HospitalInspections.org

Based on record review and staff interview, it was determined that the facility failed to develop comprehensive treatment plans that identified clearly delineated physician interventions to address specific patient problems for 7 of 8 active sample patients(A1, A2, A3, A5, A6, A7 and A8). Interventions were generic and nonspecific regardless of the identified problems. This practice compromises the treatment team's ability to evaluate progress and modify interventions.

Findings include:

A. Record Review

1. For patient A1, admitted on 4/27/11, the Treatment Plan developed on 4/28/11 listed a problem of "alteration in thought process, auditory hallucinations, paranoia, delusions, and hallucination." The physician interventions listed on the treatment plan included: "Physician to assist patient with understanding disease entity and necessity of med compliance and Physician to discuss with patient/staff: interventions to improve mood and maintain patient safety."

2. For patient A2, admitted on 5/10/11, the Treatment Plan developed on 5/11/11 listed problems of 1) "At risk for self harm thoughts of suicide with plan to OD on pills," 2) "Alteration in thought process AEB AH in manic"; 3) "Chronic pain AEB HX back pain"; and 4) "ETOH W/D." The physician interventions listed on the treatment plan included: "Physician to assist patient with understanding disease entity and necessity of med compliance and Physician to discuss with patient/staff: interventions to improve mood and maintain patient safety."

3. For patient A3, admitted on 3/07/11, the treatment plan developed on 3/08/11 listed problems of 1) "ATP AEB Paranoid/delusional AEB pt thinks she is being stabbed and cut by staff and AH"; 2) "Dyspepsia"; 3) "Potential for infection/Fever"; 4) "Acute pain/Headache" and 5) "At risk for falls R/T to Low Blood Pressure." The physician interventions listed on the treatment plan included: "Physician to assist patient with understanding disease entity and necessity of med compliance and Physician to discuss with patient/staff: help with coping skills and discharge planning."

4. For patient A5, admitted on 4/26/11, the treatment plan started on 4/26/11 listed problems of 1) "DTO AEB aggression towards others" and 2) "Difficulty maintaining safe behavior when angry." The physician interventions listed on the treatment plan included: "Physician to assist patient with understanding disease entity and necessity of med compliance; and Physician to discuss with patient/staff: help with coping skills and discharge planning."

5. For patient A6, admitted on 5/11/11, the treatment plan started on 5/11/11 listed problems of 1) "At risk for self harm AEB statements of wanting to cut throat and arms" and 2) "Alteration in thought process AEB Auditory command hallucinations to harm self." The physician interventions listed on the treatment plan included: "Physician to assist patient with understanding disease entity and necessity of med compliance;" and "Physician to discuss with patient/staff: help with coping skills and discharge planning."

6. For patient A7, admitted on 4/19/11, the treatment plan developed on 4/22/11 listed problems of 1) "Alteration in thought process AEB visual hallucinations and delusions" and 2) "acute headache pain." The physician interventions listed on the treatment plan included: "Physician to assist patient with understanding disease entity and necessity of med compliance and 2) Physician to discuss with patient/staff: interventions to improve mood and maintain patient safety."

7. For patient A8, admitted on 5/10/11, the treatment plan developed on 5/12/11 listed problems of 1) "At risk for self harm AEB SI with plan" and 2) "Acute back pain." The physician interventions listed on the treatment plan included: Physician to assist patient with understanding disease entity and necessity of med compliance and Physician to discuss with patient/staff: help with coping skills and discharge planning."

B. Interview

In an interview on 5/17/11 at 3:45PM, the Director of Performance Improvement concurred with the surveyor's findings that physician interventions were generic and nonspecific regardless of the identified problems.

This Condition is not met as evidenced by:

Based on interview and record review, the Clinical Director failed to ensure that a peer review occurred following the death of a patient in active treatment (K2). This failure results in an inability to exam patient care and to make recommendations and to modify patient treatment when indicated. (Refer to B144).

Based on record review, document review and staff interview, it was determined that the Clinical Director (the Medical Director) failed to ensure that a thorough process of peer review was completed regarding an adverse outcome (i.e. the death of Patient K2). This failure results in the inability to identify practices that may have contributed to the adverse outcome, educate peers about any changes needed, and reduce the risk of recurrences of similar events.

Findings include:

A. Medical Record/Document Review

Patient K2. The Psychiatric Evaluation dated 4/21/10 gave a past history of drug and alcohol dependence as well as a Bipolar Disorder, severe with depressive and psychotic features. These were also identified as current at admission on 4/20/2010 at 9:20PM. Following a hospital stay of approximately 48 hours, the patient was found unresponsive and expired shortly thereafter.

Record review revealed that during his hospitalization, patient K2 was prescribed a variety of psychotropic medications, and records reported that he was nauseated, had vomited, and was in acute pain, which may have been related to his chronic back pain or his detoxification process or a combination of both. On 4/22/2010 at 10:00AM, the patient was found by staff "asleep on the toilet. He was placed on fall precautions." When seen by a Nurse Practitioner at 3:15PM he was noted to be somnolent: "Pt. sleepy....not able to speak clearly," and was experiencing "sedation" as a side effect to his medication. At 4:00PM, the Social Worker/therapist noted that an attempted interview did not take place as "...patient was too sedated...." A nursing note at 8:00PM said "Pt was (sic) spent most of shift in room asleep." It was at approximately 9:00PM that the Psychiatric technician found the patient unresponsive; the nurse was alerted and a Code Blue was called at 9:05PM. CPR was performed and a transfer to St Luke's Medical Center Emergency Department occurred. Resuscitation efforts were unsuccessful.

Root Cause Analysis: Autopsy findings were obtained and a panel of facility staff was established to explore what had happened, and what might or might not have contributed to the adverse event. The only physician on the panel was the Clinical Director who was also Patient K2's attending psychiatrist. The Nurse Practitioner who had seen Patient K2 on 4/22/10 at 3:15PM was not interviewed. The autopsy report dated 8/10/2010 stated "Sudden unexpected death during alcohol and opioid withdrawal. Aspiration pneumonia."

B. Staff Interviews

1. On 5/17/2011 at 9:15AM the Performance Improvement Officer told the surveyors that the signature on the Progress Note referenced in Section A above (i.e. the Nurse Practitioner) was thought to have been that of the attending psychiatrist. Because of this confusion the Nurse Practitioner was not involved in the Root Cause analysis.

2. In an interview on 5/17/2011 at 11AM, the Performance Improvement Officer stated "This (the Root Cause Analysis report) never got to Executive Medical Committee. I was waiting for the Medical Examiner's Report. It took so long; it (the idea of getting this to Medical Staff) just slipped past me."

3. In an interview on 5/17/2011 at approximately 12PM, the Clinical Director (attending psychiatrist for patient K2) acknowledged that no peer review process had occurred. He did not explain why the event was not sent for peer review.

4. In an interview on 5/17/2011 at 3:15PM, the Performance Improvement Officer stated that the Root Cause Analysis done by the facility had not been submitted to the Joint Commission on Hospital Accreditation (JCAHO). She stated, "No, the Corporation has decided not to send that to JCAHO."

5. In an interview on 5/18/2011 at 8:15AM, the Performance Improvement Officer reported that current Medical Staff Rules and By-Laws do not address how peer reviews, such as an ad hoc Mortality and Morbidity Conference, or the placement of the adverse event as an agenda item at either full Medical Staff or Executive Medical Staff meetings, would occur.

6. The Incident Report related to this event was requested by the survey team on 5/17/2011; on 5/18/2011 at 9:05AM the Performance Improvement Officer reported that none existed, but that she had created one dated 5/18/2011 saying, "There needs to be one in there (i.e. Patient K2's medical record)".