HospitalInspections.org

Based on review of facility documents and interview with staff (EMP), it was determined that the facility failed to provide documentation that the governing body, medical staff and administrative officials are responsible and accountable for ensuring that an ongoing program for quality improvement is defined, implemented, and maintained, that quality assessment and performance improvement efforts address priorities for improved quality of care, that all improvement actions are evaluated, and determine the number of distinct improvement projects is conducted annually for the facility's 2018 Quality Plan.

Findings include:

Review of LifeCare Behavioral Health Hospital Performance Improvement Plan, dated February 2018, revealed, " ...Leadership: The Governing Body, Medical Staff, and Hospital Administration are responsible and accountable for ensuring: a. That an ongoing program is defined, implemented, and maintained. b. That the ongoing program contains elements of performance improvement, patient safety, and the reduction of medical errors. c. That the program addresses priorities for improving the quality of care and the evaluation of improvement actions. d. That clear expectations for safety are established. e. That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance, and for reducing risk to patients."
Review of Governing Board Meeting Minutes dated August 25, 2017, December 1, 2017, March 16, 2018, and June 8, 2018, revealed no documentation of governing board review of the Performance Improvement Plan dated February 2018.
Interview with EMP1 on July 9, 2018, at approximately 1:00 pm, revealed, "I don't know why, but I didn't do it (review the performance improvement plan with the board)."

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure nursing care policies and procedures consistent with professionally recognized standards of nursing practice were followed for seven of eight medical records reviewed (MR1, MR2, MR4, MR6, MR7, MR8, and MR9).

Findings include:

Review of facility policy and procedure "Seclusion and Restraints for Behavioral Management" reviewed July 2017, revealed "Treatment Plan/Team The order must be in accordance with a written modification to the patient's plan of care. If seclusion or restraints are used, it is added to the treatment plan as an intervention."

Review of "Therapeutic Activity Documentation" reviewed July 2017, revealed "C. Group Participation Record/Progress Notes 1. Social Work/Therapeutic Activity staff will document on the Group Participation Note for each patient and each activity on a daily basis. 2. For those patients that were unable to attend group, therapeutic activity staff will document the reasons why. 3. The Group Participation Record is placed on the medical record on a daily basis."

Review of MR1 revealed the patient was admitted from July 17, 2017, thru July 22, 2017. Further review revealed a Treatment Plan" dated July 22, 2017, "... will actively participate in programming to develop positive self-esteem" Further review revealed documentation the patient attended groups on July 18 and 19, 2017, with no further documentation of why the patient did not attend on the other days as per above policy.

Review of MR2 revealed the patient was admitted from May 7, 2018, thru May 18, 2018. Further review revealed a Treatment Plan" dated May 7, 2018, "Nursing will maintain consistency with daily schedule" Further review revealed documentation the patient attended groups on May 8, 9,12, and 13, 2018, with no further documentation of why the patient did not attend groups on the other days as per above policy.

Review of MR4 revealed the patient was admitted from January 15, 2018, thru February 13, 2018. Further review revealed a Treatment Plan" dated January 15, 2018, "... will attend core group in AM & PM" Further review revealed no documentation of why the patient did not attend groups during the admission as per above policy. Continued review revealed the patient was placed in Seclusion on January 15, 2018 at 4:14 PM with no documentation of written modification to the patient's plan of care as per above policy.

Review of MR6 revealed the patient was admitted from May 6, 2018, thru May 16, 2018. Further review revealed a Treatment Plan" dated May 6, 2018, "... will attend 2 activity groups & actively participate ... nurse will encourage pt to participate in group" Further review revealed documentation the patient attended group on May 15, 2018, at 1015 with no further documentation of why the patient did not attend groups on the other days as per above policy.

Review of MR7 revealed the patient was admitted from May 15, 2018, thru May 19, 2018. Further review revealed a Treatment Plan" dated May 17, 2018, "... will comply with ... and care" with no documentation of why the patient did not attend groups during the admission as per above policy.

Review of MR8 revealed the patient was admitted from January 22, 2018, thru January 31, 2018. Further review revealed a Treatment Plan" dated January 23, 2018, "... will attend groups in AM & PM and activity participate" Further review revealed documentation the patient attended group on January 28, 2018, the pateint declined and January 31, 2018 the patient attended group at 1:00 PM with no further documentation of why the patient did not attend groups on the other days as per above policy. Continued review revealed the patient was placed in 2 point restraints on January 25, 2018 at 12:55 PM and seclusion at 10:50 PM with no documentation of written modification to the patient's plan of care as per above policy.

Review of MR9 revealed the patient was placed in a waist restraint on June 7, 2018, at 8:50 AM with no documentation of a written modification to the patient's plan of care as per above policy.

During review of the medical records EMP1 confirmed the above findings with no documentation of attendants for group therapy.

Interview with EMP1 on July 10, 2018, at approximately 12:00 PM confirmed the above findings with the restraints and revealed "There is no one specific care plan for restraints."

Based on staff interview (EMP) and a tour of the facility, it was determined that the facility failed to ensure the temperature range of hot water in the patient showers was maintained between 105 - 120 degrees farenheit.

Findings include:

Review of the 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities revealed, "Table 2.1-3 Hot Water Use - General Hospital ... Temperature (F) Clinical 105 - 120 degree ... The range represents the maximum and minimum allowable temperatures."
1) Request was made for actual temperature checks in patient rooms. Rooms 2119, 2158 and 2103 had temperatures 74 to 76 degrees farenheit, room 2032 had a temperature 80 degrees farenheit.

2) Interview with EMP4 on July 10, 2018, revealed, "we have had a problem with water temps in patient rooms for some time. We have ligature faucets in the patient rooms, the faucets have less output of water than conventional faucets."