09/30/07 — Cherry report cites patient, medication violations

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Cherry report cites patient, medication violations

By Phyllis Moore
Published in News on September 30, 2007 2:09 AM

As Cherry Hospital's response to a recent state investigation winds down, the News-Argus has obtained a copy of the report that lodged all the allegations of deficiencies.

The 52-page document had been issued mid-month by the Department of Health and Human Services and Centers for Medicare and Medicaid Services in Atlanta. It contained many cross-references to three core issues that had not been met at the hospital -- governing body, patients' rights and nursing services.

After complaints were received about the delivery of services at Cherry, two state survey teams, one from the Division of Health Services Regulations and one from the Joint Commission, made a visit to the hospital to investigate. The review teams were there from Sept. 4 through 7, reviewing records and policy procedures, interviewing staff and observing patient activity.

Following the visit, Cherry was placed under "immediate jeopardy" status because it did not meet the conditions of participation to be eligible for receipt of federal funding for Medicaid and Medicare patients.

In a letter to Dr. Jack St. Clair, Cherry Hospital director, dated Sept. 17, the report stated that the Secretary of Health and Human Services was authorized to conduct surveys of accredited hospitals participating in the Medicare program if there were "'substantial allegations' indicating serious deficiencies that could potentially affect the health and safety of patients.

"When a hospital, regardless of its JCAIIO accreditation status, is found to be out of compliance with one or more Conditions of Participation, and immediate or serious threat to patient health and safety exists, a determination must be made that the facility no longer meets the requirements for participation as a provider of services in the Medicare program."

The letter went on to say that such a determination was made at Cherry, resulting in the threat of its provider agreement for federal funding being terminated Sept. 30 if an adequate plan for change was not approved.

The state survey agency was to conduct a re-survey by Sept. 30 to determine if conditions that constituted immediate jeopardy had been removed and corrections made. The visit happened on Friday, just two days shy of the cut-off date, but proved positive. The "immediate jeopardy" status originally imposed was lifted. State and local mental health officials have maintained the document centers around only a few cases of alleged impropriety and fall under the three categories -- nursing services, patients' rights and the governing body of the hospital.

Among some of the evidentiary aspects of the report were several specific incidents involving patients:

*A 30-year-old male patient involuntarily admitted April 1, 2007, for schizophrenia who requested and obtained permission to go outside for a smoke while at the therapeutic center with other patients on the evening of April 12.

A short while later, the patient was determined to be missing and was not found until 8:55 p.m. According to the report, he "had sustained some physical injuries and abrasions, which were treated by the facility's physician assistant."

The state found there was "not a uniform procedure for the recreation therapy technicians to use throughout the facility ... the therapeutic recreation department does not have a policy or procedure for taking patients off the units."

Investigation also showed that leadership was made aware of the elopement shortly after the patient went missing. However, it alleged that "leadership failed to ensure patient safety by failing to have a hospital-wide process in place to supervise and monitor patients with a known risk to elope and are considered a danger to self and others, resulting in an elopement."

*A 45-year-old male, admitted Jan. 23, 2007, with diagnoses of paranoid schizophrenia, cocaine abuse and hypertension. On Jan. 28 around 8:50 a.m., the man was reportedly found slumped in a chair, pale and unresponsive. Oxygen was not applied until emergency medical services arrived, some 20 minutes after he was found unresponsive. He was then transported to an acute hospital.

The investigation revealed "the facility continues to have issues with response to medical emergencies ... leadership failed to ensure patient safety by failing to have a hospital-wide process in place for immediate monitoring and intervention in the event of a serious medical emergency."

According to the report, the hospital responded to the two cases by introducing a new policy, establishing guidelines and revising policies to address the issue.

Findings regarding the hospital's governing body included failure to ensure systems were in place to provide for a safety environment and ensure supervision of a patient with a risk to elope ... failed to provide an organized nursing service by failing to ensure appropriate emergency measures were provided ... and ensure the least restrictive restraint measure was utilized to restrain patients.

*A 29-year-old male, admitted Aug. 2, 2007, for evaluation of treatment of alcohol dependence. The following day the subject was reportedly combative and struck at staff members. According to a facility police department case report, an officer arrived and "found the patient that was to be transported was in leather restraints. The staff on the ward stated that the patient was combative. The EMT in charge stated that the patient would have to be restrained in the ambulance or they would not transport the patient to the hospital. The EMS and (hospital) staff expected me to place metal handcuffs on the patient so that he could be transported."

The officer further indicated he did not feel the restraints were warranted as the patient was not violent or combative, and said such to the administrative nurse supervisor.

"The unit nurse in charge called (physician) and he did give the order for the patient to be handcuffed while being transported in the ambulance," the officer was quoted as saying.

Findings from the survey team were that "the facility's nursing staff failed to initiate appropriate emergency measures to 2 of 2 unresponsive patients during a medical emergency ... failed to follow orders for 2 of 10 sampled closed medical records ... failed to update the patient's care plan related to elopement risk for 2 of 6 patients that attempted to elope/escape ... failed to date multidose vials when opening ... prior to administering the first dose to patients on 2 of 3 nursing units observed during the tour."

*A 14-year-old female, admitted May 8 with attention-deficit disorder, paranoia and bi-polar personality, allegedly started walking in the middle of the roadway while walking with another patient on the way back from church one Sunday. Upon return to the hospital, her behavior escalated and she attempted to run out of the building, whereupon she was "placed in a NCI (North Carolina Intervention) hold for 3 minutes," the report said.

When the survey team interviewed family psychiatry staff involved in her care, the patient was said to have been believed to be "an escape risk."

Other findings centered around expired or outdated medications at the hospital.

During a Sept. 4 visit to U2 second floor medication room, a refrigerator reportedly contained an open vial dated Aug. 11, along with written recommendation to discard 30 days after opening.

The report also contained comments from an interview with the hospital's pharmacist, who stated, "I should have done a better job of checking the medication refrigerator. I am supposed to check the medications inside the refrigerator. I did not check the drugs. I just checked on the checklist that they were in date. The medications should have been discarded."

A visit the same day to the psychiatric medical infirmary unit refrigerator turned up similar findings -- an open vial with "7/24/05" written on the box as well as other undated vials.

Ten expired boxes of sutures were found in the second floor of the U2 building, three dated January 2007 and seven others without an expiration date. Fourteen culture tubes with an expiration date of April 20 as well as an opened, undated half-empty bottle of Cidex (a disinfectant) were also found, the latter which had instructions to "discard after bottle has been opened 14 days."

A nurse supervisor interviewed on Sept. 4 told officials "all the above supplies have been here longer than I have, and I have been here 12 years."