided). Interview revealed annual training was removed from the hospital's Blitz because it (annual training) just got so big, some trainings had to be trimmed. Interview revealed annual education addressing skin or wound issues and preventive measures had not been provided since 2013. Interview revealed education on skin or wound issues and preventive measures was indicated and would be added back to the annual Blitz. Interview revealed This is an area we can certainly improve on.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy and procedures review, medical record review, observation, and interviews, the hospital's nursing staff failed to prepare and administer medications according to medical staff policies and procedures for 1 of 2 patients (#5) receiving intravenous (IV) medications. The findings include: Review on 12/03/2015 of the hospital's Standard Precautions policy revised January 12, 2015 revealed Policy: Healthcare workers...will treat all blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin as potentially infectious. Appropriate barriers including Personal Protective Equipment (PPE) will be used to avoid direct contact...Equipment:...gloves, gown, mask, eye shield; goggles...General Information A. Standard Precautions 1. Standard Precautions are designed to reduce the risk of transmission of microorganisms (potentially infectious bacteria)...Standard Precautions put a barrier between the healthcare worker and the blood or other potentially infectious material (OPIM) of any patients...2. Use Standard Precautions for the care of all patients. 3. Personal protective equipment (PPE) is available in all patient care areas...Procedure A....1. Gloves a. Wear gloves when exposure to or contact with body substance or OPIM is planned or anticipated... Review on 12/02/2015 of Patient #5's History and Physical (H&P) dated 11/28/2015 at 0048 revealed a [AGE] year old (y.o.) female presented to the hospital's Emergency Department requesting detoxification (medical treatment of substance use involving no substance use until the bloodstream is free of toxins). Review revealed a diagnosis of Hyponatremia (low sodium: chemical that helps regulate the amount of water in and around cells within the body); Severe Hypokalemia (low potassium: a chemical that is critical to the proper functioning of nerve and muscles cells); Acute Alcohol Intoxication (condition in which more alcohol is consumed than the liver can filter out of the body); Starvation (lack of food); and Chronic Hepatitis C (condition caused by the hepatitis C virus). Review of the Medication Administration Record (MAR) revealed a scheduled dose of Reglan (used to treat nausea, vomiting, loss of appetite, and heartburn) 10 mg intravenous (IV: route used to administer medication directly into the bloodstream) before meals. Observation on 12/02/2015 at 1150 of Patient #5's medication pass by RN #7 revealed RN #7 did not don gloves prior to accessing the patient's saline lock (intravenous (IV) catheter that is threaded into a vein, flushed with saline, and then capped off for later use). Observation revealed RN #7 did not aspirate to verify blood return prior to flushing with normal saline (NS) and stated, This (IV lock) is a little stiff (referring to administration of the initial NS flush). Can you feel that? You've had this (IV lock) for a while haven't you? Observation revealed RN #7 did not aspirate to verify blood return prior to administration of the scheduled dose of Reglan 10 mg or the second flush of NS immediately following the Reglan 10 mg administration. Interview on 12/02/2015 at 1200 with RN #7 revealed I typically wear gloves with central lines (a catheter [small, flexible tube] inserted into a vein with the tip positioned near the heart) but not on peripheral (a catheter placed into a vein in order to administer medication or fluids) lines. Interview revealed I try to practice good hand hygiene. Interview revealed, No, I did not (aspirate) before either flush or the Reglan. Interview revealed, I watched the site for any indications of swelling as I flushed the lock and during administration of the Reglan. Interview revealed hospital staff did not follow the hospital's Standard Precautions policy. Interview on 12/02/2015 at 1210 with Nurse Manager #1 revealed Yes, you would normally wear gloves anytime there is potential exposure to blood or body fluids and to protect the patient. Interview revealed gloves should be worn when accessing any IV due to the potential blood exposure. Interview revealed IV lock placement should be verified via gentle aspiration to ensure placement prior to all medication administration. Interview revealed staff did not follow the hospital's Standard Precautions policy or access the IV correctly.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy review, medical record review, internal document review and staff interview, the hospital staff failed to ensure discharged hospital patients received ordered post-hospital care by verifying a receiving facility had medications and supplies to meet the patient's discharge needs in 1 of 1 sampled patients discharged to another facility with post-hospital intravenous medication orders (Patient #2, RN (Registered Nurse) #1). Findings include: Review on 10/08/2014 of the hospital's policy and procedure Discharge Planning Overview (revised 05/08/2014) revealed 1. The care management (CM) staff will ensure that appropriate copies of medical records are made prior to the anticipated discharge time, and will arrange for transportation needs. Staff will send electronic communication message to unit to copy chart in preparation for transfer to SNF (Skilled Nursing Facility). 2. Change in patient plan of care, medication, etc from time of facility acceptance to date of transfer to the facility will be communicated by CM staff to the facility prior to discharge. The review of the policy revealed no other information for when the CM staff is not available at the hospital after their working hours are completed and the patient's are discharged to facility's after the CM working hours. A closed medical record review on 10/08/2014 for patient #2 revealed the patient was admitted on [DATE] with a diagnosis of Empyema, Pneumonia, Diabetes, COPD (Chronic Obstructive Pulmonary Disease), and chronic Atrial Fibrillation. Review of the patient revealed the patient was administered the intravenous (IV) antibiotic medication Merepenam while in hospital along with oral antibiotic medications. The documentation from the physician's discharge summary revealed the patient was to be discharged from the hospital after starting on the IV Merepenam before discharge to a SNF with the same therapies (IV infusion) and follow up by infectious disease physicians. The patient was discharged from the hospital with a PICC (Temporary IV insertion catheter) intact for the SNF to use. The patient was discharged from the hospital to the SNF on 08/11/2014. Documentation review in the medical record revealed the hospital's CM staff electronically provided the SNF a provider link of information on 08/07/2014 that did not include the IV antibiotic Merepenam that was not ordered at that time. Further review for 08/11/2014 revealed the hospital's staff nurse (RN #1) telephoned the facility at 1902 (after CM working hours) with report of the patient being discharged and transferred to the facility. No documentation was found that the RN made the facility aware of the need and availability of the IV antibiotic Merepenam. The review revealed the patient was transferred to the facility and the medication information was sent with the patient to the facility for review by the facility upon arrival of the patient. Further review on 10/09/2014 for patient #2's internal documentation and follow up review revealed The patient was transferred to the SNF for skilled nursing care. The staff at the SNF reported to the hospital on [DATE] that the IV Merepenam was not on the patient information (Provider Link on 08/07/2014) received with referral. The IV medication was listed on the discharge paperwork sent with the patient to the SNF, but no advanced information was presented to the facility. The investigation revealed the patient did not receive her IV antibiotic at the SNF and was brought back to the hospital for outpatient insertion of a PICC placement since the original PICC was discontinued at the SNF. The patient was documented as returning to the hospital on [DATE] for the PICC insertion. The documentation from the infectious disease physician group revealed the patient would have to remain at SNF for an additional three (3) weeks to receive the IV antibiotic due to the mistake. Interview on 10/08/2014 at 1550 with RN #1 revealed that she did perform the discharge for patient #2 on 08/11/2014 from the hospital. The interview revealed that she did not remember specific information about the patient but after reviewing her documentation did telephone the LPN (Licensed Practical Nurse) at the SNF with discharge instruction. The interview also revealed that she did not inquire whether or not the SNF had the availability or not start the IV antibiotic as the discharge planners take care of that part. The interview confirmed that there is no system in place to ensure that a receiving facility has the medications or supplies when patients are discharged to those facilities after the discharge planning staff has left the hospital and is no longer working. Interview on 10/09/2014 at 0917 with the hospital's Executive Director of Care Management revealed We have staff through 5 pm and the previous information is sent during the admission and before discharge. We may need to change the system for discharge to ensure that after 5 pm there is no missing information. The interview revealed the finding and need for system change to ensure that patient's discharged from the hospital after discharge planning hours are able to receive their post-hospital ordered care. NC 895 NC 091
Based on job description review, personnel file reviews, and staff interviews, the hospital's nursing staff failed to ensure documentation of on-going telemetry monitoring competencies for 3 of 3 Monitor Technicians sampled (#1, #2, and #3), assigned to monitor telemetry patients when on-duty. The findings include: Review on June 19, 2014 of the monitor technician job description, updated May 2005 revealed, Role Summary: Observe telemetry monitors continuously, interprets and documents rhythm tracings and maintains telemetry equipment and supplies. Essential Accountabilities: 1. Observes monitors and documents rhythms and strips Performance Criteria: 1...2. Interprets rhythm accurately... 1. Personnel file review on June 19, 2014 for Monitor Technician #1 revealed documentation the last telemetry monitoring competencies were conducted July 14, 2009. Further review revealed no available documentation of on-going telemetry monitoring competencies for 2010, 2011, 2012, 2013, and 2014. Interview on June 18, 2014 at 1130 with Monitor Technician #1 revealed telemetry monitoring updates were received via e-mail and competency evaluations were performed annually. Interview on June 19, 2014 at 1000 during personnel file reviews with Human Resource Assistant #1 indicated there was no available documentation of on-going telemetry monitoring competencies for Monitor Technician #1. Interview on June 19, 2014 at 1620 with the Director of the Center of Nursing Excellence #1 revealed, annual competency evaluations were probably conducted informally. Further interview revealed there was no available documentation of on-going telemetry monitoring competencies for the Monitor Technicians. 2. Personnel file review on June 19, 2014 for Monitor Technician #2 revealed documentation the last telemetry monitoring competencies were conducted in 2006. Further review revealed no available documentation of on-going telemetry monitoring competencies for 2007, 2008, 2009, 2010, 2011, 2012, 2013, and 2014. Interview on June 19, 2014 at ~1530 during personnel file reviews with Human Resource Assistant #1 revealed there was no available documentation of on-going telemetry monitoring competencies for Monitor Technician #2. Interview on June 19, 2014 at 1620 with the Director of the Center of Nursing Excellence #1 revealed, annual competency evaluations were probably conducted informally. Further interview revealed there was no available documentation of on-going telemetry monitoring competencies for the Monitor Technicians. 3. Personnel file review on June 19, 2014 for Monitor Technician #3 revealed the monitor technician transitioned into the role October 23, 2011. Review revealed no available documentation of on-going telemetry monitoring competencies for 2012, 2013, and 2014. Interview on June 19, 2014 at ~1530 during personnel file reviews with Human Resource Assistant #1 indicated there was no available documentation of on-going telemetry monitoring competencies for Monitor Technician #3. Interview on June 19, 2014 at 1620 with the Director of the Center of Nursing Excellence #1 revealed annual competency evaluations were probably conducted informally. Further interview revealed there was no available documentation of on-going telemetry monitoring competencies for the Monitor Technicians. Subsequently, the hospital staff failed to provide any available documentation of on-going telemetry monitoring competencies for Monitor Technician #1, #2, and #3. NC 004
Based on hospital policy and procedure review, closed medical record review, and staff and physician interviews, the hospital staff failed to comply with 42 CFR 489.24. The findings include: 1. The hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize 1 of 21 patients with a mental health emergent medical condition (Patient #47). ~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on hospital policy and procedure review, closed medical record review, and staff and physician interviews, the hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, further medical examination and treatment as required to stabilize 1 of 21 patients with a mental health emergent medical condition (Patient #47). The findings include: Review of the hospital's policy, Emergency Medical Treatment and Active Labor (sic) Act (EMTALA), revised 02/26/2014, revealed, (Name of Hospital) accepts clinically appropriate patients within the system's capability, resources and capacity. ...(Name of Hospital) will adopt and enforce policies and procedures to ensure compliance of all hospitals, their staffs, and medical staffs with the requirements of the...EMTALA regulations. ...DEFINITIONS: ...D. 'Emergency Medical Condition': 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably to expected to result in a. Placing the health of the individual...in serious jeopardy...G. 'To stabilize or stabilized: ' 1. With respect to an emergency medical condition, the patient is provided such medical treatment of the condition as is necessary to assure,within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient...3. The emergency medical condition has resolved. H. 'Stable for discharge:' ...2. With respect to an individual with a psychiatric condition, a physician or QMP (qualified medical provider) in consultation with a physician determines that the patient is protected and prevented from injury himself/herself or others until the transfer is concluded. ...EMTALA PROVISIONS OVERVIEW ...STABILIZATION: A. When the hospital determines that an individual has an EMC (emergency medical condition), and the EMC is appropriate and within the capacity and capability of the hospital facilities and qualified personnel, the individual experiencing an EMC must be stabilized prior to transfer or discharge...'Stabilization' for discharge is achieved when the patient's EMC has resolved to the point within reasonable clinical confidence, where the patient's continued care, where appropriate, including further diagnostic work-up and/or treatment, could be performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with discharge instructions. ...1. For psychiatric patients, ... 'stable to discharge' is achieved when the patient is no longer an imminent threat to self or others within reasonable clinical confidence .... Closed DED record of Patient #47 revealed a [AGE] year old male who presented to the hospital's DED on 03/12/2014 via EMS (Emergency Management Services) at 0109 on a voluntary basis with chief complaint of intoxication and suicidal ideation. Record review revealed Patient #47 requested detoxification. Record review revealed Patient #47 was admitted to the hospital's behavioral health unit on 03/14/2014 at 2225. Review of the discharge summary dictated by a psychiatrist revealed the patient was non-compliant with medication and had quit taking Lithium a year ago. Record review revealed the patient was started on Tegratol (mood stabilizing medication) on admission and had a therapeutic level of 6.4 on 03/20/2014. Further review revealed the patient was homeless, a shelter was found for him and gas money was obtained for the patient to travel to Marion (36 miles). Further review revealed the patient was no longer a danger to himself or others and was discharged at 1015 on 03/20/2014. Further record review of Patient #47 revealed the patient returned ambulatory to the hospital's DED on 03/20/2014 at 1642 (6 hours, 27 minutes after discharge) with chief complaint of suicidal ideation. Record review revealed the patient was triaged at 1715 by Registered Nurse (RN) #1 and was assigned an ESI level of 2. Further review revealed Patient #47 was medically screened by a family nurse practitioner (FNP #1) at 1831. Review of FNP#1's dictated note revealed, ...History of Present Illness 52 yo (year old) male with forced, rapid speech who is here tonight after discharge today from our facility. The patient tells me that his discharge plan included follow up care and he was going to live in Marion at a facility that would be able to help him 'get back on his feet ' . The patient tells me that he left our facility and went to 'get my wallet and my keys'. When asked where they had been left he tells me 'at Helen's bridge'. The patient reports that he found his wallet without difficulty, but he could not find his keys. He tells me that this was so traumatic to him that he began feeling overwhelmed. He tells me that 'everything I own is in my truck'. He tells me that he tried to get his 'case worker to help me', but he could not afford a locksmith and so when he found that he was not going to get into his truck he began thinking about suicide. The patient tells me that he went 'to the top of 445 Biltmore, but someone waved at me so I did not jump- I did not want to make a mess' ... He decided to come here. When asked if he was still suicidal, he tells me yes. When asked what he thinks would help these suicidal thoughts, the patient tells me 'if someone would get me in to my truck' . No physical complaints. Recent hx (history of CVA (cerebrovascular accident). Review of Systems Other significant review of systems. The systems are reviewed and negative with exceptions as recorded in present illness. Past Medical/Family/Social History ...Social History Alcohol: The patient has a history of alcohol abuse. He reports that he has maintained his sobriety from detox. ...Occupation: Unemployed, Family/Social Situation: Homeless Physical Examination ... Behavior: Cooperative. The patient is repetitive with forced, rapid speech. ...Medical Decision Making Differential Diagnosis Anxiety disorder, Suicidal Risk... . Further review revealed a urine drug screen was positive for barbiturates. Further review of FNP#1's medical screening exam revealed, ...I feel strongly that the patient's homelessness is contributing to his issues. He was happy with the discharge plan from earlier, but tells me that without his truck and belongings, he cannot go to Marion. He now feels hopeless and overwhelmed. He reports a near suicide attempt earlier. We have monitored the patient during the ER (emergency room ) course and he remains stable. After speaking with the psychiatric intake team it is felt that he would benefit from further evaluation. His belongings have been secured and he has been under direct monitor observation. ... . Further review reveled the patient's care was transferred to the psychiatric intake team for further evaluation. Further record review of Patient #47 revealed an evaluation was ordered and completed by a licensed clinical social worker (LCSW#1) from the hospital's behavioral health unit on 03/20/2014 at 2252. Review of the LCSW #1's dictated assessment revealed, ...Pt is a 52 yo DWM (divorced, white male) diagnosed with Bipolar I, mixed and Alcohol dependency. He is suspected of throwing his keys and wallet into the woods when he ran out of gas. He does present with rapid and pressured speech, loose association and ruminations around his truck keys. He is a poor historian describing how he went to Myrtle Beach for vacation and a job two weeks ago but then hoped to go to Augusta and find work at the Master's golf tournament and didn't, so he returned to Asheville. He shared info (information) about feeling he was having a heart attack or stroke while in Myrtle Beach but then found it was anxiety...He was discharged from Copestone (Hospital's behavioral health unit) today following an admission on 03/14. He had a previous admission on 10/2-10/8/13. Directed at getting money from his parents per the medical record. Suspected of malingering at that time yet displaying symptoms of mania that stabilized. Pt presents manic with rapid speech and a disheveled appearance. He states that he hasn't worked for some time and but previously sold real estate and was a gardener. When he left Copestone today, he was to go to a shelter in Marion, the John Thompson Ctr but didn't get there due to his 'freak out' when he threw his keys and wallet into the woods. He states that he then was able to find his wallet but not his keys so he couldn't go to Marion and walked to the ED to ask for help. He states that he had his 8th dose of Tegratol today as he no longer wants to take lithium which he took for 30 years. He reports drinking 8 beers two weeks ago and none since. His truck remains in the parking lot of October Road with his belongings. Pt reports his first hospitalization at [AGE] yo in Highland Hospital in Asheville with multiple detoxes and treatment throughout the years. Pt wants to go into the hospital for stabilization. He denies using any other drugs but alcohol. He denies SI (suicidal ideation)/HI (homicidal ideation/AVH (auditory-visual hallucinations) though he earlier reported attempting to jump off a building near October Road. Pt states he would 'just like to get some help to get to the John Thompson Ctr in Marion'. Pt denies any support system in the area in the way of family or friends. ...Recommendations: Recommend telepsych with possible observation and discharge in AM if stable mood. (FNP #1) agrees. ...Pt cooperative and resting... . Further record review revealed Patient #47 was transferred to the hospital's PEA (psychiatric evaluation area) on 03/20/2014 at 0300. Further review revealed a progress note dictated by Psychiatrist #1 on 03/21/2014, time unknown, electronically signed on 03/21/2014 at 1551. Review revealed, Interval History: The patient was seen and the chart reviewed. The patient apparently was just discharged from Copestone the day prior to presentation. His car ran out of gas and for unknown reasons he threw his keys into the woods. He now cannot find his keys and all his belongings are inside the car. The patient was very clear with me that what he was looking for was a locksmith or someone to help him get into his car. He adamantly denied any thoughts of self-harm and said 'I just want to get in my car and go to my shelter in Marion'. I explained to the patient that a hospital is not a place for getting someone to make keys. The patient understood but was very focused on someone findings him a way to get into the car. The patient ultimately requested discharge and said that he would find a way to get someone to help him to get into his car. We did contact his shelter and he still has been waiting for them. He continued to deny any thoughts of self-harm. Review of Systems Constitutional: Negative. Gastrointestinal: Negative. Neurologic: No tremor. Vital Signs (last 24 hrs) Last Charted Temp 97.7 Heart Rate 94 Resp (Respiratory) Rate 20 SBP (Systolic Blood Pressure) 110 DBP (Diastolic Blood Pressure) 83 Sp02 (Oxygen Saturation) 99 Psych Mental Status Exam: Appearance: Normal. Musculoskeletal: No abnormality. Gait and Station: No abnormality. Behavior: Cooperative. Speech: No abnormalities. Mood: Euthymic. Affect: Full range of affect. Thought Content: No abnormality. No suicidal ideation. No homicidal ideation. Perceptual Disturbances: No hallucinations/illusions. Thought Process: Linear, Organized. Level of Intelligence: Average. Sensorium/Concentration: Normal. Orientation: Oriented x 4. Abstraction: Appropriate. Language: No abnormality. Memory: Intact. Fund of Knowledge: Appropriate for education and socioeconomic status. Insight: Lack of awareness of problems, mild impairment. Judgment: Mild impairment. ...Impression and Plan [AGE] year-old Caucasian male with a long history of bipolar disorder who presented one day after discharge from Copestone upset because he had lost his keys. He did initially present as manic and suicidal per the record but on my evaluation is quite linear and organized, adamantly denies any thoughts of self-harm. He is quite open about the fact that he came to the hospital to find someone who would assist or pay for him to get a new daily (sic) key for his car. When told that we could not do this for him he did request discharge. The patient is psychiatric stable for discharge. Diagnosis: Bipolar disorder, type I, mixed. Alcohol dependence. Tegrotol 200 mg po BID Disposition: The patient is very clear that he came to the hospital in order to get assistance with getting into his car. On my evaluation he adamantly denies any thoughts of self-harm. He still has his other medications on him. He still has the shelter bed available for him. He does not meet inpatient criteria and is psychiatric stable for discharge . Further review revealed an order by Psychiatrist #1 dated 03/21/2014 at 1228 ( 9 hours, 28 minutes after admission for suicidal ideation) for Patient #47 to be discharged . Further record review revealed a dictated note by a Licensed Clinical Social Worker (LCSW#2) on 03/21/2014 at 1119. Review of the note revealed, ...spoke with pt about options and how to best assist him in getting to the Marion shelter. Pt was drinking coffee and watching TV both times PC (professional counselor) spoke with him. PC recommended that pt call some locksmiths...Pt reported that he had already done that and that he just wanted to be dc'd (discharged ). Pt tried to speak with security about possibilities about getting a key made but they would not speak with him. PC recommended that pt be transported back to his vehicle to look for the keys again, but he wants to go on foot up to MMH (Hospital) so he can talk to security there as he is sure that one of them knows someone that can help him. (Psychiatrist #1) states that he is OK with pt being dc/d on foot. Pt did get mildly agitated about getting out quickly after he was informed that a locksmith was not being funded by the hospital . Further record review revealed an assessment completed by RN #2 on 03/21/2014 at 0817. Review revealed documentation by RN #2 that Patient #47 was not having suicidal ideations. Further review revealed the patient was discharged at 1301. Review of the written discharge instructions provided to the patient included to go to the McDowell Mission in Marion and telephone numbers for mobile crisis and suicide prevention hotlines. Further review revealed the patient was discharged with Tegratol and Thiamine prescriptions. Interview on 04/09/2014 at 1145 with RN #1 revealed she triaged Patient #47 in the hospital's DED on 03/20/2014 at 1715. Interview revealed, He was suicidal. He told me he had a plan. I didn't press him for information or the details of the plan. A behavioral health evaluation was done in the ED. Interview on 04/09/2014 at 1400 with LCSW #1 revealed she met with Patient #47 in the hospital's DED on 03/20/2014. Interview revealed, He was very polite, friendly and appreciative of the services he was getting. He was slightly manic. He needed assistance with a key for his truck. Based on my interaction with him, I felt like he needed a full mental health evaluation. I consulted with (FNP#1). We collaborated and decided he needed a full mental health evaluation. She medically cleared him and he was transferred to the PEA (psychiatric evaluation area). His care was transferred to the psych intake department. I asked him if he was suicidal. He said, 'no, I'm fine. I just need my key'. He was very vague about the key. Interview further revealed, I found out he had jumped about 6:00 (pm) on 03/21/2014. Interview on 04/09/2014 at 1500 with FNP#1 revealed she remembered Patient #47. Interview revealed, I completed his screening exam when he came back into the ED that day. I said he was feeling depressed and that he had contemplated suicide that day. Interview further revealed the FNP ordered a behavioral health evaluation based on standing orders and his previous diagnosis. Interview on 04/09/2014 at 1300 with Psychiatrist #1 revealed he made rounds on the PEA the morning of 03/20/2014. Interview revealed Patient #47 was calm and organized. He was focused on the issue with his keys. Further interview revealed, he denied wanting to hurt himself. He wanted help to get his keys. I told him we would do all we could to help him. We had found him a men's shelter in Marion the day before. He said he was starting his new life in Marion. We offered him transportation to the shelter in Marion. He would have none of that. His plan was to get a locksmith to get his car. He left with the yellow pages out of the phone book with locksmiths in the area. Interview further revealed, He didn't meet criteria for IVC (involuntary commitment). Interview further revealed, I got a call from our practice manager about 4:30 (pm) on the 21st. She told me what had happened, that he had jumped from the parking deck and was dead. I have reviewed his records. I don't know anything else I could have done. I'm trying not to beat myself up...it's just sad. . Interview on 04/09/2014 at 1330 with RN #2 revealed she was Patient #47's primary nurse on 03/21/2014 beginning at 0700. Interview revealed, He told me he was embarrassed to be back. He told me a lengthy story about how he couldn't find his car keys. He said he just needed help to get his keys. Further interview revealed, I asked him was he suicidal or homicidal and he said 'no, just needed help to get to Marion'. The Social Worker offered him a cab voucher to get to Marion and even offered to help get his belongings from the car. He said, 'no', he needed the vehicle. He said he phoned a friend and was able to get $50 to have the car rekeyed. He was happy about that. Interview further revealed, I discharged him after lunch. We went over his discharge papers. He appeared hopeful. I don't know anything we could have done differently. Review of the local county's rescue squad report dated 03/21/2014 with Patient #47's name documented in the space for patient information revealed the rescue squad was dispatched at 1716 for routine body transport. Review revealed, arrived on scene to find APD (Asheville Police Department), APD Forensics and detectives on scene. Pt was found on ground beneath four story parking deck. Pt had been witnessed jumping from parking deck at 16:10 (3 hours, 9 minutes after discharge) according to APD. Pt sustained severe trauma to head, neck, extremities and internal injury...transported to morgue.... Consequently, Patient #47 presented to the Hospital's DED on 03/14/2014 with suicidal ideation, was admitted to the inpatient psychiatric unit, discharged on [DATE] at 1015 and returned to the DED on 03/20/2014 at 1642 (6 hours, 27 minutes after discharge), was placed in the psychiatric area of the DED for observation and further evaluation, was discharged on [DATE] at 1301( 9 hours, 28 minutes after admission for suicidal ideation) and committed suicide around 1610 (3 hours, 9 minutes after discharge). NC 572 and NC 349
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital policies, medical records and staff interviews, nursing staff failed to evaluate 2 of 7 patients for a dietary consult who had food Allergies and/or Intolerance (#6 and 8) The findings include: Review of Nutrition Policy CP.5.01.Initial Assessment and Prioritization revealed RN (registered nurse) nutrition screening triggers (Infant, Pediatric, Adolescent and Specific) will identify any criteria that apply to the patient's condition upon admission. Computer generated consults will be directed to the Metabolic Pediatric team for assessment....Preferences: Food Allergies/ Intolerance and /or Cultural or Ethnic Needs... 1. Open record review for patient record #6 revealed a 9 year old was admitted on [DATE] with diagnosis of prolonged Bipolar Affective Disorder and Anxiety Depression. Review of the admission nursing assessment dated [DATE] revealed the patient had allergies to Peanuts and Iodine. Review of the assessment Nutritional History indicated None. The nutritional assessment allowed several selections which included Food Allergies/ Intolerance and /or Cultural or Ethnic Needs which indicated a need for Dietitian Consult. Review of the medical record on 2/26/13 revealed no evidence a consult was directed to the Metabolic Pediatric team for assessment. Medical record review on 2/26/13 revealed no evidence that nursing staff had notified dietary of the patient's allergy to Peanuts until 2/26/13 (8 days after admission). Interview with patient #6 on 2/26/13 at 4:45pm confirmed she had a peanut allergy. The patient indicated the peanut allergy resulted in hives. Interview with the Registered Nurse on 2/26/13 assigned to this patient confirmed the patient had a Peanut allergy. She had notified dietary of the Peanut allergy on 2/26/13. Interview with Administrative Staff on 2/27/12 at 10:30 am confirmed there was no evidence a consult was directed to the Metabolic Pediatric team for assessment. 2. Closed record review for patient record #8 revealed an [AGE] year old was admitted on [DATE] with diagnosis of Mood Disorder and Aspergers' Disorder. Review of the admission nursing assessment dated [DATE] revealed the patient had allergies to Bananas, Lactose, Lettuce, Mushrooms, Seroquel, Tenex and Wheat. Review of the assessment Nutritional History indicated None. The nutritional assessment allowed several selections which included Food Allergies/Intolerance and /or Cultural or Ethnic Needs which indicated a need for Dietitian Consult. Review of annotations by nursing staff on 9/17/12 revealed Dietary sent some foods that were not on his diet. Staff offered to call for proper foods... Review of the Discharge summary revealed the patient was discharged on [DATE]. The summary included the physician documentation of the hospital course. The physician documented ___(patient's name) achieved level 2 early in hospitalization ; however, often had difficulty with transition, arguing about bedtime and frustration over his heart healthy diet and dietary restrictions due to food allergy. Review of the medical record on 2/26/13 revealed no evidence a consult was directed to the Metabolic Pediatric team for assessment. Interview with Administrative Staff on 2/27/12 at 11:00 am confirmed there was no evidence a consult was directed to the Metabolic Pediatric team for assessment. NC 827
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess pain per policy for 9 of 27 sampled Emergency Department (ED) patients (#30, #8, #7, #6, #15, #27, #10, #23 and #25). The findings include: Review of current ED policy entitled Triage dated 09/28/2008 revealed, ...Procedure:...6. Patients are assessed for the presence of pain during the triage process.... Review of current hospital policy entitled Nursing Pain Assessment and Management dated 01/2011 revealed, ...Procedure: 1. Initial Assessment a. As part of the admission history, each patient is questioned about the presence of pain. b. If pain is present, a detailed assessment of the pain is completed which minimally includes location, intensity, and goal for relief (target score)....2. Ongoing assessment....c. When pain is identified the frequency of assessment is driven by the pain management plan and the patient's response to interventions. d. Pain assessment is completed when a PRN (as needed) intervention is provided to determine the appropriateness and effectiveness of the intervention....Hierarchy of Pain Assessment....I. Self-report....Tools: Adults: 0-10 scale and Verbal Descriptor....Pediatric, developmentally delayed, mentally handicapped: Wong-Baker FACES; 0-10 scale....III. Behaviors....Tools:...Pediatric: FLACC (Face, Legs, Activity, Cry, Consolability Scale)....5. Evaluation and Documentation a. Evaluation of response to intervention is performed within one hour of intervention and includes...if obtainable, a follow-up pain rating.... 1. Closed medical record review for Patient #30 revealed a 6 year-old male that presented to the ED via EMS (Emergency Medical Services ambulance) on 02/28/2012 at 1752 accompanied by his mother with chief complaint of seizure today. Record review revealed documentation the triage nurse assessed the patient at 1800. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the patient was treated and subsequently discharged to home with a diagnosis of [DIAGNOSES REDACTED] Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/21/2012 at 1140 revealed the manager expected to see Wong-Baker or FLACC assessment tools used for the assessment of pain in pediatric patients. Interview confirmed there was no available documentation the patient was assessed for pain during the triage assessment or during the remainder of the ED visit (4 hours and 12 minutes). 2. Closed medical record review for Patient #8 revealed a [AGE] year-old male that (MDS) dated [DATE] at 1436 with chief complaint of headache for 5 weeks with associated bilateral tinnitus (ringing in ears). Record review revealed documentation the triage nurse assessed the patient at 1454. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the first documented assessment of the patient's pain at 1834, at which time the patient rated the pain 8 out 10 (on a scale of 0 to 10, with 10 being the most intense pain). Record review revealed the patient was given Dilaudid (narcotic analgesic) and Toradol (non steroidal anti-inflammatory medication) via intramuscular injection for pain at 1917. Record review revealed the next available documentation of pain assessment at 2058 (1 hour and 41 minutes after pain medications), at which time the patient rated the pain 4 out of 10. Record review revealed the patient was treated and subsequently discharged to home with a diagnosis of [DIAGNOSES REDACTED] Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/20/2012 at 1600 confirmed there was no available documentation the patient was assessed for pain in triage or within one hour after he received pain medication. 3. Closed medical record review for Patient #7 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1237 with chief complaint of possible seizure. Record review revealed the patient had a history of chronic back pain. Record review revealed documentation the triage nurse assessed the patient at 1242. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the first documented assessment of the patient's pain at 1427, at which time the patient complained of neck pain that she rated 5 out 10 (on a scale of 0 to 10, with 10 being the most intense pain). Record review revealed the patient was treated and subsequently discharged to home with diagnoses of [DIAGNOSES REDACTED] Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain in triage. 4. Closed medical record review for Patient #6 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1204 with chief complaint of headache for 2 days. Record review revealed documentation the triage nurse assessed the patient at 1227. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the first documented assessment of the patient's pain at 1338, at which time the patient rated her pain 10 out 10 (on a scale of 0 to 10, with 10 being the most intense pain). Record review revealed the patient was treated and subsequently discharged to home with diagnoses of [DIAGNOSES REDACTED] Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/20/2012 at 1600 confirmed there was no available documentation the patient was assessed for pain in triage.
5. Closed medical record review for Patient #15 revealed a [AGE] year-old male that (MDS) dated [DATE] at 1932 with a chief complaint of post procedural fever. Record review revealed documentation the triage nurse assessed the patient at 1938. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the patient was treated and subsequently transferred to another acute care hospital on [DATE] at 0010 with a diagnosis of [DIAGNOSES REDACTED]. Interview on 03/23/2012 at 1430 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain during the triage assessment or during the remainder of the ED visit (4 hours and 38 minutes). 6. Closed medical record review for Patient #27 revealed a 6 year-old male that (MDS) dated [DATE] at 2238 accompanied by his mother with a chief complaint of abdominal pain, nausea, vomiting and fever. Record review revealed documentation the triage nurse assessed the patient at 2238. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the patient was given Fentanyl (medication for pain) on 12/26/2011 at 0154. Review of the record revealed the medication was ordered to be given prn (as needed) for pain. Review of the record revealed no documentation of an assessment of pain prior to administration of the pain medication, at the time of administration or after administration of the pain medication. Record review revealed the patient was discharged home on 12/26/2011 at 0246. Record review revealed no documentation of a pain assessment during the ED visit (4 hours and 8 minutes). Interview on 03/21/2012 at 1145 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/21/2012 at 1140 revealed the manager expected to see Wong-Baker or FLACC assessment tools used for the assessment of pain in pediatric patients. Interview confirmed there was no available documentation the patient was assessed for pain during the triage assessment or during the remainder of the ED visit (4 hours and 8 minutes). 7. Closed medical record review for Patient #10 revealed a [AGE] year-old male that (MDS) dated [DATE] at 2152 with a chief complaint of facial pain due to trauma injury. Record review revealed documentation the triage nurse assessed the patient at 2217. Review of the triage nurse's assessment revealed documentation the patient had a pain level of 9 (scale of 0 - 10, with 10 the worst pain) at 2217. Record review revealed the patient was given Norco (medication for pain) on 03/09/2012 at 0413. Record review revealed no documentation of a pain assessment from 2217 (pain level of 9) through 0413 (5 hours and 56 minutes). Review of the record revealed no documentation of an assessment of pain at the time of administration or after administration of the pain medication. Record review revealed the patient was discharged home on 03/09/2012 at 0422. Interview on 03/21/2012 at 1145 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain after the triage assessment or during the remainder of the ED visit (6 hours and 5 minutes). 8. Closed medical record review for Patient #23 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1745 with a chief complaint of chest pain. Record review revealed documentation the triage nurse assessed the patient at 1753. Review of the triage nurse's assessment revealed documentation the patient had a pain level of 10 (scale of 0 - 10, with 10 the worst pain) at 1753. Record review revealed the patient was given Dilaudid (medication for pain) at 2016 for pain described as a level 10. Record review revealed the patient was discharged home on 03/17/2012 at 2044. Record review revealed no documentation of a pain assessment after the pain medication was administered. Interview on 03/21/2012 at 1145 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain after the pain medication was administered. 9. Closed medical record review for Patient #25 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1522 with a chief complaint of seizure and abdominal pain. Record review revealed documentation the triage nurse assessed the patient at 1525. Review of the triage nurse's assessment revealed documentation the patient had a pain level of 8 (scale of 0 - 10, with 10 the worst pain) at 1525. Record review revealed the patient was discharged home on 03/18/2012 at 1800. Record review revealed no documentation of an assessment of pain after triage or during the remainder of the ED visit (2 hours and 23 minutes). Interview on 03/21/2012 at 1210 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain after the triage assessment or during the remainder of the ED visit (2 hours and 23 minutes).
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