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Tag No.: A0395
Based on record review and interview, it was determined that the nursing staff failed to evaluate the care for each patient on an ongoing basis for 1 patient in a survey sample of 19 patients. (Patient identifier is #3.)
Findings include:
Review on 10/31/16 of Patient #3's Assessment Progress Notes revealed the following: "Very agitated rolling on floor and grunting" written on 8/26/16 at 6:37a.m., "Pt was observed lying on the floor in her room, first on her back, then on her stomach, kicking her legs up and down repetitively" written on 8/27/16 at 2:12 p.m. "Remains nonverbal making growling or moaning sounds, laying on the floor on her belly a lot of the shift. Flapping her arms and legs" written on 8/27/16 at 9:49 p.m.. There was no documentation of physical assessments performed after the above behaviors; however, the behaviors may be related to the bruising discovered and noted in the Assessment Progress Notes dated 8/28/16 at 1:31 p.m. "Bruising noted on lower back at lumbar level, under her R breast and on her arms, possibly d/t rolling around on the floor."
Interview on 11/1/16 at 1:10 p.m. with Staff B (Attending Psychiatrist) revealed that an assessment would be done and documented after episodes of potential self injurious behaviors.
Interview on 11/1/16 at 3:10 p.m. with Staff A (Administrator) revealed that the hospital did not have a policy or procedure for performing assessments after potential self injurious behaviors.
Tag No.: A0405
Based on record review and interview, it was determined that the facility failed to properly monitor medication therapy with laboratory data to allow for early identification of toxicity in 1 of 5 patients reviewed on Lithium therapy out of a survey sample of 19 Patients. (Patient identifier is #3.)
Findings include:
Review on 10/31/16 of Patient #3's physician orders revealed the following orders: "Lithium Level Friday 8/26/16." written on 8/22/16 at 12:35. Further review of Patient #3's physician orders revealed Lithium was discontinued on 8/26/16 at 2:45 p.m.
Interview on 11/1/16 at 1:10 p.m. with Staff B (Attending Psychiatrist) confirmed the above finding. Staff B revealed that Staff B had ordered blood work for Friday 8/26/16 for Patient #3, but after discussions with nursing staff, Staff B was told that nursing staff would not be able to draw Patient #3. Nursing staff told Staff B that Patient #3 was a difficult draw blood for lab work and it would be necessary to wait until Monday when the contracted laboratory was scheduled for regular phlebotomy services. Staff B was concerned about potential lithium toxicity on Friday 8/26/16 and discontinued Lithium the same day.
Review of laboratory results for Patient #3 from 8/28/16 revealed it was collected at the hospital by nursing staff on 8/28/16 at 10:45 a.m. with a Lithium level result of 1.53 mmol/L (millimoles per litre). The laboratory indicated on the laboratory report that lithium toxicity is >1.50 mmol/L.
Review of Patient #3's Progress note for 8/28/16 at 1:31 p.m. revealed the following note: "Lab results indicated Li (Lithium) Level critical at 1.53, elevate CK (Creatine Kinase), potential UTI (Urinary Track Infection). Dr. [name omitted] notified who ordered pt (patient) be transferred to [hospital name omitted] via emergent ambulance." Further review of the progress note revealed concerns of worsening mental status and signs and symptoms of catatonia.
Tag No.: A0449
Based on record review and interview, it was determined that the facility failed to maintain medical records that were accurate and complete for 3 patients in a survey sample of 19 patients. (Patient identifiers are #3, #8 and #10.)
Findings include:
Patient #3
Review on 10/31/16 of Patient #3's Assessment Progress Notes revealed the following: "Very agitated rolling on floor and grunting" written on 8/26/16 at 6:37a.m., "Pt was observed lying on the floor in her room, first on her back, then on her stomach, kicking her legs up and down repetitively" written on 8/27/16 at 2:12 p.m. "Remains nonverbal making growling or moaning sounds, laying on the floor on her belly a lot of the shift. Flapping her arms and legs" written on 8/27/16 at 9:49 p.m.. There was no documentation of physical assessments performed after the above behaviors; however, the behaviors may be related to the bruising discovered and noted in the Assessment Progress Notes dated 8/28/16 at 1:31 p.m. "Bruising noted on lower back at lumbar level, under her R breast and on her arms, possibly d/t rolling around on the floor."
Interview on 11/1/16 at 1:10 p.m. with Staff B (Attending Psychiatrist) revealed that an assessment would be done and documented after episodes of self injurious behaviors.
Interview on 11/1/16 at 3:10 p.m. with Staff A (Administrator) revealed that the hospital did not have a policy or procedure for performing assessments after self injurious behaviors.
Patient #8
Review of this patient's Absolute Discharge Summary for Discharge Date: 08/01/16 reveals that it was dictated by Staff F, (Advanced Practice Registered Nurse) and Staff H, (physician assistant) and signed in August 2016 by Staff F and by two physicians, with time signed provided for these three signatures, but Staff H's signature is dated 3/11 with no year indicated, and time signed is not provided but entered as NA [not applicable].
Patient #10
Review of the "Short Stay Discharge Summary" for date of admission 7/27/16 and date of discharge 7/27/16 reveals that the patient was admitted for worsening depression and suicidal ideation. Review of the "PHYSICIAN ORDERS ON ADMISSION" reveals "Admit to New Hampshire Hospital inpatient services ... Date: 7/27/16 Time: 12:15 PM It is anticipated that the evaluation and stabilization for the patient will be a minimum of 72 hours." The patient's Legal Status is checked off as IEA [Involuntary Emergency Admission].
An "Admission Psychiatric Evaluation Rpt" Date / Time 7/27/16 12:34 PM, relates "Chronic suicide ideation" with an "Initial Plan" that includes "Will consider and plan for discharge today. I am concerned (as are other members of the team) that extending hospitalization can be detrimental to the patient's ability to develop/improve coping skills...." The "PHYSICIAN ORDERS ON DISCHARGE" signed by Staff F, (Advanced Practice Registered Nurse) relates Type of Discharge: Absolute 7/27/16 2:00 PM. Review of the "Discharge Instruction Plan" dated 7/27/16 reveals that the patient refused to sign that "The above discharge instructions have been reviewed with me prior to discharge." The "PSYCHIATRIC DISCHARGE PROGRESS NOTE REPORT" for 7/27/16 2:33 p.m. relates, in part, that the patient's Reason for Admission was "on an IEA for depressive symptoms and suicidal ideation" and Condition on Discharge is "Unchanged from Admission". Prognosis is left blank. The report relates "... hospitalization would be detrimental to the patient in the long term ...."
The "Discharge Instruction Plan" signed by Staff D, (Social Worker) on 7/27/16 1:30 p.m. relates "Reason For Admission Suicide - Attempt, Threat, Or Danger" and "Discharge Type Conditional Home or Self-Car[e]." The plan informed Patient #10 that they had an appointment scheduled at Patient #10's apartment the same day at 3:30 p.m. The patient "Refused to sign" the statement "The above discharge instruction have been reviewed with me prior to discharge". Staff D's Social Worker Progress Note written at 1:51 p.m. on 7/27/16 relates, in part, "... [Patient #10] refused to sign [Patient #10's] discharge instructions....all of [Patient #10's] providers here at NHH [New Hampshire Hospital] and ... MHC [Mental Health Center] are in agreement that the greatest chance of improvement comes with [Patient #10's] ability to engage in the outpatient program".
Review of the Nurse Progress Note written on 7/27/16 03:18 p.m. reveals "... [Patient #10] was absolutely discharged at 2pm transported via NHH transportation. [Patient #10] appeared to be upset during this interaction... declines to review discharge medication instruction sheet as well as discharge instruction sheet. RN [registered nurse] attempted to review appointment scheduled for her today and she stated she wasn't going to be around for this appointment.... [Patient #10] reported that [Patient #10] had a plan to 'end it tonight'." Clinical record review reveals no documented reassessment of the patient following Patient #10's stated plan to "end it tonight".
Additional review of this admission reveals inconsistent documentation as to whether the patient's discharge was Absolute or Conditional, and this discrepancy is not addressed in the record. The "Short Stay Discharge Summary" dictated on 7/27/16 at 2:13 p.m. documents the Discharge Type as Conditional. Interview on 11/1/16 with Staff D (Social Worker) confirmed that the patient's 7/27/16 discharge was Conditional, not Absolute. The facility's policy and procedure "Title: Conditional Discharge ... Effective Date: 12/23/15" relates "No conditional discharge shall be granted unless the patient to be discharged or his/her guardian, if any, has knowledge of and, following an informed decision, consents to the term and conditions of discharge and the provisions of He-M 609. Consent shall be documented in writing...."
Interview with Staff D, Social Worker, on 11/1/16 revealed that Staff D did the discharge as a Conditional Discharge, and Staff D would have done nothing differently if the discharge was Absolute or Conditional. Staff D explained the reason Patient #10 did not sign the acknowledgement on the Discharge Instruction Plan was Patient #10 didn't want to be discharged. Staff D related that Staff D had a verbal order from the doctor for Conditional Discharge of Patient #10. Review of the clinical record revealed no documentation of a verbal order for the Conditional Discharge of Patient #10.
Interview on 11/2/16 at 11:00 a.m. with Staff E (Medical Doctor) revealed Patient #10's discharge was ordered as absolute, but changed to conditional due to court involvement. Staff E confirmed that the discharge team, which included Staff E, were aware of Patient #10's suicidal ideations, but that Patient #10 had made the same statements at her prior discharge from the facility. Staff E also explained that it is unusual for an IEA to be less than 24 hours; however, in this case Patient #10 had just been discharged 2 days prior and her demeanor and suicidal ideations were the same with no increase in risk.
Interview on 11/2/16 at 12:30 p.m. with Staff F (Psychiatric Advanced Practice Registered Nurse) revealed discharge team, which included Staff F, agreed that Patient #10's discharge was appropriate due to the following: Patient #10's mood and behavior had not changed since prior admission, Patient #10 was assessed as a moderate risk due to suicidal ideations without recent suicide attempt, Patient #10 had services in place in the community as well as her community case manager was coming to visit her that afternoon and Patient #10 had family support in the area. Staff F confirmed Staff F's note on Patient #10's Short Stay Discharge Summary dated and signed 8/4/16 at 10:30 a.m. which stated, "It was reiterated to the patient that long-term hospitalization would not be beneficial to [pronoun omitted] and that [pronoun omitted] needs to be able to utilize, practice and improve [pronoun omitted] coping skills out in a real and natural setting. It was also emphasized to the patient that an inpatient hospitalization would be detrimental to [pronoun omitted] participation with her ACT (Assertive Community Treatment) team."
Tag No.: A0821
Based on record review and interview, it was determined that the facility failed to reassess the discharge plan for appropriateness, for one patient in a survey sample of 19 patients. (Patient identifier is #10.)
Findings include:
Review of Patient #10's "CONDITIONAL DISCHARGE SUMMARY" reveals a hospital discharge on 7/25/16 after a one week stay. Reason for admission was, in part, a plan to overdose on Tylenol. Review of the "Discharge Instruction Plan" reveals that Patient #10 signed on 7/25/16 to acknowledge that discharge instructions were reviewed with Patient #10 prior to discharge. The "PSYCHIATRIC DISCHARGE PROGRESS NOTE REPORT" dated 7/25/16 noted the patient's Condition on Discharge as "Improved".
Review of the "Short Stay Discharge Summary" for date of admission 7/27/16 and date of discharge 7/27/16 reveals that the patient was admitted for worsening depression and suicidal ideation. Review of the "PHYSICIAN ORDERS ON ADMISSION" reveals "Admit to New Hampshire Hospital inpatient services ... Date: 7/27/16 Time: 12:15 PM It is anticipated that the evaluation and stabilization for the patient will be a minimum of 72 hours." The patient's Legal Status is checked off as IEA [Involuntary Emergency Admission].
At a local hospital emergency department, Patient #10 stated on the Triage Assessment form dated 7/26/16 at 16:08, "I am having suicidal ideation. It started yesterday and is stronger today. I have a plan." On 7/27/16 at 12:34 PM on the Admission Psychiatric Evaluation Rpt [sic] (report) the patient's chief complaint states, "I'm trying to save my own life here". The reason for reason for admission/History of present illness states, ".......severe borderline personality d/o (disorder), dependent traints, chronic suidical ideation, past dx (diagnosis) of bipolar d/o, presenting on IEA for worsening depression and suicidal ideation with thoughts of overdosing or jumping out of window. Afraid to be alone, needs more time in the hospital.......". Suicide Risk factors listed the following: "(1) Age <19 or >45, (1) [sic] Previous attempt/Psychiatric care, (2)Determined to repeat or ambivalent re: future attempt (2) [sic] Hopelessness, (1) [sic] Absence of social support (family, friends, work, school, church)". The facility's Admission Profile lists emergency contact as "none". On the facility's "Access Assessment" dated 7/26/16 at 10:07 PM under the Suicidal Assessment Instrument it is documented that Patient #10 does have suicidal ideation and has a plan to "jump out a window or to overdose", [pronoun omitted] "insists [pronoun omitted] will do so if [pronoun omitted] is discharged". Previous suicide attempts are documented at "multiple overdoses and ICU (Intensive Care Unit) or transfer to Boston admission status post suicide attempts". [pronoun omitted] "has access to high windows, OTC (over the counter) pills". [pronoun omitted] "suicide plan was interrupted by pt (patient), told case manager about plan to come to hospital, declined any attempt at safety planning or alternative care options, case manager accompanies pt to hospital ED (emergency department). "Pt unable/unwilling to safety plan". Patient #10 has had 4 admissions in July 2016 for this facility. [pronoun omitted] does not feel [pronoun omitted] can stay safe outpatient as documented in the "Access Assessment".
A "Comprehensive Social Assessment" was completed on 5/17/16 by the facility when Patient #10 was admitted on an IEA due to suicidality, as [pronoun omitted] attempted to overdose of Tylenol. Documentation of safety risks are listed as follows: .......has had many suicide attempts, includiing cutting wrists, drinking bleach, overdosing, and jumping out of as [sic] window. .......denies becoming aggressive toward others. .......has taken numerous overdoses of medication both prescribed and over the counter. Although [pronoun omitted] works closely with [pronoun omitted] therapist and case manager [pronoun omitted] has impulsively attempted suicide many times. [pronoun omitted] was provided some education regrading the high level of Tylenol in [pronoun omitted] system while in the hospital. [pronoun omitted] has been made aware of the unintended outcome of permanent scarring of the liver and possible coma/brain death. .......seems disinterested and is questionable if [pronoun omitted] should return to [pronoun omitted] own apartment with the level of lethality of [pronoun omitted] attempts. [pronoun omitted] was asked to consider group home living or increased supervision in an effort to lower chances of impulsive attempts when isolating."
An "Admission Psychiatric Evaluation Rpt" Date / Time 7/27/16 12:34 PM, relates "Chronic suicide ideation" with an "Initial Plan" that includes "Will consider and plan for discharge today. I am concerned (as are other members of the team) that extending hospitalization can be detrimental to the patient's ability to develop/improve coping skills...." The "PHYSICIAN ORDERS ON DISCHARGE" signed by Staff F, (Advanced Practice Registered Nurse) relates Type of Discharge: Absolute 7/27/16 2:00 PM. Review of the "Discharge Instruction Plan" dated 7/27/16 reveals that the patient refused to sign that "The above discharge instructions have been reviewed with me prior to discharge." The "PSYCHIATRIC DISCHARGE PROGESS NOTE REPORT" for 7/27/16 2:33 p.m. relates, in part, that the patient's Reason for Admission was "on an IEA for depressive symptoms and suicidal ideation" and Condition on Discharge is "Unchanged from Admission". Prognosis is left blank. The report relates "... hospitalization would be detrimental to the patient in the long term ...."
The "Discharge Instruction Plan" signed by Staff D, (Social Worker) on 7/27/16 1:30 p.m. relates "Reason For Admission Suicide - Attempt, Threat, Or Danger" and "Discharge Type Conditional Home or Self-Car[e]." The plan informed Patient #10 that they had an appointment scheduled at Patient #10's apartment the same day at 3:30 p.m. The patient "Refused to sign" the statement "The above discharge instruction have been reviewed with me prior to discharge". Staff D's Social Worker Progress Note written at 1:51 p.m. on 7/27/16 relates, in part, "... [Patient #10] refused to sign [Patient #10's] discharge instructions....all of [Patient #10's] providers here at NHH [New Hampshire Hospital] and ... MHC [Mental Health Center] are in agreement that the greatest chance of improvement comes with [Patient #10's] ability to engage in the outpatient program".
Review of the "Nurse Progress Note" written on 7/27/16 03:18 p.m. reveals "... [Patient #10] was absolutely discharged at 2pm transported via NHH transportation. [Patient #10] appeared to be upset during this interaction... declines to review discharge medication instruction sheet as well as discharge instruction sheet. RN [registered nurse] attempted to review appointment scheduled for [pronoun omitted] today and [pronoun omitted] stated [pronoun omitted] wasn't going to be around for this appointment.... [Patient #10] reported that [Patient #10] had a plan to 'end it tonight'." Clinical record review reveals no documented reassessment of the patient following Patient #10's stated plan to "end it tonight".
Additional review of this admission reveals inconsistent documentation as to whether the patient's discharge was Absolute or Conditional, and this discrepancy is not addressed in the record. The "Short Stay Discharge Summary" dictated on 7/27/16 at 2:13 p.m. documents the Discharge Type as Conditional. Interview on 11/1/16 with Staff D (Social Worker) confirmed that the patient's 7/27/16 discharge was Conditional, not Absolute. The facility's policy and procedure "Title: Conditional Discharge ... Effective Date: 12/23/15" relates "No conditional discharge shall be granted unless the patient to be discharged or his/her guardian, if any, has knowledge of and, following an informed decision, consents to the term and conditions of discharge and the provisions of He-M 609. Consent shall be documented in writing...."
Interview with Staff G, Discharge Planning, on 11/1/16 revealed that Patient #10 was a Conditional Discharge, and when there's a doctor's order for Absolute Discharge in an IEA patient, it needs to go to review and the Medical Director needs to okay it. Review of the clinical record did not reveal documentation that a review had been initiated in response to the Physician Orders on Discharge which related Type of Discharge: Absolute 7/27/16 2:00 PM.
Interview on 11/2/16 at 11:00 a.m. with Staff E (Medical Doctor) revealed Patient #10's discharge was ordered as absolute, but changed to conditional due to court involvement. Staff E confirmed that the discharge team, which included Staff E, were aware of Patient #10's suicidal ideations, but that Patient #10 had made the same statements at [pronoun omitted] prior discharge from the facility. Staff E also explained that it is unusual for an IEA to be less than 24 hours; however, in this case Patient #10 had just been discharged 2 days prior and [pronoun omitted] demeanor and suicidal ideations were the same with no increase in risk.
Interview on 11/2/16 at 12:30 p.m. with Staff F (Psychiatric Advanced Practice Registered Nurse) revealed discharge team, which included Staff F, agreed that Patient #10's discharge was appropriate due to the following: Patient #10's mood and behavior had not changed since prior admission, Patient #10 was assessed as a moderate risk due to suicidal ideations without recent suicide attempt, Patient #10 had services in place in the community as well as [pronoun omitted] community case manager was coming to visit [pronoun omitted] that afternoon and Patient #10 had family support in the area. Staff F confirmed Staff F's note on Patient #10's Short Stay Discharge Summary dated and signed 8/4/16 at 10:30 a.m. which stated, "It was reiterated to the patient that long-term hospitalization would not be beneficial to [pronoun omitted] and that [pronoun omitted] needs to be able to utilize, practice and improve [pronoun omitted] coping skills out in a real and natural setting. It was also emphasized to the patient that an inpatient hospitalization would be detrimental to [pronoun omitted] participation with [pronoun omitted] ACT (Assertive Community Treatment) team."
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