Initial Comments:
This report is the result of an unannounced onsite complaint investigation completed on August 17-18, 2023, with additonal onsite survey time concluding on August 31, 2023, at Clarion Psychiatric Center. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.13(c)(2) STANDARD
PATIENT RIGHTS: CARE IN SAFE SETTING
Name - Component - 00
The patient has the right to receive care in a safe setting.
Observations:
Based on a review of facility policy and information, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide a safe environment for two of ten patients (MR1 and MR2).
Findings include:
A review of facility "CONTRABAND LIST" Effective June 2022, revealed "...No Sharp Metal objects ...".
A review of facility policy, "Physical Aggression", revised December 20202, revealed "...PRINCIPLE A. To provide a safe environment for patients, visitors and staff B. To protect patients, visitors, and staff from harm C. To prevent property destruction...".
1. A review of MR1 revealed the patient was voluntarily admitted to inpatient treatment on June 1, 2023, for " ...Unstable mood with suicidal ideations ... " . Review of MR1 revealed the patient was able to obtain and utilize a pen to self harm/harm others on two separate occasions resulting in a chemical restraint on July 10, 2023, and physical and chemical restraints on July 14, 2023.
2. A review of MR2 revealed the patient was voluntarily admitted to inpatient treatment on July 8, 2023, for "suicidal ideation". Review of "RN Event Nursing Progress Note" within MR2 indicated "...[MR2] went behind the nurse's station @ 2046. ... [He/She] removed several pens from the drawer & staff removed [him/her] from nurse's station by direction ...".
3. A review of facility information revealed the patients to MR1 & MR2 were able to gain access to pens at the nurse's station and were threatening to self-harm and harm others. Further review of the information revealed the nurse's station was unsecured approximately 13 times on July 14, 2023, between approximately 6:50 PM and 10:00 PM.
4. A tour of the facility was conducted at approximately 10:20 AM on August 18, 2023. During the tour of unit G, two packs of ball point pens and a pair of scissors were found in an unlocked drawer at the nurses station.
5. A policy was requested for the supervision of the nursing station, however the facility indicated there was no policy related to the securing or supervison of the nursing station.
Interview, at approximately 1:15 PM on August 18, 2023, with EMP9 confirmed the above findings "...periods where it is not as far as imminent safety...", when asked if the nurse's station was secured at all times.
Interview, at approximately 1:45 PM on August 18, 2023, with EMP11 confirmed the above findings indicating "...nursing station should be supervised at all times...they were able to grab a pen. ..."
Plan of Correction:By submitting this Plan of Correction, the facility does not admit that it violated the regulations. The facility also reserves the right to amend the Plan of Correction as necessary and to contest the deficiencies, findings, conclusions, and actions to the agency.
1. To correct the deficiency: All contraband has been removed from the nurses' stations and locking cabinets are being ordered to further secure necessary items. Milieu Management Trainings were initiated on 8/18/23 and completion is required by all staff by 10/2/23. A Milieu Management Performance Improvement Team was established on 8/18/23 and meets weekly. Nurses' station audits were added to weekly Leadership Rounds on 8/23/23 to monitor for contraband. The Physical Aggression Policy was reviewed with all staff by 9/8/23. On 9/11/23 Handle with Care drills were initiated and are ongoing monthly. Handle with Care Trainers we re-trained on 10/13/23.
2. To protect patients in similar situations: The Physical Aggression Policy is reviewed with all new employees in New Employee Orientation. Handle with Care drills are conducted monthly. Leadership rounds now contain an audit of the nurses' stations to monitor for contraband. A contraband policy has been put in place for the facility and will include observation of the nurses' stations. This policy will be presented to Medical Executive Committee and Board of Governors on October 26, 2023. Milieu Management trainings are assigned in HealthStream to all new employees during New Employee Orientation. Review of high-risk patients weekly in Milieu Management Performance Improvement Team.
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur: The Physical Aggression Policy will be reviewed with new staff during New Hire Orientation. When conducting rounds, the Leadership Team will also audit the nurses' stations for contraband. All staff will be assigned to review the Contraband Policy and sign an attestation that they did so. The Milieu Management Trainings will be assigned to all new staff. The Milieu Management Treatment Team will continue to meet weekly.
4.Performance Monitoring: The Director of Human Resources will oversee the review of the Physical Aggression Policy by new staff in New Employee Orientation. The Director of Education and Training will assign the Contraband Policy in HealthStream and will report to the Performance Improvement Committee the percentage of staff completion monthly until we reach 100% completion. The Director of Education and Training will also assign and monitor the completion of the Milieu Management Trainings. Senior Leaders are responsible for conducting leadership rounds to include an audit of the nurses' station for contraband. These audits are provided to the Director of Performance Improvement for report to the Performance Improvement Committee monthly.
5. Dates when corrective action will be completed:
Milieu Management Performance Improvement Team initiated 8/18/23 and meets weekly.
Physical Aggression Policy review completed by 9/8/23 – will be reviewed with all new hires at orientation.
Handle with Care Drills initiated 9/11/23. October's drill was held on 10/17/23 and will be held monthly thereafter.
Nurses' Station Contraband Audits initiated 8/23/23 and occur with weekly leadership rounds.
Milieu Management Trainings 10/2/23.
Contraband Policy was assigned 10/19/23 to all staff for review with attestation with a deadline of 11/17/23.
482.24(c)(2) STANDARD
CONTENT OF RECORD: ORDERS DATED & SIGNED
Name - Component - 00
All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.
Observations:
Based on review of medical records (MR), review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure telephone and verbal orders, were read back for accuracy and countersigned by the provider within 24 hours per facility policy for one of three restraint records reviewed (MR1).
Findings include:
Review, at 11:00 AM on August 24, 2023, of facility policy "Telephone and Verbal Orders" revised July 2023 revealed "It is the policy of Clarion Psychiatric Center that telephone and verbal orders may be obtained in situations where the provider is not readily available to write the order. The telephone or verbal order can only be obtained by an RN, LPN, or Pharmacist. All verbal and telephone orders must be Read Back and Verified (RBAV) to ensure order accuracy. ... PROCEDURES B. All Telephone and Verbal orders require verification. Once the RN, LPN, or Pharmacist has received the order they will repeat it back to the provider (RBAV) to ensure accuracy. C. Telephone and Verbal orders must be countersigned, dated, and timed by the provider within 24 hours. ...".
1. Review of MR1 revealed telephone orders for chemical restraints signed by an RN dated July 14, 2023, at 2300 and 2310. No documentation within the orders were found indicating the order was read back for accuracy per facility policy. The telephone orders were countersigned on July 17, 2023, not within 24 hours per facility policy.
2. Further review of MR1 revealed telephone orders for physical restraints signed by an RN dated July 14, 2023, at 2300 and 2315. No documentation within the orders were found indicating the order was read back for accuracy per facility policy. The telephone order was countersigned on July 17, 2023, not within 24 hours per facility policy.
Interview on August 17, 2023, at approximately 1:15 PM with EMP3 confirmed the above findings indicating "it probably won't be in there" when asked about restraint documentation within the medical record.
Plan of Correction:By submitting this Plan of Correction, the facility does not admit that it violated the regulations. The facility also reserves the right to amend the Plan of Correction as necessary and to contest the deficiencies, findings, conclusions, and actions to the agency.
1. To correct the deficiency: Clarion Psychiatric center does have a policy in place on Telephone and Verbal Orders. All open charts were reviewed for any unsigned restraint orders.
2. To protect patients in similar situations: Re-education will be provided on the facility policy on Telephone and Verbal Orders to Pharmacists, RNs, LPNs, and Providers.
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur: the existing policy will be in HealthStream for Pharmacists, RNs, LPNs, and Providers to review, and an attestation of review and understanding will be required. This policy will also be reviewed with providers in Medical Executive Committee meeting.
4. Performance Monitoring: The Director of Education & Training will assign the Telephone and Verbal Orders policy review in HealthStream and will report back to the Performance Improvement Committee the percentage of completion on a weekly basis. All restraint packets are reviewed to verify that telephone and verbal orders were read back to the prescriber and that the order was authenticated within 24 hours. Any deficiencies will be addressed with the nurse completing the packet and/or the prescriber.
5. Dates when corrective action will be completed:
The policy was assigned in HealthStream for review on 10/19/23 and attestation with a completion deadline of 11/17/23. The policy will be reviewed with providers in the Medical Executive Committee Meeting on 10/26/23.
100% of the restraint packets will be reviewed by nursing
|